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Translated from the Seventh German Edition, with additions by William Sterling, m. d , sc. d., Brackenburg Professor of Physiology and History in Owen's College and Victoria University, Manchester; Examiner in the Honors' School of Science, Uni- versity of Oxford, England. Fourth Edition, Revised and Enlarged. Royal Octavo. Cloth, $7.00; Leather, $8.00 " Landois' Physiology is, without question, the best text-book on the subject that has ever been written."—New York Medical Record. 83* Complete Circulars and Sample Pages of these Books sent upon application. Valuable Handbooks. ROBINSON. THE LATIN GRAMMAR OF PHARMACY AND MEDICINE. By H. D. Robinson, ph.d., Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Introduction by L. E. Sayre, ph.g., Professor of Pharmacy, and Dean of the Dept. of Pharmacy in the University of Kansas, and including two extensive vocabu^ laries, English Latin and Latin-English. i2mo. 275 pages. Cloth, $2.00 "It is a work that meets with my hearty approval. There is great need of just such a book in our American schools o< pharmacy and medicine. "—£. S. Bastin, Professor of Botany, Dept. of Pharmacy, Northwestern University, Chicago. "The object of this useful book is a very laudable one, namely, to improve, if possible, the Latin used by both physicians and druggists, chiefly in the prescribing of drugs. While it is true that many of the profession find it unnecessary to remember the genitive endings of words used in medicine, because of the customary abbreviations in prescribing-writing, there are others who frequently desire to write their directions to the druggist in Latin, in order that the patient may not learn of facts about which it is often necessary for him to remain in ignorance. 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It is completed by an excellent set of tables and an index."—Louisville Medical News. DAVIS. A MANUAL OF PRACTICAL OBSTETRICS. 140 Illustrations, including Several Plates. By Edward P. Davis, a.m., M D., Clinical Lecturer on Obstetrics in the Jefferson Medical College; Professor of Obstetrics and Diseases of Children in the Philadelphia Poly- clinic ; Visiting Obstetrician to the Philadelphia Hospital; Physician to the Children's Department of the Howard Hospital; Member of the American Gynaecological Society. l2mo. Cloth, $2.00 " This manual is, unlike many of its class, not a mere compilation, but contains a number of practical hints not usually found in larger works. The chapters on the diagnosis of preg- nancy, the treatment of normal and premature labor, operative obstetrics, the puerperal state, and post-partum hemorrhage commend themselves especially by their clearness and conciseness. If the advice given in Chapter VI, on the examination of patients before the beginning of labor, were generally followed there would be an immense difference in the ma- ternal and foetal mortality. The chapter on the laceration of the perineum and pelvic floor is a useful one. The style is clear and concise, the illustrations helpful; in fact, the work is one which deserves, and will obtain, a wide circulation."—The Medical Record, January 16,1892. MANUAL FOR SELF-EXAMINATION. Being 3000 Questions on Medical Subjects, Anatomy, Physiology, Materia Medica, Therapeutics, Chemistry, Surgery, Practice, Obstetrics, Gynaecology, Diseases of Children, etc., with References to the Correct Answers. 64010. Cloth, Net, 10 cts. "With this little work the student can Quiz himself in every department of medicine—and he can do it as thoroughly as a skillful Quiz-master can do it. When we were a student we would have hailed with the greatest pleasure a little work like this one. We advise every medical student to secure a copy of this work and make daily use of it."—Cincinnati Medical News, September 29,1891. P. BLAKISTON, SON &. CO., Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. From PROF. J. M. DaCOSTA.—"I find it an excellent work, doing credit to the learning and discrimination of the author." A NEW MEDICAL DICTIONARY. Compact and concise, including all the Words and Phrases used in medicine, with Pronunciation and Definitions. BASED ON RECENT MEDICAL LITERATURE. i m GE0RGE M- GOULD, A.B.,M.D., Ophthalmic Surgeon to the Philadelphia Hospital, Clinical Chief Ophthalmo- logical Dept.,German Hospital, Phila- delphia. SEVERAL THOUSAND NEW WORDS Small, Square 8vo, Half Morocco, as above, NOT CONTAINED IN ANY with Thumb Index, . . . $4.25 Plain Dark Leather, without Thumb Index, 3.25 SIMILAR WORK. Among others it contains Tables of the Arteries, of the Bacilli, giving the Name, Habitat, etc.; of Ganglia, Leucomaines, Micrococci, Muscles, Nerves, Plexuses, Ptomaines, with the Name, Formula, Physiological Action, etc.; Comparison of Thermometers; Weights and Measures, of Vital Statistics, etc. OPINIONS OF PROMINENT MEDICAL TEACHERS. " The compact size of this dictionary, its clear type, and its accuracy are unfailing pointers to its coming popularity."—fohn B. Hamilton, Supervising Surgeon-General U. S. Marine Hospital Service, Washington. " It is certainly as convenient and as useful a volume as can be found, regarding contents as well as arrangement."—Julius Pohlman, Prof, of Physiology, University of Buffalo. " I have examined it with considerable care, and am very much pleased with it. It is a handy book for reference, and so far as I have examined it, it is accurate in every particular." —£. H. Bartley, Prof, of Chemistry, Long Island College Hospital, Brooklyn. " I consider this the dictionary of all others for the medical student, and shall see that it is placed on our list of text-books.—A. R. Thomas, M.D., Dean Hahnemann Medical College, Ph iladelphia. " It will be recommended among our text-books in our new catalogue."—S. E. Chailll, M.D., Dean Medical Dept., Tulane University, New Orleans. " Compact, exact, up to date, and the tables are most excellent and instructive. I prefer it to the larger and older books."—Prof. C. B. Parker, Medical Dept., Western Reserve University, Cleveland. " I have given your' New Medical Dictionary' a critical examination. Its size has made it convenient to the study table and handy fo.' frequent use. At the same time it is compre- hensive as to the number of words, including those of the latest coinage, and concise in its definitions. The etymology and accentuation materially enhance its value, and help to make it worthy a place with the classical books of reference for medical students."—y. W. Holland, M.D., Dean Jefferson Medical College, Philadelphia. 49" 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 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 con- cise, and are really the best line of text-books that could be found for either student or practitioner." BLAKISTON'S TqUIZ=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. j(Kg~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. <^TThe authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. O-They are arranged in the most approved form, thorough and concise, containing over 300 illustrations, inserted wherever they could tfe used to advantage. tfB-Can be used by students of any college. ittTThey 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 price, will be sent, postpaid, by the publishers. In ordering, always specify " Blakiston's ? Quiz-Compends ? ." No. 1. HUMAN ANATOMY. Fifth Revised and Enlarged Edition. Including Visceral Anatomy. Can be used with either Morris' or Gray's Anatomy. 117 Illus- trations 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., Physician-in-Chief, Philadelphia Hospital, late Demonstrator of Clinical Medicine, Jefferson College, Philadelphia. No. 3. PRACTICE OF MEDICINE. Part II. Fourth Edition, Revised, En- larged, and Improved. Same author as No. 2. No. 4. PHYSIOLOGY. Seventh Edition, with new Illustrations and a table of Physi - ological Constants. Enlarged and Revised. By A. P. Brubaker, m. d., Professor of Physiology and General Pathology in the Pennsylvania College of Dental Surgery; Demonstrator of Physiology, Jefferson College, Philadelphia. No. 5. OBSTETRICS. Fifth Edition. By Henry G. Landis, m. d. Revised and Edited by Wm. H. Wells, m. d , Ass't Demonstrator of Obstetrics, Jefferson College, Philadelphia Enlarged. 47 Illustrations No. 6. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Fifth Revised Edition. By Samuel O. L. Potter, m. v., Professor of Practice, Cooper Medical College, San Francisco ; late A. A. Surgeon, U. S.- Army. No. 7. GYNECOLOGY. A New Book. By Wm. H. Wells, m. d , Ass't Demonstrator of Obstetrics, Jefferson College, Philadelphia. Illustrated. No. 8. DISEASES OF THE EYE AND REFRACTION, including Treatment and Surgery By L. Webster Fox, m. D.,and George M. Gould, m. d. With39 Form- ulae and 71 Illustrations. Second Edition. No. 9. SURGERY, Minor Surgery, and Bandaging. Fifth Edition, Enlarged and Improved. By Okville Horwitz, b. s., m. d., Clinical Professor of Genito-urinary Surgery and Venereal Diseases in Jefferson Medical College ; Surgeon to Philadelphia Hospital, etc. With 98 Formulae and 167 Illustrations. No. 10. CHEMISTRY. Inorganic and Organic. Third Edition. Including Urin- alysis, Animal Chemistry, Chemistry of Milk, Blood, Tissues, the Secretions, etc. By Henry Lhffmann, m.d., Professor of Chemistry in Pennsylvania College of Dental Surgery and in the Woman's Medical College, Philadelphia. No. 11. PHARMACY. Fourth 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 Jefferson College and Woman's Medi- cal College, Philadelphia. Carefully revised in accordance with the new U. S. P. No. 12. VETERINARY ANATOMY AND PHYSIOLOGY. Illustrated. By Wm. 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. No. 13. WARREN. DENTAL PATHOLOGY AND DENTAL MEDICINE. Second Edition. Illustrated. Containing all the most noteworthy points of interest to the Dental Student and a Section on Emergencies. By Geo. W. Warren, d.d.s., Chief of Clinical Staff, Pennsylvania College of Dental Surgery, Philadelphia. No. 14. DISEASES OF CHILDREN. Colored Plate. By Marcus P. Hatfield, Professor of Diseases of Children, Chicago Medical College. Price, each, $1.00. Interleaved, for taking Notes, $1.25. P. BLAKISTON, SON & CO., 1012 Walnut St., Philadelphia. COMPEND OF OBSTETRICS. LAN D I S. FEMALE pelvis. MALE PELVIS. ?QUIZ-COMPENDS? No. 5. COMPEND OBSTETRICS ESPECIALLY ADAPTED TO THE USE OF MEDICAL STUDENTS AND PHYSICIANS. BY HENRY G. LANDIS, A.M., M.D., LATE PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN IN STARLING MEDICAL COLLEGE. REVISED AND EDITED BY WILLIAM H. WELLS, M. D., ASSISTANT DEMONSTRATOR OF CLINICAL OBSTETRICS IN THE JEFFERSON MEDICAL COLLEGE; CLINICAL ASSISTANT TO THE CHAIR OF OBSTETRICS AND DIS- EASES OF INFANCY IN THE PHILADELPHIA POLYCLINIC, ETC. FIFTH EDITION ILLUSTRATED PHILADELPHIA P. BLAKISTON, SON & CO., IOI2 WALNUT STREET. 1893. WMii IL *-L &A i^GTCNL 0, "i>> VVQ IOO Entered according to Act of Congress, in the year 1893, by P. BLAKISTON, SON & CO., In the office of the Librarian of Congress, at Washington, D. C. DUPLICATE Press of Wm. F. Fell & Co., 1220-24 Sansom ST., PHILADELPHIA. PREFACE TO FIFTH EDITION. The continued success of Landis' Compend of Obstetrics seems to warrant its revision. Most of the original teachings, which have so long made it popular as an aid to the student of mid- wifery, have been retained. A few subjects seeming incompatible with modern obstetric teaching have been omitted. Several pages have been added; principally upon the subjects of the most modern obstetric operations, and the congenital defects and diseases of early infancy. A number of illustrations, which it is believed will be found of interest and use to the student, have been introduced. W. H. Wells. Philadelphia, October 24, i8gj. PREFACE TO FIR^T 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 com- position. 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, imprac- ticable 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 usefulness. It has been made more com- plete by the addition of paragraphs and illustrations upon subjects before overlooked or inadequately treated, and by an index. H. G. L. vi TABLE OF CONTENTS. PAGE Introduction,...................... g The Pelvis,........................ n Joints of,....................... 14 Pelvic Diameters,.................... 16 " Planes,..................... 17 " Muscles,..................... 18 Reproductive Organs. Anatomy. The Uterus,..................... 20 Ligaments,....................... 22 Fallopian Tubes,.................... 24 Parovarium,...................... 24 Ovaries,........................ 24 Vagina,........................ 25 Douglas' Cul-de-sac,................... 25 Hymen,........................ 26 Carunculas,...................... 26 Bulb of Vagina,.................... 26 Vulvo-vaginal Glands, .•................. 26 Vulva,........................ 27 Labia Majora,..................... 27 Mons Veneris,..................... 27 Commissures,..................... 27 Clitoris,........................ 27 Labia Minora,..................... 28 Vestibule,....................... 28 Meatus,........................ 28 Urethra,......................... 28 Perineum,....................... 28 Physiology. Ovulation,....................... 29 Menstruation,...................... 32 The Breasts,...................... 34 Pregnancy. Fecundation,...................... 36 Changes in Ovum,.................. . 38 Nourishment of Embryo,................ 40 vii Vlll TABLE OF CONTENTS. PAGE Coverings of Embryo,.................. 41 Changes in Womb...................42-45 The Placenta,..................... 42 Multiple Pregnancy,................... 46 Extra-uterine " ................... 47 Hydatid " ................... 50 Mole " ................... 52 Spurious " ................... 52 Premature Labor,.................... 53 Signs of Pregnancy.................... 56 Labor. Clinical History,.................... 68 Duties of the Physician,................. 77 Alechanism of Labor,................... 83 Pathology of Labor. Dystocia,.......................102 Uterine Inertia,.....................102 Rigidity of Cervix, etc.,.................105 Deformities of Pelvis,..................107 Ovular Dystocia,....................114 Twin Labor,...................... 117 Accidental Hemorrhage,.................119 Unavoidable Hemorrhage,................119 Placenta Previa,....................120 Post-partum Hemorrhage,................123 Rupture of Uterus,...................125 Eclampsia,......................126 Placental Dystocia,...................130 Inversion of Uterus,...................132 Obstetrical Operations. The Forceps,......................134 Version.........................I43 Embryotomy......................145 Cesarean Section,....................147 Porro's Operation,....................149 Gastro-elytrotomy,...................149 Symphyseotomy,....................149 Induction of Labor,..................152 The Period after Delivery. Involution of the Uterus,.................153 Puerperal Diseases,...................158 Congenital Defects,...................163 Conjunctivitis of the New-born,..............165 Diseases of the Umbilicus,................165 Jaundice in the New-born,................167 Tetanus " " " .............. ' 168 QUESTIONS ON OBSTETRICS. INTRODUCTION. What is Obstetrics? The science and art of affording aid to women in labor. What are the synonyms for obstetrics ? Midwifery, accouchement, maieutics, tocology. What is meant by science and art ? The science of Obstetrics embraces the definite rules of procedure founded upon a correct knowledge of the nature of Labor and its complications ; the art consists in the skilful 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 ? ist. The Anatomy of the parts concerned in labor, viz.: the repro- ductive 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 ? ist. Internal, viz.: the ovaries, oviducts, uterus, and vagina. 2d. External, viz. : the mons veneris; labia majora and minora; b 9 10 QUESTIONS ON OBSTETRICS. clitoris ; vestibule and fossa navicularis ; hymen, or carunculae myrtiformes; fourchette and perineum ; and also the breasts, or mammary glands. Where are they situated ? With the exception of the breasts and mons veneris, they are VULVA OF A VIRGIN. i. Labia majora of right side. Fourchette. 3. Labia minora. 4. Clitoris. 5. Ureth- ral orifice. 6. Vestibule 7. Orifice of the vagina. 8. Hymen, q. Orifice of theVa°nVaSln 10' Anterlor commissure of the labia majora. 11. Orifice of placed within the Pelvis, or below it, between the thighs. The mons veneris is placed directly upon the symphysis pubis, and the breasts on the pectoralis major muscle of either side, from the 3d to the 7th rib. THE PELVIS. II THE PELVIS. What is the Pelvis ? A bony structure, placed at the inferior extremity of the verte- bral column, which it supports above, while it rests on the femora below. It is divided into the true and false pelvis. Why is it called the pelvis ? Because, when clothed with muscles, ligaments, and fasciae, 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 vertebrae. It is curved, being concave in front. How many articular surfaces does it present ? Six: by three it is connected with the last lumbar vertebra above; by one on each side, with the ossa innominata, and by one below, with the coccyx. What is the coccyx ? A small and similarly wedge-shaped bone, apparently formed by the fusion of three or four vertebral bodies. It has one articu- lar surface above, by which it is connected with the sacrum. It tapers from that bone, and is supposed to be the remains of the caudal vertebrae of animals. 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 composed of three separate pieces, the ilium, ischium, and pubes. Their point of juncture is found in a cup- shaped depression on the outside of the bone, called the acetabu- lum. When do the several parts of the os innominatum unite ? By the twenty-fifth year. What uses has the pelvis ? ist. To support and transmit the weight of the body. 12 QUESTIONS ON OBSTETRICS. 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 ol the ischia in the sitting posture. How is the weight of the body transmitted to the femora ? By two beams of bone, consisting of the upper part of the sacrum and body of the ilium on either side. What are these beams called ? The sacro-iliac beams (see Fig. 2). 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. Fig. 2. 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. What is this beam called ? The pubic beam (see Fig. 2). Why are these beams not straight ? They are arched outwardly to make more room in the pelvis, to enable it to fulfil its second and third uses. THE PELVIS. 13 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. 