Saunders ' Question Compmds Essentials of Obstetrics WE.Ashton.MiD. Digitized by Micfpspft® This book was digitized by Microsoft Corporation in cooperation with Cornell University Libraries, 2007. You may use and print this copy in limited quantity for your personal purposes, but may not distribute or provide access to it (or modified or partial versions of it) for revenue-generating or other commercial purposes. Digitized by Microsoft® Cornell University Library RG 531.A82 Essentials of obstetrics; arranged in the 3 1924 000 323 091 Digitized by Microsoft® Digitized by Microsoft® Digitized by Microsoft® Digitized by Microsoft® ESSENTIALS OBSTETRICS, Digitized by Microsoft® Since the issue of the first volume of the Saunders Question =Compends, OVER 200,000 COPIES of these unrivalled publications have been sold. This enormous sale is indisputable evidence of the value of these self-helps to students and physicians. Digitized by Microsoft® SAUNDERS' QUESTION-COMPENDS. No. 5. ESSENTIALS » OBSTETRICS ARRANGED IN THE FORM OF QUESTIONS AND ANSWERS PREPARED E8FBOIAILY BOB STUDENTS OF MEDICINE. BY WILLIAM EASTERLY ASHTON, M. D., PROFESSOR OF GYNECOLOGY IN THE MEDICO-CHIRURGICAL COLLEGE OF PHILADELPHIA; OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL. FIFTH EDITION, REVISED AND ENLARGED. SEVENTY-FIVE ILLUSTRATIONS. PHILADELPHIA W. B. SAUNDERS & COMPANY 1902 \ ) II' Digitized by Microsoft® y\&, i A 3-k 1 BY VI PAN"? Copyright, 1900, , B. SAUNDERS & COl 2w" :RCr £i %^'H f W " *' SAUNDERS * COMPANY. Yi./,«f. II, J Digitized by Microsoft® TO EDWARD H, COATES, Esq. ®|[U Mxxmt IS DEDICATED AS A SLIGHT TOKEN OP THE AUTHOR'S APPRECIATION OF HIS FRIENDSHIP AND OF HIS CHARACTER AS A MAN. Digitized by Microsoft® Digitized by Microsoft® PREFACE TO FIFTH EDITION. A constant and increasing demand for this book has necessitated issuing the fifth edition within a compara- tively short time. In preparing this edition the work has been thoroughly revised and the most recent progress has been incorporated, so that the volume continues to represent a practical, up-to-date presentation of the ac- cepted teaching of the best obstetric authorities. The flattering reception accorded the work by the medical press, together with the rapid sale of several editions, indicates that the book possesses features of distinct value for meeting the needs of students and practitioners. W. A. Newman Dorland. Digitized by Microsoft® Digitized by Microsoft® PREFACE TO FIRST EDITION. This manual is to assist the student in mastering the essentials of the science and art of obstetrics. As a work of this kind must of necessity be limited in its character, the author has relied upon his experience as a teacher for the selection of such matter as, in his judgment, will prove of most value. He has endeavored to present in a clear and concise man- ner the views of the present day, and the standard works of Parvin, Goodell, Lusk, Playfair, Hirst's American System of Obstetrics, Winckel's Diseases of Women, Hart and Barbour, Thomas, Emmet, and Charpentier's Oyclopcedia of Obstetrics and Gynecology have been consulted. The chapter on obstetric auscultation and palpation has been fully discussed and embodies the didactic and bedside in- structions of Prof. Parvin. In the preparation of the chapter on Ccesarean section the writer is indebted to an article written by Dr. Gustav Zinke, the illustration showing the deep and superficial uterine sutures being taken from the same source. He is also indebted to his friend Dr. Henry H. Sherk for several of the illustrations, and to his former student Dr. James C. Bloomfield for the preparation of the index. William Easterly Ashton. 222 South Eighth Street, Philadelphia- Digitized by Microsoft® Digitized by Microsoft® CONTENTS. PAGE Introduction 17 Anatomy of the pelvis 17 The pelvic joints 18 The pelvic inlet 20 The pelvic outlet 22 The pelvic cavity 23 The obliquity, planes, and axis of the pelvis . . 26 The soft parts of the pelvis 28 The female generative organs 31 Embryology ..." 34 Development of the female generative organs ... 40 External organs 40 Internal organs 42 Development of the embryo and foetus .... 44 Physiology of the foetus 46 The foetal head and trunk 51 The foetal head 51 The foetal trunk 53 The attitude and presentation of the foetus ... 54 Puberty, nubility, ovulation, menstruation, and menopause 54 Pregnancy 63 Conception 63 Changes in the maternal organism .... 65 Signs and diagnosis of pregnancy .... 69 Differential diagnosis of pregnancy .... 76 Multiple pregnancy 80 Diagnosis of multiple pregnancies ... 81 Diseases of pregnancy 82 Nausea and vomiting 82 xiii Digitized by Microsoft® XIV CONTENTS. Hyperemesis ...... (Edema. Varicose veius Salivation. Kelaxation of the pelvic joints Diseases of the organs of generation Diseases of the ovum ..... Myxomatous degeneration of the. placenta, or hyd form mole .... Polyhydramnios Abortion Ectopic development of the ovum Placenta prsevia .... Accidental hemorrhage Eclampsia Labor Mechanism of labor Management of labor . Anaesthesia . Preliminary preparations First stage Second stage . Preservation of the perineum Third, or placental stage Asphyxia neonatorum . Management of occipito-posterior Face presentations Brow presentations Pelvic presentations Antisepsis .... Labor and puerperal state The pathology of labor Precipitate labor . Prolonged labor Dystocia due to the foetus Dorsal displacement of the arm Excessive development of the foetus Premature ossification . Large size of the body . positions atidi- Digitized by Microsoft® CONTENTS. XV Large size of the foetal head Hydrocephalus Monstrosities . Dystocia in plural deliveries Prolapse of the fun Deformities of the pelvis . Rupture of the uterus Inversion of the uterus Post-partum hemorrhage . Primary hemorrhage Secondary hemorrhage Puerperal septicaemia . Phlegmasia alba dolens Obstetric operations The induction of premature labor The induction of abortion Version, or turning Cephalic version Pelvic version Podalic version The forceps Embryotomy . Symphysiotomy The Caesarean section Porro operation The post-mortem Caesarean section Post-mortem extraction through the natural PAGE 178 178 181 187 190 194 201 204 207 207 209 209 215 216 216 218 220 220 222 223 226 236 243 244 248 248 248 Digitized by Microsoft® Digitized by Microsoft® ESSENTIALS OF OBSTETRICS. INTRODUCTION. What is obstetrics ? The care of women during pregnancy, labor, and in the puer- peral state. What are the synonyms for obstetrics ? Tocology, parturition, midwifery, accouchement, and maieutics. What do you mean by the science and art of obstetrics ? " Obstetric science means the classified knowledge of the laws of human reproduction ; obstetric art includes the rules drawn from those laws or from intelligent experience." ANATOMY OF THE PELVIS. 1 What bones form the anatomical pelvis ? The coccyx, sacrum, and the ossa innominata. What bones form the obstetric pelvis ? See fig. 1. The coccyx, sacrum, ossa innominata, and the last lumbar ver- tebra. What is meant by the static pelvis ? The bony pelvis. What is meant by the dynamic pelvis ? " The pelvis in the living subject and in labor." 1 For the anatomical description of the pelvis the student is referred to his text-books. 2 Digitized by Microsoft® 18 ESSENTIALS OF OBSTETRICS. How is the pelvis divided ? Into two parts : one, the upper, false or greater pelvis ; the other, the lower, true or lesser pelvis. What is the dividing line hetween the true and false pelvis ? The ilio-pectineal line. What are the four cardinal points of Capuron ? The right and left saero-iliac joints, and the right and left ilio- pectineal eminences. What is the promontory or sacro-vertehral angle ? The prominence formed at the point of articulation of the sacrum with the spine. What bones form the anterior, lateral, and posterior walls of the true pelvis ? The anterior and lateral walls are formed by the innominate bones ; the posterior wall by the last lumbar vertebra, the sacrum, and coccyx. What is the length of the anterior, lateral, and posterior walls of the true pelvis ? The anterior wall measures from 4 to 4£ cm. (1J to 1J in.) ; the lateral 9 to 9J cm. (3} to 3| in.) ; the posterior 12f cm. (5 in.), or, following the curve of the sacrum and coccyx, 14 cm. (5J in.). The Pelvic Joints. How many joints unite the bones of the obstetric pelvis? Seven. Name them. One pubic; one sacro-coccygeal ; two sacro-iliac; and three sacro-vertebral. What joints are amphiarthrodial ? The pubic, the sacro-coccygeal, the sacro-iliac, and the articular surface of the body of the last lumbar and the first sacral vertebrae. Digitized by Microsoft® ANATOMY OF THE PELVIS. 19 Fio. 1. Female pelvis. Fig. 2. Plane of the brim of the pelvis. Digitized by Microsoft® 20 ESSENTIALS OF OBSTETRICS. What joints are arthrodial ? The two articulations formed by the articular processes of the last lumbar and first sacral vertebrae. Are any of the diameters of the pelvis increased or dimin- ished by movements in the pelvic joints ? The antero-posterior diameter of the outlet is increased by the movement in the sacro-coccygeal joint ; this movement may occur between the first and second bones of the coccyx ; less frequently between the second and third, or between the third and fourth. It is probable that there is a lessening of the antero-posterior diameter of the inlet, with an increase in the corresponding diame- ter of the outlet caused by the elevation and depression of the pubic joint; this may be produced either by the sacrum moving forward upon an imaginary transverse line, or by the movements of the iliac bones on the sacrum itself. The antero-posterior di- ameter of the inlet is increased by placing the woman in Walcher's posture, the weight of the limbs dragging the symphysis down and away from the promontory of the sacrum. What are the functions of the pelvic joints ? In addition to their influence upon the pelvic diameters already referred to, they decompose forces received by the lower extremi- ties, and thus prevent sudden shocks being transmitted directly to the contents of the pelvis. What changes occur in the pelvic joints during preg- nancy ? The ligaments become elongated and swollen, the fibro-cartilages distended with serum and softened, and there is a slight separa- tion between the bones. These changes are most marked in the pubic joint; they can be demonstrated by introducing the finger into the vagina and pressing against the inferior border of the symphysis, at the same time directing the patient to stand first on one foot and then on the other. The Pelvic Inlet. What is the pelvic inlet ? The entrance to the cavity of the pelvis. Digitized by Microsoft® ANATOMY OF THE PELVIS. 21 Fig. 3. The outlet of the pelvis. Fis. 4. Anterior posterior diameters of inlet. S, P. Saero-supra-pubic diameter. S, Pi. Sacro-subpubie diameter. S, Pis. Minimum diameter. Digitized by Microsoft® 22 ESSENTIALS OF OBSTETRICS. How is it bounded? See fig. 2. Posteriorly, by the promontory and the anterior edge of the alae of the sacrum ; laterally, by the ilio-pectineal line ; anteriorly, by the ilio-pectineal eminences, and the posterior edge of the oblique rami and body of the pubes. What are the synonyms for the inlet ? Margin, isthmus, and superior strait or brim. What is the shape of the inlet ? It is heart-shaped ; pointed in front, and encroached upon pos- teriorly by the promontory. What are the diameters of the inlet ? i An antero-posterior ; a transverse ; and two oblique diameters (right and left). Between what points are the diameters taken ? The antero-posterior (sacro-supra-pubic, or conjugate) extends from the central point of the upper margin of the symphysis to the sacral promontory ; it measures 11 cm. (4.3 inches). The two oblique diameters connect the four cardinal points of Capuron ; that starting from the left sacro-iliac synchondrosis being named the left, that from the right, the right oblique ; they each measure 12J cm. (about 5 inches). The transverse or bis- iliac is the widest measurement between the ilia, averaging 13£ cm. (about 5.3 inches). What does the circumference measure? About 40 cm. (15f inches) ; according to Parvin, 15.8 inches ; Lusk. 16 inches. The Pelvic Outlet. How is the pelvic outlet bounded ? See fig. 3. Posteriorly, by the coccyx; anteriorly, by the subpubic liga- ment; and on either side by the ischio-pubic ramus, the tuberosity of the ischium, and the sciatic ligaments. Digitized by Microsoft® ANATOMY OF THE PELVIS. 23 What is the shape of the outlet? Cordate at rest ; almost circular in labor. What are the diameters of the outlet? An antero-posterior ; a transverse ; and two oblique diameters (right and left). Between what points are the diameters taken? The antero-posterior (coccy-pubic or conjugate) extends from the subpubic ligament to the tip of the coccyx ; it measures 9£ cm. (3| inches), increasing to 11 cm. (4J inches) in labor. The transverse (bisischiac) is measured between the inner borders of the ischial tuberosities (11 cm. or 4J inches). The oblique diameters connect on either side the middle of the inferior surface of the great sacro-sciatic ligament with the point of union of the ischio-pubic rami ; they measure 12| cm. (about 5 inches). Are the oblique diameters of the outlet considered of obstet- ric importance? No ; owing to the yielding of the sciatic ligaments. Is the antero-posterior diameter increased during labor? Yes; 1J cm. (about one inch) by the retrocession of the coccyx. What does the circumference of the outlet measure ? 34J cm. (about 13£ inches). The Pelvic Cavity. How is the pelvic cavity bounded ? By the inlet above and the outlet below. What is its shape ? Irregularly barrel-shaped. Digitized by Microsoft® 24 ESSENTIALS OF OBSTETRICS. Is the bony wall of the cavity complete in any horizontal pelvic plane? No; for example, the movable coccyx is opposite the pubic symphysis, and thus at all points of the cavity there is motion, protecting from pressure the foetus and the mother. Into how many sections is the pelvic cavity divided ? Two ; an anterior and posterior inclined plane. What line divides these planes ? A line passing between the ilio-pectineal eminences and the spine of the ischium on each side. The anterior plane is directed downward and forward, while the posterior inclines toward the sacrum and coccyx. What are the diameters of the cavity of the pelvis ? An antero-posterior ; a transverse; and two oblique diameters (right and left). Between what points are the diameters taken ? The antero-posterior diameter extends from the middle of the pubic symphysis to the middle of a line between the second and third sacral vertebrae, or, as taught by some authorities, to the centre of the third sacral vertebra. The transverse intersects in the same plane the conjugate and oblique diameters. The two oblique diameters are measured from the centre of each great sciatic foramen to the centre of the ischio-pubic foramen of the opposite side. What do the diameters measure ? Purvin. Playfair. A. P., 12 cm. (about 4| inches). 12J cm. (about 5 inches). T., " " " 10| cm. " 4.2 " O., The antero-posterior measurements increase from above below, while the transverse decrease. What are some of the other diameters of the pelvis ? Fig. 4. 1. The sacro-cotyloid diameter, which extends from the pro- montory to a point immediately above the cotyloid cavity ; it Digitized by Microsoft® ANATOMY OF THE PELVIS. 25 A , B, forms with the horizon, F, G, an angle of about 55°. C, D, a line from the promontory of the sacrum to the space between the tuberosities of the ischia— the line // indicates the plane of the cavity of the pelvis. The circle, J, is the circle o r curve of Cams. Fig. 6. PUSHED BACK Section showing the inelinatSJn of Htie? ChantreuiLi OBSTETRICAL CONJUGATE HORIZON, ing to Naegele. (Tarnier et 26 ESSENTIALS OF OBSTETRICS. measures 9£ cm. (3|[ inches). 2. The sacro-subpubic, lower, or inclined conjugate diameter, from the subpubic ligament to the sacro-vertebral angle. 3. The minimum, useful, or obstetric di- ameter, beginning about two-fifths of an inch below the upper border of the symphysis, and extending to the promontory. 4. The sacro-pectineal diameter, from the promontory to the upper border of the oblique ramus of the pubic bone, below the subpubic angle. 5. The diagonal conjugate, from the superior margin of the pubes to the centre of the third sacral vertebra. The Obliquity, Planes, and Axes of the Pelvis. What is meant by the obliquity of the pelvis ? See fig. 5. The angle which the pelvis forms with the spinal column. What are the causes of this obliquity ? First, the cartilage between the sacrum and the last lumbar ver- tebra is twice as thick in front as it is behind ; second, the body of the fifth lumbar vertebra is thicker in front than behind ; third, the obliquity of the articulating surface of the first sacral vertebra; and fourth, the obliquity of the articulation of the innominate bones with the sacrum. What angle does the antero-posterior diameter of the inlet make with a horizontal line ? Naegele makes the angle 60 degrees, the patient standing. What angle does the diagonal conjugate make with a horizontal line ? Mayer makes the angle 30 degrees. What angle does the antero-posterior diameter make with the axis of the body ? An angle from 130 to 140 degrees. What angle does the antero-posterior diameter of the outlet make with a horizontal line ? An angle from 10 to 11 degrees. Digitized by Microsoft® ANATOMY OF THE PELVIS. 27 Does the retrocession of the coccyx affect the size of this angle ? Yes; it changes with the movements of the coccyx during labor. What is the height of the sacro-vertebral angle above the upper surface of the pubic symphysis ? About 9J cm. (3| inches). At what point would a line touch passing horizontally backward from the upper margin of the symphysis? The junction of the second and third bones of the coccyx. Does the pelvic inclination remain in a fixed state ? No ; it changes with the different positions of the body. What do you mean by the planes of the pelvis ? See fig. 6. Imaginary surfaces touching all the points of the circumference at any portion. Thus we speak of the plane of the inlet and out- let, and also the planes of the pelvic cavity. The planes of the cavity are not parallel ; starting from the posterior wall they con- verge and meet in front of the symphysis pubis. What do you mean by the axis of the inlet and outlet ? A line drawn perpendicular to the centre of their planes. If the axis of the inlet be continued upward it would pass out at the umbilicus ; backward it would strike the apex of the coccyx, or the sacro-coccygeal joint. The axis of the outlet continued upward, intersects the axis of the inlet at the centre of the pelvic cavity, and ends at the promontory ; if the coccyx be pushed backward, it strikes the lower edge of the first sacral vertebra. Continued backward it passes out at the perineum near the anus. What do you mean by the axis of the cavity ? An imaginary curved line passing through the pelvic cavity, and at all points equally distant from the pubic symphysis and the sacrum and coccyx ; it represents the sum of the axes of a series of planes at various levels of the pelvic cavity. It is called the curve of Cams. Digitized by Microsoft® 28 ESSENTIALS OF OBSTETEICS. Is the relation between the pelvic axes and the pelvic planes unchangeable ? Yes. Is the relation of the planes and axes to the body un- changeable 1 No ; for example, if the subject is in the erect position, the plane of the inlet is almost horizontal ; in the recumbent position, how- ever, the plane is nearly vertical. The Soft Parts of the Pelvis. What are the functions of the psoas and iliacus muscles ? The ilio-psoas muscles, acting from above, flex the thigh and rotate it outward ; from below, the muscles of both sides pull the spine and pelvis forward. When the body is recumbent they assist . in raising the trunk ; they also uphold the erect position. The iliacus muscle serves as a support to the impregnated uterus, and assists in labor. What modifications are produced in the bony pelvis by the soft parts ? They lessen the pelvic diameters, the depth of the iliac fossae, and the obliquity of the iliac bones. They also change the direc- tion of the pelvic axis. What pelvic diameters are lessened 1 At the inlet, the transverse diameter is decreased about 1J cm. (J inch) by the ilio-psoas muscles; the oblique diameters are decreased one-eighth of an inch, the left oblique being still fur- ther lessened by the presence of the rectum. In the cavity all the diameters are lessened from one-fifth to one-quarter of an inch. What muscles lessen the depth of the iliac fossae ? The iliacus muscles. What muscles lessen the obliquity of the iliac bones ? The psoas muscles. Digitized by Microsoft® ANATOMY OF THE PELVIS. 