Columbia (Mnitif r^ttp 
 
 mtl\t€\tyt\tMmfaxk 
 
 CoUege of ^ijpsiitians anb ^nvstons 
 ILihmtp 
 
CU6L -U^ 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/bestmethodofteacOOedga 
 
THE BEST METHOD OF TEACHING 
 
 OBSTETRICS AND AIDS IN 
 
 OBSTETRIC TEACHING 
 
 BY 
 
 JAMES CLIFTON EDGAR, M.D. 
 
 ASSOCIATE PROFESSOR OF OBSTETRICS AND GYNyECOLOGY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF THE 
 
 CITY OF NEW YORK ; ATTENDING PHYSICIAN TO THE SOCIETY OF THE LYING-IN HOSPITAL, TO THE 
 
 NEW YORK MATERNITY AND TO THE EMERGENCY HOSPITAL; LECTURER AND EXAMINER 
 
 ON OBSTETRICS IN THE NEW YORK TRAINING SCHOOL FOR NURSES 
 
 WITH NUMEROUS ILLUSTRATIONS 
 
 REPRINTED FROM THE NEW YORK MEDICAL JOURNAL 
 OF NOVEMBER 14, 21, sS, AND DECEMBER j, i8g6. 
 
 N H W YORK 
 
 D. APPLETON AND COMPANY 
 
 1896 
 
I^Q- s:i^ 
 
 Copyright, 1896, 
 BY D. APPLETON AND COMPANY. 
 
THE BEST METHOD OF TEACHING OBSTETKICS. 
 
 It is a little more than seven years ago that our 
 honored fellow, Dr. Theophilus Parvin, at the thir- 
 teenth annual meeting of this academy, made, as the 
 majority of us will recollect, a most earnest plea for 
 practical obstetrics in the courses of instruction given by 
 our medical colleges. It was then clearly shown by him 
 that while the science of obstetrics was admirably taught 
 in many of our American medical schools, the art of 
 midwifery was and had been sadly neglected; that the 
 vast majority of American medical students graduated 
 each year without ever having witnessed, still less having 
 had charge of, a case of labor; that in many medical 
 schools not even the practical diagnosis of pregnancy 
 by palpation and auscultation was taught. 
 
 The truth of these statements has never been ques- 
 tioned. Up to that time it had been customary in this 
 country for most medical students to graduate either 
 without any practical knowledge of midwifery, or with 
 such only as they were able to obtain by witnessing an 
 occasional case in a clinic, or possibly by treating women 
 in coniinement in their own homes without the super- 
 vision or aid of an instructor. 
 
 The result was inevitable. The art of obstetrics 
 was learned by the young practitioner often at the ex- 
 pense of serious if not fatal injury to his first confinement 
 cases. During the past decade a revolution has been in 
 progress in the teaching of medicine in this country. 
 The two- and three-year courses are gradually but surely 
 being replaced by four years of instruction; college terms 
 of five, six, or seven months are being lengthened to 
 eight and even nine. 
 
 The haphazard theoretical or didactic teaching of the 
 old two-year course has already been largely supplanted 
 by systematic recitations and practical and thorough 
 laboratory instruction. The clinical instruction to large 
 audiences of former years is generally supplemented by 
 practical clinical work performed by small sections of 
 the class. In many medical colleges it is undoubtedly 
 still customary to cling to the old form of lecture de- 
 livered to large audiences. It is, however, gradually 
 but surely being replaced by systematic graded courses 
 of practical and clinical instruction. 
 
 Has the subject of obstetrics, usually classed as the 
 last of the seven fundamental divisions of medicine, 
 kept pace with the remaining six in this reform? To a 
 certain extent, yes. As to the question whether it has 
 advanced with the same rapidity as the others, we are 
 compelled to answer in the negative. 
 
 The history of medical progress in the past few 
 years certainly points to some reform in the teaching 
 
 * Read before the American Academy of Medicine, Atlanta, May 4, 
 
 of the art of midwifery, shown in marked improve- 
 ments in the matter of instruction in colleges al- 
 ready possessing lying-in departments, and in the estab- 
 lishment of new institutions whose main purpose is the 
 imparting of practical instruction, not only to the under- 
 graduate student, but to the graduate physician as well. 
 
 Ten years ago not a single medical school in iS'ew 
 York city, for instance, required its students even to 
 witness cases of confinement before graduating. At 
 that time there were nine institution in New York 
 either wholly devoted to lying-in patients, or with lying- 
 in departments attached, and in none of these was sys- 
 tematic instruction in obstetrics given. To-day six 
 medical schools require that each student before gradua- 
 tion shall have attended at least six cases of confinement, 
 and there are some thirteen institutions devoted wholly 
 or in part to obstetrics, five of these giving systematic 
 instruction to students in midwifery. 
 
 In spite of these facts, there appears to be no doubt 
 that the teaching of obstetrics generally, throughout 
 the country, is at this time anything but what it should 
 be, and that " clinical instruction is largely conspicuous 
 by its absence." 
 
 " The number of great maternity hospitals in this 
 country in which students can receive practical training 
 can be numbered on the fingers of one hand. As a coun- 
 try we are far behind in this matter." f 
 
 The best method to teach midwifery can not be de- 
 scribed under any single method, but must, of necessity, 
 be a combined method — a system — a combination of 
 recitations, demonstrations, manikin practice, attendance 
 upon clinics, practical bedside or hospital work, and 
 theoretical lectures, the teaching of the science and 
 art of obstetrics. The classified knowledge of the laws 
 which govern menstruation, ovulation, pregnancy, labor, 
 the puerperium, and obstetric surgery on the one hand, 
 and the intelligent appreciation and practical application 
 of the acquired classified knowledge at the bedside on 
 the other. 
 
 Although history tells us obstetric science has had 
 a tardy development, that not until the sixteenth or sev- 
 enteenth century was it fully established, still, from an 
 educational standpoint, the science has far outstripped 
 the art in the race. May the time soon come — and the 
 indications point to its being not far away — when both 
 shall be equally well taught. 
 
 The natural and, as experience teaches us, the best 
 sequence for the student to follow is for him to acquire 
 a working knowledge of the science of obstetrics before he 
 applies himself to the art. This he does in his recitations, 
 
 f Mann. President's Address. Iramaclions of the American Chjiim 
 cological SorAety, No. 20, 1895. 
 
THE BEST METHOD OF TEACHINO OBSTETBIGS. 
 
 clinics, and demonstrations. Further, we believe it advis- 
 able to defer the taking up of the general subject of 
 obstetrics until the pupil has had at least one year's 
 instruction in the medical school, especially in physiolo- 
 gy and anatomy. Without this preliminary study the 
 student can not profitably or comfortably digest instruc- 
 tion in the elements of the physiology and pathology 
 
 FlQ. 1.— Vertical meyiul section of tlie bony pelvis cast in aliimiuum and 
 mounted by means of a hand screw upon a blackboard and tripod. The 
 bodies of tbe lumbar, sacral, and coccygeal vertebree are outlined and num- 
 bered. The hand screw permits tbe cast being set at any angle. An outline 
 of tbe b( ny pelvis showing the axis of the pelvic inlet and those of the bony 
 and partiu"ient outlets is permanently sketched upon the blackboard below. 
 (From a photograph.) 
 
 of the puerperium, delivery, and pregnancy. He must 
 be familiar with the characters of the various tissues 
 of the hard and soft parts concerned, to which constant 
 reference is made in his recitation year, in terms of mi- 
 croscopic and Mstological anatomy. 
 
 Whatever may be the place of topograpliieal anatomy 
 in courses of anatomy i^er se, its consideration should 
 come early, at the very beginning, in a course of ob- 
 stetric teaching. It is in a high degree necessary that 
 the pupil shall have mastered, by the time he enters upon 
 his obstetric training, not only the size, shape, and con- 
 sistency of the normal lower abdominal and pelvic or- 
 gans, but the relations in space which such organs as the 
 labia, clitoris, meatus urinarius, and hymen, together with 
 their glands, blood-vessels and nerves; the uterus and 
 vagina, kidneys, ureters, bladder, and urethra; the 
 sigmoid flexure, rectum, and anus; abdominal aorta, 
 ovarian, external and internal iliac, and uterine arteries; 
 ovaries, Falloppian tubes, and ligaments of the uterus; 
 pelvic muscles, peritona3um, glandular, vascular, and 
 aerve supply, sustain to one another. If in addition the 
 itudent has mastered the elements of histology, then, 
 md only then, can he be considered fully equipped 
 to receive elementary instruction from the department 
 of obstetrics, and the head of this department is then 
 free, as he should be, to direct his whole energies to the 
 .vork which he has been appointed to undertake. After 
 this, the pupil's work in obstetrics should be so sys- 
 tematized as to blend progressively with the work of his 
 remaining three years in the medical school, and render 
 him at the end of that time not only capable of answer- 
 ing the few simple questions found to-day upon the 
 final or State examination paper, but fully competent 
 as well to care intelligently for women in normal labor, 
 and at least to recognize, if not meet, the ordinary com- 
 plications of the lying-in state, labor, and pregnancy. 
 
 E.xperience has taught us that this end is most surely 
 and thoroughly attained by pursuing some such plan as 
 the following, in the sequence named: 
 
 I. Systematic biweekly or triweekly recitations dur- 
 ing the second college year. 
 
 II. (1) Demonstrations and manikin work; (2) at- 
 tendance upon obstetric clinics; and (3) laboratory work 
 during the third collegiate year. 
 
 III. A resident service in a maternity hospital, which 
 shall include (1) the examination of pregnancy under 
 competent instructors; the actual confinement of pa- 
 tients by tlie student himself, under rigid supervision 
 in both; (2) "ward" or indoor service, and (3) "out- 
 door " or polyclinic service; (4) the attendance upon the 
 obstetric clinics of the hospital; (5) theoretical lectures 
 (illustrative in character); and (6) recitations subse- 
 quently upon the previous practical work performed by 
 the student. 
 
 IV. Theoretical lectures (illustrative in character) 
 upon advanced obstetrics. 
 
 I. Systematic Biweekly oe Teiweekly Eecitations 
 
 DUEING THE SECOND COLLEGE YeAE. 
 
 Attention has been called to the unfortunate custom 
 still prevalent in many medical colleges throughout this 
 country to teach obstetrics to large audiences by means 
 
THE BEST METHOD OF TEAOEISO 0BSTETRI08. 
 
 of the didactic or theoretical lecture. Within a few years 
 the attempt has been made b}' certain institutions to 
 
 a. 9.— Pelvis and blackboard of Fig. 1 used to demonstrate forceps applied to 
 fcetal head at the pelvic inlet and dangers that result from the faulty posi- 
 tion of the handles and traction in this wrong direction. {From a photo- 
 
 supplant this lecture course wholly or in part by thi.' 
 recitation. Since the introduction of this latter method 
 of teaching the shortcomings and faults of the old 
 didactic lecture, still generally in use, have become mori' 
 than ever apparent. Moreover, the contrast of the two 
 systems has resulted in benefit in quite another way, 
 since it has markedly changed the character and font' 
 of the theoretical lectures which still exist as supple- 
 ments to the recitational and practical work, raising 
 them to a higher plane, giving them a more practical anil 
 illustrative form, and thus making them in every wa} 
 more helpful to the student. 
 
 Although the advantages of the recitation systeu! 
 are more perceptible each year in the better qualiiied 
 graduating classes, still, we believe the recitation, so fai 
 as obstetrics is concerned, can be made of still greatei 
 value and interest to the student, even though the in 
 structors be comparatively young men. 
 
 It is not sufficient that the section of twenty or 
 thirty pupils be required to learn and recite in a per- 
 functory manner the principles and laws of obstetric sci- 
 ence as set forth in some good text-book in biweekly or 
 triweekly recitations, but these principles and laws must 
 be brought home and rendered real and interesting to 
 him by abundant illustration. 
 
 Perhaps in no other branch of medicine is this ob- 
 
 ject so readily attained as in obstetrics, since the under- 
 lying principles of the subject for the most part rest upon 
 the well-known laws of anatomy, physiology, and phys- 
 ics, all of which permit a wide range of illustration. 
 
 No department of obstetrics is to-day complete with- 
 out such means of illustration, and it should be the in- 
 structor's duty to make such intelligent use of them as 
 to supplement the labors of the head of the department, 
 relieve him of much of the theoretical work, and, at the 
 same time, better prepare the student for an intelligent 
 appreciation of his subsequent demonstration work, at- 
 tendance upon obstetric clinics, and finally for his resi- 
 dence in the maternity hospital. 
 
 The instructor will do well if, at the beginning of 
 the session, he lays out a schedule for his "entire course, 
 gauging his hours of recitation so as to cover the entire 
 field of the subject in the teaching year. 
 
 There should be plenty of blackboard space at his 
 command — pelves entire, sagittal and transverse sections 
 of the same, diagrams and charts, carefully selected mod- 
 els, wet and dry preparations, and the more common ob- 
 stetric instruments. 
 
 ,With a little ingenuity and forethought each indi- 
 vidual member of a section of say twenty students may be 
 tested regarding his appreciation of the subject in hand 
 during the recitation hour. 
 
 This is readily accomplished by assigning a portion 
 
 Fig. 8.— Pelvis and blackboard of Fig. 1, showing breech presentation with left 
 buttock caught at the pelvic inlet and the dangers of faulty traction on the 
 prolapsed leg in a horizontal plane. (From a photograph.) 
 
 of the section to the blackboard, to execute there a dia- 
 gram, enumerate a series of principles, or write defini- 
 tions, which are subsequently criticised by the instructor. 
 Another squad is assigned to a number of wet and dry 
 specimens conveniently placed on trays, which the stu- 
 dent, after a time given to look them over, is called upon 
 to demonstrate. 
 
THE BEST METHOD OF TEACHTN'O OBSTETRICS. 
 
 Among the wet specimens of especial use at tliis 
 time are placenta with membranes and cord attached 
 and preserved in alcohol or formalin; ova of the first 
 few months to demonstrate the transition from chorion 
 to placenta, the amnion, the umbilical vesicle, and so on; 
 a uterus showing the decidua of menstruation, another 
 the decidua of pregnancy; also a collection of preserved 
 embi-yos and foetuses, all of which the student shall be 
 required to inspect or measure, and describe not only the 
 gross appearances and characteristics, but also the chro- 
 nology of each. Any or all of these specimens the pa- 
 thologist of a maternity or large general hospital may 
 readily secure. 
 
 The dry preparations may include mounted placentiE, 
 injected through the vessels of the cords with different 
 colored material or corrosive preparations of the same. 
 These may comprise the normal conditions of the vessels 
 and departures therefrom. 
 
 Fig. 4.— Pelvis and blackboard of Fig. 1 used to demonstrate sling applied to 
 the breech and faulty direction of traction thereon. Position of double sling 
 for breech extraction also illustrated. (From a photograph.) 
 