4). Fig. 3. The same as in Fig 2, but with the beams arched; the dotted lines show the original direction of force. Fig. 4. The same as in Fig. 3, 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 are jarring and concussion prevented ? By placing joints at the center of each beam. How is the diminution of strength caused by these joints remedied ? By covering them with powerful ligaments. 14 QUESTIONS ON OBSTETRICS. 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. 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 the 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, especi- ally among the lower races, approach the male type.) See Fig. 5. What joints exist in the pelvis ? Three lumbo-sacral above (one between the bodies and two be- tween the articular processes), two sacro-iliac (one on each side), the pubic joint, in front, and the sacro-coccygeal joint, behind. What are the pelvic joints called ? Symphyses, and the pubic joint is often called, by way of dis- tinction, the symphysis. THE pelvis. 15 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 demon- strable synovial sac; the other joints can only be shown to have sacs during pregnancy. What is the sacral promontory ? The projection or angle formed by the top of the sacrum in front at its junction with the vertebra above. It is often called simply the promontory. Fig. 5- What is the ilio-pectineal line ? A bony ridge or raised line, which, beginning at the promontory, extends around each side of the pelvis, within, until it meets the opposite line at the symphysis pubis. What parts lie above it ? The wings of the sacrum, iliac fossae, and crests, and the last lumbar vertebra forming the bony parts, or 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 16 QUESTIONS ON OBSTETRICS. 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 aceta- bulum, 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 cardinal points of Capuron ? The sacro-iliac joints and ilio-pectineal eminences. 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 (or sacro-supra-pubic) diameter of the inlet ? A line drawn from the promontory to the top of the symphysis pubis. It is about 4^ inches, or 11.5 centimeters. What are the oblique diameters ? Lines drawn from the sacro-iliac symphysis of either side to a point in front of the pectineal eminence of the opposite side (Meadows). The one drawn from the right sacro-iliac symphysis is called the right oblique; the one from the left symphysis, the left oblique. They are about 5.3 inches, or 13.5 centimeters. What is the transverse diameter of the inlet ? A line drawn directly across the pelvis from one pectineal emi- nence to the other. In the normal pelvis it is about 4.8 inches, or 12.5 centimeters. What is the circumference of the pelvic inlet ? About 15.8 inches, or 40 centimeters. THE pelvis. 17 What are the diameters of the outlet ? The conjugate and transverse. What is the conjugate diameter of the outlet ? A line drawn from the tip of the coccyx to the under edge of the symphysis 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, or about 15 centimeters; ordinarily it measures about 4.3 inches, or 11 centimeters. « What is the transverse diameter of the outlet ? A line drawn from one tuberosity of the F,G- 6- ischium to the opposite one, and measures about 4 inches, or ' 11 centimeters in the nor- mal pelvis. What is the depth of the pelvic cavity ? 1 ]/2 inches, or 3.8 cen- timeters in front; 2,% in- ches, or 8.9 centimeters at sides ; posteriorly, 4^ inches, or 10.8 centime- ters, or following the curve of the sacrum, it is about 5^ inches, or 13.8 centimeters. The average diameters are about 41/ to 5 inches, or 12 centimeters. What are the planes of the pelvis ? Imaginary levels, drawn through any part of the pelvic circum- ference (Playfair), to facilitate the description of the relations of the pelvis to the child, vertebral 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. a b. Conjugate diameter of Inlet. ef. Conjugate diameter of Outlet. 18 QUESTIONS ON OBSTETRICS. What is the plane of the inlet ? A plane drawn transversely through the conjugate diameter of the inlet and limited by the circumference of the inlet. What is the plane of the outlet ? A plane drawn transversely through the conjugate diameter of the outlet, and limited by the circumference of the outlet. How are these planes used to show the position of the pelvis in different postures ? In the erect .posture the plane of the inlet makes an angle of 6o° with the horizon. In the semi-recumbent posture the same plane is directly horizontal, and in the recumbent posture it forms a reversed angle of 450 with the horizon. What is the axis of the pelvis ? As usually given it is a line drawn from the center of the conju- gate diameter of the inlet, parallel to the face of the sacrum and coccyx, to the center of the conjugate diameter of the outlet. (The line^- k in Fig. 6.) What is the obliquity of the pelvis ? The planes of the pelvis and the spinal column stand in the relation of an obtuse angle; this is the obliquity of the pelvis. How is the pelvis lined within ? By certain muscles, blood-vessels, nerves, and fasciae. What muscles are contained in it ? 1. The Psoas-iliacus muscle on either side, consists, first, of the iliacus internus, which, in its origin, covers almost the entire inner aspect of the wing of the ilium, uniting with the psoas magnus, which passes over the upper border of the sacrum. Their conjoined body passes along the border of the sacro-iliac arch, and by a common tendon passes out of the pelvis, between the anterior inferior iliac spine and the ilio-pectineal 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 anterior pelvic walls and passes out under the sacro-ischiatic arch. THE pelvis. 19 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, pre- Fig. 7. serving them from pressure, while the pyriformis performs the same office for the sciatic nerve, which lies along its border. QUESTIONS ON OBSTETRICS. THE REPRODUCTIVE ORGANS. THE INTERNAL ORGANS. What and where is the Uterus ? The uterus or womb is a hollow muscular organ, situated in the center 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. Fig. 8. A. Fundus. B. Cavity of uterus. C. Internal os. D. Fallopian tubes or oviducts. E. Fimbriated extremity. F. Ovary. G. Round ligament. H. Ligament of ovary. I. Tubo-ovarian ligament. J. External os. O. Cavity of cervix, showing ruga. V. Vagina, b. Mouths of oviducts. Into what parts is it divided ? Into, first, the cervix or neck, about an inch long; and second, 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 Fig. 9). What openings are found in the cervix ? The os externum, or os uteri, called also tke os (j), is a small THE REPRODUCTIVE ORGANS. 21 Fig. 9. opening into the cavity of the cervix at its lower end. The con- striction between the cavities of the neck and body is called the os internum (c). What is the structure of the uterus ? It is mainly composed of muscular tissue, with fibrous connec- tive tissue, blood vessels and nerves. On the outside, it is mainly covered with peritoneum, and on the inside, is lined with mucous membrane, called the endometrium. How are the muscular fibers arranged ? For the most part they are irregularly and inextricably interlaced and surround the large blood-vessels which penetrate between them, but a circular arrangement of fibers 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 heli- cine or spiral, and are derived mainly from the two uterine and two ovarian arteries ; the latter also supply the ovaries and oviducts. The veins are short, of large caliber, and freely communicating; these, after emerging from the uterus, form on each side a large plexus, situated in the folds of the broad ligament, known as the utero-ovarian plexus. During pregnancy large sinuses are formed. These peculiarities 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 the plexus uterinus magnus, formed by branches from the superior mesenteric plexus and from the ovarian ganglia. 2d. The sympathetic nervous system also furnishes fibers. 3d. The vaso-motor apparatus has much influence upon the womb. 4th. Independent ganglia, like those found in the heart, are em- bedded in the uterine tissue. 2'2 QUESTIONS ON OBSTETRICS. How is the uterus supplied with lymphatics? These are divided into three sets, one for each coat of the organ. They are connected with the pelvic and lumbar ganglia, into which they empty. What kind of mucous membrane lines the uterus? The membrane lining the body is quite thick and vascular, and is composed— I. Of a mesh of connective tissue containing many spindle-shaped cells. 2. Of many tubular glands, which give the surface of the mem- brane a perforated appearance. 3. Of ciliated cylindrical epithelium, which lines 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. Cilia are only found in the upper two-thirds, the lower third being formed of pavement epithelium. What distinguishing peculiarity has the uterine mucous mem- brane ? It has no basement layer of connective tissue, and merges irregularly into the muscular tissue. What kind of mucus is secreted by the uterine mucous mem- brane ? A viscid, alkaline mucus. What are ovula Nabothi ? These are racemose glands in the cervical mucous membrane which 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 THE REPRODUCTIVE ORGANS. 23 across the pelvis, to be merged into the common abdominal peri- toneum. These transverse folds, enclosing muscular and fibrous tissues, blood-vessels, nerves, and lymphatics, are called the broad ligaments, and divide the pelvis into two compartments; in the anterior one the bladder is situated, in the posterior, the rectum. What are the round ligaments ? They are two rounded cords, composed of fibrous tissue, inter- spersed with muscular fibers, which extend underneath the peri- toneum, 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 center 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 ist, rises and falls with the respiratory movements, and, 2d, is pushed backward and forward by the varying con- ditions of fulness in the bladder and rectum. What supports the uterus ? ist. The uterus is swung from the sacrum by the utero-sacral liga- ments. 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 existence of a partial vacuum in the abdominal cavity, aids in maintaining the uterus in its normal position. 24 QUESTIONS ON OBSTETRICS. 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 fetus 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 mem- brane, which is identical with that of the uterus. The average caliber 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 embedded 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 mus- cular fibers 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). 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. THE REPRODUCTIVE ORGANS. 2-"> 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 fibers, for the most part circularly arranged. The external coat is continuous with the ordinary cellular tissue or packing of the pelvis; the middle or muscular coat is composed of two layers of fibers, longitudinal and transverse. It is composed of unstriped or involuntary muscle. Within, it is lined with mucous mem-, brane, 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 three to five inches, varying in individuals and in races, two and one-half inches for anterior and a little over three inches for the posterior wall (Lusk). Where is Douglas' cul de sac ? It is situated in the abdominal cavity, directly behind the poste- rior vaginal pouch, and therefore between the vagina and rectum. C 26 QUESTIONS ON OBSTETRICS. It is a very important space, because, being the most dependent portion of the abdominal cavity, effusions of blood or other fluid and tumors of various kinds are often to be found in it. How does the vagina terminate below ? It terminates in a circular fold of mucous membrane called the hymen. From the fact that this fold is often more developed in its posterior half, it usually appears as a crescentic fold, stretching across the opening of the vagina. (See 8, Fig. i.) 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 carunculae myrtiformes. It is said, however, that these bodies sometimes coexist with the hymen, being placed a little distance behind it. What are the bulbs of the vagina ? They are masses 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. They are supposed to correspond to the two halves of the male bulbous urethrae. 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 embedded 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 excite- ment and coitus. THE REPRODUCTIVE' ORGANS. 27 THE EXTERNAL ORGANS, OR PUDENDA. See Fig. i. What is the vulva ? The name given to the external organs collectively, but often used to denote the genital fissure or vulval canal. What are the labia majora ? Elevated folds of cutaneous tissue, which are found on either side of the genital fissure. What is the structure of the labia majora? They consist of cutaneous folds containing loosely arranged cel- lular tissue, with some fat. On the outer surface they are covered by a free growth of stout, curly hair, similar to that found in the axilla. On their inner surface they are furnished with a consider- able 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. It marks the anterior boundary of the perineum. 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 pro- ject behind the posterior commissure, which is called the four- chette. The little dimple or cup between this fold and the com- missure 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 resem- bles and is the analogue of the male penis. It consists of two 28 QUESTIONS ON OBSTETRICS. corpora cavernosa, which are attached to the under edge of the pubic bone, and by their free end project slightly under the anterior commissure. The part which is visible is about the size of a pea. What are the labia minora ? Called also the Nymphce. They are two folds of dartoid tissue, covered by skin, which cover the clitoris in a manner similar to the prepuce of the penis, and extend backward along the sides of the labia majora for about one-half their extent. What is their structure ? Is nearly resembles that of the male scrotum, inclosing also some erectile tissue. What is the vestibule ? The space which extends from the clitoris to the opening of the vagina, and is bounded laterally by the labia minora. What and where is the meatus urinarius ? It is the opening of the urethra, and is placed at the posterior limit of the vestibule, and therefore just above the opening of the vagina. It is situated in a tubercle or slight eminence. How long is the female urethra ? About one and one-half inches. How is the urethra situated with respect to the vagina ? It lies directly over it, and can be distinctly recognized, by the finger introduced into the vagina, as a tubular ridge above the anterior wall of the vagina. What is the perineum ? The space between the vulva and anus, and bounded laterally by the tuberosities of the ischia. What is the perineal body ? It consists of a wedge-shaped band of fibrous elastic tissue, which stretches across from one ischial tuberosity 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 fibers of the sphincter muscles, which are placed about the ends of the vagina and rectum. OVULATION. 29 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 ovula- tion in 10 per cent, of infants examined by them.) But it does not occur with much vigor until womanhood. o. Ovarian tissue, y. Yolk. z.p. Zona pellucida or vitelline membrane, g.v. Germ- inalvesicle. g. s. Germinal spot. D. p. Discus proligerous. m.g. Membrana granu- losa. M. p. Membrana propria. 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 proto- 30 QUESTIONS ON OBSTETRICS. plasm, ^th of an inch in diameter. It is structureless, except that it contains at one point a small body like a nucleus, called the germinal vesicle, which in turn contains a smaller body, like a nucleolus, called the germinal spot. The ovum is surrounded by a thin envelope of albuminous matter, called the zona pellu cida, or vitelline membrane, but which is not a distinct membrane until after impregnation, the ovum itself being called, also, the vitellus or yolk. Describe the process of ovulation. The ovisac, at first very minute, is embedded in the cortical layer of the ovary. Its wall consists of a layer of cells, called the membrana propria, within which is found a second layer, the membrana granulosa. An accumulation of these cells form a little mound, called the proligerous disk, and in this the ovum is situated. These cells secrete within the ovisac an albuminous fluid. While the ovisac increases in size, it also approaches the surface of the ovary, having then attained a diameter of one-fourth to one-half of an inch. At this point it stops growing, while the fluid continues to be secreted in its interior. This finally subjects the ovisac and the overlying covering of the ovary to a bursting pressure ; the ovisac is ruptured, and the ovum, with some of the fluid and epithelium of the ovisac, is extruded upon the surface of the ovary. What happens to the ovisac after the discharge of the ovum ? Several things may occur :— i. The entire contents of the ovisac may be extruded, the walls collapse, and within a week or two a small linear cicatrix only is left to show that ovulation has occurred. 2. Some blood may be effused into the sac at the time of rupture. A clot is formed, which is slowly absorbed; as its hematin be- comes faded and yellowish, it is called the corpus luteum. 3. Should the woman become pregnant, the walls of the ovisac may continue to secrete fluid. This is due to the increased blood supply which pregnancy occasions ; and this leads to the forma- tion of a large, yellowish body, called the corpus luteum of preg- nancy. OVULATION. 31 What coverings has the ovum when it escapes from the ovisac ? It is covered externally by a layer of cells from the membrana granulosa, called the discus proligerous, internally by a thick transparent membrane termed the vitelline membrane, or, from the way in which it transmits light it is called the zona pellucida. The ovum and zona pellucida are not, however, in immediate con- tact, for between them there is found a space, termed the perivi- telline space, which permits ameboid movement of the protoplasm of the egg. How is the appearance of the ovary affected by age ? In youth it is smooth; after repeated ovulation it becomes fis- sured and wrinkled ; in old age atrophy takes place, and it returns to nearly its infantile appearance. What happens to the ovum after its escape from the ovisac ? i. It may drop into the abdominal cavity and perish. 