29 What changes are produced in the direction of the pelvic axis by the soft parts ? A curved line equally distant from the sacrum and the pubes represents the axis of the static pelvis ; this, however, is not true of the dynamic pelvis. The dynamic pelvis presents a cavity which is a cylindrical canal, having an anterior and a posterior wall, nearly vertical. The fundus of this cavity is at the coccyx and its opening upon the anterior wall. The axis, therefore, of the birth-canal "is at first a line directed backward and down- ward, and then a line almost perpendicular to it." What is the pelvic floor ? " The pelvic floor is a thick, fleshy, elastic layer, dovetailed all round to the bony pelvic outlet." What are the synonyms for the pelvic floor ? Pelvic diaphragm, inferior wall of the pelvis, perineal wall, and perineum. What organs perforate the pelvic floor ? The rectum, vagina, and urethra. How are these openings closed 1 The vagina and the urethra by the apposition of their walls ; the rectum by the contraction of its sphincter. What structures enter into the formation of the pelvic floor? The peritoneum, subperitoneal cellular tissue, aponeurotic fascia?, muscles, superficial fascia, and skin. What organs lie on the outer or skin surface of the pelvic floor ? The external organs of generation. What organs lie on the inner or peritoneal surface ? The uterus and its annexa. Describe the peritoneum lining the pelvic floor. At the symphysis pubis the peritoneum is reflected from the an- terior abdominal wall on to the bladder, and passing over its pos- Digitized by Microsoft® 30 ESSENTIALS OP OBSTETRICS. terior surface it crosses on to the uterus at the isthmus, forming a pouch, called the vesico-uterine cul-de-sac. It covers all of the anterior surface of the uterus above the isthmus, and passing over the fundus it invests the posterior surface down to the vaginal junction. From this point it continues downward on the posterior wall of the vagina for about four-fifths of an inch, and is then re- flected on to the anterior wall of the rectum ; the pouch formed at this point is called Douglas's, or the retro-uterine or recto-uterine cul-de-sac. What is the perineum ? That part of the floor of the pelvis which is bounded, externally, by the anus, the tuberosities of the ischia, and the vulvar opening; internally, by the walls of the rectum and vagina. What is the length of the perineum from the anus to the vulvar opening ? In the parous less than an inch, in the riulliparous somewhat over an inch. During pregnancy it measures an inch and a half, and in labor it is extended by the presenting part to five inches and a half. Upon what does the distensibility of the perineum de- pend? The perineal- body. What is the perineal body ? A mass of elastic and muscular tissue, placed in the centre of the perineum. How is the pelvic floor in its relations to labor divided ? Into a pubic and a sacral segment. Describe these segments. " The pubic segment is made up of loose tissue, viz., bladder, urethra, anterior vaginal wall, and bladder-peritoneum. It is attached in front to the symphysis pubis." " The sacral segment is attached to the coccyx and sacrum • it consists of rectum, perineum, and strong tendinous and muscular tissue." Digitized by Microsoft® ANATOMY OP THE PELVIS. 31 What effect has labor upon these segments? The contractions of the uterus pull up the pubic segment, while the sacral segment is pushed down by the presenting part. In what direction does the vagina pass through the pelvic floor? Obliquely, parallel to the antero-posterior diameter of the inlet. The Female Generative Organs. 1 How are the organs of generation divided ? See tig. 7. 1st. Internal, viz., the uterus and its appendages (the ovaries and oviducts) ; and the vagina. 2d. External, viz., the mons veneris, labia majora and minora, clitoris, vestibule, fossa navicularis, hymen, and fourchette ; and also the mammary glands. What term is used to include all of the external organs ? The pudendum or pudendum muliebre. The vulva does not include the mons veneris, although it is occasionally used as a synonym. What is the reaction of the vaginal secretions? Acid. What is the reaction of the glandular secretions of the uterus? Alkaline. What is the direction of the current produced by the ciliae of the epithelium of the uterus ? Toward the oviducts. What is the direction of the current produced by the ciliae of the oviducts? Toward the uterus. What are the functions of the vagina ? 1st. An organ of copulation. 1 The anatomy of the organs is to be found in the text-books. Digitized by Microsoft® ESSENTIALS OF OBSTETRICS. Fia. 7. External organs of generation (in the virgin). 1, labium majus; 2, fourchette; 3, the nympha; 4, glans clitoridis; 5, meatus urethra;; 6, vestibule; 7, orifice of va- gina ; 8, hymen : 9, orifice of the glands of Duverney ; 10, anal orifice. (Sappey.) Fig. 8. Segmentation of the ovum. A, the ovum divided into two cells; B, the two cells divided into four ; C, the four cells divided into eight ; D, by repeated segmentation the ovum has become a round, mulberry-shaped mass — the morula. (Haeckel.) Digitized by Microsoft® ANATOMY OF THE PELVIS. 33 2d. An excretory canal for the uterus. 3d. An organ of parturition. What are the functions of the uterus ? 1st. An organ of gestation. 2d. An organ of parturition. What is the function of the ovary ? Spontaneous ovulation. What uses have the oviducts ? They convey the spermatozoids to the ovaries, and the ovules pass through them to the uterus. What is the function of the vulvo-vaginal glands ? They secrete a viscid mucus, which lubricates the parts during coition. What is the vestibule ? It is a triangular-shaped space, bounded at its apex by the clitoris, on its sides by the nymphse, and at its base by the anterior edge of the vaginal opening. It is of importance on account of the situation of the meatus urinarius, which is placed a little above the middle of its base. What methods are used in the introduction of the catheter ? It may be introduced either by means of sight or touch. 1. Touch. Insert the index finger into the vagina, its palmar surface looking upward, and make moderate pressure against the anterior wall of the vagina ;«now pass the catheter along the finger until the opening of the vagina is reached, and then by slightly elevating the point of the instrument it will pass into the urethra. Separate the nymphse, at the apex of the vestibule, with the index finger, and pass it down toward the vagina until the meatus is" felt at its base; the urethro-vaginal tubercle is an important guide in this method, as the meatus is placed just above it. 2. Sight. This method of introduction is useful when the parts are swelled during labor, and is always preferable because of the lessened danger of septic infection. 3 Digitized by Microsoft® 34 ESSENTIALS OF OBSTETRICS. EMBRYOLOGY Describe the changes which take place in the ovum after impregnation. See figs. 8, 9, and 10. 1. The germinal vesicle immediately disappears. 2. The union of the male with the female pronucleus ; the former is the head of the spermatozoid, while the latter is the remains of the germinal vesicle. 3. Cleavage or segmentation of the vitellus ; this process con- tinues until the vitellus is completely subdivided, forming a mul- berry-like mass, called the muriform body. 4. The outer cells of the muriform body arrange themselves in a single, layer beneath the vitelline membrane, and enclose the inner or smaller cells. The blastopore is the point at which the inner cells are not completely covered over. 5. Next the opening of the blastopore closes. 6. The blastodermic vesicle is now formed by the appearance of a fluid which separates the inner and outer cells ; the former col- lecting in a mass, and adhering to the latter at a point which was originally the blastopore. 7. A third layer next appears between the outer and inner layers of cells. The blastodermic vesicle is now composed of three layers, viz., the external, or epiblast; the middle, or mesoblast; and the interna], or hypoblast. 8. The area germinativa is now developed ; it can be seen by removing the vitelline membrane and exposing the epiblast. It is oval in shape ; its central portion is light in color (area pellu- cida) ; and it is surrounded by an opaque area (area opaca). 9. Next there appears within the area pellucida a groove or fur- row (primitive groove) ; this eventually becomes the spinal canal. 10. Folds grow upward from the sides of the primitive groove and arching over unite with each other, forming the spinal canal ; these folds are called the dorsal plates. Projecting forward from the bases of these plates are two folds (abdominal plates), which eventually unite with each other, and enclose the cavity of the abdomen. 11. In growing forward the abdominal plates divide the blasto- Digitized by Microsoft® EMBRYOLOGY. Fig. 9. 36 a o, area opaca; ap y area pellucida; with beginning formation of embryo from the embryonic spot. From the ovum of a rabbit on the ninth day. Owing to the advanced stage of development, the area pellucida has lost its primitive shape, and presents the appearance of a constricted ovoid. (Kolliker.) Fig. 10. Transverse section of egg in early stage of development. 1, external and median layers of blastodermic membrane; 2, 2, dorsal plates; 3, internal layer of blasto- dermic membrane. (Dalton.) Digitized by Microsoft® 36 ESSENTIALS OF OBSTETRICS. Fig. 11. Formation of the decidua, first Btage. Fig. 12. Section of ovum. Digitized by Microsoft® EMBKYOLOGY. 37 dermic vesicle into two parts, the external portion of which is the yelk sac (umbilical vesicle), while the internal is embryonic; the vitelline duct is the canal between them. The omphalo-mesen- teric artery and vein and intermediate capillaries are seen on the surface of the umbilical vesicle. Describe the changes in the mucous membrane of the uterus incident to pregnancy. See fig. 11. These consist in the formation of the deciduous membranes. When the ovum reaches the uterus the mucous membrane of the latter " is swelled and thrown into folds," and the ovum finds a lodgement in one of the spaces between these folds. That part of the mucous membrane upon which the ovum rests is called the placental decidua, or membrana (decidua) serotina; the folds which surround it are the ovular decidua, or decidua reflexa ; and all the rest of the mucous membrane of the cavity of the uterus is the uterine decidua. or decidua vera. The folds, forming the ovular decidua, grow, and arching over the ovum, unite and com- pletely surround it. By the end of the third month the ovular decidua and the uterine decidua unite; they then begin grad- ually to atrophy and separate from'the uterus. Describe the development of the amnion. See fig. 12. From the sides of the embryo, and also from its caudal and cephalic ends, the epiblast rises up into folds, which finally meet and form a complete sac. These folds consist of an external and internal layer ; the former, or false amnion, unites with the vitelline membrane ; while the latter, or true amnion, forms the most internal of the membranes covering the foetus. Describe the development of the allantois. During the development of the amnion (the 20th day) the um- bilical vesicle begins to disappear, and the allantois is seen spring- ing from the terminal portion of the intestine. At first it is sau- sage-like in shape, but afterward it becomes spread out and fuses with the internal surface of the false amnion. Describe the development of the chorion. About the twelfth day the zona pellucida becomes covered Digitized by Microsoft® 38 ESSENTIALS OF OBSTETEICS. with small solid villi ; it is then called the primitive chorion. A little later, the permanent chorion is formed by the union of the primitive chorion with the false amnion and the allantois. The vessels of the allantois penetrate into the villi of the chorion, which now become vascular and take on hypertrophy. This hypertrophy continues until the third month when all the villi atrophy, except those attached to the placental decidua, which, continuing to enlarge, assist in the formation of the placenta. The chorial villi, up to the third month, are often spoken of as the " shaggy coat," or chorion frondosum. How many days does the ovum take in passing through the oviduct ? About eight or ten days. What is its size when it enters the uterus ? That of a small pea. What is the function of the allantois ? To carry the allantoic arteries to the chorion, thus assisting in the development of the placenta. What is the function of the chorion ? To assist in the formation of the placenta. What are the foetal appendages ? From without in : the decidual, chorion, and amnion ; the pla- centa and cord are also included. What are the uses of the liquor amnii ? During pregnancy: 1. To prevent injury to the contents of the uterus. 2. To assist in the movements of the foetus, and also to lessen their inconvenience to the mother. 3. To aid in the development of the foetus and uterus. 4. To nourish the foetus. During labor : 1. To protect from pressure the foetus and cord. 2. To assist in the dilatation of the os uteri. 3. To lubricate and cleanse the birth-canal. Digitized by Microsoft® EMBRYOLOGY. 39 Describe the development of the placenta. It begins to develop at the third month, and is completely formed by the fourth. The chorial villi, which are in relation with the placental decidua, continuing to grow dip down into the mucous membrane. Meanwhile the placental decidua sends out villi which interlock with those of the chorion, thus forming a close connection between the two. Blood-sinuses now appear in the maternal part of the placenta, into which bloodvessels from the mother pass in and out ; the chorial villi float in these sinuses. What is the usual situation of the placenta ? Upon the anterior or posterior wall, near the orifice of one of the oviducts. What are the functions of the placenta ? 1. Nutrition. 2. Kespiration. 3. "An emunctory for the products of excretion in the foetus." 4. A glycogenic function. When does the umbilical cord begin to develop ? At the end of the fourth week. From what structure is the cord developed ? The stalk of the allantois ; it has originally two arteries and two veins. What structures compose the fully developed cord ? Wharton's jelly, the umbilical vein and arteries, and traces of the stalk of the allantois and umbilical vesicle ; these are all in- closed in a sheath derived from the amnion. To what part of the placenta is the cord usually attached? Midway between its centre and margin. What is a battledore placenta ? A placenta in which the cord has a marginal attachment. Digitized by Microsoft® 40 ESSENTIALS OF OBSTETRICS. DEVELOPMENT OF THE FEMALE GENERATIVE ORGANS. External Organs. See fig. 13. What is the cloaca? The terminal portion of the intestine after the formation of the vesicle of the allantois ; it is the opening common to the allantois, the intestine, and the Wolffian ducts. How long does the cloaca remain ? Until the middle of the third month, when it is divided by a wall, thus forming the rectal and uro-genital cavities. How long does the uro-genital cavity remain ? Until some time in the fourth month, when it is divided into the urethra and vagina. From what is the clitoris developed ? The genital tubercle. What is the genital tubercle ? The genital swelling or tubercle is a prominence in front of the opening of the cloaca. From what are the labia major a developed ? The genital folds. What are the genital folds 1 Two folds, placed one on either side of the genital tubercle and the orifice of the cloaca. From what are the labia minora developed ? From the sides of the genital fissure or furrow. What is the genital fissure ? A furrow extending from the lower part of the genital swelling to the orifice of the cloaca. Digitized by Microsoft® FEMALE GENERATIVE ORGANS. 41 Fig. 13. Rudimentary sexual organs. The internal organs represented at the seventh week of foetal life ; the external organs belong to a later period. 1, spinal column; 3, 3, Wolffian bodies; 5, glands destined to become the ovaries in the female, the tes- ticles in the male; 6, Wolffian duct; 7, filaments of Miiller; 8, bladder; 9, tubercle, forming the rudiment of either the clitoris or penis; 10, folds destined to form the labia majora (in the male the scrotum) ; 11, sinus uro-genitalis ; 12, anus. (Luschka.) Fig. 14. Coil rsfl n f fn»t a 1 42 ESSENTIALS OF OBSTETRICS. From what is the perineum developed? From the lower surface of the wall which divided the cloaca into two cavities. Internal Organs. See fig. 13. From what are the internal organs of generation devel- oped? The Wolffian bodies and Miillerian ducts. What are the Wolffian bodies ? They are two glandular bodies placed one on either side of the spinal column during embryonic life. What is the structure of a Wolffian body ? It is composed of a series of fine tubes, placed in a transverse position, which empty into an excretory duct, known as the Wolf- fian duct. What are the synonyms for the Wolffian body ? The primitive, false, or primordial kidney; also the kidney of Oken. What is a Miller's duct ? A duct developed on the outer surface of the Wolffian body. How many Miillerian ducts are there? Two ; one for each Wolffian body. Describe their development. They begin as a layer of germinative epithelium which dips down into the structure of the outer surface of the Wolffian body. These depressions eventually become covered over, thus forming two tubes or canals. What organs are derived from Miiller's ducts ? The oviducts, uterus, and vagina. Describe their formation. The ducts of Muller, passing forward, unite in the median line, at a point situated below the round ligaments. Above, they Digitized by Microsoft® FEMALE GENERATIVE ORGANS. 