 Still another squad is in the same way assigned to 
 carefully selected models, and the remainder of the class 
 is then questioned upon the subject of the day, enough 
 of the latter part of the hour being reserved for demon- 
 strations and criticisms of those assigned to the black- 
 board, specimens, and models. Such a plan is by no 
 means difficult to carry out, as experience will prove. 
 
 Regarding the models, there is practically no limit 
 to their number, as we show in another place (demon- 
 strations and manikin work), but perhaps the most use- 
 ful of them all at this time will be found a sagittal sec- 
 tion of the pelvis, cast in aluminum, and so mounted 
 upon a portable blackboard as to allow of being fixed in 
 the proper planes of both dorsal and upright positions. 
 
 Nothing has been of greater aid to us than this 
 
 contrivance, since, with chalk, pelvic planes, angles, 
 curves of bony pelvis, and parturient canal may be clear- 
 ly demonstrated. 
 
 We can not too strongly urge the importance and 
 the benefit to the student of actually handling the wet 
 and dry preparations, pelves in whole or in part, models, 
 and instruments used in the recitation. 
 
 To illustrate the foregoing, take the subject of pel- 
 vic deformity, for example. Five students are assigned 
 to manikins with the sacral promontories set to give true 
 conjugates from three inches and three quarters to two 
 inches and a half. A pelvimeter is at hand, and the stu- 
 dents are asked to state, after examining the diagonal 
 and true conjugates, the difference between these, ihe 
 factors influencing this difl'erence, the effect on labor 
 of the contracted pelvis, and the necessity for interfer- 
 ence. 
 
 Among another squad of five pupils are distributed 
 five copper-plated models of moderate pelvic deformity, 
 and by means of a pelvimeter the students are requested 
 to find the more important diameters, and finally to state 
 the probable cause of deformity, and the effect upon 
 labor of the same. 
 
 Still another squad of five pupils is assigned black- 
 board space, one to enumerate the principal pelvic diame- 
 ters and their usual lengths, another to demonstrate the 
 three conjugates of the pelvic brim, another the more 
 common kinds of pelvic deformity, another the causes, 
 and still another the methods of delivery. 
 
 The remainder of the section can now be quizzed 
 upon some special branch of the subject — for example, the 
 relation between pelvic contraction and malpresenta- 
 tion, position, and attitude, as illustrated by means of 
 models in sagittal and transverse sections; and, lastly, the 
 work of each individual student is inspected, and if 
 necessary criticised, the whole section being appealed to 
 for opinions on difficult points. 
 
 II. (1) Demonstrations and Manikin Wokk; (3) 
 Attendance upon Obsteteic Clinics; (3) and 
 Laboeatokt Work during the Third Collegiate 
 Year. 
 
 Not even at this time in the student's course is it 
 practical or advisable to attempt to handle classes that 
 exceed thirty. 
 
 It is desirable that the position of instructor in ob- 
 stetrics take on more the nature of a demonstration of 
 obstetrics; that his department consist of a combined 
 museum, manikin, and recitation room, furnished with 
 a generous supply of manikins, models, embryological, 
 anatomical, and pathological wet and dry specimens, 
 charts, diagrams — in short, all the recognized aids to 
 obstetric teaching. 
 
 In such an obstetrical laboratory the recitations and 
 demonstrations should be conducted to small sections of 
 the class as above described. 
 
THE BEST METHOD OF TEACHING OBSTETRICS. 
 
 1. Demonstrations and Manilcin Worh. 
 
 So far as the demonstrations and manikin work 
 go, biweekly or triweekly meetings, for a period of 
 six to eight weeks, will pretty thoroughly cover the 
 ground. 
 
 It is well for the instructor to aim in this section 
 work not only at a systematic course in manikin work, 
 but also at the same time a review of the theoretical 
 work gone over in the second year, giving it, so far as 
 possible, a practical application. This, with a little at- 
 tention, can be readily accomplished. 
 
 The models may be of plaster, or papier-mache repro- 
 ductions of plaster and clay, copper-plated models, or 
 composition, or of a miscellaneous character. With 
 them the parturient canal with its curves; the mechanism 
 of cervical dilatation in primiparae and multiparas; the 
 size and shape of the uterus at the several months of ges- 
 tation; the degrees of uterine, vaginal, and perineal rup- 
 tures, and methods of the repair of the latter; involution 
 of the puerperal uterus, as shown in a series of papier- 
 mache reproductions of frozen sections; the various forms 
 of pelvic deformity; the action and use of various cervi- 
 
 FiG. 5, — Pelvis of Fifr. 1. Manual method of meatsi 
 
 Here again, with a little ingenuity, most, if not all, 
 of the section or squad may he assigned some task to 
 perform during a given hour, so that the student shall 
 take as active a part as possible, leaving little of his 
 time without some occupation. 
 
 Such demonstrations and manikin work will call for 
 more apparatus, models, and specimens than was re- 
 quired in the recitations of the preceding year. An 
 abundance of blackboard space is required as before; 
 pelves entire, and in sagittal and transverse sections, 
 must be constantly at hand; three or four good manikins, 
 with a supply of puppets, foetal cadavers (preserved in 
 formalin or alcohol), embryos, foetuses, placenta3, with 
 their membranes in different stages of development, and 
 carefully selected models for use alone and in con- 
 junction with the manikins. 
 
 Ing the diagonal conjugate. tFrom a photograph.) 
 
 eal dilators; the intra-uterine tamponade; the puerperal 
 ciirette; the ligature in cervical hcemorrhage; manual 
 dilatation of the os, and many other obstetric condi- 
 tions. (See Aids in Obstetric Teaching, to be published 
 in a subsequent number.) We must insist, however, upon 
 the recognition of the proper place of these models in ob- 
 stetric teaching, and sound a caution regarding their use. 
 They should be viewed as auxiliaries, as adjuncts, and as 
 a better preparation for subsequent practical instruction; 
 and care must be used that no false or exaggerated im- 
 pression is conveyed to the student in their use. In an- 
 other paper we shall describe in detail the manner of 
 their production. As in the recitation system, the same 
 general plan of assigning work may be employed, the 
 student, however, being required to take a more active 
 part. 
 
TEE BEST METHOD OF TEACHING OBSTETBICS. 
 
 Thus, by a general illustration and a demonstration 
 form of instruction, much that heretofore has been more 
 or less problematical may be cleared up, and new interest 
 may be given to many obstetric subjects which, by rea- 
 son of their obsoureness and "dryness," proved stum- 
 bling blocks to the student, and later to the practising 
 physician. 
 
 This is the time and opportunity given the student 
 to acquire that manual training in obstetric procedures 
 which may never recur until he is in active practice, and 
 he should be made to appreciate his advantages. 
 
 It is at this time that he acquires the kind of train- 
 ing which gives to the intending physician the practice 
 to make him intelligent and expert in the use of his 
 knowledge; the kind of training which saves the newly 
 
 orrhage. Eight or ten students are assigned to manikins, 
 in which are placed leather models of the puerperal 
 uterus. Gauze, volsella, dressing, and needle forceps, nee- 
 dles and ligatures, and specula, all of which are part 
 of the equipment of the department, are at hand. 
 
 Each student, with the assistance of a second, and 
 under the supervision of the instructor, is required to 
 pack the uterus with gauze (Fig. 7) and also place a liga- 
 ture in the apex of the laceration in the neck of the 
 model (Fig. 8). The models are then removed from 
 the manildn, and the manner of gauze packing and the 
 position of the ligature demonstrated and criticised 
 by the instructor. Copper-plated plaster casts of the 
 several degrees of vaginal and perineal lacerations are 
 distributed to other pupils for inspection and subsequent 
 
 Flo. 6. — PelviB of Fig. 1. Instrumental method of measuring tlie obstetrical conjugate directly by 
 
 of Faraba?uf' 8 pelvimeter. 
 
 appointed hospital interne the mortification, in the pres- 
 ence of his seniors, of applying the forceps upside down; 
 the kind of training which causes the interne or newly 
 appointed instructor ever to remember that there is such 
 a thing as a curve to the parturient canal, and that trac- 
 tion with the forceps applied to the brim or on a leg in 
 high arrest of the breech, in a horizontal plane, quite 
 possibly result in disaster to mother and child! For close 
 observation will show that improper and faulty traction 
 with the forceps has cost the lives of more mothers and 
 children than almost any other obstetric operation, in 
 proportion toils frequency. To impress this fact upon the 
 pupil's mind, he must be made to see in what the danger 
 lies. By means of such training the physician's first cases 
 of confinement will be saved much that otherwise would 
 be experimental and crude in the manner of treatment. 
 Take, for example, the subject of post-partum haem- 
 
 demonstration. Other students are assigned blackboard 
 space to enumerate origin of hfemorrhage after delivery, 
 mechanism and causes, and principles of treatment. 
 
 Such a course can not be considered complete with- 
 out an occasional demonstration of the diagnosis of 
 pregnancy upon the living subject. Cases of pregnancy 
 may for this purpose be sent in from the dispensary of 
 the institution or from a maternity hospital. 
 
 These demonstrations can be made a valuable pre- 
 liminary to the resident hospital course to follow later. 
 Information obtained by inspection, palpation, and aus- 
 cultation can be interestingly dwelt upon by the in- 
 structor, and appreciated by the student. 
 
 2. Attendance upon Oistetric Clinics. 
 
 An occasional attendance at an obstetric clinic during 
 this third year will be of the greatest assistance in fixing 
 
THE BEST METHOD OF TEAOHINO OBSTETRICS. 
 
 Fig. 7.— Leather model of puerperal uterus placed in manikin, and used to demonstrate packing of the puerperal uterus with gauze to control postpartum hsemor- 
 rhage proper, or to secure drainage in atonic or septic conditions of the uterus. 
 
 Fig. S. — Leather model of puerperal uterun placed in manikin, and used to demonstrate treatment of powt-partum hB3morrhage due to a deeply lacerated cervix. 
 
10 
 
 TEE BEST METHOD OF TEACHING OBSTETRICS. 
 
 the theoretical work of the second year, and the demon- 
 strations and manikin work the student takes part in at 
 this time. 
 
 If possible, his time should be so laid out as to permit 
 the student to attend over a stated period the obstetric 
 clinics of the hospital, or until he has watched the de- 
 livery of several cases of confinement. If it can be ar- 
 ranged for him to take at this time his practice in the 
 out-patient department of the hospital, in the examina- 
 tion and diagnosis of pregnancy, so much the better, 
 for the student can then learn the preliminary princi- 
 ples of cleanliness, thus anticipating his resident service 
 in the maternity. 
 
 3. Laboratory Worh. 
 
 Provision should be made for those students who 
 desire special opportunities to study histology, pathology, 
 bacteriology, and embryology, that would not be ob- 
 tained in the regular courses of the colleges they attend. 
 Little time will be left for such work after the regular 
 laboratory courses in histology, pathology, and bacteri- 
 ology, consequently advanced research on the part of 
 the student is best undertaken during the vacation in- 
 tervals or after graduation. 
 
 III. A Eesident Seetice in a Maternity Hos- 
 pital, WHICH SHALL INCLUDE (1) THE EXAMINA- 
 TION OP Peegnanct under Competent Insteuct- 
 OEs; THE Actual Deliveet oe Patients by the 
 Student Himself, dndee Eigid Supeevision, in 
 BOTH. (3) " Ward " or Indooe Seevice. (3) 
 " Outdoor oe Polyclinic Seevice. (4) The 
 Attendance upon the Obsteteic Clinics of 
 THE Hospital. Also (5) Theoeetical Lectures 
 (illusteative in character), and (6) Eecita- 
 TiONS Subsequently upon the Previous Prac- 
 tical Work performed by the Student. 
 
 Resident Maternity Service. 
 
 Without entering into the controversy regarding the 
 actual amount of participation on the part of the student 
 in the practical work of the hospital or of the polyclinic 
 or " outdoor " service, we believe that such obstetric 
 courses should to-day demand not only that the student 
 shall witness the delivery of the patients, but also that 
 he shall personally actually confine the patients, always 
 in the presence of an expert and critical instructor. 
 Moreover, the subsequent care of the puerperal woman 
 and newborn child should rest with the student, always 
 again under a complete system of cheeks against accident 
 and under the most rigid supervision. That this is not 
 only practical but possible can be abundantly shown by 
 records of thousands of cases of confinement thus man- 
 aged without accident. 
 
 It has been charged against this practical system 
 of teaching, as applied to the medical student, that it 
 carries with it a high mortality rate, and that the pa- 
 
 tients treated under such a system are subject to unneces- 
 sary exposure. 
 
 The first objection is abundantly answered by the 
 records of many such practical systems established years 
 ago in Germany, and by those of several established 
 within the past decade in this country. 
 
 The latter objection can only hold good by reason of 
 a lapse in the rigid, critical, and constant supervision 
 on the part of the instructors, which must at all times 
 pervade such practical systems of instruction. 
 
 The student will best appreciate and profit by this 
 course if it is taken during his third year, or, better, in 
 vacation time, between his third and fourth years, when 
 he has full leisure to give to it. He should be brought 
 to look upon this practical course as the most valuable 
 and important of his whole obstetrical teaching, for all 
 that he has previously learned is to be tested and fixed 
 in his mind; theoretical deductions are to give place to 
 practical application; he will now not only observe his 
 classified knowledge applied at the bedside, but use and 
 apply it himself. 
 
 There is no doubt that students, as a rule, fully ap- 
 preciate the advantages of such clinical work, although 
 it demands extra time and much work. It is no un- 
 common occurrence, in one institution at least devoted 
 to education in practical obstetrics, for the student to 
 ask the privilege to remain over his regular period of 
 service, or even to return after a lapse of several months 
 and, repeat his practical obstetric course, although he has 
 already more than fulfilled the requirements for gradua- 
 tion. 
 
 1. The Examination of Pregnancy. 2. The "Ward" 
 
 Service. 
 
 It is advisable that the first of the student's observa- 
 tions should be in the examination of pregnancy. The 
 first few days of his service should be rather passive ones. 
 He should be called to witness all the deliveries and 
 operations in the wards or operating room; he should 
 attend such clinical lectures as shall be given; accom- 
 pany the attending or resident physician in his diurnal 
 rounds, and in addition should spend several hours each 
 day in the out-patient examining room or waiting ward, 
 where, under a competent instructor, he should be re- 
 quired to take an active part in the examination and 
 diagnosis of pregnancy, including pelvimetry, and 
 should, under the supervision of the instructor, be re- 
 quired to fill in properly and sign his name to the liis- 
 tories of pregnancy. It will be well if the record charts 
 used at tliis time — and later for confinement cases and 
 the newborn child — be fuller and more detailed in their 
 requirements than perhaps the medical records of a 
 hospital would demand. This is intended to bring out 
 the student's faculties of observation, and a wider con- 
 sideration of the subject than is generally considered 
 necessary. Examinations thus carried out under the 
 eye of the instructor, with attention to minute details, 
 
TBE BEST METHOD OP TEAOHINQ OBSTETBIOS. 
 