2. It is wafted toward the open end of the Fallopian tube by means of a current in the fluid bathing the tissues, which current is caused by the action of ciliated epithelial cells, and is always directed toward the tube. 3. The end of the tube may, by a spasmodic movement, clasp the surface of the ovary and draw the ovum into the tube. 4. When in the tube it is passed on to the womb (a) by a ciliary current, and (b) possibly by peristalsis, and from the womb it is discharged with the mucus, etc., unless fecundated. 5. It may become fecundated and remain within the mother until developed into a child. How often does ovulation take place ? It is irregular in its occurrence. A number of ovisacs are con- stantly being developed, with greater or less rapidity, and the amount of the blood supply of the ovary controls the rate of de- velopment. Frequent coitus leads to frequent ovulation for this reason. What is the usual interval between the discharge of successive ova ? Usually once a month, because the greatest increase in the blood supply occurs once a month, during menstruation. 32 QUESTIONS ON OBSTETRICS. MENSTRUATION. What is Menstruation ? A periodical disturbance in the female, characterized by— i. An increase in the vascular tension throughout the body. 2. A special determination of blood to the pelvic organs (or pelvic hyperemia). 3. A renovation of the uterine mucous membrane. 4. A discharge of blood mixed with mucus from the uterus. How often does menstruation occur ? Once every twenty-eight days; but the interval varies in some women from three to six weeks. What is the first evidence of menstruation? An increase in the vascular tension and a sense of fulness in the pelvic region, which may be accompanied by pain. What effect has the pelvic hyperemia on the ovaries ? By increasing the blood supply it hastens the development of the ovisacs, and one or more usually rupture at this time. What effect has the pelvic hyperemia on the uterus ? The uterus becomes larger and softer, and its mucous membrane undergoes changes as follows: 1. New cells are formed. 2. The outer layer or layers of epithelium are thrown off. 3. The mem- brane is turgid with blood and thrown into folds. 4. There is increased functional activity in the mucous follicles, and a more abundant secretion of mucus. 5. Some of the superficial capilla- ries break down, and an oozing of blood takes place. What is the clinical course of menstruation ? 1. The woman notices a leucorrhea for one or two days. 2. A discharge of blood for three days (average). 3. A continuance of leucorrhea for one or two days. Is menstruation attended with pain ? Not normally, but the majority of women experience some de- gree of pelvic pain, because the parts are hypersensitive, from some departure from the normal condition. The pain is usually referred to the "small of the back;" also to the ovarian regions and to the hypogastrium. There also may be present sensations of rapid changes of temperature, chilliness or heat; the bladder MENSTRUATION. 33 may be quite irritable, and diarrhea may appear. Some women become hysterical at these times. What peculiarities has the menstrual blood ? i. It is blood mixed with epithelial cells. 2. It does not coagulate when moderate in amount, because it is made acid by the vaginal mucus. How much blood is discharged during menstruation ? From §ss to ^iij in all; but the amount varies. Is the blood during menstruation always discharged from the uterus ? No. The uterine mucous membrane sometimes fails to undergo its usual changes, and weakened capillaries in any part of the body may break down under the increased vascular tension. Thus we' may have menstrual hemorrhage from the stomach, lungs, breasts, or any part whatever. What is this condition called ? Vicarious menstruation, or xenomenia. What are the popular names for menstruation ? To be unwell; to see anything; to be regular; the periods; courses ; sickness ; monthlies ; turns ; changes, and flowers. What is the object of menstruation ? To insure the development of ova by a periodical increase in the ovarian blood supply, and to favor the detention of the ovum in the uterus by the changes in the mucous membrane. When do women begin to menstruate ? As soon as they become women, which period is called puberty. When does puberty begin ? It varies, from race, climate, and social condition. The average is at the age of fifteen years. What physical signs attend the age of puberty ? The reproductive organs are fully developed, the breasts enlarge, the pubes is covered with hair, and the whole form of the girl be- comes rounded and womanly. When do women cease to menstruate ? At about the age of forty-five years, which period is called the 7nenopause or climacteric, or " the change of life." 34 QUESTIONS ON OBSTETRICS. What symptoms usually herald the approach of the menopause ? Menstruation becomes irregular and finally ceases. Sudden flushes of heat and cold, and hyperemias of the cerebrum or of other organs of the body may appear. Some women are quite ill at this time. What happens to the reproductive organs at the menopause ? They gradually atrophy, but the possibility of child-bearing may continue until the age of fifty-five years (F. Barker). Does the capacity for child-bearing cease with the menopause ? Usually it does ; but as ovulation occasionally outlasts the men- strual function, impregnation may in some cases take place after the menopause. Does impregnation ever take place before menstruation begins ? Ovulation sometimes precedes menstruation, and consequently such a case is possible. What is the main function of the uterus ? To receive the fecundated ovum, and to retain it until it is de- veloped into a mature fetus. What is the function of the oviducts ? To convey the ova to the uterus, and the spermatozoa to the ova. What is the function of the vagina ? It serves as a duct or outlet for the discharge of the uterine secretions, including the escape of the child in labor, and also to admit the male organ, so that the semen may gain access to the ovum. What is the function of the external organs ? They are endowed with great sensibility, and are mainly con- cerned with the function of coitus. The nymphae also serve to direct the stream of urine as it passes from the meatus urinarius. What is the structure of the breast ? The breast is a gland of the racemose variety, and is composed of fifteen or twenty lobes of glandular tissue, with a packing of areolar and adipose tissue. The lobes are compounded of the lobules produced by the aggregation of the terminal acini, in which the milk is formed. The ducts of each lobule unite with each other to form a terminal canal, called the galactophorous MENSTRUATION. 35 duct, of which there is one for each lobe (Playfair). These empty upon the face or extremity of the cylindrical appendage called the nipple. What is the areola ? A circular patch of cutaneous tissue around the base of the nipple, of pink color in virgins, and darker in those who have borne children and in brunettes. It contains also many sebaceous Fig. ii. Fig. 12. 1. Galactophorous duct. 0]a- xhey enlarge greatly during 2. Lobuli of the mammary J ° ° ' glands. pregnancy. What is the nipple ? The nipple is a conical projection arising from the center of the areola. It is about half an inch in height. Of what re the nipple composed ? Principally of the terminals of the galactophorous ducts, seba- ceous glands, fat, connective tissue, longitudinal and transverse muscular fibers, and skin. It has also been supposed by some to contain erectile tissue. Affections of the mammary glands will be treated in the chapter on " The Period After Delivery." 36 QUESTIONS ON OBSTETRICS. PREGNANCY. What is pregnancy ? The condition in which a woman contains a living and growing fetus. What are the essential requisites for the occurrence of preg- nancy ? I. That a fully matured ovum shall be recently discharged from the ovary. 2. That male semen shall come in contact with such an ovum before it leaves the uterus. What synonyms are given for this act? Fecundation, impregnation, incarnation, conception. Fig. 13. Q. A 1 1 I HEAD AND UPPER PART OF SPERMATOZOA. 1. Seen from above. 2. Side view. What is fecundation ? The act by which the male semen imparts to the ovum the power of developing into a fetus. What part of the semen has this property ? The spermatozoa; each spermatozoon resembles a ciliated epi- thelial cell, except in being apparently structureless or homo- geneous. Each drop of semen contains thousands, all of which are in constant vibratile motion during life. Their length is about vhst0 vhv of an inch- PREGNANCY. 37 How long do the spermatozoa retain their vitality ? They have been found in full vigor eight days after their intro- duction into the vagina. What is the average rate of motion in a spermatozoon ? About an inch in five minutes (Henle). What agents lengthen the life of the spermatozoon ? Their vitality is promoted by warmth, a slightly alkaline solution, the secretion of the uterus. It would seem also that it is possible for them to live for a considerable time in menstrual blood. What agents destroy the life of the spermatozoon ? Injection of vinegar, acids generally, strong alkaline solutions, and bichlorid of mercury in a strength of i to 10,000 or 12,000; cold, while retarding their movements, does not kill them. When is sexual intercourse most liable to be followed by con- ception ? During the week following the cessation of the menstrual flow, the probability being greatest in the earlier days and diminishing as the week advances. How and where is contact between the spermatozoa and ovum brought about ? 1. During coitus the semen is ejected against the cervix uteri and upper part of the vagina. 2. During the orgasm of the female the uterus sucks or pumps the spermatozoa 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 uteri internum. 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 3S QUESTIONS ON OBSTETRICS. 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 dis- tance may be traveled by the spermatozoa unaided. What changes take place in the ovum after fecundation ? I. When the ovum is mature, two small cells are detached from the main body of cells ; these are called polar globules. It was formerly supposed that these were associated with the disappear- ance of the germinal vesicle, but recent experiments have de- monstrated that the germinal vesicle plays an active part in their formation. This can take place independently of fecundation. 2. The portion of the ovum remaining after the throwing off of the polar globules is called the " female pronucleus." Fig. 14. SEGMENTATION OF THE VITELLUS. 3. Fecundation is effected by the penetration of the head of one spermatozoon. This is called the " male pronucleus." 4. The male and female pronucleus coalesce. The ovum is now called the oosperm. 5. The segmentation of the nucleus and vitellus, /. H inches. In the cervico-frontal, an elliptical outline; long diameter 4— inches. Transverse diameter 3^ inches. In the cervico-bregmatic, a circular outline ; long diameter 3^ inches. Transverse diameter 3^ inches. What important deduction may be drawn from these facts ? The more the head is flexed the smaller is the outline presented. What is the circumference of the fetal head ? The circumference of the head from the chin to the vertex, using the latter term to express the highest part of the skull, with- out reference to any fixed anatomical point, is about 14^ inches. The circumference at the sub-occipito-bregmatic diameter is but 13 inches. (Lusk). Name the important diameters of the fetal trunk. The bis-acromial 4.7 inches. Is capable of compression. Bis- trochanteric, 3.5 inches. In how many ways may the vertex enter the pelvis ? The elliptical outline of the head may enter with the occiput in front and to the left or right, i.e., in relation with the ilio-pectineal eminences of either side, and behind and to the right or left, i.e., in relation with the sacro-iliac joint o.f either side. There are, therefore, four positions of the vertex, named as follows :— 1. Left Occipito-Anterior. 2. Right Occipito-Anterior. 3. Right Occipito-Posterior. 4. Left Occipito-Posterior. How many positions are there of the Face presentation ? Since the face has also an elliptical outline; with the mentum or chin at one end in relation with the sacro-iliac joints or ilio-pecti- neal eminences of either side, we have the same arrangement as in the vertex, or :— 1. Left Mento-Anterior. 2. Right Mento-Anterior. 3. Right Mento-Posterior. 4. Left Mento-Posterior. 88 QUESTIONS ON OBSTETRICS. How many positions are there of the Breech' presentation ? Since the breech has also an elliptical outline, with the sacrum in a direct line with the occiput, we have the same arrangement as in the vertex, or:— I. Left Sacro-Anterior. 2. Right Sacro Anterior. 3. Right Sacro-Posterior. 4. Left Sacro-Posterior. How many positions are there of the Transverse presentation ? For the sake of uniformity we may assume an elliptical outline for the shoulder, with the dorsum, or back of the shoulder, as the name-point. This gives us the same arrangement as in the other presentations, or:— 1. Left Dorso-Anterior. 2. Right Dorso-Anterior. 3. Right Dorso-Posterior. 4. Left Dorso-Posterior. How may the positions be more briefly designated ? By initials, as L. O. A. for left occipito-anterior, R. S. P. for right sacro-posterior, and so on. How may these sixteen positions be represented in a single scheme ? Left ^---' 'Anterior. 0r by ini!ials only- Right S.2 o o Anterior. r^a Rightg J §| Posterior. *£*' Left 0 2c/>Q Posterior. K*V" «---.---' LO P. How is the head situated at the beginning of labor in the L. O. A. position ? The occiput points to the left ilio-pectineal eminence; the bi- frontal suture is opposite the right sacro-iliac symphysis, and the sagittal suture lies in the right oblique diameter. What is the mechanism of delivery in the L. Q. A. position ? 1. Flexion occurs, whereby the cervico-frontal, or even the cervico- bregmatic diameter, is substituted for the occipito-frontal, thus reducing the outline presenting in the pelvis. THE MECHANISM OF LABOR. gg 2. The head descends in the pelvis, and at the same time a level- ing movement occurs by which the forehead descends more rapidly than the occiput, and becomes level with it. 3. While the head descends it also rotates, so that the sagittal Fig. 28. suture is finally brought into the median line by the time the head reaches the pelvic outlet: the shoulders, having also rotated occupy the transverse diameter of the outlet. o 90 QUESTIONS ON OBSTETRICS. 4. When the head reaches the outlet the occiput or nape of the neck remains fixed under the sub-pubic arch, while the fore- head and face sweep over the perineum by a movement of extension. Fig. 30. 5. After the head is born it undergoes a movement of external rotation, or restitution, because the shoulders, occupying the transverse diameter of the outlet, now undergo a movement of internal rotation, so that the bis-acromial diameter is finally brought into the median line, the right shoulder turning under the pubic symphysis. THE MECHANISM OF LABOR. 9] 6. The right shoulder is now forced down under the sub-pubic liga- ment, and, the trunk pivoting upon the arm just below the shoulder, delivery of the body occurs by a movement of latero- flexion. What variations occur in the mechanism of the L. O. A. posi- tion ? If there is not a close fit between the head and the pelvis there may be less flexion and rotation, but no substantial difference in the mechanism occurs. The shoulders may vary greatly, due usually to the length of the neck and the time when they are com- pelled to follow the head. Thus, they may enter the pelvis directly transversely and rotate indifferently into, either oblique diameter, and at any level, which will also control the movement of restitution. What is the mechanism of delivery in the R. O. A. position? The same as in the first, or L. O. A. position, except that the sagittal suture is in the left oblique diameter, and the occiput directed toward the right ilio-pectineal eminence; and in general the same description will apply throughout, substituting right for left, and vice versa. How often does this position occur ? Very seldom, owing to the infrequency of left lateral obliquity of the womb, and the presence of the rectum on the left side of the pelvis. How is the head situated in the R. O. P. position? The occiput is opposite the right sacro-iliac symphysis, the fore- head opposite the left ilio-pectineal eminence, and the sagittal suture lies in the right oblique diameter. What is the mechanism of delivery in the R. O. P. position ? There are four different processes by which it may be terminated: i. Anterior rotation at the inlet. 2. Anterior rotation at the outlet, or during descent. 3. Anterior rotation on the perineum, and, 4. Posterior rotation throughout. What is meant by anterior rotation ? The rotation of the head so as to bring the occiput in front, there- by converting the position into an R. O. A. QUESTIONS ON OBSTETRICS. How does anterior rotation occur ? I. From the fact that the foramen magnum is near the occipital end of the head, the shoulders are thrown further back in this position, and therefore the right shoulder impinges upon the vertebral column or promontory. If it should be pushed off on the right side, the child's back will be brought in front. This twists the neck, and the untwisting force of its elastic structure tends to rotate the head with the occiput in front. This occurs most easily at the inlet, next at the outlet or during descent, and rarely, even when the head has reached the perineum. 2. The resistance of the posterior pelvic wall to the occiput is greater than that of the anterior wall upon the forehead, owing to the nar- rowing of the pelvis under the sacro-iliac arch, which also aids in anterior rotation, and according to some, is the only cause. What must occur before anterior rotation ? Flexion, continued until the circular cervico-bregmatic outline is reached. Under what circumstances does posterior rotation occur ? If the child's back is turned toward the mother's back, and re- mains so, the head cannot rotate anteriorly, and is delivered with the forehead under the sub-pubic arch. What difficulties are encountered in posterior rotation ? I. The labor is more prolonged, because the uterine force is trans- mitted through the posterior and narrow portion of the pelvis. 