43 remain separated, forming the oviducts, but below the round liga- ments they are in apposition with one another, thus forming the uterus and vagina ; the fusion of the two tubes is complete by the eighth week. The extremity of each tube forms the ampulla or pavilion. The presence of a secondary ampulla is readily under- stood, by the failure of the original gutter, from which the tube developed, to close completely over at a given point. After fusion has taken place between the two tubes, below the round ligaments, the intervening partition is absorbed, thus, that which was at first a double uterus and vagina, now becomes two single organs. Describe the development of the ovary. An elongated mass of embryonic connective tissue covered by germinative epithelium appears on the inner surface of the Wolf- fian body ; this is the beginning of the development of the ovary. The stroma of the ovary is derived from the connective tissue while the ovules and ovisacs are developed from the epithelium The primordial ovules appear in the epithelium as round cells, having a nucleus and nucleolus. The ovisacs are developed from the epithelium, which adheres to the ovules as they dip down into the structure of the ovary. What is the cause of anomalies of the uterus ? An arrest of foetal development. What is a uterus unicornis ? A one-horned uterus. It is caused by an incomplete develop- ment of one of Miiller's ducts ; generally there is but one oviduct. What is a uterus duplex ? It is simply two uteri, caused by the failure of the fully devel- oped Miiller's ducts to unite. What is a uterus bicornis ? A two-horned uterus. It is caused by a partial union between the ducts of Miiller — i. e., they unite, but below the normal point. What is a uterus cordiformis ? A uterus in which there is an incomplete development of the fundus; it is depressed, and resembles in shape the heart of a playing-card. Digitized by Microsoft® 44 ESSENTIALS OP OBSTETRICS. What is a uterus septus bilocularis ? A uterus which has two cavities ; a double uterus. It is caused by the walls of Muller's ducts not being absorbed. A uterus semi- partitus has two uterine cavities with a single cervix. Will any of these anomalies prevent pregnancy ? No. Development of the Embryo and Foetus. What do you mean by the terms embryo and foetus ? The product of conception is known as an embryo up to three months, after which it is called a foetus. Describe the development of the embryo and foetus in the successive months of pregnancy. Fikst Month : Size. — 12th day the ovum measures § cm. (£th inch); 15th day the embryo is T J jth of an inch ; 20th day £th of an inch ; 21st day &th of an inch ; and at the end of the month 1J cm. (about J inch) ; the ovum being the size of a pigeon's egg. Structure.— 12th day it is composed of the vitelline membrane covered with villi, and of the blastodermic vesicle ; 15th day of the primitive groove, amnion, allantois, and the umbilical vesicle. The heart is also seen, a simple cavity, and commencing to beat, the vitelline circulation is established ; the Wolffian ducts also begin to develop ; 18th day the heart is S-shaped ; 20th day the visceral arches and clefts are seen ; 21st day the heart has four cavities, and the eyes, ears, and mouth begin to develop ; at the end of the month rudimentary limbs are seen. Second Month : Size. — The ovum is the size of a hen's egg ; the embryo is from 3J to 4 cm. (1 to 1J inches) in length, and weighs 1 drachm. The umbilical cord is 2| cm. (about 1 inch) in length. Structure. — The visceral arches and clefts close; hare-lip and cleft-palate are impossible subsequent to the second month. The eyelids and external ears are seen ; about the middle of the month the external organs of generation begin to develop, and about the Digitized by Microsoft® FEMALE GENERATIVE ORGANS. 45 seventh week the testicles or ovaries are seen. The fingers and toes are indicated, but they are fused together. The umbilical vesicle, reduced in size, hangs from the embryo by a narrow stalk. Thikd Month : Size. — The ovum is as large as a goose's egg ; the foetus is from 8J to 9 cm. (3 to 3J inches) long, and weighs from 5 drachms to 1 ounce. The umbilical cord is Q\ cm. (2| inches) long, and begins to assume a spiral form. Structure. — The placenta is fully developed by the end of the month. The fingers and toes are separated, and membrane-like nails appear. The eyes are closer together and the ears well de- veloped. Spina bifida is seldom anterior, and more often lumbar than dorsal or cervical. This is accounted for by the fact that ossification takes place last in the lumbar vertebrae and that the bodies are the first portion to become ossified. Foukth Month : Size. — Length, 16 cm. (6} in.) ; weight, 4 ounces. The cord measures 19 cm. (7J in.), and the gelatine of Wharton is formed. Structure. — The external organs of generation are developed, and the sex can be distinguished by the middle of the month. Lanugo (soft fine hair) is seen on the body, and hair begins to develop on the scalp. Slight movements of the extremities occur. Vitality.— -If born at the end of the month, the foetus may live a few hours. Fifth Month : Size. — Length, 25 cm. (almost 10 in.); weight, 10 ounces; cord 30 J cm. (12 in.) long. Structure. — Movements are distinct and felt by the mother about the middle of the month. The vernix caseosa is seen. Vitality. — If born at the end of the month, the foetus breathes and cries feebly, dying in a few hours. Sixth Month : Size. — Length, 30 cm. (about 12 in.) ; weight, 1 pound. Vitality. — If born, the foetus lives from 1 to 15 days. Seventh Month : Size. — Length, 35 cm. (13f in.); weight, 3 to 4 pounds. Structure; — The testicles are felt near the scrotum, and the nails are almost completely developed. Digitized by Microsoft® 46 ESSENTIALS OF OBSTETRICS. Vitality.— "Che foetus is viable. The artificial feeding of prema- ture children by means of a stomach tube (gavage) places the period of viability much earlier. Eighth Month : Size.— Length, 40 cm. (15| in.) ; weight, 4 to 5 pounds. Ninth Month (fetus at term) : Length, 50 or 51 cm. (19£ to 22 in.) ; weight, 6 to 7 pounds. The body is plump ; the lanugo has nearly disappeared ; the nails of the fingers and toes are hard, the former projecting beyond the finger- tips ; the testicles have descended into the scrotum, and the labia majora are in apposition; the hair on the scalp is 1 to 2 inches long; the vernix caseosa is found chiefly on the back and flexor surfaces of the joints. The child cries lustily and nurses vigor- ously ; in the course of a few hours it passes urine and meconium. PHYSIOLOGY OF THE F03TUS. What are the functions of the foetus 1 Nutrition, circulation, respiration, secretion, and innervation. How are the embryo and ftetus nourished ? During the passage of the impregnated ovum through the ovi- duct it is nourished first by the discus proligerus, and later by an albuminous substance or a " special liquid " derived from the mucous membrane of the oviduct. After it reaches the uterus it receives nourishment from the villi of the chorion and a liquid secretion from the uterine mucous membrane ; later from the um- bilical vesicle, the nutritive materials of which are carried to the embryo through the omphalo-mesenteric veins. After the formation of the allantois the umbilical vesicle atrophies, and the villi of the chorion, especially those in relation with the placental decidua, furnish its nutritive supply ; the liquor amnii also adding a small amount of nourishment. Finally the placenta is the chief source of nourishment. Describe the different circulations of intra-uterine life. See fig. 14. First. The vitelline, blastodermic, or umbilical circulation. Digitized by Microsoft® PHYSIOLOGY OF THE FCETUS. 47 This circulation depends upon the umbilical vesicle. The heart, at this period of embryonic life, consists of a single cavity. At its upper end are given off the first aortic arches ; at its lower, the omphalo-mesenteric veins. The blood propelled from the heart passes into the body of the embryo through the aortic arches, and is then distributed to the vascular area of the umbilical vesicle by the omphalo-mesenteric arteries ; from the venous sinus of the area it is returned to the heart by the omphalo-mesenteric veins. Second. The foetal, allantoid, or placental circulation. To understand this subject properly it is necessary to study the structures peculiar to the circulatory apparatus of the foetus, viz., 1st, the ductus venosus, connecting the umbilical vein with the in- ferior vena cava ; 2d, the Eustachian valve, placed at the entrance of the inferior vena cava into the right auricle ; it turns the blood into the foramen ovale ; 3d, the foramen ovale, a large opening in the septum between the auricles ; and, 4th, the ductus arteriosus, connecting the pulmonary artery with the aorta; it enters the latter somewhat below the point at which the arteries of the head and upper extremities are given off. The blood from the placenta, rich with nutritive material and oxygen, is carried to the foetus by the umbilical vein ; after entering at the umbilicus the blood is divided into two currents. The larger current passes into the inferior vena cava through the ductus venosus, while the smaller one entering the liver is carried to the vena cava by the hepatic veins. The blood in the inferior cava, composed chiefly of pure blood from the placenta, goes to the right auricle, but the Eustachian valve turns the cur- rent through the foramen ovale into the left auricle, from which it passes into the left ventricle. The blood from the head and upper extremities passes into the right auricle through the superior vena cava, from which it enters the right ventricle. The heart contracting sends the blood from the left ventricle into the aorta, and from the right ventricle into the pulmonary artery. The blood from the left ventricle supplies the head and upper extremities ; that which enters the pulmonary artery from the right ventricle passes into the aorta through the ductus arteri- osus, somewhat below the point at which the arteries of the head and upper extremities are given off. The impure blood from the Digitized by Microsoft® 48 ESSENTIALS OF OBSTETRICS. right ventricle after entering the aorta supplies the trunk, lower extremities, and placenta; passing from the aorta into the internal iliacs, it enters the hypogastric arteries and thus is returned to the placenta. What organ receives the purest blood ? The liver. What changes take place in the circulatory apparatus after birth? 1. The ductus arteriosus begins immediately to contract after respiration is established, and is completely closed in from two to ten days; it degenerates into a cord connecting the left pulmonary artery to the arch of the aorta. 2. The foramen ovale is closed by the tenth day ; occasionally it remains permanently open, giving rise to a condition known as cyanosis neonatorum. 3. A portion of the hypogastric arteries remain pervious and are known as the superior vesical arteries. 4. The umbilical veins and ductus venosus are obliterated in from two to five days ; the former becoming the round ligament of the liver. What is the respiratory organ of the fetus ? The placenta. What are the proofs of this ? 1. The abundance of haemoglobin found in the blood. 2. The difference in color of the blood in the umbilical vein and arteries. 3. The temporary interruption in the placental circulation causes the blood in the umbilical vein to become dark. 4. Complete and permanent arrest of the placental circulation causes death by asphyxia. 5. Pulmonary respiration is the only substitute for placental. 6. Oxygen has been found in the foetal blood by spectroscopic examination. Digitized by Microsoft® PHYSIOLOGY OF THE FCETUS. 49 Describe the secretory organs of the foetus ? 1. The skin. The sebaceous glands begin to develop a short time before the fifth month, and their secretion is seen about two weeks later ; it becomes abundant during the sixth month. The vernix caseosa, seen during the latter part of the fifth month, is composed largely of epidermic scales and fat globules ; sebaceous matter also enters into its formation. The vernix caseosa prevents osmosis from the fcetal bloodvessels. The sudoriparous glands, developing later than the sebaceous, do not secrete during fcetal life. 2. The serous membranes. Hydrocephalus, hydrothorax, and ascites prove that these membranes secrete during intra-uterine life. 3. The intestinal mucous membrane, liver, and pancreas. The liver is developed about the fifth month, and forms bile, which passes into the small and large intestines. Meconium is a tena- cious, odorless, greenish, or black substance, consisting of the secretions of the liver, pancreas, and intestinal mucous membrane; it may also contain materials derived from the liquor amnii. 4. The kidneys. These organs secrete during the latter half of intra-uterine life, and it is probable that the foetus voids its urine into the liquor amnii. What is known as to the movements and sensations of the foetus ? The movements of the foetus are recognized by the mother at about four months and a half. It probably moves its upper and lower extremities as early as the sixteenth or even the twelfth week. As to whether foetal movements are reflex or voluntary is still a question of doubt. It is impossible for the foetus to see, hear, or smell. Taste is the earliest sense developed, and has been shown to exist in a child born at seven months. 4 Digitized by Microsoft® 50 ESSENTIALS OF OBSTETRICS. Fig. 15. Foetal head, as seen from above. (Hodge.) Fig. 16. OCCIPITOMENTAL' OCCIPITOFRONTAL, SUB-OCCIPITO-BREGMATIC 1 CERVICO-BREGMATIC. Anterior-posterior aod vertical diameters of the foetal head. (Tarnier et Chantreuil.) Fig. 17. BI-PARIETAL. BITEMPORAL. Microsoft® diagram showing transverse diameters of foetal head. (Tarnier et Chantreuil.) THE FffiTAL HEAD AND TRUNK. 51 The Foetal Head and Trunk, The Foetal Head. How is the foetal head divided ? Into the face and cranium. How is the cranium divided ? Into the vault and base of the skull ; the former is compressible, while the latter is incompressible. What are the peculiarities of the bones of the cranium ? 1. They are loosely united by membrane or cartilage. 2. They are flexible on account of incomplete ossification. 3. The mobility of the squamous portion of the occipital bone, which is united to the basilar portion by cartilage. Name the sutures of the foetal head. See fig. 15. The sagittal, fronto-parietal, and occipito-parietal. The sagittal suture extends from the root of the nose to the superior angle of the occipital bone; that portion situated between the two frontal bones is often spoken of as the frontal suture. The fronto-parietal separates the frontal and parietal bones ; it is also called the coronal suture. The occipito-parietal, or lambdoidal suture is placed between the occipital and parietal bones. What are the fontanelles ? See fig. 15. Membranous spaces formed by the intersection of the sutures. Name them. The anterior and the posterior fontanelles. The former is also called the bregma; it is large and quadrangular in shape, and is formed by the intersection of the sagittal and fronto-parietal sutures; it is easily recognized in labor. The latter is triangular in shape, and is formed by the junction of the sagittal with the occipito-parietal suture. It is obliterated in labor by the over- riding of the bones. Digitized by Microsoft® 52 ESSENTIALS OP OBSTETRICS. How are the diameters of the foetal head classified ? Into the antero-posterior ; the transverse; and the vertical diameters. Name them. See figs. 16 and 17. The antero-posterior are : the maximum ; the occipito-mental ; the occipito-frontal ; and the suboccipito-bregmatic. The transverse are : the biparietal ; bitemporal ; and the bimas- toid. The vertical are : the fronto-mental and the trachelo- or cervico- or laryngo-bregmatic. Between what two points are the diameters taken and what do they measure ? Maximum, from the chin to a point in the sagittal suture mid- way between the two fontanelles. Occipito-mental, from the superior angle of the occiput to the chin. Occipito-frontal, from the superior angle of the occiput to the root of the nose. Sub-occipito-bregmatic, from the union of the occiput with the neck to the middle of the bregma. Biparietal, between the parietal bosses. Bitemporal, between the extremities of the fronto-parietal suture. Bimastoid, between the mastoid processes. Fronto-mental, between the top of the forehead and the chin. Trachelo-bregmatic, from the middle of the bregma to the neck near the larynx. Maximum, 13f cm. (5£ in.). Bitemporal, 8 cm. (3.15 in.). Occipito-mental, 13J cm. (5 J in.). Bimastoid, 7| cm. (3 in.). Occipito-frontal, llf cm. (4£ in.). Fronto-mental, 8 cm. (3.15 in.). Suboccipito-bregmatic, 91 cm. Trachelo-bregmatic, 9£ cm. (3| (3f in.). in.). Biparietal, 9J cm. (3f in.). What does the great circumference of the foetal head measure ? 34$ cm. (13$ in.). Digitized by Microsoft® THE FCETAL HEAD AND TRUNK. 53 What does the small circumference measure? 31£ cm. (about 12f in.). What alteration of diameters occurs during labor ? In presentations of the vertex : 1. Lessening of the O.-M. and O.-F. diameters. 2. Lessening of the Sub-O.-B. and B.-T. diameters. 3. Slight lessening of the B.-P. diameter. 4. Increase of the M. diameter. 5. The B.-M., diameter remains unaltered. In presentations of the breech : There is little or no alteration of diameters. In presentation of the face : 1. Increase of the O.-M. and O.-F. diameters. 2. Lessening of the F.-M. and T.-B. diameters. What do you mean by flexion of the head ? A bending forward, the chin resting upon the chest. What do you mean by extension of the head ? A bending backward, the occiput coming in contact with the back of the fcetus. Does an extensive rotation of the head from side injure the cord or the ligaments ? No. The face may be turned almost directly posterior without any injury resulting; the larynx, however, may be injured. The Foetal Trunk. What are the diameters of the trunk? The bis-acromial, the dorso-sternal, the bis-trochanteric, and the sacro-pubic. What do they measure ? Bis-acromial, 12 cm. (4.7 in.) ; it can be compressed 2£ cm. (1 in.). Dorso-sternal, 9| cm. (3.7 in.). Bis-trochanteric, 8f cm. (about 3.5 in.). Digitized by Microsoft® 54 ESSENTIALS OF OBSTETRICS. Sacro-pubic, 2 inches ; increased to 4 inches by the flexion of the legs and thighs upon the abdomen. All of the diameters can be more or less compressed. The Attitude and Presentation of the Foetus. What is meant by the attitude of the foetus ? See fig. 18. "The general form and direction of the trunk, and the position of the limbs with reference to it" (Parvin). What are the causes of its attitude ? 1. The continuance of its embryonic form; its first distinct shape being that of a curve. 2. Pajot's law of accommodation : " When a solid body iscon- tained in another, if the container is the seat of alternate move- ment and rest, if the surfaces are slippery and little angular, the content constantly tends to accommodate its form and dimen- sions to the form and capacity of the container." What is meant by the presentation of the foetus ? " That part of the foetus which is in relation with the pelvic inlet" (Parvin). "That portion of the foetus which occupies the lower segment of the uterus " (Lusk). Does the foetus change its position in utero ? Yes. Especially in multipara ; it is common to find transverse presentations changing into normal ones, but rare for breech to change into head presentations. PUBERTY, NUBILITY, OVULATION, MEN- STRUATION, AND MENOPAUSE. What is puberty ? " Puberty is that epoch in human life when the individual first becomes capable of reproduction " (Parvin). At what age does it occur ? It occurs earlier in warm countries, later in cold climates. In Digitized by Microsoft® THE FCBTAL HEAD AND TRUNK. 