 11 
 
 as well as general observations in the examination and 
 care of even a few cases of pregnancy, labor, and new- 
 born children, will prove of far greater advantage to the 
 student than a much greater number cared for by him 
 without direct instruction and supervision. 
 
 No better time than this can be selected to incul- 
 cate in the student the principles of obstetrical clean- 
 liness, mechanical and chemical. 
 
 Eules and exphcit directions for personal cleanli- 
 ness and disinfection may be printed to advantage in 
 ; bold type and hung in the examining room, as is the 
 custom in some foreign maternities, notably of Prague. 
 Moreover, by this plan the same rigid cleansing and dis- 
 infecting of the hand and forearm is applied to the ex- 
 amination of pregnancy as to that of labor, and to carry 
 it out properly an abundant supply of fresh water, soap, 
 brushes, and mercuric chloride are called for. 
 
 With an abundance of material, such examinations 
 of the dispensary and waiting women of the hospital 
 may, after the student has examined several cases under 
 proper supervision, readily be made to resemble the 
 " touch course " of the foreign maternities. 
 
 With two students assigned to a case they may be 
 given time, after cleansing of their hands under super- 
 vision and according to the rules of the institution, to 
 examine the women both externally and internally. 
 The instructor in charge then examines the cases and 
 questions the students regarding the general condition 
 of the patient, the time of gestation, posture and presen- 
 tation of the foetus, condition of the mammary glands, 
 anterior abdominal "walls, external genitals, pelvic con- 
 tents, size of the bony pelvis, and departures from the 
 normal in hard or soft parts. 
 
 He may now, with great precaution, be permitted to 
 examine several cases in labor in the wards or delivery 
 room; then under rigid and expert supervision he may 
 be allowed to care for the entire confinement. The in- 
 structor must stand ready at this time to correct errors in 
 cleanliness, and criticise unskillfulness in management. 
 Under the supervision of the instructor, as in the 
 examination of pregnancy, the student should be di- 
 rected in the filling out of a complete history of labor 
 and child, going into the minutest details in order to 
 train his faculties of observation, and to this his name 
 should be signed, so that he may understand that he 
 personally is held to account for the future welfare of the 
 case. 
 
 Should the student remain on " ward " duty, 
 the future care of the case is assigned to him, still under 
 supervision of the ward instructor, and the daily ob- 
 servations upon mother and child are taken by him 
 and criticised at the diurnal rounds of the attending 
 or resident physician. 
 
 .3. " Outdoor " or Polyclinic Service. 
 The systematic training the student has received in the 
 wards renders it possible for him to put this same train- 
 
 ing in practice in the care of women in their own homes. 
 Thus, a large class of the poor of great cities, who either 
 can not or will not enter a maternity hospital, may be 
 reached. It is no doubt true, so far as this country is 
 concerned, that while a small proportion of the poor 
 dependent upon charity for proper aid in confinement 
 is cared for in maternity hospitals, by far the greater 
 number remain at home and must be attended there. 
 Tliis outdoor, polyclinic, or tenement-house service on 
 the part of the student can only be rendered practical 
 by an elaborate and carefully supervised system; by the 
 most thorough checks against accident; by an abundant 
 supply of clinical instructors; and by establishing 
 throughout the district to be covered by the service a 
 number of substations to the main hospital building, 
 so situated that one at least shall be easily accessible to 
 each patient on the waiting list, and all in touch with 
 the main hospital by means of telephonic connection. 
 
 Here, again, it can be abundantly proved that such 
 a system is not only feasible, but capable of being car- 
 ried on successfully. Eegarding the greater advantage 
 to the student of the outdoor maternity system, as com- 
 pared with the indoor service, there can be no question. 
 In the former, the pupil, being thrown more upon his 
 own resources and responsibility, becomes no longer a 
 looker-on, an assistant, but, being practically in charge 
 of the case of confinement, he profits by his experience 
 accordingly. The limits of the present paper forbid 
 our enlarging further upon the machinery by means of 
 which such outdoor lying-in services are conducted. 
 Moreover, descriptions of such systems, carried on in Bal- 
 timore, Philadelphia, New York, and Boston, have been 
 sufficiently dwelt upon during the past ten years. 
 
 4. Obstetric Clinics. 
 
 With a properly equipped operating room and amphi- 
 theatre, each normal or abnormal dehvery in the ma- 
 ternity may be made the occasion for an pbstetric clinic, 
 all the students on the premises being summoned for the 
 occasion. For this to be properly carried out, it should 
 be demanded of the resident staff that it shall also be a 
 teaching staff, and that a preliminary history of the 
 case, in each instance, should be concisely stated, as well 
 as a careful exposition of each step of the labor or opera- 
 tive procedure. 
 
 Such obstetric clinics could readily be made to re- 
 semble the diagnosis classes held abroad, as, for in- 
 stance, in Munich or Prague, where parturient women 
 are rolled into the amphitheatre from the ward or de- 
 livery room, and tv,-o students are called down from the 
 seats, required to render their hands and forearms ob- 
 stetrically clean, in the presence and under the criticism 
 of the instructor, then to examine the case, make their 
 diagnosis of pregnancy or labor, presentation, condi- 
 tion of OS, membranes, vagina, vulva, bladder, rectum, 
 and hard parts, and finally undergo questioning from 
 the instructor regarding their findings in the case. 
 
13 
 
 THE BEST METHOD OF TEACHINO OBSTETRICS. 
 
 Should operation or interference be called for it is to be 
 performed by the instructor; but should the case prove 
 a normal one, the student may be permitted to complete 
 the case, always under the criticism and supervision 
 of the instructor, who should be expected to address 
 not only the students at the case but the entire au- 
 dience. 
 
 Many points of practical interest connected with the 
 management of the second and tlaird stages of labor, the 
 handling of the cliild, the care of its eyes, the administra- 
 tion of the post-partum douche, the watching of the 
 fundus uteri, the application of an occlusion dressing 
 and abdominal binder, may be brought home in a most 
 thorough as well as interesting manner. 
 
 The further conduct of mother and cliild may rest 
 with the two students confining the case, and they should 
 be held responsible for subsequent departures from the 
 normal condition. 
 
 5. Theoretical Lectures. 
 
 Little time will be left to the pupil for theoretical in- 
 struction during his maternity service. This should 
 precede and follow his practical instruction. 
 
 What theoretical teacliing he does receive at tliis 
 time should have direct bearing upon the work in hand, 
 and should rather take for its subject abnormal or in- 
 teresting cases occurring in the recent service of the 
 hospital. 
 
 6. Recitations. 
 
 What we have said regarding lectures applies equally 
 to recitations. One or two a week, however, will prove 
 of the greatest value in fixing the previous practical 
 work of the student. It will be found here that the use 
 of those aids to illustration to which reference has already 
 been made in the college course will prove of untold 
 value in firmly establishing the principles of practical 
 obstetrics in the pupil's mind. 
 
 It may be mentioned here that most of these aids, 
 with the exception of the wet and dry specimens, are of 
 such a nature as to be readily kept clean, and thus free 
 from even the suspicion of danger as regards their use 
 in a maternity. 
 
 IV. Theoretical or Didactic Lectures (illus- 
 trative IN character) upon Advanced Obstet- 
 rics. 
 
 A good deal has recently been written regarding 
 the passing of the theoretical or didactic lecture, and 
 the fact that it is less generally made use of than here- 
 tofore has, in the foregoing pages, already been alluded 
 to. I can not but believe, however, that, so far as 
 obstetrics is concerned, the theoretical lecture, in a modi- 
 fied form, still has its place and can accomplish much 
 good. 
 
 ' I do not refer to the old-fashioned lecture of fifty- 
 five minutes, devoted to rehearsing the course of a dis- 
 
 ease, interspersed with anecdote and clinical experience 
 of the speaker, but we have reference to a lecture — theo- 
 retical in part, to be sure, but partly recitation and partly 
 demonstration — which deals with the pathological con- 
 ditions of more advanced obstetrics, and covers sue! 
 subjects as abortion and premature labor, extra-uterine 
 gestation, the mechanics and physics of labor, ruptures 
 of the genital tract, puerperal infection, and the rarer 
 forms of pelvic deformity. 
 
 Fifteen minutes at the commencement of such a 
 lecture can, to advantage, be given to recitation upon 
 the subject of the preceding lecture, and pathological 
 specimens, models, the blackboard, and the lantern and 
 screen are not to be neglected as means of demonstration 
 and illustration. 
 
 In conclusion, I desire to affirm my deep con- 
 viction that the subject of obstetrics should be consid- 
 ered in no sense of the term a specialty, but a depart- 
 ment of medicine and surgery. 
 
 Further, that in the recitations, demonstrations, 
 laboratory work, clinics, practical bedside instruction, 
 and theoretical lectures, already alluded to, the in- 
 structor should render a service not only to his hsteners 
 but to medicine in general, by rising to something higher 
 than a mere perfunctory performance of his assigned 
 duties, and impress clearly upon his class the fact that 
 midwifery is not a specialty but an integral part, a sub- 
 division only of medicine and surgery. 
 
 No part of any subject can be properly understood 
 unless it is studied in its relations to the whole. The in- 
 terdependence and intimate relationship of these three 
 branches can not be too clearly brought out or too often 
 insisted upon. The light shed by each on the compli- 
 cations of the others is too bright and too valuable to 
 be lost in the obscurity of prejudice and misconception. 
 
 Obstetrics to-day, and at all times, should be taught 
 equally as a department of medicine and as a department 
 of surgery. 
 
 The day, which fortunately for suffering women has 
 passed, has not faded from the memory of living men — 
 men indeed who took an active part in raising midwifery 
 to its present position, when the obstetrician was refused 
 his equal place by his brother physicians and surgeons, 
 using the words in their narrowest sense, when he was 
 not permitted to operate in the great hospitals of the 
 centres of population, and his art was relegated to the 
 place it occupies now in the hands of the midwife! With 
 the advance of medicine in general during the last half 
 century has come the recognition from every quarter 
 of the kinship of these allied branches, and of the knowl- 
 edge added to the general fund by the obstetrician's 
 painstaking research. It is just these facts which we 
 claim should be continually brought to the student's 
 nttention, in order that he may not in his future career * 
 
 ■Barnes. Inaugural Address. Glasffnw Medicaljmirnal, Decemher, 
 
THE BEST METEOD OF TEAOHINQ OBSTETRICS. 
 
 13 
 
 fall into the error of regarding midwifery as a thing 
 apart from general medicine, and, further, that, if 
 his work should chance to lie more particularly in 
 other fields, he may carry with him a just appreciation 
 ;of an art in which he has been at least thoroughly 
 drilled. 
 
 In illustration of what has been said, it may not be 
 amiss to cite a few instances demonstrating that the 
 physiological and pathological states of pregnancy, the 
 puerperium and labor, the therapeutical and surgical 
 measures adopted in handling them, differ certainly not 
 in kind from these conditions found elsewhere. It is 
 only that the greater skill of the accoucheur after long 
 training gives him an advantage readily recognizable. 
 The toxiemia of pregnancy is toxaemia still in spite of 
 its graver import, perhaps, in the danger to the life of 
 mother and child, and its indications in the way of 
 treatment are the same, save for the additional obstetri- 
 cal treatment. Transient glycosuria disappearing with 
 the termination of labor or the onset of lactation, jaun- 
 dice, haemorrhage, cardiac hypertrophy, thrombosis, em- 
 bolism, offer no essential differences, and, further, exhibit 
 the particular morbid condition in its inception, throw- 
 ing a light on its astiology often obtainable in no other 
 way (Barnes, loc. cit.). We are too prone to accept the 
 findings in the dead house as cause rather than effect, 
 and to neglect the opportunity furnished by the preg- 
 nant state to observe the affection at its outset and there- 
 by discover the true methods of prevention and cure. 
 Metabolism, in both its forms, here furnishes unequaled 
 opening for study to the physiologist. There is much 
 to be learned from observation of the progress of inter- 
 current disease — e. g., tuberculosis, under the intense 
 
 vascular and nervous strain of pregnancy. The same is 
 true of skin affections, both as to their nature and aeti- 
 ology. The so-called "mask of pregnancy" is the 
 chloasma of other states; herpes gestationis is derma- 
 titis herpetiformis; and here the dermatologists may find 
 a clew to the origin of these affections. These statements 
 are equally applicable in the province of surgery and 
 surgical pathology. 
 
 Gynaecology may, with reason and right, be ranked 
 as a specialty, its technical procedures entitling it to 
 such a place, but not so obstetrics. 
 
 Eepair of injuries produced by labor, instrumental 
 or manual dilatation of the cervix, symphysiotomy, cu- 
 rettage, fall more naturally to the obstetrician only be- 
 cause of his skill and experience in their operative details, 
 not because the general surgeon is not entirely com- 
 petent to perform them. 
 
 Certain measures, as perforation, cephalotripsy, for- 
 ceps and version operations, manual removal of the pla- 
 centa, decapitation, evisceration, correction of malpres- 
 entations, positions, and attitudes, closely approach the 
 border line of specialism, but some of these have greatly 
 fallen into disuse since the introduction of other per- 
 fected operations offering a^ chance of life to the child. 
 
 Cesarean section itself is merely the removal by the 
 knife of a foreign body from the interior of a hollow vis- 
 cus whose outlet is partially occluded. 
 
 This argument may appear at first sight a digression 
 from the subject in hand, but reflection will show not 
 only the justice but the necessity of its introduction. 
 His student career is the time when the physician is most 
 impressionable, and when facts are most readily brought 
 home and fixed in his mind. 
 
AIDS m OBSTETRIC TEACHmG* 
 
 PART I. 
 
 Jmxrodcction. 
 
 The underlying principles of obstetrics are based 
 upon certain recognized and well-known laws of anato- 
 my, physiology, and physics, which allow of a wide range 
 of illustration. 
 
 Without a question, the best single method for the 
 student to acquire a practical and lasting knowledge 
 of midwifery is in the personal and actual care of par- 
 turient and puerperal women — no student, however, 
 
 especially regarding the anatomical and mechanical prin- 
 ciples involved, much of his practical experience goes 
 for nothing and is wasted upon him. The shortcomings 
 of the theoretical or didactic obstetric lecture have in the 
 past few years received considerable attention, but most of 
 those who have arraigned the didactic form of instruction 
 in the strongest terms have offered us no substitute other 
 than a general plea for more practical work. 
 
 As I stated in the preceding paper, I believe a modi- 
 fied theoretical lecture still has its place in obstetric 
 
 Pig. 9.—^ represents the model finished in clay and ready to receive the first coat of paper strips moistened in watet ; B represents the clay model covered with 
 the first layer and the application of the paper strips dipped in hot carpenter's glue; ('shows a transverse section of the completed paper model, with its 
 ' interior filled with excelsior, and the surface ready for the first coat of paint. 
 
 should be allowed this privilege without previous train- 
 ing — and in withessing various obstetrical procedures in 
 a clinic; but unless his mind has been made familiar 
 with the main principles of the subject, or his attention 
 is fixed at the time by means of abundant illustration, 
 
 * Read before the American Gynfecological Society at its twenty-liist 
 annual meetinp;, New York, May 26, 189(5. [The illustrations are num- 
 bered continuously with those in the author's previous article to facili- 
 tate reference from the one article to the other.] 
 
 teacliing — namely, a didactic lecture that is in part reci- 
 tation, in part demonstration, and which is freely and 
 abundantly illustrated by various means, some of which 
 I suggest in this paper. 
 