2. The perineum is endangered, because the head cannot be fully flexed while passing over it. How may we recognize the R. O. P. position ? i. At the beginning of labor the anterior fontanelle (usually large) will be found very accessible in front and to the left. 2. As flexion occurs the fontanelle will move upward and become less accessible, which is directly the reverse of the course fol- lowed by the posterior fontanelle in L. O. A. How should the R. O. P. position be managed ? As soon as discovered, a reasonable effort should be made to rotate the shoulders with the back in front, by external manipula- tion. This may be aided by two fingers placed upon the vertex, THE MECHANISM OF LABOR. 93 and similarly employed in endeavoring to rotate the head. If these efforts fail, we may leave the case to the uterine efforts, until it is evident that natural delivery will take too long, when we should employ the forceps. What is to be avoided ? Attempts to rotate the head without reference to the position of the shoulders. It endangers the child's life, from over-twisting of the neck, and is rarely successful. What is the mechanism of delivery in the L. O. P. position ? The same as in the third or R. O. P., except that anterior rotation converts it into an L. O. A., and in general left is to be substi- tuted for right, and vice versa, throughout the description. What are the causes of the Face presentation ? i. From a misdirection of the uterine axis (due to pendulous abdo- men and the like) the contractions may propel the head, orig- inally presenting the vertex in such manner that its occiput is arrested at the brim, while the facial end, being free, descends. Thus an L. O. A. may be converted into an R. M. P., and an R. O. P. into an L. M. A. 2. External violence or jarring may disturb and change the pre- sentation. 3. The child may, by reflex movements, extend its head. What plane and diameters are described in the Face presenta- tion ? A plane drawn through the anterior limit of the anterior fonta- nelle, the malar bones, and the* junction of the chin and neck, is called the trachelo-bregmatic plane. It is of elliptical outline and nearly parallel to the cervico-breg- matic plane, but smaller. Its long diameter is called the trachelo- bregmatic ; its transverse diameter, drawn from one malar bone to the opposite, the bi-malar. How is the head situated in the L. M. A. position ? The chin is opposite a point in front of the left acetabulum ; the anterior fontanelle is opposite the right sacro-iliac symphysis. The features of the face (eyes, nose, mouth, etc.) may be felt between the'points. 94 QUESTIONS ON OBSTETRICS. What is the mechanism of delivery in the L. M. A. position ? The head descends with its trachelo-bregmatic diameter pre- senting in the oblique diameter, and without difficulty, until the cervico-bregmatic plane has entered the pelvis. By this time the diameter of the neck or upper part of the chest is added to the cervico-bregmatic diameter, and this constitutes too large a bulk to pass. Delay therefore occurs. How is this difficulty overcome ? As soon as the head can reach far enough to be acted on by the perineum, the perineal force (see page 84) will cause the head to be flexed, and allow it to sweep easily over the perineum. Therefore, if the head is small, or the neck long, there may be no delay in flexion and delivery. Otherwise the head must remain stationary until it is moulded and wire-drawn, so as to enable it to reach the perineum. What effect has this delay, etc., upon the child ? 1. It is endangered by the pressure upon its cervical structure. 2. The caput succedaneum forms easily upon the face, and the parts may be perilously swollen and infiltrated. What treatment is demanded, and why ? Since the delivery can be readily accomplished by securing flexion after the face has reached the inferior strait, we should assist the mechanism— 1. By attempting to flex the head with the fingers, and 2. With the forceps, if the fingers fail, or traction is necessary to bring the head low enough to lie flexed. What is the mechanism of the R. M. A. position ? The face enters the pelvis with the chin in front and to the right, and in general the same description will apply, substituting right for left and vice versa, throughout. What is the mechanism of the R. M. P. position ? 1. The trachelo-bregmatic plane enters the pelvis with the chin opposite the right sacro-iliac symphysis. The forehead remains stationary at the front part of the brim, while the base of the skull and upper part of the chest attempt to advance under the sacro-iliac arch, which is impracticable. THE MECHANISM OF LABOR. 95 2. The shoulders will thus be made to impinge upon the vertebral column, and will have a tendency to be pushed to the right of the promontory, with the back in front. This will twist the neck, and tend to rotate the head into an R. M. A. position, when the labor is terminated as in that position. The key to the mechanism, therefore, is anterior rotation at or near the inlet. If this fails to occur, the head and chest become tightly wedged, and unless the head is very small, or the pelvis large, delivery is impossible. What is the mechanism of the L. M. P. position ? The face enters the pelvis with the chin behind and to the left, and in general the same description will apply, substituting left for right and vice versa, throughout. What is the Brow presentation ? A variety of the Face presentation, the upper part of the face presenting. It is either converted into a full face or into a vertex presentation, or cannot be delivered naturally unless the head is very small. What plane and diameter are described in the Breech presenta- tion ? A plane drawn transversely through the ilia and sacrum, called the bis-iliac, from its long diameter, drawn between the crests of the ilia. It is of elliptical outline and almost identical with that of the shoulders. How is the breech situated in the L. S. A. position ? The sacrum is in front of the left acetabulum, the right ilium under the left sacro-iliac symphysis ; the left ilium in front of the right acetabulum, and the pubes in the free space in front of the right sacro-iliac symphysis. What is the mechanism of the L. S. A. position ? The bis-iliac diameter enters the pelvis in the left oblique dia- meter, rotating during descent, so that when it arrives at the vulva the left ilium is directly in front and the sacrum directly toward the left side. Since the breech is quite compressible, advantage is taken of this to enable it to pass out of the vulva with less dis- tention of the perineum, by one of the hips passing in advance of 96 QUESTIONS ON OBSTETRICS. the other. The breech being born, the body and legs emerge, next the shoulders, following the same mechanism, and finally the head, which enters in the right oblique diameter, and passes down strongly flexed. What is the mechanism of the R. S. A. position ? The same as in the first, substituting right for left, etc. What is the mechanism of the R. S. P. and L. S. P. positions ? So far as the breech is concerned, the mechanism is the same as in the sacro-anterior position (making allowance for change in direction). But when the head enters the pelvis it will be in an occipito-posterior position, and there will be the same need for anterior rotation as in the corresponding vertex positions. What dangers are connected with the breech presentation ? i. Compression of the funis. 4. Extension of arms over head. 2. Premature respiration. 5. Extension of the head. 3. Inhalation of mucus, etc. 6. Rupture of the perineum. How may the funis be compressed ? If there is any delay in the birth of the head after the body is born, the funis may be compressed between the head and pelvic walls, thus asphyxiating the child. What is premature respiration ? After the birth of the body, the contact of air may excite respira- tion, and abolish the placental circulation. Delay after this may result in asphyxia. How may inhalation of mucus.occur? The child may respire while the head is detained in the passages, and may draw mucus or fluids into the lungs, causing either asphyxia or pneumonia after birth. How may the arms be extended ? The arms are naturally flexed upon the child's body, and pass out with it, but if arrested by the pelvic walls, they may be extended alongside of the head, increasing its diameter, and mak- ing delivery impossible until they are brought down. How are the arms to be brought down ? One or two fingers are to be passed by the child's head and laid upon an arm from behind. The arm is then to be pushed across THE MECHANISM OF LABOR. 97 the child's face, and so on until brought down by the side of the body. This may be repeated with the other, if both are extended. How may the head be extended ? The head is usually so tightly grasped by the uterus and vaginal walls as to be kept flexed, but if the pelvis is small, or improper traction is made upon the body, it may be extended, and will then present a large outline in passing through the pelvis. This makes its advance more difficult, and may cause a laceration of the perineum. What is the fetal mortality in the breech presentation ? From 30 to 50 per cent. How should a breech case be managed throughout ? As a rule it should not be interfered with until the breech is born. The physician should then— 1. As soon as the hips are delivered, draw down a loop of the cord, as otherwise it may be compressed between the child's head and the pelvic brim during the descent of the former, and, not being able to pass down as rapidly as is required, it may be torn off at the umbilicus or so stretched as to interfere with the placental circulation. If the cord is pulsating strongly, place the loop thus drawn down out of the way in the postero-lateral part of the pelvic excavation. If the pulsation is feeble or absent, hurry the delivery. 2. As the shoulders are coming down, endeavor to secure anterior rotation if it is in a posterior position. 3. As soon as the body is born, bring down the arms, if extended. 4. If the head is not at once born, pass two fingers to its mouth, to secure a supply of air and to admit of respiration. 5. Draw the body down against and parallel to the perineum (to flex the head). Then elevate the body, turning it over on the mother's abdomen while making traction. An assistant, if pos- sible, should press upon the hypogastrium, to force the head down. Repeat the maneuver, if necessary. What is Smellie's Method of Extraction of the after-coming Head? In this method the body of the child is wrapped in a warm nap- kin and placed astride the operator's arm. The index and middle 98 QUESTIONS ON OBSTETRICS. fingers are on the canine fossa on each side of the child's nose. Upward pressure is made at the same time with the fingers of the other hand upon the occiput. By raising the trunk, the head is rolled out over the perineum. The head must be completely ro- tated before this method can be used. This method is particularly adapted for extraction when the fetal head has entered the pelvis. What is the so-called Smellie-Veit modified method ? This consists in combined traction on the chin and shoulders and is frequently used when the above method has failed. One hand is introduced as in the Smellie method and the index and middle fingers of the other hand should be forked upon the shoulders. A somewhat downward traction should be made, until the cervical region is under the pubes. If, by an upward movement of both arms the body is elevated, the face will rotate over the perineum. It is claimed that by this method the greatest traction can be used with the least damage to the child. What means should be used where the occiput has rotated into the hollow of the sacrum ? Lusk advises incases where the forehead is pressed against the symphysis to reverse the above-named method. As the fingers are forked upon the shoulders, the back of the child should rest upon the arm. The chin should be flexed with one or two fingers of the other hand. Traction should be made in a downward direction. What is the method of Prague ? The feet are seized with one hand, and the body directed nearly vertically downward. While this is being done the fingers of the other hand are hooked upon the shoulders, so that the finger-tips rest above each clavicle. Both hands exercise traction at the same time. It is sometimes necessary when uterine contractions are weak, to have an assistant make pressure on the head through the abdominal walls. After the head has passed the superior strait, the feet should be quickly raised toward the mother's abdomen. How should this method be modified where the occiput rotates into the hollow of the sacrum ? The body of the child should be directed toward the mother's ab- domen, so as to cause rotation of the occiput over the perineum. THE MECHANISM OF LABOR. 99 In what cases is the Prague method of greatest service ? In somewhat contracted pelves, in which the chin normally is partially extended as the head engages in the sagittal diameter of the brain. (Lusk.) What caution is necessary in pulling upon the child's body ? The neck breaks with the weight of ioo pounds, and decapitation occurs with 120 pounds. (Matthews Duncan.) Fig. 32. Under what circumstances is earlier interference indicated ? When the labor is unduly protracted we may suspect that the soft breech is spreading out and being wedged in the pelvis, rather than being molded into a shape suitable for passing. We may then— 100 QUESTIONS ON OBSTETRICS. I. Carefully introduce the hand and bring down one or both legs to use in making traction, or 2. We may use a fillet. Pass a silk handkerchief or roller bandage over the child's groin, to use in making traction. A " blunt hook " or other metallic instrument should never be used on a living child. What varieties of the breech presentation occur ? One or both feet or legs may come in advance of the breech, which is called a Breech footling. How does the descent of one or both feet affect the mechanism ? Very little, except by offering a temptation to pull upon them, and thus to extend the arms and head. The first stage of labor may be longer, from the want of an even dilating wedge in the os. How is the child situated in the L. D. A. position ? The right shoulder presents in the os uteri, the head lying in the left iliac fossa and the breech in the right iliac fossa, or a little higher. How is the child situated in the R. D. A. position ? The left shoulder presents in the os, the head lying in the right iliac fossa, and the breech in the left iliac, or a little higher. How is the child situated in the R. D. P. position ? The right shoulder presents in the os, the head lying in the right iliac fossa, and the breech in the left iliac fossa, or a little higher. How is the child situated in the L. D. P. position ? The left shoulder presents in the os, the head lying in the left iliac fossa, and the breech in the right iliac fossa, or a little higher. What are the modes of delivery in the transverse presentation ? There is no natural mechanism, but I. The child, if very small, may be doubled up and expelled. (Rare.) 2. The child may be spontaneously turned in utero, so that it becomes either a vertex or breech presentation. (Rarer.) 3. After the child has been doubled up the breech may be pushed down after great efforts. This is called spontaneous evolution. (Rarest.) THE MECHANISM OF LABOR. 101 How should a transverse presentation be managed ? We should not await any of the spontaneous methods, but turn the child to a vertex or breech presentation. (See Version.) If this is impossible, we will have to perforate the chest and reduce the size of the child. (See Embryotomy.) What variety of the transverse presentation occurs ? The hand or arm may be in advance of the shoulder, and may Fig. 33. present at the vulva. Care should be taken not to confound the hand and foot with each other. What anomalous presentations are occasionally observed ? 1. The body of the child may be so doubled that the feet pre- sent with the vertex or face. 2. One or both hands may be added to the vertex or face presentation. 3. The funis may present with any of the others. UY2 QUESTIONS ON OBSTETRICS. PATHOLOGY OF LABOR. DYSTOCIA. What is dystocia ? The technical name for labor which departs from the normal standard. How is labor rendered abnormal ? By disease, defect, or accident affecting— i. The motive force. 2. The fetus and its attachments. 3. The mother's tissues or general condition. We have, therefore, three classes of dystocia: 1. Uterine; 2. Ovular; 3. Maternal. In what way may the motive force be affected ? It may be: 1. Excessive. 2. Deficient. 3. Irregular. What evils may excessive uterine action occasion ? 1. Precipitate labor, involving'a too sudden emptying of the womb, with laceration of the cervix and perineum. 2. Rupture of the womb when there is much resistance. Opium, chloral, or anesthetics will control it. What is deficient action ? Uterine inertia, or any deficiency in the power, length or fre- quency of the uterine contractions. What evils may uterine inertia occasion ? The principal one, and which involves many evils, is delay in the labor. Delay is hurtful, more or less, according to the stage in which it occurs. 1. At all times the protraction of labor beyond its normal limits en- feebles the mother and endangers the child's circulation. 2. In the* second stage additional dangers arise, from pressure upon the maternal tissues, with possibilities of sloughing, fistulas, and septic processes. 3. In the third stage inertia may lead to fatal hemorrhage, throm- bosis in uterine sinuses, with subsequent septicemia and other diseases. What are the causes of uterine inertia ? 1. Defective innervation or circulation of the uterus. 2. Paralysis of the uterus from over-distention. 3. Organic defects in the uterine muscles. PATHOLOGY OF LABOR. 103 In what ways may the innervation and circulation of the womb be affected ? The nervous supply of the uterus being spinal, cerebral (vaso- motor), and ganglionic, it may be affected by mental emotion, the shrinking from pain of the hysterical temperament, improper ven- tilation, or from either direct or indirect disturbance of the uterine center. The latter may be occasioned by malarial poisoning or by reflex influences from other disturbed organs. Premature rupture of the membranes is frequently associated with inertia, probably as cause. How may the uterus be paralyzed from over-distention ? The walls of the uterus may be mechanically over-distended by twins or dropsy of the amnion, making the contractions feeble. What organic defects are met with ? The uterus which has frequently gone through the processes of pregnancy, often has its fibrous and uncontractile element increased at the expense of the muscular tissue. This decreases the power of the uterus ; hence, old multiparas frequently have protracted labor from this cause. It is said that fatty degeneration sometimes occurs. How should uterine inertia be treated ? If sufficiently great to unduly prolong labor we should— I. Endeavor to ascertain and remove the cause. 