55 Fio. 18. First cranial position. Fig. 39. Ovary with ripe oviaac. Digitized by Microsoft® 56 ESSENTIALS OF OBSTETRICS. temperate climates it usually occurs between the fourteenth and sixteenth years, in the largest number of girls occurring in the fifteenth year. It may occur as early as the tenth or eleventh year, or not until the eighteenth or twentieth. What changes occur in the female at puberty ? The breasts enlarge, the pelvis widens, hair appears on the mons veneris and labia majora, the body fills out, and the char- acter changes. Two functions are now established, viz., ovulation and menstruation. What is nubility 1 The period of fitness for reproduction. How old should a woman be to bear children ? Twenty years. What is ovulation? " The maturing and rupture of ovisacs, with the subsequent escape of ovules" (Parvin). Is ovulation periodical ? No. Is the discharge of an ovule periodical ? Yes, in all probability. Does ovulation occur during pregnancy and lactation? No ; it may, however, occur in rare cases. What changes take place in the ovary at the time of puberty ? See fig. 19. A number of the ovisacs begin to mature, and one of them, more developed than the rest, projects from the surface of the ovary; becoming greatly distended, it ruptures and the ovule escapes. The development of the ovisacs causes a congestion, and an increase in the vascular tension of the ovary. What are the causes of rupture of the ovisac ? 1. An increase of its contents, due either to the breaking down of the membrana granulosa, or to a fluid secreted by it. 2. A hemorrhage into the ovisac. Digitized by Microsoft® PUBERTY, OVULATION, ETC. 57 3. Fatty degeneration of the wall of the ovisac. 4. Contraction of the coat of the ovisac. 5. Contraction of the muscular fibres of the ovary. How is the ovule carried through the oviduct? 1. By the movements of the ciliae. 2. By the peristaltic contractions of the oviducts. What changes occur in the non-impregnated ovum ? The throwing off of polar cells, or globules. Describe this process. The germinal vesicle moves from the centre to the periphery of the ovule, and a portion projecting beyond it becomes constricted and is thrown oif ; this is repeated several times. What is the corpus luteum ? The corpus luteum, or yellow body, is the result of certain changes which take place in the ovisac subsequent to its rupture and the escape of its contents. How is the corpus luteum formed ? The edges of the tear in the wall of the ovisac become glued together by an exudation. The internal layer of the ovisac becomes hypertrophied, while the external layer contracts, thus throwing the former into folds, which, eventually coming in contact, unite and obliterate the sac. The hypertrophy of the inner layer is due to the development of cells; the granules which they contain mul- tiply and are converted into globules. How are the corpora lutea divided ? 1. Corpora lutea of menstruation. 2. Corpora lutea of pregnancy. What is the history of the corpus luteum of menstruation ? It reaches its greatest size in from ten to thirty days, and then takes on atrophy ; by eight or nine weeks nothing remains but a cicatrix. What is the history of the corpus luteum of pregnancy ? It reaches its greatest size in from thirty to forty days, and Digitized by Microsoft® 58 ESSENTIALS OF OBSTETRICS. remains without any change until the beginning of the fifth month, when it slowly decreases in size until the end of pregnancy, at which time it is two-thirds its largest dimensions ; one month after labor it is obliterated. What is the value of the corpus luteum of pregnancy as a sign of conception? Of very little value, as its characteristics are not constant. How is the ovule carried to the oviduct ? It is directed along the groove of the tubo-ovarian ligament by the cilise and also by the current produced by the cilise of the ampulla. Some authorities teach~that the fimbriated extremity of the ovi- duct grasps the ovary, and that the ovule is shot, as it were, into its proper course ; this is not generally accepted. What surrounds the ovule as it escapes from the ovisac ? The discus proligerus; an accumulation of the cells-forming the membrana granulosa. What is meant by external migration of the ovule ? The entrance of the ovule into the oviduct of the opposite side from the ovary from which it escaped. How is this explained ? By the current produced by the cilia? being stronger on the opposite side ; in some cases by an occlusion of the tube on the same side. The ovum passes over behind the womb. What is menstruation ? "A temporary and intermittent function of the female organ- ism ; it has for its most obvious phenomenon a discharge of blood from the genital canal." (Parvin.) How are the phenomena of menstruation divided ? 1. General phenomena. 2. Local phenomena. What are the general phenomena ? Chilliness ; flashes of heat ; pain in different parts of the body; Digitized by Microsoft® PUBERTY, OVULATION, ETC. 59 and , in some cases, hysteria. Some women are sleepy, and but few care for active exercise. Among other symptoms which may be noted as occurring in some cases, are diarrhoea, irritability of the bladder, a dark circle under the eyes, swelling and painful sensa- tions in the breasts, and a sense of fulness in the head. What are the local phenomena ? The changes in the ovary have already been described; they consist in the enlargement and congestion of the organ and the rupturing of an ovisac. The uterus becomes greatly congested and increased in size; the cervix becomes softer and violet-colored, and the external os and internal os are open. The mucous mem- brane of the cavity is greatly congested and swollen ; it becomes folded, and the surface presents an irregular appearance. The glands secrete abundantly. The epithelium loosens and is de- tached; the capillaries, no longer supported, rupture, and the blood escapes. The oviducts become congested, their walls thicken, and blood sometimes escapes into them. The vagina becomes of a violet color, its secretion more abundant, and its temperature slightly elevated. The external organs are swollen, and occasionally there is a pruritus. What is the source of the hemorrhage ? From the mucous membrane of the cavity of the uterus, and also probably from the oviducts. Is the entire mucous membrane of the uterus thrown off during menstruation ? Williams believes that the mucous membrane is entirely removed down to the muscular fibres ; Kundrat and Engelmann hold that only the superficial layer is thrown off; and M&ricke claims that none is shed at a menstrual period. What causes rupture of the capillaries ? 1. Great distention. 2. Fatty degeneration, with removal of the superficial epithe- lium of the uterine cavity. What is the character of the flow ? At first it is pale, consisting chiefly of mucus, with a slight Digitized by Microsoft® 60 ESSENTIALS OF OBSTETRICS. amount of blood; later it becomes bright red, and, finally, at the close of menstruation it lessens in quantity, and becomes pale again. The discharge is non-coagulable. This is due to its ad- mixture with the glandular secretions, and also on account of being defibrinated. It has a peculiar odor, and is alkaline in re- action ; the odor is probably due to retention, or to admixture wrth the secretions. What is the quantity of the flow ? From four to six ounces. What is the duration of the flow ? Generally from three to four days* How often does the flow recur ? Every lunar month, or twenty-eight days. Is it necessary for every healthy woman to follow a certain average as to the quantity, duration, or recurrence of the flow ? No ; " every woman is a law unto herself." Cases are on record of women who were in perfect health, menstruating every forty- eight days ; again, two cases where the flow occurred only two or three times a year ; this cannot be called normal, however. What causes influence the first appearance of menstrua- tion? 1. Climate. 2. Eace. 3. Residence. 4. Heredity. 5. Genital sense. What is the genital sense ? ''The greater or less vigor shown in the development of ovisacs;" the sexual desire. Does menstruation occur during pregnancy and lactation ? No ; except in rare cases. Digitized by Microsoft® PUBERTY, OVULATION, ETC. 6i What is the connection between ovulation and menstrua- tion? Ovulation is independent of menstruation, but menstruation is dependent upon ovulation — i. e., the development of many ovisacs, not the periodical rupture of one. The reflex irritation caused by ovulation produces congestion of the organs of generation, which, continuing, is relieved by men- struation. Thus we have a condition of plethora followed by that of anaemia; ovarian irritation continuing, hypersemia again takes place, to be relieved later on by menstruation. What is the menopause ? "The end of menstrual life." When does it occur ? There is no definite time ; in the majority of cases from forty- five to fifty years of age. What effect has the time of puberty upon the appearance of the menopause ? If puberty comes on early the menopause usually appears late, while delayed puberty indicates an early end of menstrual life. What are some of the symptoms at the time of the meno- pause ? The menstrual flow does not stop suddenly, but becoming irreg- ular, and after a time ceasing, it begins again after several months, and finally ceases altogether. At this time there are apt to be congestions of the head, lungs, and especially of the liver; the breasts and abdomen may enlarge, and the woman imagines her- self pregnant. Later, atrophy of the external and internal or- gans of generation takes place, and the woman loses, as it were, her sex. Can pregnancy occur after the menopause ? Yes; as ovulation may continue, in some cases, for several months or years. Can pregnancy occur prior to menstruation ? Yes ; as ovulation may begin, in some cases, before the appear- ance of the menstrual flow. Digitized by Microsoft® 62 ESSENTIALS Of OBSTETRICS. Fig. 20. Spermatozoa from the human subject (magnified eight hundred diameters^. (Luschka.) Fig. 21. Uterus of a multipara at term.— a, a', Eraune's orifice; d, rf', Muller's ring; o, , urethra; i?, vagina ; F, rectum. Fig. 24. Hydatidiform degeneration of the chorion. Digitized by Microsoft® DISEASES OF PREGNANCY. 93 What are the results of the retention of urine ? In six days the mucous membrane of the bladder sloughs; in ten days perforation occurs. What is sacculation of the uterus? A rare termination of incarceration in which the free wall of the uterus distends without rupture to accommodate the growing foetus. What is the treatment of incarceration ? The indication is to replace the uterus. The bladder and bowels should be evacuated, the former with a catheter ; if this is found to be impossible, then aspirate about three inches above the pubes. In a number of cases spontaneous restitution occurs after the bladder is emptied ; if this does not occur, then the uterus must be replaced. If the uterus is bound down by adhesions and cannot be restored, then abortion must be induced. To restore the uterus place the patient in the knee-chest position and make steady pressure upon the fundus with two fingers either in the vagina or rectum. Another plan is the " push and pull " method already referred to. In cases requiring the use of an anesthetic, place the patient in Sims' latero-prone position and make pressure upon the fundus of the uterus by means of four fingers introduced into either the vagina or rectum. Playfair, in cases of incarcera- tion, advises the use of a rubber bag introduced into the vagina and filled with water ; the water must be let out every few hours to allow the woman to empty the bladder. Generally the uterus is replaced in twenty-four hours by this method. After the uterus has been replaced, the patient should wear a pessary ; a relapse is not likely to occur. Diseases of the Ovum. Myxomatous Degeneration of the Placenta, or Hydatidiform Mole. What is the morbid anatomy ? See fig. 24. It is a disease of the chorial villi. A great number of cyst-like formations are found, varying in size from a millet-seed to a walnut; the cysts are of many different shapes. The investing epithelium of the villi and their contents undergo hypertrophy and mucoid degeneration. The pedicle of a cyst contains the Digitized by Microsoft® 94 ESSENTIALS OF OBSTETRICS. same tissue as Wharton's jelly of the umbilical cord. The cysts contain albumen and mucin, which resemble in appearance the liquor amnii. If the disease occurs before the second month, the degeneration involves the entire surface of the chorion, resulting in the death - of the embryo, which undergoes solution, leaving the amniotic cavity empty ; the vessels of the villi are obliterated. If the dis- ease occurs after the placenta begins to form, the degeneration is limited to the placental part of the chorion ; although in some cases cysts are found in other parts. If the degeneration be suffi- cient to destroy the foetus, it becomes disintegrated and is found in the amnion cavity. If only a portion of the placenta is involved, the foetus may go to term; the uterus may contain, occasionally, a healthy foetus together with an hydatidiform mole. An hydatidiform mole resembles in appearance a bunch of grapes or currants. Eetention of the placenta or rupture of the uterus may occur in this disease, caused by the degenerated villi penetrating into the uterine sinuses. What is the etiology of hydatidiform mole ? The disease is less frequent in primiparse than in multipara ; it is more frequent in women of advanced age; it generally occurs during the first months of pregnancy, but it cannot occur after the latter part of the third month. The exciting causes of this disease are as yet unsettled. They may be maternal in origin or due to disease of the ovum. In proof of the former theory may be mentioned the frequent recur- rence of the condition in the same woman, and its frequent asso- ciation with uterine fibroids and with a carcinomatous or syphilitic dyscrasia. The probability of the latter theory is supported by the fact that a healthy foetus is occasionally found associated with a hydatidiform mole. Again, cases occur in which the death of the foetus cannot be accounted for by the degeneration of the villi on account of the limited extent of the disease. Spiegelberg believes the disease to be due to an abnormal development of the allantois. Describe the symptoms. 1. Rapid enlargement of the abdomen. Digitized by Microsoft® DISEASES OF PREGNANCY. 95 2. Attacks of hemorrhage, or a muco-sanguinolent discharge: 3. Expulsion of vesicles. 4. Doughy feel of the uterus on palpation. 5. Obscure fluctuation. 6. The foetal members cannot be recognized by palpation. 7. The lower segment of the uterus is tense. 8. Lumbar and sacral pains. 9. The foetal heart sounds cannot be heard. 10. Ballottement is prevented. The diagnosis is made by the above subjective and objective symptoms ; the discharge of vesicles is the only certain symptom. What is the prognosis ? The patient never goes to term and the foetus in nearly all cases dies. The danger to the mother is from hemorrhage and sepsis. What is the treatment ? If the hemorrhage is slight, no active treatment is advised. Place the patient at rest, and give cold drinks and opium. If the hemorrhage is grave, then introduce a tampon and give ergot. , If the hemorrhage returns, then the indication is to dilate the cervical canal and empty the uterus. The dilatation of the cervix may be accomplished by the finger, or by Barnes's or Tarnier's dilator. The use of tents increases the dangers of septicaemia. After the uterus is emptied of its contents, wash out the cavity with a warm solution of corrosive sublimate, 1 part to 3000. If hemorrhage occurs, apply the perchloride of iron. The after-treatment consists of rest and the administration of ergot. The use of Thomas's dull-wire curette is advised in cases where there is a persistent hemorrhage. Polyhydramnios. What is polyhydramnios ? An excess in the amount of liquor amnii. What is the etiology of polyhydramnios ? There are various theories, as follows : 1. Patulous condition of the vasa propria. Digitized by Microsoft® 96 ESSENTIALS OF OBSTETRICS. 2. Disease of the foetal heart, lungs, or liver. 3. Increased activity of the kidneys. 4. Changes in the maternal circulation. 5. A morbid condition of the decidua, chorion, or amnion. 6. Syphilis. The disease is more frequent in the multigravida than in ihe primigravida. How many forms of the disease are described ? Two : an acute and chronic form. What are the symptoms of polyhydramnios ? 1. Rapid development of the uterus. 2. The uterine walls are tense and elastic. 3. Obscure sense of fluctuation. 4. Foetal heart sounds faint or absent. 5. Foetus cannot be recognized by palpation. 6. The cervix is high up and more or less shortened. 7. The foetus moves from one position to another with great ease. Other symptoms are : dyspnoea, palpitation of the heart, irrita- bility of the stomach, oedema of the lower extremities, and inguinal, lumbar, sacral, and abdominal pains. The symptoms occur, as a rule, about the fourth or fifth month ; in some cases earlier. The accumulation of fluid is gradual. In the acute form the accumulation of fluid may take place in a few days ; in addition to the symptoms of the chronic form, fever, vomiting, and intense pain, are present. What is the diagnosis ? The diagnosis depends upon the subjective and objective symp- toms already described. Braxton Hicks's sign is of great value in determining the existence of pregnancy. Polyhydramnios may be mistaken for a multiple pregnancy. What is the prognosis ? Very grave for the child ; nearly one-fourth die. The prognosis for the mother is favorable, unless the disease is associated with an organic affection of the heart. The danger of post-partum hemor- rhage should not be forgotten. Digitized by Microsoft® ABORTION. 97 How is the treatment divided? Into 1, the expectant plan ; 2, the active plan. The former consists in the use of an abdominal supporter, and refraining from active exercise. The latter, or active plan of treatment, is indicated whenever grave symptoms are present, due to over-distention, and when there are serious disturbances of the mother's heart. The indication is to induce abortion or premature labor. The membranes should be punctured high up, and in the interval of the pains. The hand should be used as a plug in the vagina to prevent the rapid discharge of the liquor amnii. If the presentation is normal, leave the further progress of the case to nature; turning is indicated if the foetus presents by the shoulders. Prophylactic measures should be taken against post- partum hemorrhage. Abortion. What is abortion ? " Abortion, or miscarriage, is the expulsion of the product of conception before the time that the foetus is viable" (Parvin). How is abortion divided ? Into 1. Ovular ; during the first three weeks. 2. Embryonic ; up to the fourth month. 3. Foetal ; subsequent to the fourth month. How is abortion classified ? Into 1. Spontaneous. 2. Artificial ; subdivided into (a) Therapeutic. (b) Criminal. According to some authorities, the term abortion is used when the ovum is expelled during the first three months ; subsequent to the third month up to the time of viability, the term miscarriage is employed. What is meant by the term incomplete abortion? The expulsion of the embryo or foetus without the membranes or placenta. Digitized by Microsoft® 98 ESSENTIALS OF OBSTETRICS. What is meant by the term missed abortion ? The death of the fetus not followed, within two weeks, by its expulsion. At what period of pregnancy do abortions usually occur ? Spontaneous abortions generally occur in the first three months; and, as a rule, at a time corresponding with what would have been a monthly flow. Criminal abortions usually occur from the third lo the sixth month. How are causes of abortion divided ? Into the paternal, maternal, and ovular causes. What are the paternal causes ? 1. Syphilis. 2. Alcoholism. 3. Exhausting chronic diseases. 4. Working in sulphur. 