 Not a decade ago the memory was the only faculty 
 appealed to and cultivated in the teaching of obstetrics. 
 The student's mind was made the recipient of isolated 
 facts, and required to retain them by brute force as it 
 were. That memory has its place and is an important 
 factor we make no question, but it is the power to ob- 
 
AIDS IN OBSTETRIC TE AGEING. 
 
 15 
 
 ve, to grasp, to comprehend, to utilize, to put two and 
 ,fO together and reach a logical conclusion — that is the 
 fundamental principle of practical education. 
 
 It has been for the readier and better cultivation of 
 those two faculties of the mind, so essential to the medi- 
 
 of the instructor in the recitation room may be abso- 
 lutely wasted upon the pupil, whereas were simple and 
 familiar objects and models, which possess the third 
 dimension of space, made use of in conjunction with 
 the description, the subject would immediately appeal to 
 
 f 
 
 ■Fig. 10. Fin. 11. Fig. Vi. 
 
 Fio. 10.— Non-gravid uterus (.3" y. 2" y. 1"). (Plaster cast from Nature ; J natu- 
 ral size ; from a photograph.) 
 Fig. 11.— Gravid uterus at end of first month (3j" x 2^" x Ij"), Marked an- 
 tero-posterior growth. Piriform shape preserved. Almost cylindrical. 
 ■•""■ cast ; i natural size ; from a photograph.) 
 
 .id uterus at end of second month (4i" x 3,}" v 3"). Further 
 -rior growth. Pjriform shape still preserved. (Paper model ; 
 i uaiu ... sl.-^e ; from a photograph.) 
 
 cal student — namely, the reason and perception — that 
 necessity has compelled us to invent these various aids in 
 obstetric teaching presented to the American Gynse- 
 eological Society to-day. The medical student entering, 
 for example, upon his recitation course in obstetrics 
 in his second college year, will of necessity, both in his 
 
 Fig. 14. 
 
 Fig. 1.3.— Gravid uterus at end of third month (.5" x l" x 3"). Pyriform 
 shape gradually disappearing. Shape nearly spherical. (Paper model ; J 
 natural size ; from a photograph.) 
 
 Fig. 14.— Gravid uterus at end of fourth month (6" x 5" x 4"). Marked 
 ovoid. Anterior surface round as a ball ; posterior surface flattened. Cor- 
 pus uteri furnishes principal element of growth. Tubes considerably below 
 the horns. Size and shape influenced by fcetus, placenta, liquor amnii, and 
 disease. (Paper model ; i natural size ; from a photograph.) 
 
 the student, new interest would be awakened, and the 
 facts in question be rendered so plain and simple as not 
 readily to be misunderstood or forgotten. 
 
 Diagrams fail because they are unreal, because they 
 are not readily understood, because the anatomical rela- 
 tionships are obscured, because only one surface of the 
 
 Fig. 15. 
 
 Fig. 16. 
 
 Fig. 16.— Gravid uterus at end of fifth month (7" x 6" x b"). Characteristics 
 same as at end of fourth month. (Paper model ; i natural size ; from a 
 photograph.) 
 
 Fig. 16.— Gravid uterus at end of sixth month (8i" x 6J" x 6"). Ovoid grad- 
 ually becoming egg-shaped. Posterior wall flattened by spinal column. 
 Tubes considerably below horns. Size and shape influenced by foetus, pla- 
 centa, liquor amnii, and disease. (Paper model ; J natural size ; from a 
 photograph.) 
 
 reading and his class-room work, encounter many new 
 and unfamiliar words, or many which have heretofore 
 been used in quite another sense, and, moreover, to such 
 an extent that he completely fails to grasp the underly- 
 ing principles that they are intended to convey. Thus, 
 an elaborate description in the text-book or ou the part 
 
 Pig. 17.— Gravid uterus at end of seventh month (lOj" x 7J" x 61"). Egg- 
 shaped. Broadest just below fundus. Longitudinal axis predominates. 
 Posterior wall flattened by spinal column. Tubes still farther below horns. 
 Size and shape influenced by fojtua, placenta, liquor amnii, and disease 
 (Paper model ; i natural size ; from a photograph.) 
 
 object is presented. The model succeeds since the re- 
 verse obtains. Take, for example, the flattened pelvis of 
 rhachitis. The student's interest is immediately awak- 
 ened and held if such a pelvis be placed in his hands 
 with the request to point out the departures from the 
 normal condition. 
 
16 
 
 AIDS IN OBSTETRIC TEAGEINO. 
 
 Injuries to the pelvic floor become much more real | So in the description of the involution of the puer- 
 and easily understood when reproduced in casts, with | perium and the relations of the uterus to the surrounding 
 real sutures in place, than by chalk on the blackboard I parts, paper reproductions of frozen sections will render 
 or diagrams in text-books. So, too, the history of the | us great service in holding the student's attention and 
 
 Pig. 18. 
 
 Fig. 18.— Gravid uterus at end of eighth month (lU" x 8" x 7"). Character- 
 istics same as at end of seventh month. (Paper model ; i natural size'; from 
 a photograph.) 
 
 Fig. 19.— Gravid uterus at end of ninth month (13" x 9J" x 8i"). Ovoid- 
 shaped. Longitudinal axis predominates. Broad fundus. Anterior surface 
 more convex than heretofore. Posterior depression caused by lumbo-sacral 
 
 progress of pregnancy becomes simplified with models 
 of the pregnant uterus to illustrate it; the changes in the 
 vaginal portion of the cervix, the supravaginal portion, 
 the internal and external os, as well as the mechanism 
 of dilatation, and the passage of the fcetus through the 
 
 Fig. 20.— Vertical mesial section of the parturient canal at the end of the stage 
 of dilatation, from a woman who died during labor. (After Karl Braune ; 
 weight, one pound and three quarters. Paper model. From a photograph.) 
 
 OS and ostium vaginae, become realities never to be for- 
 gotten, with a series of flexible models to represent the 
 same, which the student is called upon to examine and 
 demonstrate personally. 
 
 Fig. 19.- 
 angle. Fundus, rarely regular, depends on posture of foetus. Festal head 
 causes increased development of anterior part of lower uterine segment. 
 "Sacciform dilatation of lower uterine segment." Size and shape influ- 
 enced by fcetus, placenta, liquor amnii, and disease. (Paper model ; i nat- 
 ural size ; from a photograph.) 
 
 fixing the facts regarding them. Moreover, subsequent 
 practical work in the lying-in hospital and outdoor ma- 
 lernity service becomes not only more profltable and in- 
 structive to the student, but safer for the patients after 
 such ocular demonstrations of familiar obstetric prin- 
 
 FiQ. 21.— Same as Fig. 20, with fcetal cadaver placed in right anterior position 
 of the vertex. Head well engaged, internal rotation just beginning. (Paper 
 model; from a photograph.) 
 
 ciples. Again, we have found some of these aids — as the 
 leather puerperal uterus, paper models of pregnant and 
 puerperal uteri, composition cervices, and perineal 
 lacerations — of lasting and practical value in the instruc- 
 
AIDS IN OBSTETRIO TEACHING. 
 
 17 
 
 tion in obstetrics of nurses still in the training school of I the aids herein set forth, either in the delivery or lec- 
 a general or maternity hospital. We have repeatedly | ture room, are rendered much more interesting, profit- 
 
 FiG. 22.— Diagrammatic \ertical medial section ol piutunent canal at bcj^inniug 
 of the first stage of labor to illustrate \aginal and eupriviginal portions of 
 the cervix. Useful to illustrate poitnre presentation and position of the 
 foetus, use of vaginal tampon, varieties of cervical dilators, placenta prsevia, 
 and many other conditions. (Paper model.) 
 
 Fig. 23. — Same as Fig. 22 ; illustrates fcetal cadaver in right anterior position 
 of the vertex, central placenta previa, Barnes's bag, and vaginal tamponade 
 in position. DemoDetratesdangers of the Barnes's bag producing premature 
 separation of the placenta beyond the ring of the internal os and the result- 
 ing internal or concealed ho3morrhage by reason of the distal extremity of 
 the Barnes's bag projecting too far into the cavity of the lower uterine seg- 
 ment. (Paper model ; from a photograph.) 
 
 observed, by reason of the slight knowledge of anatomy, 
 physiology, and histology which these pupil nurses pos- 
 sess, that demonstrations supplemented by the use of 
 
 able, and instructive, than a mere dry recital of facts. 
 This is especially true in hospitals in which practically 
 no maternity service is given to the nurses, or in those 
 
 . 3-(. —Diagrammatic verUcal mesial section of parturient ( 
 demonstrationB of intra-ulcrinc n 
 
 aJ at end of firHtHtage of labor. The uterine cavity is covoi'ed by a netting so as to permit of ocular 
 lipuiations. Illustrates internal direct podalic version. (Paper model.) 
 
18 
 
 AIDS IN OBSTETRIC TEACHING. 
 
 where the rules of the institution debar the nurse from 
 actually conducting the confinement, or even making a 
 vaginal examination. 
 
 Objection is occasionally raised, justly or unjustly, 
 that general obstetric demonstration, apart from the bed- 
 side or clinic, carries with it the necessity of handling 
 wet and dried anatomical material — fcetal cadavers, for 
 instance — and, consequently, a suspicion of uncleanli- 
 ness. 
 
 Not the least advantage of the greater number of the 
 
 specimens of pelvic deformity, and an interchange of 
 such models, together with their clinical history, may 
 accomplish much to raise the standard of obstetric in- 
 struction. 
 
 I'ROPEE PLACE FOE MODELS CAUTIONS EEGAEDINQ 
 
 THEIE USE. 
 
 I desire at the outset emphaticaly to disclaim any 
 intention of impljdng or suggesting that the aids in 
 obstetric teaching herein described and illustrated are 
 
 Fig. 25. 
 Mechaniem of cervical dilatation i 
 
 primiparee (diagrammatic). (Paper models ; from a photograph.) 
 
 aids in obstetric teaching herein described is to be found 
 in the fact that by reason of their composition they may 
 be made and kept obstetrically clean — no small advan- 
 tage, since we often desire to use the same at the bedside 
 or in the obstetric clinic. 
 
 in any sense to replace practical bedside instruction. 
 These aids I offer as auxiliaries, as adjuncts for more 
 instructive and interesting obstetric recitations, demon- 
 strations, theoretical lectures, clinics, examinations of 
 pregnancy, and ward instruction in maternity hospitals. 
 
 Mechanism of cervical dilatation i 
 
 Fig. S8. 
 mltlparae (diagrammatic). (Paper models ; from a photograph.) 
 
 Much that I present in these pages is suggestive and 
 rudimentary in character; much, we feel, can and will 
 be improved upon as time and opportunity ofEer. For 
 example, I beg leave to suggest that plaster molds be 
 taken of specimens of pregnant uteri of known months 
 of gestation, so that from these subsequently any desired 
 number of papier-mache models may be reproduced for 
 exchange among museums and obstetric teachers. The 
 same plan may, I believe, be pursued in the case of 
 
 I can confidently assert, as the result of several 
 years' experience in the use of such aids, that they throw 
 new light upon many physiological and mechanical prob- 
 lems of midwifery, and that they moreover lend new 
 interest to many obstetric subjects, which, by reason of 
 their obscureness and dryness, have in the past proved 
 more than stumbling blocks to students, and, I may 
 truthfully add, to practitioners as well. 
 
 It can not be too strongly insisted upon that great 
 
AIDS IN OBSTETRIC TEACHING. 
 
 19 
 
 Fig. 30. — Vertical mesial seclion of piKn-ueral iiterii8 live niiuutes after delivery. 
 Patient died, heart disease. (After Webster ; paper model ; from a pho- 
 tograph.) 
 
 Fig. 29.— Vertical mesial section of the pregnant uterus at the beginning of the 
 fifth month of gestation. (Paper model ; from a photograph.) 
 
 Kio, yj.— Vertical menial Hc-ction of puerperal uterus ECConOuay of pueiperium. Fia. 32.— Vertical mcBial section of puerperal uterus three days after labor^ 
 Patient died of eclampsia thirty-six hours after labor, (After Webster; Patient died of acute yellow atrophy. Nearly full term. (After Webster ; 
 
 paper model ; from a photograph.) paper model ; from a photograph.) 
 
20 
 
 AIDS IN OBSTETRIC TEACHING. 
 
 care must be employed in the selection and use 
 of models as aids in obstetric teaching. Their 
 proper place must be constantly kept before us, 
 and wliere reproductions from Kature in paper, 
 plaster, composition, or rubber are employed, 
 we have found it safer and generally more sat- 
 isfactory to produce the natural size of the ob- 
 ject, as by enlarging, the subject may become 
 merely grotesque, or even convey a false impres- 
 sion. A wrong impression, moreover, readily 
 acquired, is often less easily corrected in this 
 connection. 
 
 If proper care is taken in the selection and 
 preparation of models, no false or exaggerated 
 impression will be conveyed, and the produc- 
 tion of models in three dimensions of space, at 
 which we always aim, secures for us a means of 
 ocular demonstration and illustration, which 
 diagrams and charts, be they ever so beautifully 
 executed, or even blackboard illustration with an 
 abundant supply of colored chalk, can never 
 equal. Diagrams are unsatisfactory; they soon 
 become tiresome to the student, and they may 
 be misleading because of the loss of the third 
 dimension of space. 
 
 The attempt on the part of the student to 
 acquire a correct and clear idea of certain funda- 
 mental obstetric principles from a study of a 
 
 J. 33.— Vertical mesial sectior 
 died of heart disease. (Afte 
 
 of puerperal uterus fifteen 
 Webster ; paper model ; fri 
 
 days after liiimr. 
 >m a photograph. 
 
 Fig. 35.— Complete rupture of the uterus involving left lateral and posterior 
 walls and extending from the contraction ring almost to the external OS, 
 which latter is intact. Also complete rupture of posterior vaginal wall just 
 below external ring, opening into Douglas's pouch. (After a specimen in 
 the Museum of the Munich Prauenklinik ; paper model ; from a photo- 
 graph.) 
 
 Fig. 36.— Complete rupture of the left posterior wall of the uterus, extending 
 from the contraction ring downward and inward across the lower uterine 
 segment, through the external os, and some distance down the posterior 
 
 FiQ. 87. 
 
 vaginal wall. This illustrates a particularly dangerous form of rupture of 
 the genital tract, because of the possibility of direct infection of the peri- 
 toneal cavity by the vaginal secretions. (Paper model ; from a photo- 
 graph.) 
 Fig. 37. — Transverse rupture of the uterus through the lower uterine segment 
 at a point halfway between the contraction ring and the external os. Can- 
 cer of the cervix. Vertical mesial section. (Paper model ; from a photo- 
 graph.) 
 