2. Place the woman under the best hygienic conditions. 3. If .the source of reflex disturbances cannot be removed, we may quiet the nerve center by chloral, opium.or the bromid of potas- sium, after which the inertia is commonly relieved. 4. Quinin is always useful in malarious districts. 5. Massage and stroking of the uterus through the abdominal walls may be tried. 6. If over-distention exists we should early rupture the mem- branes. 7. In the second stage we may supplement the uterine force [a) by Kristeller's method, {b) by the forceps. What is Kristeller's method ? Place the hands on the abdomen (facing the woman's feet). En- deavor at intervals to push the child through the pelvis. Called also expression. 104 QUESTIONS ON OBSTETRICS. What should be avoided in treating inertia ? The use of oxytocics. What are oxytocics ? Drugs credited with the power of directly affecting the uterine muscle, and of causing or strengthening contractions, such as ergot, cinnamon, borax, and many others. Of these the one most used is ergot. What objections exist to the use of ergot in labor ? It is uncertain in action, and when it does act, causes tonic con- traction of the uterus and an unremitting effort to expel the child. If this takes place before the os is dilated laceration of the cervix may occur ; if the head is large, rupture of the womb may occur ; in any event, the placental circulation will be continuously com- pressed, and the child in danger of asphyxia. Ergot should never be given before the birth of the child, and from its uncertainty, should never be depended upon in the third stage. What objections exist to the use of stimulants ? A dose of whisky is often given, increasing the woman's cour- age and the contractions of the abdominal muscles. But if labor is not speedily terminated, reaction follows, and the labor will be retarded. What is irregular action of the uterine force ? Irregular contraction of special fibers instead of general contrac- tion of all. Its typical form is called "ante-partum hour-glass contraction." In this condition, a circular band of fibers, usually a little above the cervix, contracts firmly and tonically, while the rest of the womb remains inert. This holds the child tightly in the womb, and suspends normal contractions. How should this be treated ? Relaxation should be attempted by anesthesia or by emetic doses of ipecac. These failing, our only resource is in artificial delivery by forceps, or Cesarean section, or embyrotomy. What obstructions to delivery are encountered in the maternal tissues ? i. At the os uteri; rigidity, edema, atresia, or displacement. 2. In the vagina ; fibrous bands, atresia, persistent hymen. PATHOLOGY OF LABOR. 105 3. An unyielding perineum. 4. Tumors, including a distended bladder or rectum. 5. External; edema and thrombus of the labia ; hernia. 6. Deformities of the pelvis. What is rigidity of the os (or cervix) uteri ? An unyielding and undilatable condition, due— 1. To organic changes, and, 2, to temporary spasmodic contrac- tion of the oral fibers. The first form is due to inflammatory or hypertrophic conditions by which the cervical fibers have be- come thickened and fibrous. The second form may occur at any time during the first stage of labor, and is usually associated with uterine inertia. How may organic and functional rigidity be distinguished ? 1. In organic rigidity the edges of the os are thick and dense, and the cervix has not entirely disappeared. 2. In rigidity from spasm the edges of the os are thin and tense, giving the sensation of sharp, wiry resistance. It is also associ- ated with some constitutional disturbance, the woman being ner- vous and restless and the vagina hot and less moist than usual. What treatment is indicated ? 1. In organic rigidity the uterine contractions should be allowed ample time to force open the os ; this failing, incisions should be made with a bistoury. The patient should be placed in Sims' position, the speculum introduced, and the incisions made radiating from the os, to a sufficient extent to allow the head to come through with or without the forceps. The condition is rare, and such extreme measures are rarely called for. 2. Functional rigidity depends upon much the same causes as uterine inertia, and demands similar hygienic treatment. Chloral, gr. xv, every hour, will be found effective. Over- stretching may be used. This is accomplished by inserting the index and middle fingers within the os, and spreading them forcibly, so as to stretch the oral fibers. The fingers exert so little real force that no judicious person can do harm with this procedure. It may be repeated in an hour, or with two or three successive contractions! If necessary, Molesworth's or Barnes' dilators may be used, to dilate with more force and rapidity. H 106 QUESTIONS ON OBSTETRfCS. What is edema of the cervix ? An infiltration of serum, especially into the anterior lip of the cervix, which impairs its dilatability. It is due to pressure from the child's head. What is the indication for treatment ? To remove the cause; as long as the head remains the swelling will continue; hence deliver with forceps before it becomes too extensive. What is atresia of the os uteri ? Entire closure of the os, due to inflammatory adhesions of the cervical lips. It is very rare, and demands similar treatment to organic rigidity. What is displacement of the os uteri ? Removal of the os from its usual place in the vagina, usually due to a forward displacement of the fundus. This in turn is due to a relaxed condition of the abdominal muscles. [Cases are recorded in which the fundus of the womb rested on the woman's knees, in the sitting posture, throwing the os so far back as to make it inaccessible.] The same condition is sometimes caused by tumors, displacing the womb in any direction, but the usual displacement of the os is backward, toward the promontory. What are the dangers of this condition ? I. The child's head is pressed against the anterior wall of the cervix, and is unable to leave the womb, unless through a rent in the anterior wall. 2. The incautious examiner may mistake the thinned wall for the membranes, and make the rent himself. This condition is com- mon enough to warrant every one in making the discovery of the os and the condition of its edges the first duty in labor. What treatment is indicated ? Replace the womb by pushing the fundus backward, while, if possible, the finger is hooked into the os and it is pulled forward. If the displacement has been great, a bandage should be applied around the abdomen to retain the uterus in position. What treatment is indicated for a small vagina, obstructive bands, etc. ? A vagina small enough to impede delivery will require the PATHOLOGY OF LABOR. 107 forceps to be used. Bands or a persistent hymen may be incised. While the head distends and makes tense the band, a knife placed between the head and band is allowed to be pushed through. Care should be taken to cut as little as possible, and to tear rather than cut after the edge is severed. How may the perineum obstruct labor ? i. The perineum may be congenitally defective in structure, or have been imperfectly developed during pregnancy, constituting organic rigidity. 2. Or its muscular fibers may be in a condition of spasm, or functional rigidity. The same measures may be used which are applicable in rigidity of the cervix, but the forceps may be used instead, which render us independent of the perineum. What is to be done when tumors obstruct delivery ? The treatment of a distended bladder and rectum is obvious. Empty them. No rule can be laid down for other tumors. If the tumor is safely removable or can be diminished in size, it may be done. If not, the child must be lessened in size. What treatment do the external tumors (edema, thrombus and hernia) require ? i. When edema of the labia is extensive enough to obstruct deliv- ery, a number of punctures should be made with a fine bistoury, which will speedily drain and remove it. 2. A large thrombus occasionally distends the labium obstructively. A free incision should be made, the clot turned out, and hemos- tatics applied if necessary. 3. Hernia rarely complicates labor. If irreducible, it requires avoidance of bearing down. What is the most common classification of contracted pelvis ? 1. The pelvis aquabiliter justo minor, or generally contracted pelvis, in which all the diameters are equally contracted. The pelvis cequabiliter justo major, in which all the diameters are enlarged. 2. The flattened pelvis, in which the conjugate diameter especially is diminished. The other diameters may be normal. As subdivisions of the last we have :— 108 QUESTIONS ON OBSTETRICS. (A) Simple flattened, in which only the conj ugate is decreased in size. This is the most frequent form of pelvic con- traction. (B) Generally flattened, in which the narrowing extends also to the transverse diameter. (C) Rachitic flat. The diameter between the anterior superior spines is equal to, or greater than the distance between the highest points of the iliac crests. 3. The obliquely contracted pelvis, principally caused by spinal curvature, hip disease or coxalgia, by a non-symmetry of the sacrum. Greatest dimension is in the oblique diameter. 4. The funnel-shaped pelvis, produced by posterior curvature or kyphosis of the lumbar spine. The conjugate is lengthened and the transverse diameter diminished. 5. The compressed pelvis resulting from rachitis, or osteomalacia. 6. Spondylolisthetic pelvis, narrowing caused by a slipping forward of the last lumbar vertebra upon the sacrum. 7. Pelvis narrowed by exostoses, fractures, etc. What is Scoliosis ? Lateral curvature of the spine. It may only impair one side of the'pelvis, but if great, may cause serious deformity. What effect may the justo major pelvis have on labor ? Usually labor is terminated quickly. Complications may arise however from the fetus turning transversely or from precipitate labor. What effect may the justo minor pelvis have on labor? If the child and pelvis are proportionate in size, labor goes on as usual, but in ordinary cases the labor begins when the head is at the superior strait, strong flexion occurring. The biparietal diameter is in relation with the conjugate. Describe the rachitic flat pelvis and its effect on labor. All the individual parts are decreased in size; the sacrum is pushed forward and downward ; the vertebrae are pushed forward between the wings. Usually, the venters of the ilia are inclined more strongly toward the horizon, separate more anteriorly, and are less curved. The result of this is that the distance between the anterior superior spines is as great, or greater, than that between PATHOLOGY OF LABOR. 109 the highest points of the iliac crests. The pubic arch is widened and the pelvic cavity kidney shaped. If the head presents, the sagittal suture lies in the transverse diameter. The head, instead of entering the pelvic cavity at the latter part of pregnancy, may be turned aside at the superior strait. The transverse diameter is in relation with the conjugate, the anterior parietal bone becom- ing a fixed pivot against the pubic arch, while the posterior descends Fig. 34. beneath the promontory. An attempt is made to produce extreme flexion. After the head has descended into the pelvic cavity labor proceeds in the usual way. Describe the principal characteristics of the osteomalacic pelvis. In this form of deformity softening of the bones has caused the bending inward of the anterior half of the pelvis, bringing the two pubic rami very near together in the form of an irregular beak 110 QUESTIONS ON OBSTETRICS. or projection. Indications of osteomalacia will probably appear in other parts of the body. The disease may make its appearance during pregnancy. Fig. 35- Fig. 36. Describe the deformity resulting from Coxalgia. The narrowing is principally oblique. In unilateral hip disease, the diseased femur is much decreased in size ; the diseased hip is pushed out from the symphysis and its anterior half is more arched. From the inactivity of the glutei muscles and the PATHOLOGY OF LABOR. HI increased action of the iliacus internus, the ilium is more vertical than usual, the healthy half of the pelvis is flattened and narrowed, the diseased half is hollowed out and dilated. Do deformities of the inlet affect the whole course of delivery ? Generally the trouble is over when the head has passed through the inlet, the rest of the pelvis being undeformed. What effect upon delivery is occasioned by deformities of the inlet ? 1. The presentation is apt to be irregular. 2. The agreement between the axes of the uterus and pelvis being disarranged, the uterine force is deflected, which protracts both the first and second stage. 3. The normal mechanism of delivery is perverted. 4. The inlet is made too small to admit of the child passing readily. 5. The maternal tissues are more apt to suffer from pressure due to the misdirection of the uterine force. In what way is the mechanism altered ? 1. The head is usually more transversely placed, and rotation has to be made through a longer arc. 2. The head has to make a curved passage around the promon- tory before it can enter the inlet. 3. The narrowing of the pelvis delays the head until it can be compressed and moulded to a suitable size. How are degrees of deformity estimated ? By the length of conjugate diameter, as determined by pel- vimetry. What degree of contraction is compatible with delivery ? Much will depend upon the skill of the physician, but in general terms, it may be said that with a conjugate of three inches or more, a living child may be extracted, with or without the forceps ; three to two and a half inches, may be delivered by forceps or version, or at worst by craniotomy ; two and a half or less, may be delivered by craniotomy, but the statistics show that the Cesarean section is as safe. (Parry.) 1 1 2 QUESTIONS ON OBSTETRICS. Kiwisck's Table. With a sacro-pubic diameter of When the sacro-pubic diam. is CHES LINES WEEK 2 and 6 or 7 induce labor at the 30th 2 and 8 or 9 " « « ■< 3Ist 2 and io or 11 " » " " 32d 3 c< " " " 33* 3 and I " " " " 33<* 3 and 2 or 3 " " " " 34th 3 and 4 or 5 " » " " 35th 3 and 5 or 6 " " " •« 36th How would we ascertain the condition of a woman's pelvis ? 1. By her history: as to rickets in childhood ; the time of dentition; when the latter is late, it is a sign of imperfect bone formation. The shape of the head, etc.; Fig. 37. 2. The history of previous labors. Continued prolonged labors should cause a suspicion of pelvic deformity; 3. By inspection of the patient's external appearance in regard to deformities in locomotion, etc. ; 4. External pelvimetry. The external measurements taken from certain fixed landmarks on the living pelvis, by an instrument known as a pelvimeter, are generally classed as certain signs. These measurements should be taken with the patient on her back, preferably on a table, and covered with a sheet or woolen comforter. The head and shoulders should be raised and the knees flexed. PATHOLOGY OF LABOR. 113 What are the anatomical landmarks from which these measure- ments are taken ? Between the anterior superior spinous processes of the iliac bones; the distances between the iliac crests, the inter-trochanteric and the external conjugate. In measuring the above the physician should stand by the side of the patient, and holding the pelvimeter be- tween the thumb and fingers, the points should be applied to the outer sides of the points above mentioned. In measuring the external conjugate, the patient should lie on her side with her face away from the physician. Between anterior spines, .....10 inches or 24 cm. " the highest points of ) , ., ... r [ . . 11 " " 28 " the iliac crests, j " trochanters,........123^ " " 32 " The external conjugate is taken from the fossa just beneath the spinous process of the last lumbar vertebra to the middle of the upper border of the symphysis pubis. It is about 8 inches or 20 cm. This is also sometimes spoken of as Baudelocque's diam- eter, from its author. How may the internal conjugate be measured ? By subtracting y/z inches, or 9 centimeters, from the external conjugate. This is the allowance for the soft parts, sacrum and pubes. Thus the remainder, 4^ inches, or 11 centimeters, is the average length of the internal conjugate, or conjugata vera. To measure this, one or two fingers of a well asepticized hand should be passed into the vagina and extended so as to reach the sacral promontory. The point at which the anterior commissure of the vulva touches the hand may then be noted and the reach meas- ured. This is the diagonal conjugate. Deduct one inch from this for the thickness of the pubes, and we have the true or internal conjugate. In the normal pelvis, or where a very slight degree of contrac- tion exists, the promontory cannot be reached. How may the outlet be deformed ? By a narrowing of the transverse diameter, due to a too close approach of the ischia ; or of the conjugate diameter, due to 114 QUESTIONS ON OBSTETRICS. anchylosis or rigidity of the sacro-coccygeal joint. The first is rare, and the second common in old primipara. What treatment is indicated ? Sufficient additional force to enable the head to pass, which is best furnished by the forceps. OVULAR DYSTOCIA. What departures from the normal condition occur in connection with the fetus and its envelopes ? i. The membranes {a) may rupture prematurely; {b) may be too tough ; {c) there may be an extra amniotic sac ; {d) there may be hydrops amnii. 2. The funis {a) may prolapse ; {b) may be too short. 3. The child may be enlarged or deformed by {a) hydrocephalus ; {b) hydrothorax ; {c) ascites; {d) edema ; {e) putridity; (/) by ankylosis of joints. 4. Parts of the child may be displaced : [a) prolapse of arm or foot by head ; {b) arm behind the occiput. 5. There may be more than one child, called multiple labor. What effect has the premature rupture of the membranes ? 1. No bag of waters is formed to assist in dilating the os. 2. The uterine walls close upon the irregular projections of the child, instead of upon the evenly pressing water-sac, and irregu- lar contractions may occur. 3. The first stage is prolonged. 4. The child is subjected to greater pressure, and may be injured. What harm is occasioned by too thick membranes ? Hours may elapse in fruitless efforts of the womb to rupture them; and they require to be artificially punctured. What is a "caul " ? In rare cases, where there is little liquor amnii and the mem- branes are elastic, the child is born with its head enveloped in the membranes, which is called being born with a caul. [The mem- branes, when dried and preserved, are said to be a charm against death by drowning.] The practical point is to tear or cut open the sac as soon as possible, to prevent asphyxia of the child. PATHOLOGY OF LABOR. 