5. Sexual excesses. 6. Old age or extreme youth. 7. Lead-poisoning. How are the maternal causes divided 1 Into external and internal causes. What are external causes ? 1. Violent exercise. 2. Traumatisms ; accidental or intentional. 3. Tight corsets. 4. Pressure upon varicose veins. 5. Surgical operations. 6. Coition. 7. High altitudes. 8. Hot vaginal injections and baths. What are internal causes ? 1. Infectious diseases (acute). Abortion due to (a) High temperature. (b) Hemorrhagic endometritis. (c) The infection of the fcetus. 2. Chronic diseases, especially syphilis. Digitized by Microsoft® ABORTION. 99 3. Causes due to the uterus, (a) Displacements. (6) Endometritis. (c) Structural disorders. 4. Pelvic adhesions. 5. Tumors. 6. Lead-poisoning. 7. Working in tobacco. 8. Organic diseases of the kidneys. 9. Sneezing, coughing, vomiting, diarrhoea, and dysentery. 10. Mental emotions. 11. Emmenagogue medicines. What are the ovular causes ? Any of the diseases which may cause the death of the embryo or foetus, such as 1. Diseases of the decidua. 2. Diseases of the placenta. (a) Apoplexy. (fi) Inflammation. (c) Fatty degeneration. (d) Syphilis. (e) Myxomatous degeneration. 3. Polyhydramnios. 4. Placenta prsevia. 5. Infectious diseases. 6. Diseases and compression of the cord. Are some women liable to a recurrence of abortion ? Yes. Habit is not to be regarded as a factor ; it is always due to the original predisposing cause still acting. How are the symptoms of abortion classified ? Into premonitory and characteristic symptoms. What are the premonitory symptoms ? These are rarely absent after the second month. They are pel- vic weight and fulness, pains in the lumbar and sacral regions, irritability of the bladder or rectum, alternate sensations of chilli- Digitized by Microsoft® 100 ESSENTIALS OF OBSTETRICS. ness and heat, and a feeling of malaise ; the secretions of the vagina are also increased. What are the characteristic symptoms ? Hemorrhage and painful uterine contractions. Abortions occurring in the first two months resemble a profuse menstrual flow, associated with dysmenorrhcea. The pain is caused by uterine congestion and by the expulsion of clots. These symp- toms continue for four or five days, and the product of conception is expelled from the vagina, surrounded by clots, or in fragments, along with the decidua. In abortions occurring prior to three months, the ovum, as a rule, is expelled entire ; subsequent to three months, the ovum generally ruptures and the foetus is expelled, while the appendages are retained for a greater or less length of time. Hemorrhage is less likely to occur the nearer the abortion takes place to the seventh month. The uterine decidua is more easily thrown off in late than in early abortions. After the placenta is formed the source of the hemorrhage is from the placental site; but before, it is from the entire surface of the uterine cavity. What are the immediate dangers of abortion ? 1. Hemorrhage with extreme anaemia. 2. Septicaemia. 3. Tetanus (rare). What are the remote dangers ? 1. Chronic parenchymatous metritis (subinvolution.) 2. Placental polypus. 3. Misplacements of the uterus. Under what conditions is an abortion inevitable ? 1. Death of the embryo or foetus. 2. An extensive detachment of the ovum. 3. Rupture of the ovum. How is a beginning abortion recognized ? By the painful uterine contractions, hemorrhage, dilatation of the cervix, and the ovum felt through the os uteri. Digitized by Microsoft® ABORTION. 101 How is the treatment of abortion divided ? 1. The prophylactic treatment. 2. The treatment of threatened abortion. 3. The treatment of inevitable abortion. What is the prophylactic treatment ? This consists in treating the cause of an abortion. Either syphilis, or retroflexion of the uterus, or endometritis, is most frequently found to be the cause in frequently recurring abortions. The patient should avoid all active exercise, especially during that period of gestation in which she has been in the habit of aborting. She should also rest at the time of the menstrual epochs. Sexual intercourse is often the cause of an abortion and should be forbidden. Sir J. Y. Simpson recommended the chlorate of potas- sium in certain diseases of the placenta ; it may be given in doses of ten to twenty grains three times daily. In cases of habitual abortion the fluid extract of viburnum prunifolium has been ad- vised ; it may be given three times daily in doses of half a tea- spoonful to a teaspoonful. The danger of abortion occurring is greatly lessened after the fourth month. What is the treatment of threatened abortion ? In all cases occurring in the early months of pregnancy there should be an examination made to ascertain the position of the uterus. If it is found retroflexed or retroverted, it should at once be replaced. The general treatment of threatened abortion is as follows : The patient should be placed in bed with light covering, and given cold drinks ; laudanum should be administered per rec- tum (twenty drops) every hour for three or four hours if the uterine contractions continue. Suppositories of opium may be used in place of laudanum. If there be restlessness and excitement, give twenty to thirty grains of chloral along with one of the injections of laudanum. The urine should be voided in the bed-pan at reg- ular intervals ; the bowels should be emptied every other day by means of an injection, or by a mild laxative. The patient should remain in bed for a week after all symptoms have disappeared. If there be a recurrence of the symptoms, she should immediately return to bed. Digitized py Microsoft® 102 ESSENTIALS OF OBSTETRICS. What are the indications and the treatment of inevitable abortion ? To control the hemorrhage and to empty the uterus. To meet these indications the tampon should be used, and left in the vagina for eight hours or more. If the hemorrhage is grave, tampon the entire vagina, and apply a T-bandage; if slight, tampon only the upper third of the vagina. The tampon may remain twelve or twenty-four hours, when it must be re- moved ; if the hemorrhage continues, it should be repeated. Generally after the removal of the tampon the ovum will be found in the vagina, or it may have descended into the cervical canal; in the latter case the ovum forms a plug, and it may now be necessary to repeat the tampon ; compression of the uterus, under these circumstances, will, in some cases, expel the ovum. Great care should be taken in the first three months not to rupture the ovum, as there would be great danger, if the accident occurred, of the abortion being incomplete. Before using the tampon empty the bladder, and wash out the vagina with a solution of corrosive sublimate, 1 part to 2000 ; the balls of absorbent cotton first intro- duced into the vagina should be dipped in carbolized water or covered with iodoform. After the removal of the tampon, again wash out the vagina with the solution of corrosive sublimate. In abortion occurring in the first two months, no active treat- ment, as a rule, is necessary ; the patient should be kept at rest in bed for several days. In cases of complete abortion active treatment is rarely necessary ; the ovum forms a plug which occupies the cervical canal and con- trols the hemorrhage. What are the uses of the tampon in the treatment of abortion ? 1 . To control hemorrhage. 2. To stimulate, contractions of the uterus. 3. To assist in the separation of the ovum from the uterus by allowing blood to accumulate between them. What is the treatment of an incomplete abortion in the first three months ? 1. The expectant plan ; or 2. The active plan. Digitized by Microsoft® ABORTION. 103 Those who follow the expectant plan of treatment advise waiting until the appendages have been separated from the uterine cavity ; this is indicated by hemorrhage followed in a day or two by an offensive discharge. The os is then dilated with Hegar's hard- rubber dilators, and the uterine cavity washed out with a warm solution of corrosive sublimate, 1 part to 3000. Next one or two fingers are introduced into the uterine cavity, at the same time making firm pressure externally with the other hand upon the fundus of the uterus ; or the uterus may be drawn down with the volsella, and then the fingers introduced. After detaching the membranes they are carried down to the os uteri where they can be seized by the finger and thumb and withdrawn. If the digital method fails, Emmet's curette forceps should be used. After the appendages have been entirely removed, Churchill's tincture of iodine should be applied to the uterine cavity. Those who employ the active plan of treatment immediately empty the uterus of the retained appendages by means of either forceps or curettes. The strictest antiseptic precautions should be employed in the treatment of incomplete abortion. The hands and instruments should be rendered thoroughly aseptic ; the vagina and uterine cavity should be washed out with a solution of corrosive sublimate before and after the removal of the remains of the ovum. What is the indication for treatment in an incomplete abortion subsequent to the fourth month ? To empty the uterus. Expression of the uterus will generally cause the placenta and membranes to be expelled ; other cases require dilatation of the os and the use of the fingers or the curette forceps. Should the uterine cavity be washed out with an antiseptic solution after a complete abortion ? No; not unless symptoms of septicaemia occur. The uterus should only be irrigated in those cases requiring the introduction of the fingers or instruments into its cavity. Digitized by Microsoft® 104 ESSENTIALS OP OBSTETRICS. What antiseptic precautions should be taken after an abortion ? The vagina should be washed out with a warm solution of cor- rosive sublimate, 1 part to 2000, immediately after the ovum is expelled. The external organs should be bathed twice a day with a solution of corrosive sublimate, and kept covered with corrosive sublimate gauze. What is the after-treatment of abortion ? The patient must remain at rest in the recumbent position for the same length of time as after a labor at full term. What is the indication for treatment in missed abortion ? To empty the uterus. Ectopic Development of the Ovum. How is ectopic gestation divided ? Into 1. Primitive cervical pregnancy. 2. Extra-uterine pregnancy. What is primitive cervical pregnancy ? The arrest and development of the ovum in the cervical canal; this variety of ectopic gestation is very rare, and abortion occurs in the first three months. What are the varieties of extra-uterine pregnancy ? 1. Tubal. (a) Interstitial. — Tubo-uterine. (6) Tubo-abdominal. (e) Tubo-ovarian. (d) Pregnancy in the rudimentary cornu of a one-horned uterus. 2. Abdominal. (a) Primary. (b) Secondary. 3. Ovarian. Describe the cause, course, and termination, of tubal preg- nancy. See figs. 25 and 26. Cause.— Inflammations of the mucous membrane associated with Digitized by Microsoft® ECTOPIC PREGNANCY. Fio. 25. Pig. 26. 105 If"- '&%;& Diagrammatic section of Fallopian tube representing the two directions of rup- ture. 2, into the peritoneal cavity ; 3, into the cavity of the broad ligament ; a, clot at point of rupture ; &, wall of Fallopian tube ; c, cavity of the broad ligament with (3) folds separated by hamic effusion, a. (Tait.) Fig. 27. Diagrammatic representatifi^fflfzfetf^J M. at time of rupture 106 ESSENTIALS OF OBSTETRICS. loss of the cilise ; dilatation and hernial pouches ; flexions and constrictions; polypus; pelvic tumors pressing upon the tube, and occlusion due to inflammation. In cases of complete occlusion there is a transmigration of the spermatozoids ; cases of trans- migration of the ovule occur in some cases. The tube may be large enough for the spermatozoids to enter, but too small to allow the ovum to pass through. Cases are recorded of two ovules pass- ing through the tube at the same time, the one in advance blocking the way of the other; the former developing in the uterus, the latter in the tube. Course. — The mucous membrane of the tube undergoes hyper- trophy, and the villi become attached to it. Generally the uterine and abdominal openings are closed ; in some cases the uterine opening remains patulous. The villi of the chorion forming the placenta penetrate to the muscular coat. At the beginning of pregnancy the muscular coat of the tube thickens, but later on it becomes thin, due to the stretching caused by the ovum. Termination. — Rupture usually occurs within the first two or three months ; in some cases the pregnancy may go on to term. After rupture the entire ovum, or only the embryo or foetus may escape into the abdominal cavity, or in some cases the entire ovum may remain in the tube. Rupture, in many cases, is followed by death caused either by internal hemorrhage or peritonitis. Recovery may occur when the product of conception dies prior to rupture. Rupture may occur between the folds of the broad liga- ment; this is an extra-peritoneal or broad-ligament pregnancy. Describe the course of an interstitial pregnancy. See fig. 27. This variety of extra-uterine pregnancy is also known as tubo- uterine. The ovum is developed in that portion of the oviduct which passes through the wall of the uterus. In the beginning of pregnancy the muscular tissue undergoes hypertrophy, and forms a sac around the ovum. As a rule, the ovum develops more rapidly than the muscular tissue, and rupture takes place generally prior to the third month; in rare cases gestation may go on to term. When the ovum is situated near the uterine cavity it may be expelled into the uterus and abortion follow. Digitized by Microsoft® ECTOPIC PREGNANCY. 107 Describe the course of tubo-abdominal and tubo-ovarian preg- nancies. Tubo-abdominal. — The ovum is developed in the ampulla of the oviduct and growing outward extends into the abdominal cavity. It is surrounded by the broad ligament, the ovary, the mesentery, the bladder, the intestines, and the uterus, which are all bound together by a plastic exudation, the result of a local peritonitis. In the beginning of gestation the ovum descends into Douglas's cul-de-sac. The external covering of the ovum in advanced preg- nancy may include the liver, kidneys, and spleen. The placenta is, as a rule, formed in the pelvic cavity. Tubo-ovarian. — The external sac of the ovum is formed by the oviduct and ovary, which are surrounded and bound together by an inflammatory exudation. In both of the above varieties of extra-uterine gestation their course and termination are like those of an abdominal gestation. Describe the course of pregnancy in the rudimentary cornu of a one-horned uterus. See fig. 28. This variety is in close anatomical relation with the tubal form. Rupture, as a rule, takes place between the third and sixth months. Tbe apex of the horn is the portion in which rupture takes place. In a case reported by Turner, pregnancy continued on to term. In a case cited by Koeberle, the fetus died during the fifth month, and was formed into a lithopffidion. The formation of the placenta is more perfect in this variety of extra-uterine gestation. Describe the course of abdominal pregnancy. See fig. 29. This variety is divided into primary and secondary abdominal pregnancy. The former is very rare ; the latter begins at first as one of the varieties of tubal pregnancy. The sac usually contains muscular fibres. The placenta may be attached to any of the abdominal or pelvic organs. Cases are on record of the ovum being free in the abdominal cavity, i. e., not surrounded by pseudo- membranes. The pregnancy, in many cases, goes to term, when the foetus dies and either becomes cartilaginous or is converged into a lithopsedion or into adipocere ,-j ttyc¥»vuvn( being retained for many months or even years. On the other hand^ Sjiippuratjou Way> Digitized by Microsoft® | 11 1: U '\ 108 ESSENTIALS OF OBSTETRICS. Fig. 28. Gestation in rudimentary horn of uterus, ,4, developed right horn ; B, rudimen- tary horn, with a rent through which the embryo had escaped ; 1, right Fallopian tube; 2, left Fallopian tube; 3, left ovary ; 4, 5, right ovary and corpus luteuiu ; 6, round ligament. Fig. 29. Uterus and. fat us in a qase of abdominal pregnancy. Digitized by Microsoft® ECTOPIC PREGNANCY. 109 occur, and the cyst rupture into the bowel or bladder, or discharge its contents through the abdominal wall. Describe an ovarian pregnancy. In this variety the fecundation and growth of the ovum, take place within the ovisac. In some cases the ovum may pass through the opening caused by the rupture of the ovisac, and thus lie almost entirely within the abdominal cavity. In ovarian preg- nancy rupture usually takes place in three or four months ; rarely the gestation may go to term. What are the symptoms of extra-nterine gestation? It is convenient to divide the symptoms into three periods, as follows: 1, to the end of the fourth month, i. e., up to the time when the sac usually ruptures ; 2, from the fourth month to the completion of spurious labor ; 3, from the completion of the labor to a period subsequent to the death of the fcetus (Parry). First Period. — During the first six weeks the symptoms of intra- uterine pregnancy may be present, more or less modified. Men- struation usually ceases, the uterus enlarges up to a certain point, and a decidua is formed ; a plug of mucus fills the cervix. The changes in the mammary glands occur ; there is gastric irritability, and there is a deposit of pigment matter. The enlargement of the uterus is greatest in the interstitial variety. From the second to the fourth month severe intermittent pains occur in the hypogas- trium. They are associated with great prostration or syncope; these symptoms may last for several hours or days. The pains are probably due to either a local peritonitis, to contractions of the uterus, or to stretching of adhesions. During this period frequent discharges of dark, clotted blood occur from the uterus; in some cases portions of the decidua are found mixed with the discharge. A vaginal examination, after the first six weeks, shows the uterus to be enlarged and displaced ; usually forward, in some cases upward, or laterally. On the side, or behind the uterus, is felt a cystic tumor more or less tender to the touch. It is some- what immovable, and in some cases ballottement and a feeling of obscure fluctuation can be detected. Second Period. — The attacks of pain lessen in frequency or dis- appear. The bloody discharges from the uterus either cease Digitized by Microsoft® 110 ESSENTIALS OF OBSTETRICS. altogether or are greatly lessened. The movements of the foetus are felt, generally en one side. The foetal heart-sounds are dis- tinctly heard, and the foetus may be recognized by touch. The abdomen is perceptibly enlarged, more on one side of the median line than on the other. The uterus becomes fixed and displaced higher up. An examination per vaginam reveals a fluctuating tumor containing a solid which gives the sign of ballottement. In some cases the fcetus can be recognized. The tumor causes irrita- bility of the bladder and rectum. Third Period. — This period is characterized at full term by a spurious labor. The pains closely resemble those of the first stage of normal labor. After continuing for several hours or days they cease. Associated with the spurious labor there is a bloody discharge from the vagina containing, in some cases, portions of the decidua. Fourth Period. — The death of the child follows the false labor. A few minutes prior to its death very active movements are ob- served. After the death of the child the liquor amnii is absorbed, and the abdomen lessens in size. This diminution in size continues and becomes permanent if decomposition does not take place. On the other hand, if decomposition occurs, symptoms of suppuration intervene. If an extra-uterine pregnancy continues to the fourth or fifth month, what variety is it likely to be ? An abdominal or ovarian ; it is almost certain not to be a tubal. What are the symptoms of rupture of the cyst? The patient complains of griping pains in the lower part of the hypogastrium, which are followed by a sudden pain of great severity; there is often a feeling as if something had ruptured inside the abdomen. These symptoms are followed by great prostration and collapse. Death rapidly ensues or the patient slowly recovers from the collapse, and peritonitis sooner or later follows. What is the treatment of extra-uterine gestation? 