AIDS IN OBSTETRIC TEACHING. 
 
 21 
 
 series of illustrations in his text-book or in the lec- 
 ture room is very apt to result in a condition of be- 
 wilderment on his part, which could readily have been 
 avoided by the free use of a few simple models. With 
 such models, recitations and demonstrations to classes 
 divided into easily handled sections can be made to 
 
 pelv 
 
 ;)ii ul' imi'rpLT^l utei-118 auir uorn at\er labor. 
 : Stratz ; paper model ; from a photograpli.) 
 
 result in much practical gain to the student, who has 
 up to this point obtained his knowledge of obstetrics 
 from text-books merely. 
 
 VARIOUS KINDS OF AIDS. 
 
 For purposes of convenience we shall enumer- 
 ate and describe the several kinds of aids to obstetric 
 teaching included in this paper under the following 
 
 I. Plaster models. 
 
 II. Paper reproductions of clay models and plaster 
 its. 
 
 III. Composition models. 
 
 IV. Miscellaneous models and aids. 
 
 V. Electro-plated casts and models. 
 
 I. Plaster Models. 
 
 Experience has taught us that plaster models per se 
 
 have a very limited field in this direction. Unless the 
 
 subjects be small and compact, the tendency of the plaster 
 
 to break, and the excessive weight in the case of the large 
 
 ones, are decided objections. 
 
 Plaster, however, will answer very well for 
 the smaller uteri of the early months, and has 
 been of service to us in securing first impressions 
 of lacerations, pregnant uteri, external genitals, 
 etc., which are su.bsequently reproduced in paper, 
 composition, rubber, or rendered serviceable and 
 durable by electro-plating with copper, as de- 
 scribed hereafter. 
 
 II. Paper Reproductions of Clay and Plaster 
 Models. 
 
 After experimenting with various kinds of 
 papier-mache, papier-mache compositions, and 
 modified plaster, we have found the method 
 proposed by Dr. W. 6. Thompson * as best 
 suited for our purpose, because of the lightness, 
 durability, and cheapness of the models made by 
 this process. 
 
 In addition to the plaster model, all that we 
 require is an abundant supply of old newspapers, 
 some carpenter's glue, shellac, or a good varnish, 
 and some ready-mixed paints. The clay model 
 or plaster-cast model having been made (see Fig. 
 9, A), it is first covered on one side with a sin- 
 gle layer of small pieces of newspaper (two by 
 four) moistened in cold water (see Fig. 9, B). 
 Every portion of the model or cast is thus cov- 
 ered with a single layer, and rapidly laid upon 
 this layer successive layers of paper dipped in 
 hot glue are added. By means of a fiat brush 
 .... i time is saved by painting the glue over the sur- 
 racted f^gg j^jjj^ rapidly laying the strips of paper upon 
 it. Special care is needed with the last layer 
 of strips only, in order to secure a smooth sur- 
 face (see Fig. 9, 0). The number of layers and sub- 
 sequent thickness of the wall should depend upon the 
 character and size of the model. In large models wire 
 gauze, strips of cheese cloth, cardboard, and even thin 
 slabs of pine, may with advantage be incorporated with 
 the paper and glue to add stability. The casing is now 
 allowed to dry thoroughly upon the clay or plaster 
 mold, and is then removed either entire or in two or 
 more sections when the former can not be done (see Fig. 
 9, C). 
 
 If the model represents, for instance, a sagittal sec- 
 tion, the interior is now carefully stuffed with loose news- 
 paper or excelsior, and a back added by means of larger 
 
 * The Use of Automatic and other Models in teaching Pliysiology, 
 Researches of the Loomis Laboratory, vol. ii, 1892. 
 
•22 
 
 AIDS IN OBSTETRIC TEAQIIINQ. 
 
 pieces of newspaper, strengthened with cheese cloth, glued 
 in the same manner as the above (see Fig. 9, C). When 
 tliis has thoroughly dried, a couple of thick coats of paint 
 are applied, to represent the object, and the whole shel- 
 lacked or varnished. For accuracy in the reproduction 
 of frozen sections (see Figs. 20, 29, 30, 31, 32, 33, and 
 34), diagrams of sagittal sections (see Figs. 23, 23, 24, 25, 
 26, 27, and 28), pathological specimens (see Figs. 35, 36, 
 and 37),wehavephotographed thecutsor rephotographed 
 the photographs, then with an enlarging lantern thrown 
 the outline of the figure upon a sheet of the thinnest 
 tissue paper until the desired size was obtained, and 
 outlined the object with a heavy pencil. Then, placing 
 the paper upon the smooth layer of clay, the modeling is 
 done directly through the paper, the moisture of the 
 clay finally absorbing the tissue paper. Thus, absolute 
 accuracy of detail and relationship can be obtained. 
 The reproductions of Webster's frozen sections (Fig. 
 20) were made in this manner. 
 
 " When finished, the model becomes as hard as board 
 and it possesses great advantage over papier-macM, which 
 is more expensive and usually brittle, unless subjected 
 to great pressure. 
 
 " This new composition is smooth and very hard, 
 watertight (for cold water), it never warps, breaks, or 
 cracks, and when painted it is difficult to believe that it 
 has been made of such cheap material." 
 
 An almost endless variety of anatomical and physio- 
 logical obstetrical models may be thus secured. 
 
 Transverse and sagittal sections are reproduced, aF 
 shown above. Where oval or round objects, as pregnant 
 uteri or tumors, are to be reproduced, the entire speci- 
 men is covered with the paper as above described, allowed 
 to dry, then cut in halves, the clay or plaster allowed to 
 drop out, and the two shells stuffed with excelsior and 
 glued together with several layers of paper strips over- 
 lapping at the seam. 
 
 1. Size and shape of the uterus during the successive 
 months of gestation. 
 
 These paper models here illustrated are, with the 
 exception of the normal uterus, not taken from Nature, 
 but are founded upon the collective descriptions and 
 average measurements given by Webster, Hart and Bar- 
 bour, Eibemont-Dessaigners, Farr and Tanner. 
 
 Should opportunity offer, more valuable and precise 
 models could undoubtedly be produced by making, im- 
 mediately after death, plaster casts of gravid uteri, 
 and then subsequently paper reproductions of the same. 
 We would offer here as a suggestion, as we do in 
 another place, that casts of such uteri from the cada- 
 ver be made which can subsequently be reproduced in 
 paper and exchanged among obstetric teachers and mu- 
 seums. Many are the uses to wliich such paper uteri 
 may be put: The height of the fundus in the several 
 months in and out of the pelvis; the changes in the 
 shape of the fundus and lower uterine segment, and 
 their influence upon the attitude, presentation, and posi- 
 
 tion of the foetus; placental insertion; physiology and 
 pathology of pregnancy and labor; and many other con- 
 ditions that will constantly suggest themselves, so that 
 such models will be in almost constant use during a 
 course of obstetric teaching. 
 
 2. Vertical mesial sections of uteri at term; mechan- 
 ism of cervical dilatation. 
 
 Fig. 20 is a reproduction in paper of Braune's frozen 
 section of the parturient uterus at the end of the first 
 stage, and Fig. 21 is the same, with a foetal cadaver intro- 
 duced to illustrate presentation and position. 
 
 Fig. 22 is a diagrammatic representation of a vertical 
 mesial section of a uterus at the beginning of the firsl 
 stage of labor, before the disappearance of the supra- 
 vaginal portion of the cervix. The uses to which these 
 two models can be put are almost endless, and students 
 in a short time can be brought to appreciate obstetric 
 conditions and situations wloich hours of explanation for- 
 merly were required to elucidate. 
 
 For example, the model of Fig. 20 can easily be made 
 to demonstrate the curve of the parturient canal, nor- 
 mal and abnormal attitude, presentation and position 
 of the fcetus, displacement of the small parts, and so on. 
 
 So the diagrammatic model of the uterus (Fig. 22), 
 with its cervical canal dilated to the size of one finger, 
 has proved of value in exhibiting various forms of cer- 
 vical dilators, as Tarnier's Barnes's, Champetier de 
 Ribes's, and others, and the advantages and the disad- 
 vantages of each; the varieties of placenta previa; the 
 uses and action of the vaginal tampon; and many other 
 conditions that will suggest themselves to the instructor. 
 
 Fig. 24 also represents a diagrammatic vertical mesial 
 section of the uterus, its open side fitted with netting 
 in order to retain the fretal cadaver or puppet during 
 demonstrations of the intra-uterine manipulations ac- 
 companying different varieties of version, reposition of . 
 prolapsed small parts, correction of malpositions and 
 postures. 
 
 The models representing cervical dilatation in primip- 
 arse and multiparffi, in Figs. 25 to 28, will, to a more lim- 
 ited extent, be found useful. 
 
 3. Eeproductions of frozen sections of gravid and 
 puerperal uteri. 
 
 It has been with some hesitation that I have at- 
 tempted the reproduction of the frozen sections of Web- 
 ster and Stratz for fear that something of the original 
 would be lost or distorted in the paper model. We 
 have therefore confined our work to the grosser ones, 
 as the puerperal uteri of Webster. In only one instance 
 have I attempted to produce a model of the gravid 
 uterus and its contained ovum (Fig. 29), and the result 
 was not altogether satisfactory. For such illustrations 
 quite as much can, we believe, be accomplished by dia- 
 gram. 
 
 The series of models representing involution, posi- 
 tion and relationships of the puerperal uteri, after Web- 
 ster's frozen sections, we have found of marked aid in 
 
AIDS IN 0B8TETRI0 TEAOJIINa. 
 
 23 
 
 demonstrating many conditions associated not only with 
 the physiology, but also the pathology of the puer- 
 perium * (Figs. 30 to 34). 
 
 * Barbour, in the Edinhurgh Medical Journal^ October 18, 1895, in 
 a series of papers upon the study of frozen sections, after passing in 
 review the various sections described by different investigators, makes 
 an estimate of the value of this method of study, as follows : Barbour 
 considers that, by means of such sections, we have gained most in 
 knowledge regarding the birth canal. He acknowledges the limitations 
 
 4. Eupture of the uterus and vagina during labor. 
 
 These models were made with a view to showing 
 the most frequent site of uterine rupture, the relation of 
 the rupture to the contraction ring and external os, 
 and the greater danger of infection when the tear in- 
 volves the vagina as well as the uterus. 
 
 which are inevitable in such study, but considers that we have by this 
 method acquired ideas which have revolutionized our conceptions of 
 study. 
 
AIDS m OBSTETRIC TEACHING. 
 
 PART II. 
 
 III. Composiiion Models. 
 In casting about some time since for a cheap substi- 
 tute for rubber in the construction of models, our atten- 
 tion was directed to the glue composition which model- 
 ers and plaster workers have for years made use of in 
 
 the manufacture of their interior decorations. Our aim 
 was to produce flexible cervices and pelvic floors by this 
 method, and after much experimenting we were com- 
 pelled to confine our models in composition here de- 
 scribed to a series of parturient cervices in different 
 
 EXjOS. 
 
 IW.OS, 
 
 SVc, 
 
 EX.OS. 
 
 Fifi. 38.— Cer 
 
 Fig. 88. 
 1 latter part of gestation ( 
 
 Fig. 40. 
 
 ' at beginning of labor. Vaginal 
 and supravaginal portions of cervix unchanged, v.y cuif of vagina ; ex. os., 
 external os and inf ravagiual portion of the cervix ; c. v. J., cervico-vaginal 
 junction ; 5. v. c, supravaginal portion of cervix ; in. os., internal os ; I. u. s., 
 lower uterine segment. (Composition model ; from a photograph.) 
 Fig. 39. — Lower uterine segment during labor. Cervix in progress of being 
 drawn up into the body of the uterus. Supra- and infravaginal portions of 
 the cervix still present, v., cuff of vagina ; ex. os., external os and infra- 
 
 vaginal portion of cervix ; c. v. J., cervico-vaginal junction ; .*;. i\j., supra- 
 vaginal portion of cervix ; in. os., internal os : I. v. s., loweruterine segment 
 (Composition model : from a photograph.) 
 Fig. 40. — Lower uterine segment during labor, v., cuff of vagina ; ex. os., ex 
 ternal os, infravaginal portion of cervix has disappeared ; c. v.j , cervico- 
 vaginal junction ; s. v. c, supravaginal cervix, small portion only remaining ; 
 in. OS., internal os ; I. n. s., lower uterine segment. (Composition model ; 
 from a photograph.) 
 
 IN. OS 
 
 Fig. 41. Fig. ■12. 
 
 Fig. 41.— Lower uterine segment during labor. Os uteri in progress of dilata- 
 tion. Supra- and infravaginal portions of the cervix have disappeared. Os 
 one third dilated, v., cuff of vagina; ex.os., external os; u v. j., utero- 
 vaginal junction ; I. u. «., lower uterine segment. (Composition model ; 
 from a photograph.) 
 
 Flo. 42. — Lower uterine segment during labor. Os uteri almost fully dilated. 
 
 Fig. 43. 
 
 v., cuff of vagina; ex. os., external os; u. v. J., utero-vaginal junction; 
 I. V. «., lower uterine segment. (Composition model ; from a photograph.) 
 Fig. 43. — Lower uterine segment at completion of first stage of labor. Os uteri 
 completely dilated, v., cuff of vagina ; ex. os., border of external os, 
 scarcely perceptible ; v. v.j.y utero-vaginal junction. (Composition model ; 
 from a photograph.) 
 
Aim IN OBSTETRIC TEACHmQ. 
 
 25 
 
 it is expelled. Subsequent contrac- 
 tion and hardening of the model will 
 depend upon the completeness with 
 which the water passes off at this 
 time. The time ■ required for this 
 heating process will depend upon the 
 size of the mass and the amount of 
 the contained water. 
 
 When ready to pour, the mass 
 should be almost free from water, of 
 a thick, creamy consistence, and no 
 small pieces of glue should remain 
 unmelted. 
 
 At this time any desired color may 
 be imparted to the composition by 
 the addition of a strong alcoholic so- 
 lution of any of the aniline series. 
 
 Preparation of the Mold. — Given 
 a clay, plaster, papier-mache, or other 
 model, which it is desired to repro- 
 duce in glue composition, it is first 
 necessary to construct a mold. For 
 the composition cervices (Kgs. 38 to 
 43) the lower segment of the papier- 
 mache model of the pregnant uterus 
 at the eighth month (Fig. 18) was 
 used. A negative mold of the lower 
 third of this uterus was taken in plas- 
 
 FiG. 44. — Instrumental dilatation or i 
 the introduction of bougies tor 
 from a photograph.) 
 
 aii'iil o.~ preparatory ]to further manual dilatation, i^auze packing, 
 iudmjtiou of labor, or cervical dilators. (Composition model ; 
 
 stages of dilatation (Figs. 38 to 43), and, after 
 all, fall back on rubber for the pelvic floor (Fig. 
 63). 
 