115 What is an extra-amniotic sac ? An effusion or secretion of fluid which sometimes occurs between the amnion and chorion. When the bag of waters is formed dur- ing labor, the sac will be formed by this fluid, and when the chorion is ruptured the fluid will escape, giving the impression that the true bag of waters has ruptured. A new bag will then form, en- closed only in the amnion. It is of no importance, except in the matter of diagnosis. What is hydrops amnii ? Dropsy of the amnion or over-secretion of fluid by the amnion. This may take place to the extent of over a gallon, distending the uterus, enfeebling and sometimes destroying the child. If the amount of fluid is great, it is well to pass a bandage around the abdomen before evacuating it, and stimulants should also be at hand. What is prolapse of the funis ? The funis, or rather a loop of the cord, may fall in advance of the head. There may be only a small knuckle, or several inches may prolapse, so that the cord even reaches to the vulva. This endangers the child's life, from pressure, but is rarely an impedi- ment to delivery. With what may the funis be confounded ? With a loop of intestine, which also may be met with after rup- ture of the womb. The finger may be passed entirely around the funis ; with the intestine, the mesentery will prevent. What treatment is indicated ? The funis should be pushed up above the inlet in the interval be- tween pains, and when the presentation is forced down by a con- traction, it will probably be retained. This can be done by the fin- gers or by repositors invented for the purpose, and may be aided by placing the woman in the knee-chest posture. It can also be done by carefully placing a loop of cord around the funis, attach- ing it to a moderately hard catheter, and pushing it gently back into the empty pelvic diameter. If the advance of the presentation does not retain it, a small piece of sponge passed between the head and the inlet will often succeed. If the cord is surely pulseless it 116 QUESTIONS ON OBSTETRICS. may be left alone, but if the child is alive and the funis cannot be retained, prompt artificial delivery is indicated. In what way does a short funis impede delivery ? By preventing the child from descending completely through the pelvis. It may be only five inches long, and if of normal length, may become shortened by being wrapped in one to four coils around the child's neck. How may a short funis be recognized during labor ? I. The head is arrested low in the pelvis; it then advances slightly with each contraction, and is abruptly jerked back by the tension of the cord. 2. Constant pain is felt in the womb, over the placental insertion. Fortunately, the occurrence is rare, since the diagnosis is not easy unless the head is born, and aid is difficult to render. What treatment is required ? Delivery by main force until the cord can be reached and cut, or is ruptured. What is hydrocephalus ? Enlargement of the fetal head by excessive development of the cerebro-spinal fluid. It may be so great as to double the length of the head diameters. The bones are thin (in extreme cases ex- panded and parchment-like in texture), and the sutures and fon- tanelles greatly enlarged. It is often associated with spina bifida. How may it be recognized ? By the softness of the head and the enlargement of the sutures and fontanelles. Moderate degrees are not recognized with certainty until the forceps are applied, when the wide divergence of the handles show the increased bulk of the head. How should it be managed ? Simple perforation of the skull will allow the fluid to escape, and permit the collapsed cranium to be withdrawn. The brain should also be broken up before the child is withdrawn. How may hydrothorax and other enlargements of the fetus obstruct delivery ? Effusion of serum in the chest (hydrothorax), abdomen (ascites), PATHOLOGY OF LABOR. 117 external cellular tissue (edema), may enlarge the bulk of the child and obstruct delivery. The joints may be ankylosed in such a position as to increase its bulk. A child dying in utero and becoming putrid may be swollen, but usually causes trouble only by poisoning the mother. In any of these cases it may be necessary to reduce the bulk of the child by embryotomy. How is prolapse of the hand or arm by the head to be treated ? The prolapsed member is to be pushed up, as in the case of pro- lapse of the funis. If the arm is behind the head (Simpson) and the diagnosis can be made, turning is indicated. In what way may the foot or feet complicate head presenta- tions ? One or both feet may present alongside of the head, in which case the child must be more or less doubled up. It may be noticed that these accidents often occur together, feet, arms and funis, in varying proportions, prolapsing at the same time. How is the complication to be treated ? If recognized before the rupture of the membranes, the feet may either be pushed up or the child turned. If at any time we find turning to be very difficult or impossible, we may know that the child is dead (because difficult to turn and doubled), and at once perform embryotomy. How may the shoulders give trouble in delivery ? By not entering the pelvis, but catching at the inlet, thus pre- venting the head from advancing. How may this be recognized and treated ? By the manner in which the head advances and is retracted, as in the case of a short funis, and by external palpation. By ex- ternal pressure the shoulders may be pushed into their proper place. TWIN LABOR. How can twin pregnancies be diagnosticated ? The diagnosis is often difficult, but generally can be determined by hearing two distinct fetal heart sounds, and fetal movements 118 QUESTIONS ON OBSTETRICS. are stronger. By palpation, two fetal forms can be made out. The abdomen is much swollen ; there is considerable bulging at each side. Sometimes a well-marked depression or sulcus occurs in the median line. What is the usual course of twin labor ? After the first child is born a short rest occurs ; the pains recur (usually within fifteen minutes) and the second child is born, and so on, if more than two. What difficulties may occur in twin labor ? i. Both children may attempt to enter the pelvis at once and be- come wedged. 2. After one head has reached the outlet, the second may enter the pelvis, with the same result. 3. Head locking may occur. What is head locking ? When the first child is born by the breech, its chin may catch upon the chin of the second child presenting by the head. What general rules may be laid down for these complica- tions ? 1. To push up one child and allow the other to come down, if possible. 2. When one child is partially born and the other wedged in with it, the first child is to be sacrificed in order to save the second. What are the fetal appendages in multiple pregnancies ? If the pregnancy results from the fecundation of one ovule con- taining two germinal vesicles, or a single germ dividing into two, there is a single placenta and communicating vessels. In these cases but one chorion exists ; generally each child has its own amnion. When the development results from the impregnation of two ovules, the vessels of the placenta do not connect. In these cases each fetus has its own chorion and amnion. Early in de- velopment a separate ovular decidua exists for each. Later, through absorption of the dividing membrane, there is but one decidua for both. PATHOLOGY OF LABOR. 119 What forms of twin monsters complicate delivery ? The principal forms are— i. Two nearly separate bodies united in front by the thorax or abdomen (ex., Siamese twins). 2. Two nearly separate bodies, united back to back by the sacrum and lower part of spinal column (ex., North Carolina sisters). 3. Dicephalous monsters; the bodies single below, but the heads separate. 4. The bodies separate, but the heads are partially united. The two latter are almost invariably still-born. (Playfair.) EFFECT OF MATERNAL CONDITIONS ON LABOR. What maternal conditions may affect labor ? 1. Syncope. 2. Hemorrhage. 3. Rupture of the uterus. 4. Eclampsia. How does syncope affect labor ? Usually by only temporarily suspending the uterine contrac- tions. If associated with organic heart disease it may prove fatal. The treatment is the same as indicated at any other time. What forms of hemorrhage are met with ? 1. From detachment of a normally implanted placenta, before the birth of the child, or accidental hemorrhage. 2. From detachment of abnormally implanted placenta, before the birth of the child, or unavoidable hemorrhage. 3. During and after the third stage, or post-partum hemorrhage. What causes premature detachment of the placenta (accidental hemorrhage) ? External violence and irregular contractions of the womb. What symptoms does it cause, and why ? Hemorrhage and colicky pains in the abdomen, but either may be absent. The hemorrhage may be concealed, i. e., the blood may dissect up the placenta and membranes without escaping from the womb, or in small quantity only. This will cause distention 120 QUESTIONS ON OBSTETRICS. of the womb and pain. If there is no external hemorrhage the symptoms of loss of blood internally will be present. What treatment is indicated ? Prompt delivery, on behalf of the child, which, after all, is usually destroyed by the impairment or total stoppage of the placental circulation; and also on account of the mother, if the hemorrhage is at all extensive. i. The os uteri should be dilated sufficiently to allow the child to pass. 2. The membranes should be ruptured, and the child at once delivered by forceps or version. The membranes should not be ruptured until we can deliver, for the evacuation of the liquor amnii gives just that much more room for the effusion of blood, without any gain in uterine contraction. 3. The woman's strength must be maintained by whisky or hot milk, and inertia guarded against. PLACENTA PREVIA. What is placenta previa? The implantation of the placenta upon the lower third of the uterine wall; to the part which dilates during labor. The placenta may be centrally placed over the os uteri; its margin may reach to the edge of the dilated os ; or any degree between these extremes may be met with. It is, therefore, divided into central, partial and. marginal placenta previa. How and why does placenta previa occur ? The ovum should be, and usually is, arrested as soon as it enters the womb, by a fold of the mucous membrane. If these folds are not prominent enough, it may advance until it arrives at the os internum, where the placenta will then be found. It is, therefore, found principally in multiparae, and in those whose organs are in a relaxed condition. What is the source of hemorrhage in placenta previa ? The blood pours from the openings in the uterine sinuses when the placenta is detached, and not from the placenta itself. PATHOLOGY OF LABOR. 121 How soon does placenta previa cause trouble, and in what manner? Rarely before the sixth or seventh month of pregnancy. About this time the cervical segment, which is smaller than the fundal region of the womb, has nearly reached its limits of growth. The placenta then grows faster than the womb, and its edge is liable to become detached. Later in pregnancy the os uteri be- comes patulous, and this again causes some separation of the placenta. As a result, hemorrhage occurs, more or less profusely. Usually, if rest is enjoined, the opened sinuses are closed by a clot, and the hemorrhage is arrested until further separation takes place. What are the dangers in placenta previa ? Death of the mother from hemorrhage, and of the child from asphyxia. The maternal mortality is one in four; fetal mortality one in two to three. What treatment is demanded when it occurs before full term ? Rest in bed, with or without a tampon, will arrest hemorrhage for the time ; the sinuses are closed by thrombi, and the case may go on to term or another hemorrhage. The patient should be allowed cold drinks ; opium may be used where pain is present. If the hemorrhage is great, it is safer to induce labor at once than to wait. Occasionally no hemorrhage occurs during pregnancy, nor even in labor. How should delivery be managed at full term ? I. Introduce one or two fingers within the os (the hand being in the vagina) and dissect the placenta from the uterine wall for about three inches from the os uteri in all directions, pushing it to one side if necessary. 2. Rupture the membranes, and if there is an unfavorable presenta- tion, turn the child and make the breech engage in the OS ; or, if the head presents, the forceps may be used, if speedy delivery is necessary. This partial detachment of the placenta will almost inevitably arrest hemorrhage (Barnes). The strength of the woman is then the main point to be cared for, and if in a reasonable time the uterus seems to be incompetent, the child may be delivered by art 122 QUESTIONS ON OBSTETRICS. What complications may interfere with this procedure ? A rigid and undilatable cervix, which is often present, because of the thickening of the tissues under the placental insertion. How is this to be overcome ? In premature cases, or when we are not prepared to dilate, the tampon may be applied for some hours. Otherwise the Moles- worth or Barnes' dilators may be used to mechanically dilate the os, if the fingers cannot do it. What is a tampon, and how applied ? A tampon is a plug made of pieces of absorbent cotton, iodoform gauze, soft rags, or similar materials, packed into the vagina so as to restrain hemorrhage. What after treatment should be used ? Absolute rest—the careful use of antisepsis to guard against puerperal fever. Many authorities advise the use of ergot for a week or so after labor. I. Place the woman in Sims' position, and introduce a Sims speculum. 2. With a pair of dressing forceps introduce a small wad of cotton batting within the os uteri. Continue to add similar pieces until the whole upper part of the vagina is packed with them. 3. Gradually withdraw the speculum, continuing to add cotton until the whole vagina is packed. 4. Apply a compress and T-bandage over the vulva. A roller bandage or lamp-wick (recommended by Foster) may be used, and will be easier to withdraw. How long should a tampon be left in place ? Seldom over twelve hours, and in placenta previa it may be necessary to remove it within an hour or two. What effect has the tampon besides restraining hemorrhage ? It excites uterine contractions and aids in dilating the os. This should always be considered where these results are not desirable. What cautions are to be observed with the tampon ? 1. The upper pieces should be moistened with a one or two per cent, solution of carbolic acid or other antiseptic. PATHOLOGY OF LABOR. 123 2. Never introduce it when the membranes have been ruptured, except in the early months of pregnancy, lest bleeding occur above it, distending the uterus. 3. Care should be taken after applying, to see that blood does not flow past or through it. There is no danger if it is properly ap- plied. What complication may occur in placenta previa after delivery ? The exposed sinuses in the cervical region may not be efficiently sealed, and hemorrhage may continue. The management will be as in post-partum hemorrhages generally. POST-PARTUM HEMORRHAGE. What is the cause of hemorrhage post-partum ? An uncontracted or incompletely contracted uterus, whereby the opened sinuses of the placental site are not compressed and bleeding is allowed. It is also favored by the retention of the placenta, clots (incomplete delivery), and by fibroid tumors. In a slight form, may be due to laceration of the cervix, vagina and perineum. What are the symptoms of post-partum hemorrhage ? 1. Usually the blood pours out so freely as to readily attract atten- tion ; if concealed or retained in the uterus, it will occasion the symptoms of internal hemorrhage. 2. The hand placed on the abdomen will not find the womb hard and in the hypogastric region, but soft and at a higher level. What are the indications for treatment ? 1. To empty the womb. 2. To make the womb contract. 3. To cause clots in the opened sinuses, if the womb fails to con- tract. 4. To support the woman's strength. How is this treatment to be carried out ? 1. The hand should be introduced into the womb, and clots or other contents removed. 124 QUESTIONS ON OBSTETRICS. 2. The hand is reintroduced and moved about, stroking the uterine walls, while the other hand is similarly engaged on the abdomen. This will often succeed in arousing contractions, and lead to the expulsion of the hand from the womb. If not, 3. Injections of hot water (1050 F.) may be used. 4. A strip of new aseptic gauze may by means of dressing forceps be inserted into the uterus as far as the fundus and loosely packed, another strip being placed in the vagina until it is full. 5. A handkerchief, soaked in vinegar, may be carried into the womb and squeezed out; or a peeled lemon; or a piece of ice. 6. The faradic current may be useful, if at hand. 7. As a last resort, and to cause clots, injections of tincture of iodin, or solution of ferric chlorid, diluted one-third, or even of full strength, may be used. How may post-partum hemorrhage from inertia be prevented ? By delivering the placenta by the method of Crede. What internal medication is proper ? Stimulants, hypodermics of strychnin sulph. grs. -fo-^j, or ergot 3), repeated, but no dependence is to be placed upon anything but local treatment. Hot milk is both stimulant and rapidly absorbed. What is the operation of transfusion ? Injecting into the circulation blood, milk, or solution of sodium chlorid, in strength of .6 per cent, (normal salt solution). To inject blood requires special and costly apparatus and great skill. Normal salt solution may be injected with little trouble. Care must be taken to avoid injecting air, and not to inject so rapidly as to dis- tend the right side of the heart. What is secondary hemorrhage and its cause ? Hemorrhage occurring after an interval of several hours, or even days, after delivery. It is usually preceded by ordinary post-partum hemorrhage, and may be due to a return of uterine inertia; the detachment of thrombi, retention of pieces of membrane, or clots ; displacement of the uterus, from a too tight bandage; and impacted rectum; sitting up too soon or depressing mental emotions. PATHOLOGY OF LABOR. 