1. Methods to destroy the life of the embryo or fcetus. Puncture.— This consists in evacuating the liquor amnii by puncturing the cyst with a trocar, introduced either through the Digitized by Microsoft® PLACENTA PREVIA, 111 Fia. 30. Fio. 31. Diagram showing the unavoidable placental separation as a consequence of cervical dilatation. Vaginal tampon in placenta prgevia. A, deeply placed dossils to each of which a cord is attached ; B> superficial dossils ■without cord ; C, pledget of charpie or pad of cotton; X>, T-bandage. (Bailly.) Digitized by Microsoft® 112 ESSENTIALS OF OBSTETRICS. rectum or vagina. The operation is not recommended on account of the great danger to the mother; cases are recorded where the pregnancy continued after the operation. Injections into the Oyst. — This plan is both uncertain and danger- ous. Morphia and atropia are the drugs usually employed. Electricity. — This consists in the use of the faradic or galvanic current. It may be a successful method, but is objectionable on account of subsequent fatal suppuration. One electrode is intro- duced into either the rectum or vagina, the other upon the abdom- inal wall. The treatment may be employed daily for from five to ten minutes, and continued until lessening in the size of the cyst indicates that the death of the foetus has been accomplished. 2. The radical (operative) treatment. The only method advised. The indications for abdominal section are summarized by J. Creig Smith, as follows : (a) "In all cases before the period of expected tubal rupture (2| to 3J months) ; in fact, -as soon as the condition has been dis- covered." (6) "In all cases of tubal rupture, as soon as possible after the condition has been diagnosed." (c) " In all cases up to the fifth month in which the foetus con- tinues to live. Between the fifth month and the period of false labor, operation is not advisable." (d) " In all cases after false labor when the child is dead and the amnion absorbed. If suppuration takes place, operation is im- perative ; if the foetus is quiescent, operation, though advisable in the view of preventing further trouble, is not urgent. Absorption of the amnion is waited for, because this indicates cessation of circulation in the placenta." (e) " In all cases where the condition endangers the life of the mother." Placenta Prsevia. What is placenta prsevia ? See fig. 30. The insertion of the placenta " to that part of the womb which always dilates as labor advances " (Rigby) — the lower segment. What are the varieties of placenta prsevia? 1. Central, in which the centre of the placenta is directly over the internal os uteri. Digitized by Microsoft® PLACENTA PREVIA. 113 2. Partial, where there is more placental tissue on one side of the os internum than on the other. 3. Marginal, where the edge of the placenta reaches down to, but not over, the internal os uteri. 4. Lateral, where the edge of the placenta is near the os uteri. How often does it occur? Once in about 1200 cases. What is the hemorrhage resulting from placenta prsevia called ? Unavoidable hemorrhage. What are the causes of placenta prsevia ? Authorities do not agree as to the cause. The following are some of the theories : The ovule does not become fecundated until it reaches the lower part of the cavity of the uterus ; the impregnated ovum is not arrested in the upper part of the uterus on account of the mucous membrane not being sufficiently swollen; a deviation in the shape or size of the uterine cavity ; uterine contractions may force the impregnated ovum down to the lower portion of the uterus; the oviducts may open near the internal os uteri ; downward growth of the decidua. It is more frequent in multipara than in primiparse (six to one), and in the poor than in the rich ; rapidly succeeding preg- nancies and abortions also predispose to placenta prsevia. Describe the characteristics of the placenta. It usually covers a larger surface of the uterine cavity than when normally implanted ; it is thinner, and the cord is usually attached to the margin ; occasionally it is velamentous. Prolapse of the cord frequently occurs during labor. What is the characteristic symptom of placenta prsevia ? Hemorrhage. — It rarely occurs before the last three months of pregnancy ; Depaul limits the time in nearly all cases to the last month and a half. The hemorrhage is sudden, painless, without any evident cause, and is intermittent. The first hemorrhage is usu- ally slight, but the amount of blood lost increases in each successive 8 Digitized by Microsoft® 114 ESSENTIALS OF OBSTETRICS. attack. If the first attack of hemorrhage occurs near the end of pregnancy, it may be so profuse as to place the life of the patient in danger. Premature labor may occur after several attacks of hemorrhage. What is the source of the hemorrhage ? See fig. 30. It results from a greater or less detachment of the placenta. The chief source of the hemorrhage is the uterine surface; a small amount of blood comes from the placental surface. What are the causes of the hemorrhage ? This is an unsettled question ; the following are some of the theories : Rupture of the veins, due to the dilatation of the cervix (Portal and Giffard) ; in the latter months the cervix grows away from the placenta (Levret) ; the placenta develops more rapidly than the cervix (Stoltz and Barnes). What is the prognosis of placenta praevia ? Grave in all cases to both mother and child. In general terms the maternal mortality is 30 to 40 per cent. ; the fetal from 75 to 80 per cent. The earlier in pregnancy the hemorrhage occurs, the greater the amount of blood lost, and the shorter the time between the attacks the graver the prognosis becomes. The great dangers after delivery are post-partum hemorrhage and septicaemia. What is the diagnosis of placenta praevia ? It is impossible to recognize placenta praevia during the first half of pregnancy. If abortion occurs, the ovum is expelled with- out rupture of the membranes; there is absence of pain prior to the hemorrhage and at the time of expulsion. During the second half of pregnancy, a hemorrhage coming on suddenly, and without any evident cause, should be looked upon as indicative. On examination per vaginam the vault of the vagina feels soft and doughy, and in some cases, where the insertion of the placenta is not central, it will be found thicker on one side than on the other ; ballottement cannot be demonstrated ; the cervix is patu- lous, elongated, and softened, and occasionally its vessels can be Digitized by Microsoft® PLACENTA PREVIA. 115 felt pulsating. The diagnosis is not positive unless the placenta can be felt through the os. What is the treatment of placenta prsevia ? See fig. 31. If the hemorrhage occurs prior to the viability of the fetus, and it does not endanger the mother's life, Parvin and Playfair advise the expectant plan of treatment. If, however, the hemorrhage is grave, then the pregnancy must be ended. Lusk, on the other hand, holds that the pregnancy should be ended if the hemorrhage occurs prior to viability, whether it be slight or profuse. After the viability of the fetus all authorities now agree that the induction of premature labor is indicated. The expectant plan of treatment employed prior to the viability of the fetus consists in absolute rest in bed, cold drinks, and the use of opium if the patient is restless or suffers pain. The nurse should be instructed in the use of the tampon, in order to prevent loss of blood, if a sudden and grave hemorrhage occurs. In the treatment of placenta praevia by the induction of prema- ture labor the chief indication to be met during dilatation of the cervix is the management of hemorrhage. If the cervix is rigid and undilated, the tampon should be employed. The tampon assists in the dilatation of the cervix and increases the force of uterine contractions ; it also serves as a plug to control the hemorrhage. The tampon should be removed at the end of four hours, according to Lusk ; Parvin holds that " it is doubtful if any harm will result should a properly applied anti- septic tampon be left for twenty-four hours." If the cervix is found to be sufficiently dilated after the removal of the tampon, the operator may use either Barnes's dilators or turn by Braxton Hicks's bimanual method. If the former be decided upon, the complete dilatation of the cervix is accomplished by the introduction of Barnes's rubber bags. The dilator of Barnes acts not only as a plug in the os uteri, but it rapidly causes complete dilatation of the cervix. After the cervix has been dilated the membranes should be ruptured and the. case left to nature, if the attachment of the placenta is not central, if the contractions of the uterus are strong, Digitized by Microsoft® 116 ESSENTIALS OF OBSTETRICS. and if the presentation is favorable. If the uterine contractions are weak, small doses of ergot should be given. The general indi- cations for the use of the forceps hold good. If the child's head is movable and does not exert sufficient pressure to control the hemorrhage, version should be performed. If the implantation be central, the placenta should be separated with the finger from around the cervix. Barnes's dilators should then be introduced, and the dilatation of the cervix completed. While the dilators are being used perform pelvic version by the external method. If this cannot be accomplished, wait until the cervix is dilated, and then perform podalic version. In order to save fetal life rapid dilatation of the cervix must be performed, followed by perforation of the membranes, and delivery of the foetus by podalic version. The after-treatment consists in guarding against post-partum hemorrhage ; ergot should be given for a week or longer. Strict antiseptic measures must be adopted before and after delivery. Accidental Hemorrhage. What is accidental hemorrhage ? Hemorrhage from the separation of a normally situated placenta. How is it divided ? Into open and concealed hemorrhage. Concealed hemorrhage occurs, according to Goodell, " (a) when the placenta is centrally detached, and the blood accumulates in the cul-de-sac formed by the firm adhesion of its margins to the uterine walls, (b) When the placenta is so detached that the blood escapes into the uterine cavity behind the membranes near the fundus, (c) When the membranes are ruptured near the de- tached placenta and the effused blood mingles with the liquor amnii. (d) When the presenting part of the foetus so accurately plugs up the maternal outlet that no existing hemorrhage escapes externally" (Lusk). What are the causes of accidental hemorrhage ? It usually occurs in multipara, especially in the weak and sickly. Digitized by Microsoft® ECLAMPSIA. 117 It may be caused by inflammation of the kidneys (acute or chronic), by anaemia, or by placental disease. It is usually caused by prolongation of pregnancy beyond term, violent exercise, or accidents; or by uterine contractions, or emotional influences. Certain acute diseases have also been given' as causes. What are the symptoms ? Extreme collapse and severe pain, absence or great feebleness of the pains of labor, distinct enlargement of the uterus, or occa- sionally a localized distention of the uterine walls. A discharge of pure blood or blood mixed with liquor amnii. In the concealed variety the diagnosis is made from the fore- going symptoms. Accidental hemorrhage may be mistaken for rupture of the uterus. Rupture of the. uterus, however, occurs after the escape of the liquor amnii, and is followed by the recession of the pre- senting part and the escape of more or less of the foetus into the abdominal cavity. What is the prognosis? Unfavorable for both mother and child. The prognosis is more favorable in the open variety. What is the treatment ? Whether the hemorrhage be grave or slight, immediate deliv- ery must be accomplished by forceps or version. Rupture the membranes and give ergot. If the os be sufficiently dilated, deliver by forceps or podalic version ; Barnes's dilators should be used if the cervix is undilated. Firm compression should be made upon the uterus. Eclampsia. Define eclampsia. "An acute disease coming on during pregnancy, labor, or the puerperal state, and characterized by a series of tonic and clonic convulsions, affecting at first the voluntary muscles, and, finally, extending to the involuntary, accompanied by a complete loss of Digitized by Microsoft® 118 ESSENTIALS OF OBSTETRICS. consciousness, and ending by a period of coma or sleep, which may result in cure or death " (Charpentier). What is the frequency of eclampsia ? Parvin places the proportion as 1 to 250 or 300 pregnancies; Lusk, 1 to 500. The disease is more frequent in pregnancy or in labor, than in the puerperal state. It is most frequent in the latter months of pregnancy. What is the etiology of eclampsia 1 The etiology of the disease is still an unsettled question. The following theories have been advanced : 1. Cerebro spinal congestion. 2. General or cerebral anaemia. 3. Anaemia of the cerebro-spinal centres, with congestion of the meninges. 4. Eclampsia is a neurosis. 5. Eclampsia depends upon a poisoning of the blood, which renders it unfit to act normally upon the nervous centres. (a) Albumen. '■—(by Urea.'- '"' ' ; ""'" '" ' '"" "'' (e) Carbonate of ammonia. (d) Extractive matters (creatin, creatinin, leucin„etc, (e) Soluble toxic ptomaines. How are the symptoms of eclampsia classified,?: Into the premonitory symptoms and the symptoms of the attack; the. latter is subdivided'into three periods as follows: -,.< .. .1, Invasion;, 2, tonic convulsions; 3, donio convulsions. . , ' What are the premonitory symptoms ? The most constant symptoms are headache, disturbance of vision, and epigastric pain." ' Among other symptoms may be mentioned somnolence or insomnia, excitement, ; vertigo, 1 - vomit- 4ng,' and despondency. What are the symptoms of the attack ? . .JPeriodof Invasion,. — Suddenly, the, eyes become fixed and then follows a short period of quiet. The attack then commences by Digitized by Microsoft® ECLAMPSIA. 119 rapid movements of the eyelids, and of the alse of the nose, fol- lowed by convulsive twitchings of the muscles of the face. The pupils are dilated and insensible to light, the mouth deviates toward the left side, and the head rotates from one side to the other. Period of Tonic Convulsions. — The convulsive movements extend from the head to the neck, body, and, finally, to the extremities. The body becomes rigid, the back is strongly arched, and the patient rests upon the bed by the head and lower extremities (opisthotonos). The arms are extended and rigid; the hands are closed, and the thumbs are flexed upon the palms. The tonic spasms involve the diaphragm and muscles of the thorax, respira- tion ceasing ; the face becomes red and swollen ; the tongue is thrust partially out of the mouth ; the saliva becomes frothy and mixed with blood, due to the tongue being bitten by the teeth. When respiration becomes reestablished, the air passes out with a whistling noise. There is complete loss of sensation and con- sciousness. The stage of tonic convulsions lasts from ten -to twenty -seconds: ■■ ' '■ ■: - - ; - : Period of Ckmic' GonvuMonB.--^h.&- convulsions -begin in the muselesof the face and extend to the body and extremities. The 'face* becomes deeply congested and horribly contorted ;the"jaws open- and close rapidly ; the tongue' may again become bitten ; the respiration is irregular and noisy; the saliva becomes frothy and mixed' with blood. As a rule, the convulsions do not cause a change in the position of the patient. In some cases, however, it isneeessary to use force to keep the woman in- bed. This period lasts- 'from one-to two minutes, and is followed-' by coma or stupor. Atit-he end of half an hour, in most cases, sensation and conscious- ness gradually return. • ■ • ■- - * : ■ -■-•••■ As a rule 1 , the attack is followed by others ; the interval in some cases may be- only a few minutes, or it may be-several hours.' In rare cases there is only one attack, which is followed by the rapid recovery of the patient. ' ' ...-..,,..-..-, What is tie prognosis ? ,,';.„ The prognqsis, js grave. The maternal mortality is. 30 per gent. ; the foetal 50 per cent. Eqlanipsia,, predisposes toj post-partum hemorrhage and inflammations during the puerperal state. Digitized by Microsoft® 120 ESSENTIALS OF OBSTETRICS. What conditions would lead to a favorable prognosis? The attacks infrequent and mild, recovery of consciousness in the intervals, small amount of albumen and urates in the urine, steady fall of the temperature, and the later in pregnancy or labor the attacks occur. What conditions would lead to an unfavorable prognosis? The uterus remaining long unemptied, the attacks frequent and severe, and occurring early in pregnancy or labor, the coma pro- found, the urine scanty and containing a large amount of albu- men and urates, and the temperature high. How is the treatment divided? Into 1. Prophylactic; 2. Curative; 3. Obstetric. Describe the treatment of eclampsia. Prophylactic. — This treatment consists in a milk diet, saline cathartics, and hot baths. If the quantity of albumen be large, the diet should be entirely of milk. The saline cathartic should be given every other morning. On the morning the cathartic is not given, the patient should take a hot bath, the temperature of which should be from 98° to 100°R The patient should remain in the water fifteen minutes, and upon coming out should be dried and wrapped in a warm blanket and given hot milk or hot water to drink. Lusk advises the tincture of the chloride of iron in full doses, for its diuretic and tonic effect. If the symptoms indicate that an attack is imminent, thirty grains each of chloral and the bromide of potassium should be given per rectum. A hydragogue cathartic should be administered to unload the bowel. The pressure upon the ureters and upon the renal vessels may be relieved by assum- ing the knee-chest position several times a day. The patient should avoid lying upon her back. Parvin advises " moderate bleeding" in cases in which the urgency of the symptoms will not admit of waiting for the action of prophylactic measures. Playfair advises small doses of the tincture of digitalis along with the tincture of the chloride of iron. The milk diet should be continued so long as the urine contains albumen. The urine should be examined daily in bad cases. Digitized by Microsoft® ECLAMPSIA. 121 If no albumen has been found in the urine for eight days, Char- pentier advises the following tonic : R . — Extract, quiniae, extract, gentianae, aa 3ij ; Ferri subcarbon- atis, gr. xv ; Pulv. rhei, q. s.— M. Ft. pil. No. 100. Sig.