 The composition mixture finally adopted was 
 one of Cooper's A-1 glue and pure glycerin, the 
 same as that used by modelers and plaster work- 
 ers, with the addition of glycerin, to give the 
 mass lasting flexibility, the glue being chosen 
 in preference to gelatin because of its being 
 cheaper. The proportion of the glue and gly- 
 cerin will depend upon the degree of flexibility 
 of the model desired. I have found that a pro- 
 portion of one part of glue to one of glycerin 
 gives the proper flexibility to the mass for the 
 cervices subsequently described. 
 
 The method is very simple and, aside from 
 the glycerin, very cheap. The glue is first 
 soaked in cold water until moist; the excess of 
 water is then removed by filtering through stout 
 burlap or other filtering material. Then, placed 
 over a water bath, the glue is melted, the gly- 
 cerin added, and the mass allowed to boil until 
 most of the small amount of water contained in 
 
 Fio. 4.').— Digital dilatation of the parturient 08. 
 supravaginal portions of the cervix present, 
 graph.) 
 
 Os admits one linger. 
 (Composition model ; 
 
 Vaginal and 
 from a photo- 
 
26 
 
 AIDS IN OBSTETBIG TEAGEING. 
 
 tor in the usual way. Then, to secure the 
 desired thickness of the composition model, 
 a la3'er of clay of the required thickness was 
 carefully placed in the negative mold, com- 
 pletely and smoothly lining it. Plaster is 
 now run in over the clay to form the core 
 of the interior of the mold. The plaster 
 heing thoroughly hard, the core and nega- 
 tive mold are separated, the clay removed 
 from the negative mold, both carefully 
 shellacked upon their opposing surfaces, 
 and when dry are oiled and fastened firmly 
 together. The mold is now ready for the 
 reception of the heated glue mass. 
 
 Pouring the Composition and casting the 
 Model. — In pouring the mass care should 
 be used that it is not too hot, otherwise it is 
 liable to stick to the mold and core by 
 removing the coating of shellac therefrom. 
 Moreover, we have found that the higher 
 the temperature at which the mass is poured 
 the greater will be the subsequent contrac- 
 tion of the model upon cooling. At ordi- 
 nary temperatures the models should not be 
 removed from the molds for at least six 
 hours. 
 
 Fig. 45.— Bimanual dilatation of the parturient OS. Os admits two fingers. Vaginal and supra 
 vaginal portions of the cervix present. Commencing shortening of the cervical canal. 
 (Composition model ; from a photograph.) 
 
 I have not found it necessary in these 
 obstetric models to keep them when not in 
 use in their molds to avoid distortion, 
 as Freeborn * advised in pathological 
 models. 
 
 Eemelting the Models. — Should the 
 models, after continued use, shrink or 
 become hard, remelting and adding an 
 additional quantity of glycerin to the 
 mass will lend new flexibility to the 
 models and render them less liable to 
 shrink. 
 
 I desire to express my indebtedness 
 to Mr. James M. Kerr, of the firm of Kerr 
 & Easario, sculptors, 229 West Thirty- 
 second Street, New York, for valuable 
 instruction and assistance in the use of 
 plaster and composition for the purpose 
 indicated in this paper. 
 
 1. Series of composition models of 
 lower uterine segment, showing mechan- 
 ism of dilatation, with the gradual disap- 
 
 FiG. 47.— Bimanual dilatation of the parturient OS. Os admits three fingers. Suprt 
 tion Of the cervix disappearing. (Composition model ; from a photograph.) 
 
 * Freeborn A New Material for Models. Proceed. 
 higs of the New York Pathological Society for 1891. 
 
AIDS IN OBSTETRIC TEACEIN&. 
 
 27 
 
 Bimanual Dilatation of the Parturient 
 Os. — Series Figs. 44 to 50 indicate our pre- 
 feiTed method of combined instrumental 
 and bimanual dilatation of the parturient 
 OS. The limits of the present paper forbid 
 my entering upon the arguments in favor of 
 this particular variety of manual dilatation, 
 which has been given an abundant trial over 
 a period of several years in many conditions 
 of the parturient cervix. 
 
 I feel justified, however, in stating in 
 this place that this method of bimanual dila- 
 tation of the OS is to be preferred to other 
 digital and instrumental methods, because 
 (1) the membranes are preserved throughout 
 the operation or until full dilatation is ob- 
 
 FiG. 48. — Bimanual dilatation of the parturient OS. O 
 position of tlie hands. (Composition model : fro 
 
 le half dilated. Lateral 
 I photograph.) 
 
 pearance of the supravaginal portion of the cer- 
 vix. 
 
 Figs. 38 to 43 represent these composition cervices, 
 and we have added, to render the illustrations more 
 graphic, an outHne sketch of the upper vagina and cervix 
 of each to indicate the changes in cervical canal, external 
 and internal os, as dilatation progresses. 
 
 The uses to which such simple composition models 
 can be put are almost endless, and we have illustrated 
 some of these in the following illustrations: 
 
 a! dilatation of the parturient os. Os two thirds dilated. 
 Entire eUacemcut of Internal os. (Composition model ; from a photo- 
 graph.^ 
 
 FiQ. 50.— Bimanual dilatation of the parturient os. Os fully dilated and being 
 stretched to prevent accidents to the after-coming head. (Composition 
 model ; from a photograph.) 
 
 tained; (3) there is no interference with the original 
 presentation and position; (3) the sense of touch of the 
 operator's fingers is unimpaired; (4) there is no constric- 
 tion of the operator's hands; (5) the amount of force ex- 
 erted upon the external ring can be better estimated, 
 and hence there is less likelihood of lacerations occur- 
 ring. 
 
 Fig. 51 represents the position of the fingers at the 
 ring of the os in bimanual dilatation; no encroachment 
 into the uterine cavity occurs. 
 
 Fig. 58 shows the position of the hands as seen in 
 
28 
 
 AIDS m OBSTETRIC TEACHING. 
 
 Fig. 51.— Bimanual dilatation of the parturient os, internal view, showing poei- 
 tion of the fingers. Os admits three fingers readily. Internal 08 still pres- 
 ent. No encroachment of the fingers upon the cavity of the lower uterine 
 segment. iComposition model ; from a photograph .) 
 
 an operation on the living subject, and is from a photo- 
 graph taken at the Emergency Hospital. 
 
 Ordinary Digital and Manual DiJalaUun of the Par- 
 turient Os. — Figs. 53 and 54 represent the ordinary digi- 
 tal (with one hand) and manual dilatation of the os, 
 in both of which methods there is unnecessary and 
 dangerous encroaching on the part of the operator's 
 hand upon the lower uterine segment and the conse- 
 quent dangers of (1) displacement of presentation or 
 position; (2) displacement of arms or cord; (3) prema- 
 ture rupture of the membranes, and loss of the valuable 
 assistance of the liquor amnii in subsequent manipula- 
 tions, as version, for instance; (4) premature separation 
 of a placenta prsevia; and (5) constriction and loss of 
 sensation in the operating hand, and with the consequent 
 danger of lacerations of the external ring from inability 
 to measure the amount of force exerted and the tension 
 of the ring, together with failure to completely paralyze 
 the ring, so that trouble in the extraction of the after- 
 coming head results. 
 
 Fig. 52.— Bimanual dilatation of the parturient oe. External view, showing position of hands. (After a photograph of the operation taken at the Emergency 
 
 Hospital.) 
 
AIDS IN OBSTETRIC TEACHING. 
 
 29 
 
 Fig. 53. — lUustratee a common method of manual dilatation of the parturient ot> 
 and the dangers that ensne of prematurely rupturing the membranes, dis- 
 placing the presenting part or separating a placenta praevia, by reason of the 
 marked encroachment of the fingers of the operator into the cavity of the 
 lower uterine segment. (Composition model : from a photograph.) 
 
 Fig. 54.— Dluetrates a common method of single-handed manual dilatation of 
 the parturient os, which has the same objections as the method depicted in 
 Fig. 53, but to a less degree. (Composition model ; from a photograph.) 
 
 f3. .')7.— Dangers of breech extraction through 
 Same as Fig, r>f). Seen from the uterine cavity, 
 a photograph.) 
 
 an imperfectly dilated os. 
 (Composition model ; froqi 
 
 gh an imperfectly dilated os. Ex- 
 the legs causes extension of the 
 ina. (From a photograph ; corn- 
 
 Fig. 55 shows the interior of the lower uterine seg- 
 ment, with an os the size of two fingers, a Barnes's 
 cervical dilator in position, and the dangerous encroach- 
 ment of the latter into the cavity of the uterus, render- 
 ing malpresentation liable to occur. 
 
 Dangers of Breech Extraction through an Imperfectly 
 Dilated Os. — Figs. 56 and 57 illustrate this condition, 
 selected from many other equally important ones. 
 
 When the student is made to see what may happen 
 
30 
 
 AIDS IN OBSTETRIC TEAOHINa. 
 
 Flo. 58.— Cervix partially dilated. Membranes ruptured. Vertex presenting. 
 Prolapse of hand and cord. (Composition model ; from a photograph.) 
 
 should lie thoughtlessl}' make traction upon a leg- 
 in breecli presentation before the completion of the 
 first stage of labor, he is not likely to forget the dan- 
 gers of such manipulutions in the extended head and 
 arms and the resulting impaction and death of the 
 foetus. 
 
 Fig. 58 represents prolapse of the cord and hand in 
 
 Fig. 59. — Cervix partially dilated. Labor obstructed by reason of partial exten- 
 sion of the head, causing occipito-frontal diameter to pass through cervix 
 and pelvis. (Composition model ; from a'photograph.) 
 
 the middle of the first stage, and its accompanying dan- 
 gers to the foetus; and Fig. 59 illustrates a common cause 
 of obstructed labor due to an imperfect attitude of the 
 fcetus. The chin has left the sternum, resulting in in- 
 complete flexion of the head and the passage of a larger 
 diameter than necessary (occipito-frontal) through the 
 .cervix and pelvis. 
 
The following twenty-four groups of illustration's are from photographs of copper-plated plaster models. 
 GROUP I.— NORMAL PELVIS. MALE TYPE. 
 
 {'^ natural size.) 
 
 LUMBO-SACRO-COCCYGEAL CURVE.-INCLINATION AND 
 SHAPE OF SYMPHYSIS.-PUBIC ARCH AND ANGLE. 
 
 
 " 
 
 " 
 
 
 ri? 
 
 rri 
 
 CIRCUMFERENCE. 
 
 24 
 
 61 
 
 TRANSVERSE OF INLET, 
 
 S 
 
 IC^ 
 
 TROCHANTERS, 
 
 (25, 
 
 32 
 
 RIGHT OBLIQUE INLET, 
 
 4^ 
 
 12. 
 
 Spines, 
 
 ?'if 
 
 25 
 
 LEFT OBLIQUE INLET, 
 
 4 
 
 12 
 
 Crests, 
 
 ID?, 
 
 Sfl 
 
 RIGHT PELVIC WALL. 
 
 4^ 
 
 II 
 
 External Conjugate, 
 
 bh 
 
 16 
 
 leftpIlvVcvi^all 
 
 4^ 
 
 IL 
 
 m 
 
 RIGHT EXTERNAL OBUOUE, 
 
 &k 
 
 21 
 
 POST?RroH"'pELVIC WALL 
 
 4^ 
 
 LEFT EXTERNAL OBLIQUE 
 
 S'4 
 
 2.1 
 
 SACRO-COCCVGEAL CURVE 
 
 5:5t 
 
 Height of Sympliysis, 
 
 I's 
 
 5 
 
 TRANSVERSE OUTLET. 
 
 3^ 
 
 <=> 
 
 DIAGONAL CONJUGATE 
 
 
 12 
 
 "SJTL"E°T';?oJi;i?E''AL., 
 
 5/4 
 
 &i 
 
 ANATOMICAL CONJUGATE, 
 
 5fi 
 
 10 
 
 ''S^TL°i''ittll1'S'' 
 
 4| 
 
 II 
 
 Obstetric Conjugate, 
 
 3/s 
 
 9 
 
 CURVE OF SACRUM, 
 
 ^ODERATcl 
 
 
 
 
 
 
 GROUP IL— NORMAL PELVIS. FEMALE TYPE. 
 
 i natural size.) 
 
 J 
 
 LUMBO-SACRO-COCCYGEAL CURVE.— INCLINATION AND 
 SHAPE OF SYMPHYSIS.-PUBIC ARCH AND ANGLE, 
 
 
 " 
 
 ~ 
 
 
 rr 
 
 fSl 
 
 CIRCUMFERENCE, 
 
 25V 
 
 S9 
 
 TRANSVERSE OF INLET, 
 
 s 
 
 12V 
 
 TROCHANTERS, 
 
 Hi 
 
 29 
 
 RIGHT OBLIQUE INLET, 
 
 s 
 
 12V 
 
 Spines, 
 
 9^4 
 
 a5 
 
 LEFT OBLIQUE INLET, 
 
 J 
 
 12', 
 
 Crests, 
 
 II 
 
 26 
 
 rightp'e°lv7c wall. 
 
 4*4 
 
 II 
 
 External Conjugate, 
 
 r 
 
 IS 
 
 LEFT PeLvTc WALL, 
 
 ik 
 
 II 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 S'4 
 
 21 
 
 po5T?riSS''pelvic wall. 
 
 4V 
 
 ll>. 
 
 LEFT EXTERNAL OBLIQUE 
 
 S'+ 
 
 21 
 
 SACRO-COCCVGEAL CURVE 
 
 ji' 
 
 (2'.2 
 
 Height of Symphysis, 
 
 1^.. 
 
 4'.: 
 
 transverse OUTLET. 
 
 4 
 
 10 
 
 DIAGONAL CONJUGATE, 
 
 + c 
 
 II 'i 
 
 ''SuTl\°t';?oJcVG°e''al,, 
 
 .H 
 
 .9V 
 
 ANATOMICAL CONJUGATE. 
 
 4 
 
 10 
 
 "Sutle°t'™?Jral°," 
 
 S 
 
 l2Jr 
 
 Obstetric Conjugate, 
 
 5,-? 
 
 10 
 
 CURVE of SACRUM, 
 
 MODERHrE 1 
 
 r- 
 
 
 ^ 
 
 PUBIC ANGLE 
 
 es 
 
 u 
 
GROUP Til.— I'ELVIS DEFORMED BY CONGENITAL DISLOCATION OF BOTH FEMURS. 
 CHILD TEN YEARS OLD. 
 
 I}{ naluval size.) 
 
 
 ^ 
 
 ^T 
 
 
 T!? 
 
 " 
 
 CIRCUMFERENCE, 
 
 lt.5r 
 
 4-Z 
 
 
 -■4 
 
 I 
 
 TROCHflNTEHS, 
 
 ^'4 
 
 t\ 
 
 RIGHT OBLIQUE INLET, 
 
 c 
 
 ic 
 
 Spines, 
 
 6% 
 
 11 
 
 LEFT OBLIQUE INLET, 
 
 c-v 
 
 <. . 
 