125 What treatment is indicated. ? The same in principle as in immediate hemorrhage, with due attention to the exciting cause. RUPTURE OF THE UTERUS. What is rupture of the uterus ? A tear or laceration in the substance of the uterine body, usually permitting the escape of the child into the abdominal cavity. How frequently does it occur ? About once in 4000 labors. Under what circumstances does it occur ? Generally during the second stage of labor, the rent beginning in the cervix and extending toward the fundus. Rarely the peri- toneal covering escapes laceration; also it occasionally occurs early in the labor, or even in premature labors. What are the predisposing causes of rupture ? Abnormal presentation, a hydrocephalic head, prolonged par- turition, a degeneration of the muscular fibers of the uterus, pro- ducing a lack of contractile power; a great difference in propor- tion between the size of the child and pelvis. How is the uterus affected ? During labor there is a tendency for the anterior wall of the cervix to be pulled upward, and for the posterior wall to be pushed downward (D. Berry Hart). If the head becomes packed in the inlet early, so as to prevent the anterior wall of the cervix from being pulled up, the anterior wall just above the head becomes greatly thinned, owing to this upward pulling, and rupture almost mvariably begins at this point. The thickened ring of fibers just above the point of thinning is known as Bandl's ring. What are the symptoms of threatened rupture ? A rising of the contraction ring of Bandl; this can be felt, can be seen in some cases, high up near the umbilicus. It is usually higher on the left than on the right side. Above this ring the uterine tissue is thickened, while below it the womb is thin, stretching more and more as labor advances. Intense pain in the pubis or abdominal region. 126 QUESTIONS ON OBSTETRICS. What symptoms denote its occurrence ? During or just after a labor pain the woman is seized with an acute and persistent pain. The form of the uterine tumor is changed and the presentation is retracted. As blood is effused from the rent, symptoms of internal hemorrhage and shock are added. The fingers passed into the vagina readily recognize the rent, and if the child has altogether escaped into the abdomi- nal cavity the intestines will have prolapsed through the rent. The uterine contractions cease. What treatment is indicated ? i. Preventive; a prompt resort to the forceps when the occurrence is feared. 2. Afterward, if the presentation is not entirely retracted, an at- tempt may be made to deliverer vias naturales. 3. In any case, unless it can be demonstrated that the peritoneum is unbroken, the abdomen should be opened by an incision,-the uterine wound closed by sutures, all blood and fluids removed from the abdominal cavity, and strict antiseptic precautions ob- served. What is the mortality from rupture ? 1. In cases abandoned to nature nearly all die. 2. When the child is delivered without gastrotomy, a few more re- cover. 3. When gastrotomy is at once performed, 60-70 per cent, recover. ECLAMPSIA. What is puerperal eclampsia ? A form of convulsions occurring before, during, or after labor, which resembles epilepsy in clinical appearance and uremic con- vulsions in cause. The typical form occurs during the second stage of labor. What is the clinical history of an attack ? 1. The patient is suddenly seized with a tonic spasm, involving the muscles of the face and thorax, usually of the upper extremities, and occasionally of all the muscles. This tonic spasm lasts for about one minute and— PATHOLOGY OF LABOR. 127 2. Is succeeded by clonic spasms or twitchings, lasting for several minutes. The convulsions subside and— 3. Are succeeded by coma, with stertorous breathing. The patient may become conscious or the convulsions may be renewed in the same order, keeping up until the patient is exhausted or re- covers. The masseter muscles are contracted tonically throughout the seizure. The interference with respiration causes the face to become red or livid. The duration of each seizure and the interval between depend upon the severity of the attack. What prodromic symptoms warn us of an attack ? 1. Severe and persistent headache is often complained of before an attack, frequently associated with disorders of vision, such as flashes of light. 2. Edema of the lower extremities or labia, or both, accompanied by any of the above symptoms, whether associated or not with albumin in the urine, should put us on our guard. A trace of albumin, however, is generally present, and with it there is usually a marked decrease in urea. What is the cause of puerperal eclampsia ? The cause is complex, the main factors being— 1. During pregnancy the blood becomes deteriorated (hydremic), and the ill-supplied nerve centers become more irritable or convulsable (Barnes). 2. The processes of elimination, especially through the kidneys, be- come defective, and urea (including other excrementitious mat- ters) is retained in the blood. Therefore the nerve centers are supplied with poisonous or irritating substances, as well as im- poverished. 3. Vascular tension is increased during pregnancy, and especially during labor, which intensifies the action of the foregoing factors. 4. During labor the interference with the cephalic circulation (from bearing down, etc.), causes hydremia of the brain and of the nerve centers especially concerned with eclampsia. Which of these factors is the most important ? The uremia, as shown by the fact that 50 per cent, of eclamptics have albumin in the urine. 128 QUESTIONS ON OBSTETRICS. Wherein does puerperal differ from uremic eclampsia? The temperature in the former is high, has been observed as high as 1090 F. (Busey); in uremia it may even be subnormal. The clinical history also differs. Wherein does puerperal eclampsia differ from other forms of convulsions ? 1. In hysteria the spasms are altogether irregular and conscious- ness is never entirely lost. 2. In apoplexy the condition of the coma is permanent, and there is a difference in the size of the pupils. There is not the amount of spasm. 3. In epilepsy, the history will .distinguish, except in labor in epi- leptics, who rarely have convulsions during parturition (Parry). In epilepsy there is the peculiar cry. What point in the etiology is disputed ? The condition of the brain, as to anemia or hyperemia. Traube and Rosenstein assert that hydremia causes edema of the brain, which in turn leads to anemia from pressure upon the capillaries from without. Others assert that anemia of the brain is essential in eclampsia, and that the base of the brain is anemic, even when the convulsions are hyperemic. What effect upon the cerebral circulation have the bearing- down efforts of the second stage, when eclampsia mostly occurs ? The cervical veins are obstructed and blood accumulates in the brain. Does this occur when eclampsia takes place before or after labor ? Not demonstrably; and in these cases we conclude that other factors exist, notably uremia—or a distinct toxemia, from various poisons generated in increased quantities during pregnancy, the amount of which is too great for elimination ; or that the elimina- tory power is for a time defective. / What treatment should be employed to prevent eclampsia ? The urine of women in the last weeks of pregnancy should al- ways be examined. Should the symptoms of continued headache, flashes of light, and albuminuria make their appearance, the patient PATHOLOGY OF LABOR. 129 should be placed on a diet nearly or entirely of milk, the bowels must be opened by saline cathartics or calomel. Hot baths at a temperature of 90 or ioo° F. are beneficial; the patient should remain in the water from 10 to 15 minutes, and be well rubbed with a coarse towel afterward. If symptoms continue after a fair trial of the above methods, the uterus must be emptied. What are the indications for treatment in puerperal eclampsia ? 1. To excite elimination by increasing the action of the skin, bowels, and bladder. 2. To relieve the irritability of the nerve centers. 3. To reduce vascular tension. 4. To reduce cerebral hyperemia. What treatment should be employed during the attack ? 1. Ether or chloroform maybe given until the chloral, etc., can be administered and take effect. A towel or a piece of wood should be placed between the teeth to prevent the tongue from being bitten. 2. Purgatives may be given, especially after delivery. Of these calomel grs. v, or croton oil gtt. ss, by mouth or rectum, are the best. To be repeated until the bowels are well moved. 3. A warm pack, to promote diaphoresis, may be used. 4. The labor, if in progress, should be terminated as soon as pos- sible, without violence. 5. Venesection, as the quickest and most powerful means of reduc- ing the vascular tension, cerebral hyperemia, and, secondarily, the nerve irritability. The necessity of this is disputed by various authors. What objections are urged against venesection ? That it is out of fashion, and does not reduce vascular tension in a healthy dog. Veratrum viride may be used instead, if there is time to wait upon its action. What drug was especially used before the discovery of chloral and the bromids ? Opium, which relieves the irritability of the nerve centers. What objections exist to its use ? It allays nerve irritability at the expense of all other indications; 130 QUESTIONS ON OBSTETRICS. when the kidneys are seriously crippled it may, itself, cause death ; it is no better than other less dangerous remedies. MISCELLANEOUS COMPLICATIONS. What complications may exist during or after the third stage of labor, besides hemorrhage ? i. Placental dystocia, or difficulties in delivering the placenta. 2. Inversion of the womb. 3. Emphysema of the neck. 4. La- ceration of the cervix, vagina, and perineum. What forms of placental dystocia occur ? 1. Adherent placenta. 2. Hour-glass contraction. 3. A pla- centa too large. 4. Clots behind an inverted placenta. 5. Utero- placental vacuum. 6. Placentae succenturiae and other anomalies of form. What is adherent placenta ? The term is properly applied to one that has contracted firm ad- hesions to the uterine wall, from inflammation during pregnancy. There is usually a history of fixed pain in the uterus. This is rare, but improper traction upon the cord may delay the separation of an otherwise normal placenta. How is adherent placenta to be treated ? Pass the hand into the uterus, find a detached edge of the placenta, and by a sawing motion with the fingers, break through the adhesions. When small pieces are adherent, they are best re- moved by means of the douche curet of Braun, in the way described under " Abortion." The strictest asepsis must be used in these cases. What is hour-glass contraction ? Irregular or tetanic contraction of a part of the uterine walls, the rest being relaxed, whereby the placenta is grasped and held as if in a sac. It may be complicated, if not caused, by adherence of the placenta. How may it be recognized ? The hand, introduced into the womb, finds apparently a second os internum high up, caused by the constriction of the muscular fibers of the womb below the placental site. PATHOLOGY OF LABOR. 131 How is it to be overcome ? The fingers, little by little, and finally the hand, are to be insinu- ated within the constricting band and its resistance overcome. This may be facilitated by anesthetics or chloral. The best reliance is upon patient and continuous manual efforts. How may the bulk of the placenta affect its delivery ? A very large placenta which has fallen centrally upon the os, instead of edgewise, may be too bulky to pass without assistance. The same may occur with a placenta of moderate size, if clots have formed behind it to such an extent as to prevent it from being doubled up. How is such a placenta to be delivered? It should be perforated centrally by one or two fingers, which will enable us to hook into and drag it down. What is utero-placental vacuum ? A rare occurrence, in which the placenta being detached, a pull upon the funis makes a vacuum between the placenta and the uterine wall, converting it into a sucker, resembling in action the leather disc by which the small boy raises bricks from the pave- ment. How may it be detected and remedied ? It resembles at first the large placenta, or one enlarged by clots, but as soon as perforated, and the vacuum destroyed, it is delivered with great ease, or even spontaneously expelled at once. What irregular forms of the placenta are met with ? i. The battledore placenta, in which the funis is inserted at the margin, instead of centrally. 2. The vessels of the cord may not unite, even at the margin, but ramify over the membranes before uniting to form the funis, known as the velamentous insertion of the cord. 3. The subdivision may extend even to the placenta, and result in there being two or more placentae, situated at different points on the uterine walls, called placenta succenturia. These anomalies are uncommon, but sometimes lead to per- plexities in the delivery of the after-birth. 132 QUESTIONS ON OBSTETRICS. INVERSION OF THE UTERUS. What is inversion of the uterus ? The uterus is turned inside out, upside down (Parvin). i. There may be a simple depression of the fundus, or it— 2. May present at the os uteri (partial inversion), or— 3. Passes through the os and extends to, or through the vulva (complete inversion). What is the cause of inversion ? Partial and irregular contraction of the uterus is the main factor; often aided by traction upon the cord in delivering the placenta. No Fig. 38. THREE DEGREES OP INVERSION. 1. Depression. 2. Introversion. 3. Complete inversion, a. Fundus uteri, b, b. In- version partially filling the uterine cavity, c. Vagina, d, d. Mouth of inverted portion.—From Parvin's Obstetrics. one can invert a healthy womb by traction upon the cord, but if the fibers under the placental site are not contracting, inversion will be very likely to occur. It may happen either before or after the placenta is detached. Violent efforts at bearing down have been ascribed as a cause. How may inversion be recognized ? 1. The woman usually complains of great pain at the moment of the accident (a sensation as of something tearing loose within her). 2. Hemorrhage and more or less shock follow. 3. The INVERSION OF THE UTERUS. 133 hand placed upon the abdomen fails to find the womb in its natural place, but instead finds a funnel-shaped depression, and when introduced within the vagina, finds there the mucous mem- brane of the interior of the uterus (unless external). It can then be mistaken for nothing but a fibroid tumor, which, of course, could not occupy the vagina just after delivery. What is the prognosis ? Although a very grave accident, the prognosis is not hopeless. It depends much on the amount of hemorrhage and shock. If remaining long in its displaced condition, inflammation is apt to occur. The more quickly the organ is replaced, the more favor- able the prognosis. How is inversion to be treated ? i. The placenta, if adherent, is to be detached. 2. The womb should then be squeezed within the hand, to reduce its bulk, and attempts made to replace the fundus, with the hand grasping it, while the other hand presses downward in the hypogastric region, making counter-pressure. 3. If this fails, endeavor to indent the uterine globe with a knuckle or the finger tips and thus reinvert it. The indentation is said to be best effected at the opening of a Fallopian tube. Pressure should be firmly and patiently continued, and if employed just after the accident rarely fails. 4. After the fundus is replaced the hand should remain within the uterus for some time, or until expelled. 5. Continuous pressure may be made by means of a colpeurynter and elastic bands. This method has been considerably used by German obstetricians. What is to be done in case of failure ? If called too late, or if replacement cannot be effected without violence, the fundus should be bathed with somewhat diluted tincture of iodin, to restrain hemorrhage, and allowed to remain inverted for one or two months, or until involution has taken place, when the reposition may "be attempted by the method of White. What is emphysema of the neck ? During the bearing-down efforts of the second stage, it some- 134 QUESTIONS ON OBSTETRICS. times happens that a few air vesicles in the lungs are ruptured, and air escapes by way of the mediastinal space to the cellular tissues of the neck and face. It is usually limited to one side, the tissues being swollen and crackling under the fingers. It may cause great alarm, but is innocuous if left alone, subsiding in a few days without any ill consequences. What ill consequences attend laceration of the mother's tis- sues ? The only immediate consequences are hemorrhage or septic infection. The remote consequences may be serious, especially when the perineum or cervix is badly torn. What is to be done when the cervix is lacerated ? Some authorities recommend that sutures should at once be in- serted ; but the general practice, if the tear does not extend into the vaginal insertion, is to let it alone. If repaired it will very likely only be torn over again at the birth of the next child. If the laceration be large, it is best repaired after involution has taken place. What is to be done when the perineum is lacerated ? Most authorities recommend that it should at once be united with sutures, unless of very slight extent. OBSTETRIC OPERATIONS. What are the capital operations of midwifery? I. The induction of premature labor. 2. The use of the for- ceps. 3. Version. 4. Symphysiotomy. 5. The Cesarean sec- tion and modifications. 6. Embryotomy in various forms. What are the obstetric forceps ? Two separate and similar pieces of steel, each fashioned into a blade and handle, intended to cross each other in the middle and be temporarily united at that point by a lock. What is the object of the forceps ? 1. They are used to seize the child's head and to make traction upon it. OBSTETRIC OPERATIONS. 135 2. They are used to aid the rotation of the head. 3. They are used to flex or extend the head, as may be required. Why is a fenestra or open space made in the blades ? To allow the parietal protuberances to project, thereby permit- ting the forceps to be applied to the head without at all adding to its bulk. What curves exist in the blades ? 