— Take five or six, pills during the day. Curative. — The patient should have her clothing loose; she should be watched to prevent her from falling out of bed— her movement, however, should not be restricted; and a folded napkin should be placed between the teeth to prevent the tongue from being bitten. The bowels should be freely acted upon by the compound powder of jalap, elaterium, calomel, or one or two drops of croton oil placed upon the back part of the tongue ; a stimulating injec- tion should also be given per rectum. Hypodermoclysis, or the rectal injection of salt-solution, is valuable in all cases. Chloroform should be given by inhalation and at the same time thirty to forty grains of chloral injected into the rectum (" in the yelk of an egg and six ounces of milk"). The chloroform should be given in full doses during the convulsions ; at the approach of another paroxysm the amount should be again increased. It may be necessary to repeat the chloral in an hour or two. The advantages of venesection are disputed. Lusk advises from eight to sixteen ounces of blood to be withdrawn as "the first step in the treatment of convulsions." Parvin holds that "bleed- ing ought not to be regarded as universally applicable." Morphia, hypodermatically, is advised by some. Lusk gives from one-sixth to one-quarter of a grain, repeating the dose in an hour, if there is a return of the convulsions. He also combines bromide of potassium along with chloral in rectal injections; giving thirty grains of each at a dose. Excellent results follow the employment of heroic doses of vera- trum viride (fl. ext. or tinct.) : 15 minims are injected hypodermati- cally, and 5 minims more injected when the pulse rises above 60. Obstetric. — If the uterus be emptied, the convulsions cease in about one-third of the cases. During the first stage, if the pains are weak, a catheter should be carefully introduced into the uterus. The dilators of Barnes, if required, should be used to dilate the cervix. After the complete dilatation of the os, the forceps should Digitized by Microsoft® 122 ESSENTIALS OF OBSTETRICS. be applied and the child delivered. Artificial means to hasten labor should only be employed in those cases in which there is a clear indication. When eclampsia occurs during pregnancy, Parvin and Lusk advise the induction of premature labor. If convulsions begin or continue after delivery, chloral, or morphia, and chloroform should be used. Lusk does not believe in the use of chloroform in the treatment of eclampsia during the puerperal state. LABOR. What is labor? " Labor is the physiological end of pregnancy, and may be de- fined as the process by which the fetus and its appendages are separated from the mother; it is travail, bringing forth" (Parvin). How is labor classified ? "Into: 1. Preriiatwre, wherb labor occurs after the fetus is viable and before full term.- ■•->•■ -• ■■'■■ ■>■ ,,,„;.-,..., .1 ;;...,,- .,., i: „« <<■■%.■ Posi/poneA, where- -labor—occurs after full term y the fetus being alive. - ■ •<' ■• ■■■■• ■••■■- --■■ > ■<«..>..,... -. - . 3. Missed, where labor occurs after full term;- jthe fetus ■benig dead. • ■■• • -'■•• •< -....-. ... ,...,...,., ,,,._,:» 4. Nakwalj where labor takes place without the assistance 6ft art. 5. Artificial, where nature 'is aided/ -or replaced by art. ' ■ What are the conditions necessary for a natural labor ? 1., Itetus.—Tfee size must not be larger than normal, and the presentation must be favorable. 2. Mother. — The parturient canal and the voluntary and inypl- untary forces must be normal. What are the determining 1 causes of labor ? ■ *■ 'This question is as yet unsettled ; the various theories may be 'found -in the text-books.'. "" .-...' What are the eilficien,t causes of labor? Thgpontracti.Qns.of the uterus,, assisted during; the second stage of labor by the abdominal muscles. Digitized by Microsoft® LABOR. 123 What are the precursory symptoms of labor ? (a) Sinking of the Uterus. — This is the descent of the foetal head enclosed by the lower portion of the uterus into the cavity of the pelvis. The waist of the patient becomes smaller, respiration less difficult, and the pressure upon the stomach is relieved. On account of the pelvic organs being pressed upon, the bladder and rectum become irritable ; there is difficulty in locomotion, and the oedema of the lower limbs is increased. The sinking of the uterus is more frequent in the primigravida than in the multi- gravida; in the latter, the uterus is more inclined to become ante- verted. Descent of the uterus generally occurs from two to four weeks prior to labor ; in some cases only one or two days, iD others, one month. This phenomenon indicates that the presenta- tion and size of the pelvis are normal. (ft) Secretions from the Cervical Glands. — A profuse glairy secre- tion takes place from the glands of the cervix. As labor approaches, it becomes mixed with blood, and is known as the '.'show,", The blood indicates, ,that a partial detachment of.the decidua near the cervix has taken place. _ A. profuse, discharge .indicates that, the, cexvix,: will dilate rapidly. ,. -,,. : ,„(<;), Changes. , in . tbs. Vagina,., apd, External Organs. ^The. .-external genitalia are swollen and- covered. by . , a copious ; secretion,; the .labia.jnajora are, separated ; and the vagina becomes, moist and relaxed „ ,o , , ., - - \ i - . •- . ; ,™ ... ■.> •,„■„.,,,., , : i(d). Painless Uterine Contractions— These, become more frequent. They, cause little or no. discomfort in the primipara?/ while in. the multipara they may become painful several days, .before, labor.'. . What are the conditions which indicate that labor has = ,,!.-,. ,71: l , •, f .::t... "..-J- ,i..f it. n If. f~ ;■.>• <;Ti-. crls u 1 1> fV,,M , r ,. 'i', ■.-.'.jit* ;,(■<,. ,,-,3 l.i.c -^ in w A i ;:a(if(U Effacement and dilatation of the cervix, with regularly recurring uterine contractions. Into how many stages is labor divided ? ■ • ■ Three. 1 ' First ■stogd, or" uterine period f- ends' with the' complete dilatation of the- cervix-; < second stage, or >' ' 'titer v-etbdominal period;" begins after complete dilatation of the cervix,-and : erids with the expuMon-of the child f-third stage t or "placental period," includes thedetaohment aad expulsion of the placenta. ■ Digitized by Microsoft® 124 ESSENTIALS OF OBSTETRICS. How are the phenomena of labor divided ? Into the physiological, plastic, and mechanical phenomena. What are the " characteristics of uterine force " ? 1. Involuntary. 2. Intermittent. 3. Peristaltic. The peristaltic wave begins at the fundus of the uterus ; the movements are so rapid that practically the contrac- tions of the uterus are simultaneous. 4. Form changes. During the intervals of uterine contraction the uterus is ovoid in shape. During contraction the transverse diameter is shortened, while the antero-posterior and longitudinal are somewhat elongated. The modifications in the diameters cause the uterus to become more or less cylindrical in shape. 5. Changes in position. The broad and round ligaments con- tracting press the uterus against the brim of the pelvis ; the latter also incline the organ anteriorly. 6. " The power of the contractions is in proportion to their fre- quency and resistance." 7. The regularity and force of the contractions depend upon the presentation of the foetus — e. g., in presentation of the vertex they are more regular than in the other presentations. 8. The contractions are painful. The character of the pain varies with the stages of labor. The pains are very severe in some women, while others suffer but little. The contractions of the uterus begin before pain is recognized by the patient, and continue after all suffering has ceased. What are the character, situation, and cause of the pains during the first and second stages of labor ? First Stage. — The patient speaks of the pains as " acute," or " grinding," or " cutting." The pains begin in the lumbo-sacral region and extend to the pubes, from whence they radiate down the thighs. The pains are caused by the dilatation of the cervix and the compression of the uterine nerves, produced by the con- tractions of the uterus. Second Stage. — The pains give a sensation of stretching or tearing. The patient speaks of them as " bearing-down pains." Digitized by Microsoft® LABOR. 125 The abdominal muscles are now brought into play, adding by their contractions to the pain felt by the patient. There is an intense sense of tearing apart of the vulvo- vaginal canal and perineum; cramps occur in the legs ; and there is a sensation of tenesmus in the rectum. The pressure exerted by the foetus upon the nerves and organs of the pelvis and the stretching of the pelvic soft parts, are the obvious causes of the pains. Describe the process by which the cervix is dilated. Fig. 32. At the beginning of labor the cervix is effaced, and the border of the os uteri is felt as a slight projection ; it is more distinct in multipara than in primiparse. As the os dilates, the uterine cavity decreases in size, and the action of the muscular fibres of the body of the uterus draws the cervix up over the advancing part of the foetus. At the beginning of a uterine contraction, the cervix becomes "thicker, irregular, as if puckered," and the os decreases in size ; later, however, the cervix becomes thin, and the os increases in size. As dilatation of the cervix advances, the decrease in the size of the os does not take place at the beginning of a contraction. In primiparse the cervix is very thin in the beginning of dila- tation. The margins of the cervix feel like a thick thread. As dilatation advances, the cervix becomes thick and oedematous, especially the anterior portion. Dilatation of the cervix is more rapid in multipara? than in primiparse. As the second stage advances, the dilatation is more rapid than in the beginning. As labor advances, the cervix no longer points posteriorly and toward the left, but it assumes a more central position. The shape of the os is round at first; later it becomes oval. The following is the mechanism of the dilatation of the cervix : 1. The longitudinal muscular fibres of the body and fundus of the uterus overcome the action of the circular fibres of the cervix, and tend to pull it open. 2. The pressure of the membranes and the presenting part mechanically dilates the cervix. 3. The uterine contractions are stimulated by the pressure of the ovum upon the cervix. Digitized by Microsoft® 126 ESSENTIALS OF OBSTETRICS. Fig. 32. Vertical section through the genital canal showing the dilatation of the cervix. PI, placenta; ot, orifice of the tube; oi, internal os; C, cervix; oc, external os; v, vagina. Fig. 33. LABOR. 127 What is the bag of waters ? See fig. 33. The foetal membranes, enclosing the liquor amnii, projecting through the os uteri. The size and form of the bag of waters de- pend upon the presentation of the foetus and upon the extent of the dilatation of the os. The bag of waters is small in a vertex presentation ; it has at first the shape of the crystal of a watch, but later it becomes hemispherical. In all the other presentations it is large, on account of the amount of liquor amnii in advance of the foetus. The bag of waters usually ruptures at the time of complete dilatation of the cervix. When rupture occurs at the end of pregnancy or in the beginning of the first stage, the labor is spoken of as a " dry labor." In catarrhal endometritis there is a collection of fluid which may be discharged before labor; this discharge is spoken of as the '' false waters." What is the diagnosis of the rupture of the bag of waters ? Intact. — During contractions: The bag of water is tense and smooth. The liquor amnii is felt in advance of the presenting part. Intervals between contractions : The bag of waters is flaccid, and can be pressed into wrinkles. Ruptured. — During contractions: The scalp becomes wrinkled. No fore- waters. Intervals between contractions: The scalp gives a different sensation to the examining finger, and it cannoi be pressed into wrinkles. By inserting the finger between the head and the uterus the liquor amnii will escape into the palm of the hand. Describe the action of the abdominal muscles. These muscles assist the uterus in the expulsion of the foetus. They are not brought into play until the end of the first stage of labor. Their action is voluntary, and remains so until the head is being expelled from the vulva, when the patient loses all control, and reflex action takes the place of voluntary effort. Describe the dilatation of the vagina and perineum. The vagina is dilated by the descent of the presenting part, and offers but little resistance, except at its orifice. At this poir.t the head may be delayed several hours. Digitized by Microsoft® 128 ESSENTIALS OF OBSTETRICS. The contractions of the muscular fibres of the vagina assist in the delivery of the body after the escape of the head. The perineum becomes slowly distended by the presenting part until it measures several inches in length. At each contraction the head advances, but it recedes again in the interval of utero-abdominal effort. The stretching of the peri- neum by the advancing head causes the anus to gape wide open and expose the anterior wall of the rectum. The head advances and then recedes until the parietal protuberances escape from the vulva, when it becomes fixed. A strong contraction almost immediately follows and the head is born ; the perineum passing over, first, the anterior fontanelle, then the forehead, and lastly, the face of the child. After the birth of the head a short interval of rest fol- lows, when contractions again come on, and the body of the child is expelled, followed by a discharge of liquor amnii mixed with blood. How long after the birth of the child is the placenta expelled ? Usually in from ten to twenty minutes. How is hemorrhage prevented after the detachment of the placenta ? By the blood becoming clotted in the mouths of the vessels, but chiefly by uterine retraction, which causes the muscular fibres of the uterus to act as "living ligatures." How is the placenta detached and expelled from the uterus ? It is detached by uterine retraction, and expelled by uterine contractions, assisted by voluntary efforts. The detachment of the placenta occurs "almost simultaneously in all parts." Playfair agrees with Duncan that the placenta presents by its edge at the mouth of the uterus ; the general view is that the festal surface presents, and that it is folded upon itself. Parvin is of the opinion that, in all probability, the part which presents depends Digitized by Microsoft® LABOR. 129 upon the part of the uterus to which the placenta was attached, " and upon whether the membranes are separated before the uterine contractions which expel it begin." What are the effects of labor on the mother and foetus? Mother. — During a uterine contraction the arterial pressure is increased, and the pulse becomes more rapid; in the interval of pain the pulse declines again to its normal condition. During the pains the respirations become slower ; but they become more rapid in the intervals. As labor advances there is a slight pro- gressive rise in the temperature. The urine is increased in amount. Vomiting may occur during the first stage ; it has no significance. If, however, it occurs during the second stage, and is associated with weak uterine contractions and exhaustion, immediate delivery is indicated. In some patients a " slight shivering " occurs at the beginning of a uterine contraction. In the intervals of uterine contractions patients have a tendency to sleep, this results from fatigue, and also from cerebral congestion. Foetus. — There is a slight increase in the rapidity of the foetal heart at the beginning of a uterine contraction ; it becomes slower during the height of a contraction, and after the pain passes off it becomes more rapid than normal for a short length of time. Discharges of urine and meconium are caused by pressure upon the foetus; a. discharge of meconium is usual in breech presen- tations, but rare in vertex presentations. What is the duration of labor ? In primiparee the average is seventeen hours; in multipara twelve hours. As a rule, the second stage is one-third that of the first stage. Labor usually begins between the hours of 9 and 12 o'clock at night, and ends between 9 o'clock in the evening and the same hour in the morning. What are the causes of false labor-pains ? Intestinal irritation, rheumatism of the uterus, and contractions of the uterine and abdominal muscles ; the first is the most frequent cause. 9 Digitized by Microsoft® 130 ESSENTIALS OF OBSTETRICS. What is the diagnosis of false from true labor-pains ' True Pains. Premonitory symptoms of labor. Begin in the lumbo-sacral re- gion and extend to the pubes. Regular in recurrence. Increase in severity. Dilatation of the cervix. Effacement of the neck. False Pains. No premonitory symptoms. Felt at all parts of the abdo- men. Irregular. No increase in severity. No dilatation. No effacement. What do you mean by the plastic phenomena of labor ? "The foetal form-changes produced in labor, and dependent upon presentation and position" (Parvin). The alterations in the diameters of the foetal head have already been discussed. What is the caput succeda- neum? See fig. 34. A swelling upon the presenting part of the foetus, due to a sero-san- guineous infiltration, the result of lack of pressure. The infiltration occurs upon that portion of the pre- senting part not subjected to press- ure. The size of the tumor depends upon the length of the labor; in rapid deliveries it is but little developed. The caput succedaneum is violet- colored ; it pits on pressure, but does not fluctuate. What is the situation of the caput succedaneum in the various presentations ? Vertex.— L. O. A., on the posterior and superior angle of the right occipital bone. E. O. A., on the posterior and superior angle of the left occipital bone. L. O. P., on the superior and anterior angle of the right occipital bone. Formation of the caput succedaneum. Digitized by Microsoft® LABOR. 131 R. O. P., on the superior and anterior angle of the left occipital bone. Face. — Fronto-anterior positions, on the superior portion of the malar region, and, in some cases, upon the eye. Fronto-posterior positions, on the superior portion of the malar region and upon the side of the mouth. Breech. — As a rule, upon the anterior thigh ; it may also include the external genitals. Shoulder. — Upon the presenting shoulder. Mechanism of Labor. What do you mean by the mechanical phenomena of labor? " The passive movements given the fetus in its expulsion." (Parvin.) How many presentations of the fcetus are given ? Fig. 35, Five: 1. The vertex. 2. The face. FlG - 35 - 3. The breech. 4. The right shoulder. 5. The left shoulder. How many positions are given for the vertex, face, and breech? Four each : 1. Left anterior. 2. Eight anterior. 3. Eightposterior 4. Left posterior. How many positions are given for each of the shoulders ? Two: An anterior and pos- Vertex presentation, terior position. Digitized by Microsoft® 132 ESSENTIALS OF OBSTETRICS. What is meant by presentation ? See fig. 36. " That part of the foetus which is in relation with the pelvic inlet" (Parvin); or "That portion of the foetus which occupies the lower segment of the uterus" (Lusk). What is meant by position ? " The relation which the presenting parts of the foetus have to certain fixed points of the inlet" (Parvin). These fixed points are the four cardinal points of Capuron; anteriorly, the ilio- pectineal eminences ; posteriorly, the sacro-iliac joints. The positions of the shoulder have no relation to these points on the inlet. By what methods can the diagnosis of presentation and position be made ? By abdominal palpation, auscultation, and vaginal touch or in- digation. How is the diagnosis of presentations made by ausculta- tion ? The uterus is divided into four parts by a transverse and a per- pendicular line. The former divides the uterus into two equal parts; the latter corresponds with the median line of the abdomen, and extends from the ensiform cartilage to the pubes. As the umbilicus is not the same distance above the pubes in all cases, the transverse line may or may not pass through it. The maximum of intensity of the foetal heart sounds is heard as follows : Vertex Presentations. — Below the transverse line and to the right or left of the perpendicular line. Face Presentations. — On the transverse line and to the right or left of the perpendicular line. Breech Presentations. — Above the transverse line and to the right or left of the perpendicular line. Shoulder Presentations. — On the perpendicular line, midway be- tween its point of intersection with the transverse line and the pubes. Digitized by Microsoft® LABOR. 