 Crests, 
 
 6> 
 
 n 
 
 right"'p'e\vIc wall. 
 
 5 
 
 T'c 
 
 External Conjugate, 
 
 4.I1 
 
 He 
 
 ^j,^IJ|[=7j^,5LL, 
 
 <u 
 
 I 
 
 RIGHT EXTERNAL OBUOUE. 
 
 •?' I: 
 
 14 
 
 post"eriSS''pelvic wall. 
 
 P 
 
 t^c 
 
 LEFT EXTERNAL OBLIQUE 
 
 s* 
 
 15!' 
 
 SACRO-COCCYGEAL CURVE 
 
 4- 
 
 10 
 
 Height Of Symphysis. 
 
 l?ii 
 
 3'-, 
 
 TRANSVERSE OUTLET. 
 
 0^ 
 
 c 
 
 DIAGONAL CONJUGATE, 
 
 3^-t 
 
 P'.2 
 
 
 ^Z's 
 
 ,?« 
 
 ANATOMICAL CONJUGATE 
 
 5'« 
 
 s 
 
 *SJ^['^t™aJral°" 
 
 2-4IT 1 
 
 Obstetric Conjugate, 
 
 3 
 
 ' ■; 
 
 CURVE OF SACRUM, 
 
 MOPERATeI 
 
 3 
 
 ^, 
 
 
 PUBIC ANGLE 
 
 ?6^ 1 
 
 GROUP IV.— PELVIS DEFORMED BY EXTREME DEGREE OF OSTEOMALACIA. 
 (DUPUYTBEN MUSEUM.) 
 
 (}£ natural size.) 
 
 
 " 
 
 ^T 
 
 
 " 
 
 fur 
 
 C.PCUMFERENCE, 
 
 24; 
 
 ti:.. 
 
 TRANSVERSE OF INLET. 
 
 4* 
 
 II 
 
 TROCHANTERS. 
 
 "'f 
 
 41^ 
 
 RIGHT OBLIQUE INLET, 
 
 4+ 
 
 II 
 
 Spines, 
 
 t'c 
 
 I'' 
 
 LEFT OBLIQUE INLET 
 
 4+ 
 
 II 
 
 Crests, 
 
 &t 
 
 fli' 
 
 RIGHT PE°Lvlc WALL, 
 
 f 
 
 10 
 
 External Conjugate. 
 
 sv 
 
 •II 
 
 ^^„'il'S',Iv,„LL. 
 
 4- 
 
 10 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 &'• 
 
 -''t 
 
 POSTERIOR PELVIC WALL, 
 
 "~i 
 
 te 
 
 LEFT EXTERNAL OBLIQUE 
 
 sv 
 
 ii 
 
 SACRO-COCCYGEAL CURVE 
 
 S'^ 
 
 15!: 
 
 Height Of Symphysis, 
 
 r> 
 
 ;> 
 
 TRANSVERSE OUTLET. 
 
 'ii 
 
 7 
 
 DIAGONAL CONJUGATE 
 
 5i 
 
 14 
 
 "Sutle°t'^?Ic"g°e"al.. 
 
 4- 
 
 10 
 
 ANATOMIC.L CONJUGATE 
 
 j" 
 
 l£'- 
 
 "SiT^Ei'Mll^l'L," 
 
 J+ 
 
 15^ 
 
 Obstetric Conjugate, 
 
 +'+ 
 
 I'l 
 
 CURVE OF SACRUM. 
 
 INKEAStD 1 
 
 
 ^,^ 
 
 
 
 4^4-"! 
 
GROUP v.— PELVIS DEFORMED BY CONGENITAL DISLOCATION OF BOTH FEMURS. 
 
 (3-^ natural size.) 
 
 
 " 
 
 " 
 
 
 P? 
 
 p^ 
 
 CIRCUMFERENCE, 
 
 r-f? 
 
 62 
 
 TRANSVERSE OF ,NLET, 
 
 1^''' 
 
 14 
 
 TROCHANTERS. 
 
 15 !f 
 
 m 
 
 RIGHT OBLIQUE INLET, 
 
 
 ir^ 
 
 Spines, 
 
 10^ 
 
 2t,i 
 
 LEFT OBLIQUE INLET, 
 
 ,-r 
 
 i?V 
 
 Crests, 
 
 (1 
 
 28 
 
 RIGHT p'e°LvIc wall. 
 
 4 
 
 10 
 
 External Conjugate, 
 
 Y 
 
 IS 
 
 leftpH.vIJwall, 
 
 4 
 
 10 
 
 RICHT EXTERNAL OBUQUE. 
 
 S4 
 
 "<•> 
 
 posteriSr'pelvio wall. 
 
 5' 
 
 \Vi 
 
 LEFT EXTERNAL OBUQUE 
 
 8-; 
 
 ^••7 
 
 sacro-coccygeal curve 
 
 ^"'^ 
 
 15 
 
 Height of Symphysis, 
 
 "'"+ 
 
 fc" 
 
 transverse outlet. 
 
 ir% 
 
 13!? 
 
 DIACONAL CONJUGATE. 
 
 ?? 
 
 15 
 
 "Su"e°t'^??Jc;g°e''al,. 
 
 y^ 
 
 <^ 
 
 ANATOMIC.L CONJUGATE. 
 
 5 
 
 I2'd 
 
 ''SiTL°T'',ircll'8'" 
 
 4* 
 
 11'? 
 
 Olistetrio Conjugate, 
 
 4i 
 
 II 
 
 curve OF SACRUM. 
 
 fLATTENEOI 
 
 r 
 
 
 ^^ 
 
 PUBIC ANGLE 
 
 115" 1 
 
 GROUP VI.— RHACHITIC PELVIS WITH ENLARGEMENT OF THE BONES. ADULT EIGHTEEN 
 YEARS OLD. (DUPUYTREN MUSEUM.) 
 
 (X n.itural size.) 
 
 
 ™ 
 
 " 
 
 
 " 
 
 " 
 
 CIRCUMFERENCE 
 
 %\ 
 
 S}'i 
 
 TRANSVERSE OF INLET. 
 
 -^V 
 
 II 
 
 TROCHANTERS. 
 
 II 
 
 'ZS 
 
 RIGHT OBLIQUE INLET. 
 
 4V 
 
 K'f 
 
 Spines, 
 
 I0^^ 
 
 LT^ 
 
 LEFT OBLIQUE INLET. 
 
 4V 
 
 It 
 
 Crests, 
 
 ]&'". 
 
 2t^ 
 
 RIGHT PE^LvIc WALL. 
 
 5^^ 
 
 9 
 
 External Conjugate, 
 
 f'^ 
 
 Wi 
 
 LEFT pR^VJ WALL, 
 
 >'S 
 
 9 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 ? 
 
 CW 
 
 POST^r'iSS^PELVIC wall. 
 
 "^-9 
 
 10 
 
 
 
 '20 
 
 SACRO-CoSgEAL CURVE 
 
 $ 
 
 I'-i 
 
 Height Of Symphysis, 
 
 I'-f 
 
 4'? 
 
 TRANSVERSE OUTLET, 
 
 4 
 
 10 
 
 DIAGONAL CONJUGATE. 
 
 'A 
 
 9 
 
 "SuTrE°T'^CTCcyl?E''AL>, 
 
 ?v 
 
 i^'c 
 
 ANATOMICAL CONJUGATE. 
 
 5 
 
 Xi 
 
 "SutlTt'IaJrau" 
 
 4 
 
 10 
 
 Obstetric Conjugate, 
 
 '""» 
 
 ik 
 
 CURVE OF SACRUM, 
 
 INCRtAftD 1 
 
 (. 
 
 
 
 
 115" 1 
 
GROUP VII.— RIIACIilTIC PELVIS WITH SLIGHT CONTRACTION OF THE PELVIC INLET AND 
 MARKED CONTRACTION OF OUTLET. LATERAL DEVIATION OF THE PROMONTORY TO 
 THE LEFT. ADULT. (DUPUYTREN MUSEUM.) 
 
 (3^ natural i 
 
 
 T? 
 
 TT 
 
 
 " 
 
 " 
 
 CIRCUMFERENCE. 
 
 V 
 
 ^yn 
 
 TRANSVERSE OF INLET. 
 
 4 
 
 10 
 
 TROCHANTERS, 
 
 n 
 
 oo 
 
 RIGHT OBLIQUE INLET 
 
 4- 
 
 10 
 
 Spines, 
 
 ?> 
 
 'iOk 
 
 LEFT OBLIQUE INLET 
 
 4 
 
 10 
 
 Crests, 
 
 e 
 
 1? 
 
 RIGHT PeIvIc wall. 
 
 "I'ii 
 
 ? 
 
 External Conjugate. 
 
 T 
 
 18 
 
 LEFT pfl.v'i'J WALL, 
 
 j'i 
 
 ^ 
 
 RIGHT EXTERNAL OBLIOUE, 
 
 l^ 
 
 1? 
 
 post?r'iSS^pelvic wall. 
 
 n 
 
 6 
 
 LEFT EXTERNAL OBLIQUE 
 
 
 li^ 
 
 SACBO-COCCYGEAL CURVE 
 
 -/-if 
 
 II 
 
 Height of Symphysis. 
 
 I's 
 
 ■i 
 
 TRANSVERSE OUTLET 
 
 2'. 
 
 6 'a 
 
 DIAGONAL CONJUGATE. 
 
 ■+y 
 
 \0k 
 
 
 j> 
 
 n 
 
 ANATOMICAL CONJUGATE. 
 
 n 
 
 \t 
 
 ''SiTL°T'':tll«"S'' 
 
 -f 
 
 10 
 
 Obstetric Conjugate, 
 
 -4- 
 
 10 
 
 CURVE OF SACRUM. 
 
 mmn 1 
 
 7 
 
 
 ^ 
 
 PUBIC ANGLE 
 
 2t"| 
 
 GROUP VIII.— DEFORMED PELVIS WITH CONTRACTION OF THE PELVIC INLET AND WIDENING 
 OF THE PELVIC OUTLET. ADULT. FALSE PROMONTORY. (DUPUYTREN MUSEUM.) 
 
 {}£ natural size.) 
 
 
 " 
 
 " 
 
 
 T? 
 
 " 
 
 C.RCUMFERENCE. 
 
 er, 
 
 SJi 
 
 TRANSVERSE OF INLET. 
 
 ;> 
 
 m 
 
 TROCHANTERS. 
 
 II 
 
 2{? 
 
 RIGHT OBLIQUE INLET, 
 
 4h 
 
 \\k 
 
 Spines, 
 
 ou 
 
 24 
 
 LEFT OBLIQUE INLET 
 
 -f'-f 
 
 If 
 
 Crests, 
 
 lov 
 
 26 
 
 RIGHT PE°Lvlc WALL. 
 
 -f 
 
 (0 
 
 External Conjugate. 
 
 bi 
 
 16 
 
 LEFT'JimJwALL. 
 
 ?l 
 
 ?^ 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 8 
 
 20£ 
 
 postehiSr'pelvic wall. 
 
 4'? 
 
 II 
 
 
 8 
 
 20; 
 
 SACRO-GOCCYGEAL CURVE 
 
 4*i 
 
 \j<i 
 
 Height Of Symphysis. 
 
 I'e 
 
 4 
 
 TRANSVERSE CUTLET. 
 
 ^ 
 
 iVi 
 
 DIAGONAL CONJUGATE. 
 
 4 
 
 10 
 
 ''SJ"e°t'^?oJcyg°e''al.. 
 
 51: 
 
 14 
 
 ANATOMIC.L CONJUGATE. 
 
 j'i 
 
 9 
 
 "SjTrE°Tli!JRAU.'' 
 
 ik 
 
 (3V 
 
 Obstetric Conjugate, 
 
 i>^ 
 
 S't 
 
 CURVE OF SACRUM. 
 
 fiATTENeo 1 
 
 « 
 
 
 
 PUBIC ANGLE 
 
 IIS'I 
 
GROUP IX.-DEFORMED PELVIS. DRIVING IN OF THE ILIUMS. CORDIFORM SHAPE OP 
 THE PELVIC INLET. FALSE PROMONTOPvY. 
 
 iX natural size.) 
 
 
 TT 
 
 ■S" 
 
 
 u!? 
 
 rinj 
 
 CIRCUMFERENCE, 
 
 18 W6 
 
 TRANSVERSE OF INLET, 
 
 fl^ 
 
 111 
 
 TROCHANTERS. 
 
 6;-* 
 
 IX 
 
 RIGHT OBLIQUE INLET, 
 
 4 
 
 w 
 
 Spines, 
 
 C) 
 
 11 
 
 LEFT OBLIQUE INLET, 
 
 i± 
 
 11 
 
 Crests, 
 
 V-4 
 
 m R.GHri'ErvlcW,LL. 
 
 jV 
 
 M 
 
 External Conjugate, 
 
 4- 
 
 10 
 
 leftpIlviJwall, 
 
 >'^ 
 
 nv 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 &\ 
 
 IT 
 
 P05TERlSST.ELVIC WALL 
 
 -/'fl 
 
 II 
 
 LEFT EXTERNAL OBLIQUE 
 
 ^h 
 
 ilk 
 
 SACRO-COCc'iGEAL CURVE 
 
 r> 
 
 |?V 
 
 Height Of Symphysis, 
 
 \'i 
 
 5 
 
 TRANSVERSE OUTLET. 
 
 5 
 
 i?i 
 
 DIAGONAL CONJUGATE 
 
 5 V 
 
 S? 
 
 °o;TrE°T';?oJc?!?E''AL,, 
 
 
 
 5 
 
 ANATOMIC.L CONJUGATE. 
 
 i's 
 
 S'l 
 
 *SJTrE°T™AjRAu" 
 
 
 
 .5' 
 
 OI)stetric Conjugate, 
 
 }H 
 
 -h 
 
 CURVE OF SACRUM. 
 
 FLATTENED 1 
 
 
 
 
 
 lt?\ 
 
 GROUP X.-RHACIIITIC PELVIS. JUTTING FORWARD OF THE SACRUM. SHORTENING OF 
 THE ANTERO-POSTERIOR DIAMETERS OF THE TRUE PELVIS. FALSE PROMONTORY 
 (DUPUYTREN MUSEUM.) 
 
 (}{ natur.il size.) 
 
 
 " 
 
 ^ 
 
 
 Tns" 
 
 n 
 
 CIRCUMFERENCE. 
 
 ?0^ 
 
 ^"•f 
 
 TRANSVERSE OF INLET. 
 
 IV 
 
 Hi 
 
 TROCHANTERS. 
 