1. The pelvic curve, so that they can be applied at any point in the pelvic canal with equal ease. 2. The head (or capital) curve, by which they are bowed out- wardly, so as to enable them to grasp and hold the head. How many forms of lock are in common use ? The mortise, or English lock; the pivot, or French lock, and the button, or German lock. How are the blades distinguished and named ? The blade to the left is called the left blade, or, when provided with the pivot or button, is sometimes called the male blade. The blade to the right is called the right blade, or, when provided with a slot, is sometimes called the female blade. When should the forceps be applied ? In any case where the head presents, and where prompt delivery is necessary (either for mother or child), or to be regarded as preferable to waiting upon the natural efforts. May they be applied during the first stage ? There are few circumstances which warrant us in applying them before full dilatation of the os. The necessity for prompt delivery should be very clear, since bruising and laceration of the cervical tissues are almost inevitable. What preliminaries are requisite to their application ? The consent of the woman being obtained, she should be given an anesthetic. She should be placed upon her back at the edge of the bed, her thighs flexed on the abdomen, and her feet sup- ported on chairs or by an assistant. A vaginal douche of some suit- able antiseptic should be given. It is necessary that the bladder and bowels should be empty. The forceps should be placed in a warm 136 QUESTIONS ON OBSTETRICS. solution of creolin (2 per cent, is best, as it is also a lubricant), or carbolic acid, 5 per cent. What station should the physician occupy ? Seated upon a chair, directly in front of the vulva, the forceps placed within reach. How should the forceps be applied to the L. O. A. position at the inlet ? 1. The physician should take the left blade in his left hand, hold- ing the handle securely, and having greased both the blade and his right hand, pass the latter into the vagina on the woman's left side high enough to enable him to feel the rim of the os uteri. Two fingers will often suffice, instead of the whole hand. DAVIS POKCtPS—UPPER VIEW. 2. Pass the blade along the palmar surface of the right hand or fingers, aiming to place the blade under the left sacro-iliac arch, and, therefore, along the left side of the child's head. This is usually very easy, as there is a free space at that point. Care should be taken to pass it between the cervix and head. 3. When the first blade has been adjusted to the head, its handle should be pressed well against the perineum, so as to keep it out of the way. 4. The right hand is now cleansed and takes up the right blade, which, with the left hand, is anointed, and the fingers of the latter passed into the vagina, to guard the rim of the os uteri. 5. The right blade is then introduced upon the palmar aspect of the fingers, with the view of insinuating it between the child's head and the pelvic walls, behind the obturator foramen, and, therefore, upon the right side of the head. OBSTETRIC OPERATIONS. 137 6. When the second blade is fully introduced, it should lie upon the first blade, with the slot just opposite the pivot, and the han- dles being now compressed, the instrument is locked and fully applied. How should the first blade be held at the beginning of introduc- tion ? As the tip of the blade enters the vulva, the handle should be Fig. 40. SHOWING THE MANNER OF INSERTING THE BLADES OF THE FORCEPS. held nearly perpendicular, with the tip above the inner limit of the right groin. The rest of the introduction resembles the pass- age of the catheter in the male. How should the second blade be held at the beginning of its introduction ? As the tip of the blade enters the vulva, the handle should lie in the line of and almost touching the left groin. The handle is J 138 QUESTIONS ON OBSTETRICS. then brought almost directly to the median line, and the blade pushed onward and upward, as soon as the handle is free from the left leg. What should be done if the instrument cannot be locked ? The second blade should be withdrawn, and more carefully reapplied. Locking can often be effected by simply pushing the handles well back upon the perineum. Fig. 41. SHOWING MANNER OF MAKING TRACTION IN A LOW APPLICATION OF THE FORCEPS. In the above cut, the left hand instead of the right is shown grasping the forceps, while the right hand protects the perineum. How should the forceps be held in making traction ? The handles should be grasped with the right hand, and gently compressed; the left hand should be placed over the lock, with a finger upon the top of each blade. How is traction to be made ? 1. The left hand presses or pushes the blades downward and backward (and slightly to the right), while the right hand pulls the handles partly in the reverse direction and partly in the line of the handles. OBSTETRIC OPERATIONS. 139 2. As the head descends, the direction of traction is changed, being made in the curve of the obstetric canal at all times. How long should traction be made ? For about a minute at a time, with an interval of the same or greater length, during which the handles should be partly unlocked, to remove the compression of the forceps from the child's head. Should traction be made during a labor pain ? The contractions may be disregarded until the head presses upon the perineum, when traction should be made only in the absence of uterine contractions, and if the operator is not sure of his skill, he should withdraw the forceps at this point. How may the forceps be withdrawn ? By reversing the motion used in applying them, and with the same deliberate ease. How are the forceps applied at the inferior strait ? The head having rotated, the blades will be on opposite sides of the pelvis, when on the sides of the head. Therefore, both blades are passed in the same manner, and nearly as the first blade is passed in the high operation. How are the forceps to be applied to an R. O. P. position at the inlet ? Precisely as in the L. O. A. position. How is traction to be made in the R. O. P. position ? 1. The handles should be grasped firmly, so as to hold the head securely while— 2. The handles are elevated, with scarcely any traction, so as to flex the head; this being a necessary part of the natural mechanism. 3. Traction should then be made in the axis of the canal, and with as little compression as possible, in order not to interfere with rotation. 4. If the twisting of the handles shows a tendency to rotate, this may be aided ; but rotation should not be forced. How are the forceps to be applied in the R. O. A. and L. O. P. positions ? The position of the head being the reverse of the L. O. A. and 140 QUESTIONS ON OBSTETRICS. R. O. P. positions, the right side of the head is behind and at a distance, the left side in front, and near. Therefore, the right blade is first applied, under the right sacro-iliac arch, and in the same way as the first blade in the other position. The left blade is then introduced in a manner corresponding to the second blade, in the L. O. A. What difficulty is then encountered ? The shank of the left blade will lie over the right blade, and the instrument cannot be locked. How is this to be remedied ? Take hold of the handles separately, and bring each handle to the median line and beyond, until the handle of the right blade can be lifted over that of the left blade. They will then be in posi- tion for locking. How are the forceps to be applied on the face presentation ? In the first and third positions, precisely as in the vertex, first and third. In the second and fourth positions, precisely as in the vertex, second and fourth. May the forceps be used on any part but the head ? They have been used upon the breech, but are of doubtful utility as compared with other procedures, and not free from danger when so applied. The objections do not, however, apply to the axis traction forceps. How are forceps applied in head-last labors ? If rotation has taken place, they should be applied to the side of the face, beneath the child's body. When the chin is in front, pass the forceps under the child's back and raise the handles. In ex- traction, when the head is flexed, the child's back should be carried toward the mother's back. How should the forceps be applied when the chin'is posterior ? In this case they should be passed under the abdomen, and the handles raised as before. In extraction, the body of the child is raised, its back directed toward the mother's abdomen. What are the dangers of forceps delivery ? Principally, dangerous laceration of the maternal soft parts, in- creasing the danger of sepsis by presenting a large absorbing sur- OBSTETRIC OPERATIONS. 141 face; increased shock. Considerable injury to the pelvic bones can be done. In the child harm may result from pressure on the skull; many cases of impaired mental condition may be traced to this source. What are the indications for the use of the forceps ? I. For delay in the second stage of labor, arising from {a) uterine inertia ; {b) any obstruction or disproportion. 2. For delay in the first stage, rarely, as in {a) placenta previa ; [b) organic rigidity; {c) absence of natural dilating agents. 3. For rapid delivery, when required, by such complications as (a) convulsions ; {b) prolapse of the funis ; {c) excessive uterine action menacing rupture. 4. For secondary purposes, as for {a) extraction of the child in the Cesarean section; {b) after rupture of the uterus; {c) for removal of tumors or foreign bodies from the maternal passages. What is the principal circumstance demanding their use ? Uterine inertia, or insufficiency of the uterine contractions to complete the labor. How long should the second stage be allowed to continue before resorting to the forceps ? Rarely over one or two hours. It is irrational to subject the woman to long-continued pain and effort when we can harmlessly deliver by art. What alternatives do we possess to the use of the forceps ? Version and embryotomy— 1. If prompt delivery is indicated in any case, and we do not possess the forceps or the skill to use them, we may employ version. 2. If the forceps fail to extract the child, or the pelvis is so de- formed as to render their use impracticable, we may perform version (according to some authorities) or resort to embryotomy. 3. The last generation of physicians used a substitute, the vectis, which is simply a single blade of the forceps. It was used to slip over the head to flex it, or by alternately pressing on one side and the other to make traction. It can do nothing which cannot be better done by the forceps. 142 QUESTIONS ON OBSTETRICS. What is axis traction ? When the forceps are applied to the head high up, at the pelvic brim, it will be found that traction made in the usual way will have no effect, but must be made in another direction, i. e., in the axis of the birth canal; that is, downward and backward, upward and forward, as the woman lies in bed. What is necessary to make this form of traction ? A pulling power must be applied to the blades in such a way Fig. 42. SIMPSON FORCEPS WITH POULET TAPES AND AXIS-TRACTION HANDLES. that traction can be made on them directly in a downward and backward direction ; this is nearly at right angles with that exer- cised normallyJ}y the handles, which is upward and forward. When and for what uses do we apply axis traction ? In cases when the woman's strength fails, the child is large, or a slight degree of pelvic contraction exists, when the head is at or above the pelvic brim, before rotation has occurred, axis traction properly applied aids rotation and tends to flex the head. VERSION. 143 How should the blades be applied ? In the same manner as the low application, except that the blades are applied in the oblique diameters so as to grasp the side of the fetal head. The forceps and head may be allowed to rotate together, traction being made only by means of the traction bar or tapes, the handles being simply raised. As soon as the pelvic floor is reached, the traction can be made upward and forward with the handles. No traction must be made by the handles before this time. VERSION. What is version ? The operation by which the presentation of the child is changed called, also, turning. How many kinds of version are there ? i. As regards the choice of presentation there are two— {a) cephalic, in which the head is made to present, and, {b) podalic, in which the breech is made to present. 2. As regards the mode by which it is effected, we have three— {a) internal, in which the hand is passed int6 the womb to effect the change; {b) 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 ? i. 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 de- formed pelves. How is internal version performed ? 1. The patient lying on her back with hips at the edge of the bed, 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. While this is being done, the 144 QUESTIONS ON OBSTETRICS. other hand makes counter pressure externally upon the fundus. 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. What cautions are necessary ? 1. To introduce the hand slowly and gently, lest the womb be lacerated. Anesthesia is generally 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 inthe knee-chest posture, which will aid in introducing the hand. How is external version performed ? 1. 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 ? 1. 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. The hand introduced into the vagina should be the same in name as the side of the pelvis toward which the fetal feet are directed. As soon as the presenting part is brought down, the membranes should be ruptured while a uterine con- traction is in progress. The strictest asepsis must be used. This is also known as Braxton Hicks' bipolar method. This method should always be tried before internal version is resorted to. Under what circumstances is version easy or difficult ? 1. When there is much liquor amnii, and the uterus is uncon- tracted, it is easy of performance. EMBRYOTOMY. 145 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 alternative opera- tion 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. What are the steps in performing embryotomy on the transverse pre- sentation ? The patient having been put under an anesthetic, and a vaginal douche of I : 5000 solution of bichlorid of mercury or other efficient antiseptic— 1. 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 simpson's cranioclast. using it. 3. A blunt hook, crotchet, or other instrument, is introduced into 140 QUESTIONS ON OBSTETRICS. 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 ;i blunt hook or embryotomy forceps. 5. In a few cases it is necessary to decapitate the child before it can be extracted. This may be done by instruments invented for the purpose, or by improvised methods, if the operator is ingenious. What is craniotomy ? The operation by which the head is lessened in size. 1. The head is pressed down and steadied by an assistant. 2. The head is perforated. 3. The brain is broken up completely, and if necessary removed by syringing out the cranial cavity. 4. Traction is made upon the head by a finger hooked into the perforation, by craniotomy forceps, or by any suitable instru- ment, and the head collapses and is drawn out. If not suffi- ciently reduced in size by these steps, we proceed to cranio- clasm. What is cranioclasm ? The operation by which the vault of the cranium is removed. 1. 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 pos- sible, 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. 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 out- side of the skull. 2. To guard the edges of fragments of bone with two fingers while withdrawing them. CESAREAN SECTION. 147 3. To preserve the most strict aseptic cleanliness. 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 ceph- alotribe) is 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. Fig. 44. HICKS' CEPHALOTRIBE. CESAREAN SECTION. What is the Cesarean section ? Gastro-hysterotomy, or the removal of the child through an in- cision 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 Cesarean section ? 1. A pelvis contracted to two inches in the conjugate, or obstructed by tumors, or other insurmountable obstacles to delivery by the natural way. 14s QUESTIONS ON OBSTETRICS. 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 Cesarean section ? i. The woman is prepared by anesthesia and the emptying of the bladder. The abdomen must be prepared as follows:— {a) Wash the field of operation thoroughly with soap and water. {b) With alcohol or ether. (d it.' — New York Medical Record. No. 6. MATERIA MEDICA, PHARMACY, PHARMACOLOGY, AND THERAPEUTICS. Just Ready. A Handbook for Students. By William Hale White, m.d., f. r. c.p., etc., Physician to, and Lec- turer on Materia Medica, Guy's Hospital; Examiner in Materia Medica, Royal College of Physicians, London, etc. American Edition. Revised by Reynold W. Wilcox, m. a., m. d., Professor of Clinical Medicine at the New York Post-Graduate Medical School and Hospital; Assistant Visiting Physician Bellevue Hospital. " Practical experience with Dr. White's book on general therapeutics, both as to its use- fulness to the student and as to the soundness of the advice which he gives, has proved that he is an author upon whom much dependence may be placed, and a careful examination of the American version of his second work, which has been published under Dr. Wilcox's eye, shows that it is also worthy of both its author and editor."—Therapeutic Gazette, January lb, 1893. No. 7. MEDICAL JURISPRUDENCE AND TOXICOLOGY. Third Edition. By John J. Reese, m.d., Professor of Medical Juris- prudence and Toxicology, University of Pennsylvania, etc. Third Edition. Enlarged. " The production of this admirable text-book by one of the two or three leading teachers of medical jurisprudence in America, will, we hope, give a new impetus to the study of forensic medicine, which, inviting and important as it is, has heretofore been strangely neglected in both legal and medical schools."—American Journal of the Medical Sciences. We heartily second the author's hope that this treatise may encourage an increasing interest in the students for that most important, but too much neglected, subject, forensic medicine. —Boston Medical and Surgical Journal. No. 8. SWANZY. DISEASES OF THE EYE. Fourth Edition, Enlarged and Improved. Diseases of the Eye and their Treatment. A Handbook for Physicians and Students. By Henry S. Swanzy, A. M., M. B., f. R. c. s. I., Surgeon to the National Eye and Ear Infirmary; Ophthalmic Surgeon to the Adelaide Hospital, Dublin; Examiner in Oph- thalmic Surgery in the Royal University of Ireland. Fourth Edition, Thoroughly Revised. 170 Illustrations. exZredSr?™«;h„afICM-dedin Producing; the most intellectually conceived and thoroughly S«k"^ ° ■ J1" W.Uhm the hmitS he has ^signed himself. As a • students- handbook, small in size and moderate in price, it can hardly be equa\cd."-Medical News. V Other Volumes in Preparation. A complete illustrated circular, with sample pages, sent free upon application. Price of Each Book, Cloth, $3.00; Leather, $3.50. P. BLAKISTON, SON & CO., Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. NATIONAL LIMARY Of MEDICINE NLM 0DDMa7t12 M iMKM^v