133 Fig. 36. Vertex presentation ; child surrounded by amniotic fluid. (Pinard.) Digitized by Microsoft® 134 ESSENTIALS OP OBSTETEICS. How is the diagnosis of positions made by auscultation ? The maximum of intensity of the foetal heart sounds is heard as follows : Vertex. L. 0. A. Midway on a line extending from the left ilio-pectineal eminence to the point of intersection of the transverse and perpen- dicular lines. R. O. A. At the same point on the right side. R. O. P. Midway on a line extending from the right sacro-iliac joint to the point of intersection of the transverse and perpendic- ular lines. L. O. P. At the same point on the left side. Face. L. F. A. On the transverse line and to the right of the perpen- dicular line. R. F. A. On the transverse line and to the left of the perpen- dicular line. R. F. P. On the transverse line and to the left of the perpen- dicular line. L. F. P. On the transverse line and to the right of the perpen- dicular line. Breech. L. S. A. At a point near the perpendicular line on a line ex- tending from the middle of last left false rib to the intersection of the transverse and perpendicular lines. R. S. A. At the same point on the right side. R. S. P. On the same line and on the same side as in R. S. A., but at a point further from the perpendicular line. L. S. P. On the same line and on the same side as in L. S. A., but at a point further from the perpendicular Hue. Shoulder. The shoulder presenting and its position cannot be diagnosed by auscultation. Auscultation gives only one point of maximum intensity, namely, on the perpendicular line midway between its point of intersection with the transverse line and the pubes. Digitized by Microsoft® LABOR. 135 What is meant by the lie of the fetus ? The relation of the longitudinal axis of the foetus with the lon- gitudinal axis of the uterus. If the longitudinal axis of the foetus corresponds with the longi- tudinal axis of the uterus, we know that the presentation is either a vertex, face, or breech. On the other hand, if the axis of the foetus is oblique in its relation with the uterus, we know that a shoulder is presenting. How is the foetal head recognized by palpation ? By its being hard, round, uniform in shape, and more or less movable. How is the breech recognized by palpation ? i It is felt as a prominent body, broader than the head ; it is less round and hard and lacks the same uniform shape of the head ; it is also immovable — i. «., it cannot be moved without displacing the body of the fcetus. Little mobile objects are felt near it, which are the lower extremities of the foetus. How is the back recognized by palpation ? It is felt as a resisting, expanded mass, which connects the head with the breech. How is the diagnosis of presentations made by palpation? First find the lie of the foetus, then where the head and breech are, and, lastly, differentiate, if the head presents, between the vertex and face. Vertex. — The lie of the foetus is longitudinal ; the head is in the lower segment of the uterus, and the breech in the upper part. Now with the head in the lower segment of the uterus, and the breech in the upper, we have either a presentation of the vertex or face. First find whether the back is anterior or posterior, and then toward which side of the pelvis it points. If the back is an- terior and toward the left we know that the position must be left anterior. If it be a vertex presentation, the head will be found Digitized by Microsoft® 136 ESSENTIALS OP OBSTETRICS. occupying the pelvic cavity. Again, the hand will sink deeper into the left side of the pelvis than into the right ; the forehead being on the right side offers a resistance. Furthermore, the occiput will be found to be continuous with the back and not separated from it by a deep furrow as would be the case in a. face presentation. Face.— The lie of the foetus is longitudinal ; the head is in the lower segment of the uterus, and the breech in the upper part. If the back is anterior and toward the left, the hand will sink deeper into the right side of the pelvis, on account of the left side being occupied by the forehead. Again, the head will be found, if labor has not begun, above the inlet, not low down and occupying the pelvic cavity, as it does in a vertex presentation. In some cases the inferior maxillary bone may be felt ; it resembles a horseshoe- like swelling. Furthermore, a deep furrow is felt between the occiput and the back of the foetus. In a face presentation the foetal heart-sounds are heard on the opposite side of the perpen- dicular line and not on the side toward which the back is present- ing. This is not so in a vertex or breech presentation, and this disagreement between palpation and auscultation should suggest to the practitioner the existence of a face presentation. Breech. — The lie of the foetus is longitudinal; the breech is in the lower segment of the uterus and the head in the upper part. The presenting part is found above the superior strait and the pelvic cavity empty. Again, the fcetal members are felt near the breech in the lower segment of the uterus. Furthermore, the head, which is in the upper part of the uterus, is found to be freely movable. Shoulder. — The lie of the foetus is oblique ; the head occupies one of the iliac fossse while the breech is on the opposite side. The head is lower than the breech, and the presenting shoulder is generally in the plane of the inlet. The pelvic cavity is found to be empty, as is also the case in a face or breech presentation. It is possible to perform cephalic ballottement. Furthermore, the shape of the abdomen is changed, being increased in its transverse diameter. The foetus is not placed in a transverse position— i. ,* 9> Henrietta Street, Covent Garden Arranged Alphabetically and Classified under Subjects See page 22 for a List of Contents classified according to subjects THE books advertised in this Catalogue as being sold by subscription are usually to be obtained from travelling solicitors, but they will be sent direct from the office of pub- lication (charges of shipment pre aid) upon receipt of the prices given. All the other books advertised are commonly for ale by booksellers in all parts of the United States; but books will be sent to any address, carriage prepaid, on receipt of the published price. Money may be^sent at the risk of the publisher in either of the following ways : A postal money order, an express money order, a bank check, and in a registered letter. Money sent in any other way is at the risk of the sender. 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An American Text-Book of Obstetrics, 2 Ash ton— Essentials of Obstetrics, 16 Boisliniere — Obstetric Accidents, . 4 Dorland — Modern Obstetrics, . . 6 Hirst— Text- Book of Obstetrics, . 8 Norris— Syllabus of Obstetrics, ... n Schaeffer — Atlas Labor and Oper. Obs. 18 Schaeffer— Atlas of Obstetrical Diag- nosis and Treatment, 18 PATHOLOGY. An American Text-Book of Pathology, 2 Durck— Atlas of Pathologic Histology, 17 Kalteyer — Essentials of Pathology, . . 16 Mallory and Wright— Pathological Technique, 10 Senn— Pathology and Surgical Treat- ment of Tumors, J 3 Stengel— Text-Book of Pathology, 14 Stengel and White — Blood, 14 Warren— Surgical Pathology, . 15 PHYSIOLOGY. American Text-Book of Physiology, . 2 Raymond— Text-Book of Physiology, . 12 Stewart— Manual of Physiology, 14 PRACTICE OF MEDICINE. American Text-Book of Theory & Prac. 3 An American Year-Book of Medicine and Surgery, 3 Anders— Practice of Medicine, ... 4 Eichhorst— Practice of Medicine, . 6 Lockwood — Practice of Medicine, . . 10 Morris— Ess. of Practice of Medicine, . 16 Nothnagel's Encyclopedia, .... 20, 21 Salinger & Kalteyer— Mod. Medicine, 12 Stevens— Practice of Medicine, . 14 SKIN AND VENEREAL. An American Text-Book of Genito- urinary and Skin Diseases, 2 Hyde and Montgomery — byphilis and the Venereal Diseases, 8 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . . 16 Mracek — Atlas of Diseases of the Skin, 17 Stelwagon — Diseases of the Skin, . . 13 Stelwagon— Ess. of Diseases of Skin, . 16 SURGERY. An American Text-Book of Surgery, . 2 An American Year-Book of Medicine and Surgery, . 3 Beck — Fractures, 4 Beck — Manual of Surgical Asepsis, . 4 DaCosta — Manual of Surgery, .... 6 Grant— Surgical Disease of Face, Mouth, and Jaws, -8 Helferich — Atlas of Fractures, ... 19 International Text-Book of Surgery, . 9 Keen — Operation Blank, 9 Keen — The Surgical Complications and Sequels of Typhoid Fever, . . . . 9 Macdonald — Surgical Diagnosis and Treatment, 10 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 16 Martin — Essentials of Surgery, 16 Moore — Orthopedic Surgery, ... n Nancrede— Principles of Surgery, . n Pye — Bandaging and Surgical Dressing, 12 Scudder — Treatment of Fractures, . . 13 Senn— Genito-Urinary Tuberculosis, . 13 Senn — Practical Surgery, . . 13 Senn — Syllabus of Surgery, 13 Senn— Pathology and Surgical Treat- ment of Tumors. 13 Sultan— Atlas of Abdominal Hernias, 19 Warren — Surgical Pathology and Ther- apeutics, J 5 Zuckerkandl— Atlas of Operative Sur- gery, *7 URINE AND URINARY DISEASES. Ogden— Clinical Examination of Urine, 11 Saundby— Renal and Urinary Diseases, 12 Wolf— Handbook of Urine Examination, 15 Wolff— Ess. of Examination of Urine, . 16 MISCELLANEOUS. Abbott— Hygiene of Transmissible Dis- eases, • * • • 4 Bastin — Laboratory Exercises in Botany, 4 Galbraith— The Four Epochs of Wo- man's Life ■ • - - 7 Golebiewski— Atlas of Diseases Caused by Accidents, \ " ' •' *** Gould and Pyle — Anomalies and Curi- osities of Medicine, . 7 Grafstrom— Massage, . 8 Keating — Life Insurance, 9 Pyle— A Manual of Personal Hygiene, . 12 1 Robson&Moynihan— Dis. of Pancreas, 12 Saunders' Medical Hand-Atlases, 17, 18, 19 j Saunders' Pocket Medical Formulary, . 12 i Saunders' Question-Compends, .... 16 i Stewart and Lawrance— Essentials of Medical Electricity, 16 , Warwick and Tunstall— First Aid, . . 15 Digitized by Microsoft® Digitized by Microsoft® SAUNDERS' MEDICAL HAND-ATLASES. THE series of books included under this title are authorized translations into English of the world-famous Lehmann Medicinische Handatlanten, which for scientific accuracy, pictorial beauty, compactness, and cheapness surpass ^ny similar volumes ever published. . Each;volume contains from. 50 to 100 colored plates, besides numer- ous illustrations in the text. Thecolored plates have been executed by the most skilful German lithographers, in some, cases more than twenty im- pressions being required tp obtain the. desired result. Each plate is accom- panied by a full and appropriate description, and each book contains a con- densed but adequate outline of the subject to which it is devoted. Gne of the most valuable features- of these atlases is that they offer a ' ready an;d satisfactory Substitute for clinical observation. Such ob- servation, of course, is available only to the residents in laTge medical centers ; and. eveittlien the requisite variety is seen, only after long years of routine hospital work. To those unable to attend important clinics these books .will ,be' .absolutely indispensable, as _ presenting in a complete and con- venient form the most accurate reproductions of clinical work, interpreted by the most competerit'pf clinical teadhers. "-',. While appreciating the value of s^ch colored plates v the profession has heretofore been pract-ieally;deb|rred from purchasing similar works because of their extremely high price, made necessary by a limited sale and an enormous expense of production. Now, howeyer s by^reason of their pro- jected universal translation and reproduction, affording international dis- tribution, the publishers have been enabled to secure for these atlases the best artisjtic 'and professional talent, tp produce them in the mbst elegant style, artel yet to offer them at a price heretofore unapproached ill cheapness. ~ The great success of the undertaking is demonstrated by the. fact that the volumes have already.apbeared in thirteen different languages— German,, English, Erench, Italian, Russian, ^Spanish, Dutch, Japanese, Danish, Swedish, Roumanian, Bohemian, and Hungarian, u . The- same careful and competent editorial supervision has been ; secured in. the English edition as in the originals. The translations have been edited by the leading American specialists in the different sub- / jects. "The volumes are of a. uniform arid convenient size (5x7^ inches), and are substantially bound in cloth. . , ■ -■ , {For List of Books, Prices, etc. see next page.) Pamphlet containing spefcimeii? / o¥ the Colored Plates sent free on application. Saunders' Medical Hand=Atlases. VOLUMES NOW READY. ATLAS AND EPITOME OP INTERNAL MEDICINE AND CLINICAL DIAGNOSIS. By Dr, Chr. Jakob, of ; Erlangen. Edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine, Philadelphia Polyclinic. ,; With -,179 colored figures "on 68 plates, 64 text-illustrations, 259 pages of text.; Cloth, $3.00 net. - ■ • - '..«. ATLAS OF LEGAL MEDICINE. By Dr. E. R. von Hoffman, of .Vienna. Edited by FREDERICK PETER-, SON, M: p., Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. With 120 colored figures on 56 plates and 193-beau- tiful half-tone illustrations.. Clgth, $3.50 net.-. ATLAS AND EPITOME OF DISEASES OF THE LARYNX. By Dr. L. GRUNWALD.'af Munich; Edited by; CHARLES P. "GRAYspN, M. D., Physician-in^Charge, Throat arid Nose Department, Hospital of the University of Pennsylvania. With 107 colored figures on 44 plates, 25 text- illustrations, and 103 pages of text. . Cloth, $2.50 net. ATLAS AND EPITOME OF OPERATIVE SURGERY. Second Edition, Thoroughly Revised and Greatly Enlarged. By, Dr. O. Zuckerkandl, of Vienna. Edited, with" additions, by J. Chal- mers DaCosta, M'. D., Professor of Principle's of Surgery and of Clinical Surgery, Jefferson Medical College, Philadelphia. With 40 colored, plates, 278 text-illustrations^' and 410 pages of text. C'°tl** $3S9 ne *." '' "'"'-' ATLAS AND EPITOME OF SYPHILIS AND THE VENEREAL DISEASES. . . "By Prof. Dr. Franz 'Mracek; of Vienna. Edited, with additions, by L. BOLTON Bangs, M. D., Professor of Genito-Urinar-y Surgeryj University and Betlevuc Hospital Medical College,. New Vori. With 71 -colored plates, 16 te,xt-illustratipns, and 122" pages of text. Cloth, $S-5P net - ATLAS AND EPITOME OF EXTERNAL DIS, OF THE EYE. By DR. O. HAAS, of Zurich. Edited .by G. E. DE SCHWEINITZ, M D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia. With 76 colored, illustrations on 40 plated and 228 pages uf text. Cloth, #3.00 net. ATLAS AND EPITOME OF SKIN DISEASES. By Prof. Dr.;Franz Mracek, of Vienna. Edited by Henry W- Stel- wagSo.n. M. D.', Clinical Professor, of Dermatology, Jefferson Medici Col- lege, Philadelphia,: With 63 colored plates, 39 half-tone illustrations, and , ,, 200 pages of text. Cloth, $3.50 net. . ; .' , \ ATLAS AND EPITOME OF SPECIAL PATHOLOGICAL HIS- TOLOGY. By DR. H. DflRCK, of Munich. Edited by LuDVIG HEKTOEN, M. D., ' Professor of Pathology, Rush Medical College, Chicago. In Two Parts! Part I., including Circulatory, Respiratory L and Gastr'o-intestinal Tract, 120 colored figures on 62 plates,. 158 pages of text. Part II. ^including Liver, Urinary Organs, Sexual Organs, Nervous System, Skin, ■ Muscles, . and Bones. 123 colored figures on. 60 plates, 192 pages of^ext-/ Per volume ;■ Cloth, $3.00 net. -..".,.' ; , .16 , .'•'-"' Digitized by Microsoft® Saunders' Medical Hand=Atlases. VOLUMES JUST ISSUED ATLAS AND EPITOME OF DISEASES CAUSED BY ACCIDENTS. .- By Dr. Ed. Golebibwski, of Berlin. Edited, with additions, by Peakce Bailey, M. D., Attending Physician to the Department -of Corrections arid'tp.the.Alinshouse and Incurablg Hospitals, New York. With 4 ATLAS AND EPITOME OF THE NERVOUS SYSTEM AND ITS DISEASES. By Professor Dr. Chr.. Jakob, of Erlangen. From the Second Revised and Enlarged German Edition. Edited, with additions, by Edward D. Fisher, M. D., Professor of Diseases of the. Nervous System, University and Bellevue -Hospital Medical College, NV Y. With 83 plates ; .copious text. $3-t° net. ' ATLAS AND EPITOME OF LABOR AND OPERATIVE OBSTETRICS. By Dr! 6. Schaeefer, of Heidelberg. From the Fifth Revised and Enlarged German Edition. Edited.^ith additions, by J, Clifton^Edgar, M. X>., Professor^ Obstetrics, and Clinical-Midwifery, Cornell University Medical School. With 126 cotored illustra- tions. $2.00 net. •'- ~ - ATLAS AND EPITOME OF OBSTETRICAL DIAGNOSIS AND TREATMENT. By Dr. O: Schaeffer, of Heidelberg. From the Second Revised and Enlarged Ger- man Edition: Edited, with additions, by J. Clifton Edgar, M. D. Professor of Obstetrics and Clinical Midwifery, Cornell University Medical School. 72 .-colored .plates, numerous text-illustrations, and copious text, g3.00.jret. ATLAS AND EPITOME OF OPHTHALMOSCOPY AND OPHTHALMOSCOPIC DIAGNOSIS. -i... ,- r. By Dr. O. Haab, of Zurich. From the Third Revised and Enlarged German EM- , tion: Edited, with additions by G. E. deSchweinitz, M."D., Professor- of Ophthal- mology. Jefferson Medical College, Philadelphia. With 152 colored figures; aild. 83 pages of text. Cloth, $3.00 net. ' ; -:-" ATLAS AND EPITOME OF BACTERIOLOGY. * Including a Hand-Book of Special Bacte'riolpgic Diagnosis. By Prof. Dr. K. B. Lehmann and Dr. R. O. Neumann, of Wur^burg.: From the Second Revis'ed.German Edition. Edited, with additions, by George H. Weaver, M. D., Assistant Professor ■, of Pathotqgy and' Bacteriology, Rush Medical -College. In Two Parts. Part'I:, con- sisting of '632 colored figure? on <9 plates. Part II,, consistingof 511 pages of text, illustrated.. Per Part : Cloth, $2.50 net. " -. ' - ATLAS AND EPITOME OF OTOLOGY. v . iy Dr. Gustav Bruhl, of Berlin, with the collaboration of Prof. Dr. A. Politzer, of Vienna. Edited, with additions, by S. MacCubn Smith, M. D.-, Clinical Professor of Otology, Jefferson Medical College, ' Phila. 244. colored figures -on 39 plates, 59 text- cuts, and 292 pages of text. Cloth, £33»net. , ^ - "'/■-:■._- ATLAS AND EPITOME OF ABDOMINAL HERNIA. By PrWatdocent Dr. Georg Sultan, of Gottingen. Edited, with additions, by Wil- liam B.Ojley, Clinical Pectijrer on Surgery,. College of, Physicians and burgeons New , - York. With 43 colored" figures on 36 'plates, 100 text-cuts, and about 250 pages ol text; In Press. ,,. . • '- " • - . " ATLAS AND EPITOME OF FRACTURES AND LUXATIONS.- By Prof. Dr. H. Helferk:h, of Kiel. - Edited, with additions, by Joseph C. Blood- GCod, Associate in Surgery, Johns* Hopkins University, Baltimore. With 215 colored figures on 72 plates, 144" text-cuts, 42 skiagraphs, and over '300 pages of text. In Press. ATLAS AND EPITOME OF DISEASES OF MOUTH, THROAT, AND NOSE. By Dr. L. Gr&nwald, of Munich*. . From the Second Revised antfJZniarged German Edition. With^ colored figures, 39 text-cuts, and 235 pages of text. * :■ ADDITIONfiS^^Si(ifiN*PPARATION ... ' "~ 1-7