 10 
 
 i^s 
 
 RIGHT OBLrQUE INLET, 
 
 i^ 
 
 llii 
 
 Spines, 
 
 QU 
 
 2-f 
 
 LEFT OBLIQUE INLET, 
 
 -\'i 
 
 II 
 
 Crests, 
 
 h 
 
 C)C) 
 
 RIGHT PE°Lvlc WALL, 
 
 ^ 
 
 5. 
 
 External Conjugate, 
 
 p^rt 
 
 15k 
 
 LEFT piLVK WALL, 
 
 3V 
 
 »-"> 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 ("'+ 
 
 m 
 
 POSTERIOR PELVIC WALL. 
 
 4V 
 
 II 
 
 LEFT EXTERNAL OBLIQUE 
 
 ("V 
 
 \v% 
 
 ^ACRO-COCc'^VGEAL CURVE 
 
 5^ 
 
 li2i 
 
 Height of Symphysis. 
 
 ['? 
 
 4 
 
 TRANSVERSE OUTLET. 
 
 ,"^i 
 
 .^ 
 
 DIAGONAL CONJUGATE, 
 
 ?i 
 
 9 
 
 ANFERO-POSTERIOR 
 
 ^ 
 
 X 
 
 ANATOMICAL CONJUGATE. 
 
 ^ 
 
 T? 
 
 ''ojTrE°T'^iACRAu" 
 
 >^ 
 
 2i 
 
 EWfP 
 
 Obstetric Conjugate, 
 
 V^ 
 
 T 
 
 CURVE OF SACRUM, 
 
 FIMT 
 
 
 ! 
 
 
 Wi 
 
 =3- 
 
GROUP XL— KHACIIITIC PELVIS. JUTTING FORWARD OF THE SACRAL PROMONTORY. 
 ANTERO-POSTERIOR FLATTENING OF THE INLET. LATERAL FLATTENING OF THE 
 OUTLET. CORDIFORM SHAPE OF THE PELVIC INLET. ADULT. FALSE PROMONTORY. 
 
 . {}{ natural i 
 
 
 " 
 
 " 
 
 
 " 
 
 " 
 
 CIBCUMFERENCE, 
 
 \?\ 
 
 ^Q 
 
 TRANSVERSE OF INLET, 
 
 5 
 
 12 'i 
 
 TROCHANTERS. 
 
 m 
 
 m 
 
 RIGHT OBLIQUE INLET, 
 
 4 
 
 10 
 
 Spines, 
 
 (O'-f 
 
 tVi 
 
 LEFT OBLIQUE INLET 
 
 4fi- 
 
 II 
 
 Crests, 
 
 lOV 
 
 £5 
 
 RIGHT p'e°LvIc wall. 
 
 -?^ 
 
 9 
 
 External Conjugate, 
 
 J 
 
 liH 
 
 LEFT PELVIC wall, 
 
 ?'? 
 
 ? 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 TV 
 
 (^? 
 
 poster'iSS^pelvic wall. 
 
 r-* 
 
 IS 
 
 LEFT EXTERNAL OBLIQUE 
 
 T's 
 
 19 
 
 SACRO.COCCYGE.L CURVE 
 
 p 
 
 If? 
 
 Height of Symphysis, 
 
 1'? 
 
 T *'' 
 
 TRANSVERSE OUTLET, 
 
 5'# 
 
 9 
 
 DIAGONAL CONJUGATE. 
 
 5V 
 
 8'f 
 
 ''S;tl"e°t';??J"ge'"ali, 
 
 4 
 
 10 
 
 ANATOMICAL CONJUGATE. 
 
 2'!^ 
 
 p'" 
 
 "SutlTt'^sIJr^'S." 
 
 5^? 
 
 f) 
 
 Obstetric Conjugate, 
 
 o 
 
 ? 
 
 CURVE OF SACRUM, 
 
 FUTTENEdI 
 
 .. 
 
 
 
 PUBIC ANGLt 
 
 SX" 1 
 
 GROUP XII.— RHACHITIC PELVIS. LATERAL DEVIATION OF THE SACRUM TO THE LEFT. 
 SINKING IN OF THE ILIUM OF THE CORRESPONDING SIDE. SHORTENING OF THE 
 RIGHT OBLIQUE DIAMETER OF THE PELVIC INLET. ADULT. FALSE PROMONTORY. 
 (DUPUYTREN MUSEUM.) 
 
 {}£ natural 
 
 
 " 
 
 T!r 
 
 
 T? 
 
 " 
 
 CIRCUMFERENCE. 
 
 20 
 
 p| 
 
 TRANSVERSE OF INLET, 
 
 4'-f 
 
 12 
 
 TROCHANTERS. 
 
 10!. 
 
 ^6 
 
 RIGHT OBLIQUE INLET, 
 
 ?'« 
 
 C) 
 
 Spines, 
 
 9'f 
 
 ??'•> 
 
 
 4V 
 
 II 
 
 Crests, 
 
 f;- 
 
 li' 
 
 RIGHT PE°Lvlc WALL, 
 
 ^V 
 
 ?'i 
 
 External Conjugate, 
 
 G 
 
 15 
 
 LEFT plmJ WALL, 
 
 ^ 
 
 Vi 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 v'V 
 
 m 
 
 POST?RlSS^PELV,C WALL, 
 
 ■f's 
 
 \n 
 
 LEFT EXTERNAL OBLIQUE 
 
 $ 
 
 ?(i{ 
 
 SACRO-COCCVGEAL CURVE 
 
 ?'f 
 
 m 
 
 Height Of Symphysis. 
 
 \h 
 
 -f'-i 
 
 TRANSVERSE OUTLET, 
 
 p'? 
 
 (4 
 
 DIAGONAL CONJUGATE, 
 
 -fV 
 
 U 
 
 ''SuTlZT''°olc"cAi.\ 
 
 T 
 
 Vi 
 
 ANATOMICAL CONJUGATE, 
 
 j's 
 
 ^ 
 
 ''Si"°j'%rc%i'S'' 
 
 i's 
 
 lOV 
 
 Obstetric Conjugate, 
 
 J} 
 
 TV 
 
 CURVE OF SACRUM, 
 
 fLATTENEO 1 
 
 n 
 
 
 
 
 '15' 1 
 
GROUP XT IT.— OVAL OBLIQUE PELVTS OF NAEGELE. 
 
 (}{ natural size.) 
 
 
 " 
 
 TT 
 
 
 ™ 
 
 TUT 
 
 CIRCUMFERENCE. 
 
 ^> 
 
 SVi X—RSE OF INLET, 
 
 4'-^ 
 
 (1 
 
 TROCHANTERS. 
 
 loV 
 
 5<.J 
 
 RIGHT OBLIQUE INLET, 
 
 yf 
 
 8 
 
 Spines, 
 
 f^^c 
 
 OO. 
 
 LEFT OBLIQUE INLET, 
 
 p 
 
 fe'f 
 
 Crests, 
 
 iO 
 
 2.T^ 
 
 RIGHT I'eIvIc wall. 
 
 4'j 
 
 ii'i 
 
 External Conjugate, , 
 
 r'c 
 
 19 
 
 ^^r-r"l'Lv"I WALL, 
 
 +'4 
 
 (1 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 G'i 
 
 IT 
 
 POSTERlSS^PELVIC WALL, 
 
 4's 
 
 II 
 
 LEFT EXTERNAL OBLIOUE, 
 
 rv 
 
 \fi 
 
 SACRO-COCC™ EAL CURVE 
 
 5"'-* 
 
 I5'2 
 
 Height of Symphysis, 
 
 
 r-- 
 
 TRANSVERSE OUTLET, 
 
 ? 
 
 T'2 
 
 DIAGONAL CONJUGATE, 
 
 4'f 
 
 ii 
 
 "™"E°T';?IJiYi?E''AL,, 
 
 -^'f 
 
 II 
 
 ANATOMICAL CONJUGATE. 
 
 r^ 
 
 11'^ 
 
 ''SJtl"e°t'!?aJrTl°,'' 
 
 +'^ 
 
 (£ 
 
 Obstetric Conjugate, 
 
 i'i 
 
 m 
 
 CURVE OF SACRUM, 
 
 flATTENtCl 
 
 ,. 
 
 
 
 PUBIC ANGLE 
 
 iU 
 
 GROUP XIV.— DEFORMED PELVIS WITH CONSIDERABLE SHORTENING OF THE TRANSVERSE 
 DIAMETER. JUTTING FORWARD OF THE SACRAL PROMONTORY. FALSE PROMONTORY. 
 
 (}£ natural size.) 
 
 
 " 
 
 " 
 
 
 " 
 
 TT 
 
 CIRCUMFERENCE, 
 
 (J^^4 
 
 -fr^ 
 
 TRANSVERSE OF INLET, 
 
 yi 
 
 ^ 
 
 TROCHANTERS. 
 
 ?''f 
 
 ?4 
 
 RIGHT OBLIQUE INLET, 
 
 ?''2 
 
 ? 
 
 Spines, 
 
 r'« 
 
 ^0 
 
 LEFT OBLIQUE INLET, 
 
 y-i 
 
 9 
 
 Crests, 
 
 8'-* 
 
 o»-> 
 
 RIGHT PE^LvIc WALL. 
 
 4 
 
 10 
 
 External Conjugate, 
 
 6V 
 
 I6'j 
 
 LEFT pIIvVc WALL. 
 
 4 
 
 10 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 r? 
 
 18 
 
 POSTERIOR PELVIC WALL. 
 
 fs 
 
 m 
 
 LEFT EXTERNAL OBLIQUE 
 
 T'lf 
 
 18 
 
 SACRO-COCCYGEAL CURVE 
 
 4'-* 
 
 1^ 
 
 Height of Symphysis, 
 
 Kif 
 
 4 
 
 TRANSVERSE OUTLET. 
 
 \"4 
 
 4'^ 
 
 DIAGONAL CONJUGATE. 
 
 4 
 
 10 
 
 ANTEflO-POSTEHIOR 
 
 5'i 
 
 1? 
 
 ANATOMICAL CONJUGATE. 
 
 y? 
 
 |0 
 
 *SufL\°T'^?AjRAL°,'' 
 
 yi 
 
 14 
 
 Obstetric Conjugate, 
 
 yi 
 
 5 
 
 CURVE OF SACRUM, 
 
 FlATTENEol 
 
 It 
 
 ^ 
 
 
 PUBIC ANCLE 
 
 5X'l 
 
GROUP XV.— PELVIS DEFORMED BY CONGENITAL DISLOCATION OF ONE FEMUR. 
 
 (3^ natural size.) 
 
 
 " 
 
 TT 
 
 
 " 
 
 fir 
 
 CIRCUMFERENCE, 
 
 S-f'f 
 
 (52 
 
 TRANSVERSE OF INLET, 
 
 ^ 
 
 iVi 
 
 TROCHANTERS. 
 
 12 
 
 pOi 
 
 RIGHT OBLiaUE INLET, 
 
 i?'i 
 
 14 
 
 Spines, 
 
 iO 
 
 ??i 
 
 
 -f!i 
 
 il'i 
 
 Crests, 
 
 9'-f 
 
 2p 
 
 RIGHT IkTlIc WALL. 
 
 4 
 
 10 
 
 External Conjugate, 
 
 T^ 
 
 1$ 
 
 LEFT PELVIC WALL, 
 
 ,? 
 
 X'% 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 ^'<? 
 
 2?^ 
 
 POSTERIOR PELVIC WALL. 
 
 j'i 
 
 9 
 
 LEFT EXTERNAL OBUaUE, 
 
 f^V 
 
 in 
 
 SACRO-clcCYGEAL CURVE 
 
 ^ (2^1 
 
 Height of Symphysis, 
 
 r-* 
 
 fa 
 
 TRANSVERSE OUTLET. 
 
 ^ 
 
 l^isJ 
 
 DIAGONAL CONJUGATE. 
 
 ?'" 
 
 l?'2 
 
 's;"e°t™oJ"l°e''al.. 
 
 4 
 
 ipI 
 
 ANATOMICAL CONJUGATE. 
 
 rs 
 
 |2 
 
 OUTLET (SACRALl. 
 
 r* 
 
 I.V^I 
 
 Obstetric Conjugate, 
 
 n 
 
 II 
 
 CURVE OF SACRUM. 
 
 IKCBMJEO 1 
 
 ,r 
 
 
 
 PUBIC ANGLE 
 
 114" 1 
 
 GROUP XVI.— RHACHITIC PELVIS. CHILD. 
 
 (^ natural size.) 
 
 
 " 
 
 " 
 
 
 " 
 
 " 
 
 CIRCUMFERENCE. 
 
 14 
 
 ??^ 
 
 TRANSVERSE OF INLET, 
 
 2'ii 
 
 ?'" 
 
 TROCHANTERS. 
 
 <^'4 
 
 n 
 
 RIGHT OBLIQUE INLET 
 
 e^rt 
 
 6 
 
 Spines, 
 
 T'l? 
 
 iH 
 
 LEFT OBLIQUE INLET. 
 
 27' 
 
 6 
 
 Crests, 
 
 (r>'i 
 
 ir 
 
 RIGHT PE°LvIc WALL. 
 
 ^ 
 
 i's 
 
 External Conjugate, 
 
 o-f 
 
 p^ 
 
 LEFT pIl^vVJ WALL. 
 
 5 
 
 n 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 j-Tt 
 
 14 
 
 POSTERlSS"'pELVIC WALL. 
 
 o 
 
 ^ 
 
 LEFT EXTERNAL OBLIQUE 
 
 ?'^ 
 
 ife 
 
 S.CRO-COCc'VgEAL CURVE 
 
 ^ 
 
 te 
 
 Height of Symphysis, 
 
 IV 
 
 i''^ 
 
 TRANSVERSE OUTLET 
 
 l'+ 
 
 ^ 
 
 DIAGONAL CONJUGATE. 
 
 <^'.7 
 
 fk- 
 
 OUTLET iCOCCYGEAL). 
 
 l'2 
 
 4 
 
 ANATOMICAL CONJUGATE. 
 
 r+ 
 
 4V 
 
 ''Si;TrE°T';iAjRA'L°'' 
 
 2'!? 
 
 ?^' 
 
 Obstetric Conjugate, 
 
 l'2 
 
 4 
 
 CURVE OF SACRUM. 
 
 INCMA^tD 1 
 
 vV. 
 
 
 
 
 65^1 
 
GROUP XVIL— PELVIS DEFORMED BY SPONTANEOUS DISLOCATION OF THE LEFT FEMUR. 
 
 (3^ natural size.) 
 
 
 " 
 
 " 
 
 
 T? 
 
 " 
 
 CJRCUMFERENCE, 
 
 ?4 
 
 C^i 
 
 TRANSVERSE OF INLET, 
 
 p 
 
 \i\ 
 
 TROCHANTER S. 
 
 II V 
 
 pO 
 
 RIGHT OBLIQUE INLET, 
 
 i"*' 
 
 /?•? 
 
 Spines, 
 
 f>'4 
 
 V 
 
 LEFT OBLIQUE INLET, 
 
 -f'e 
 
 i(v 
 
 Orests, 
 
 \0'i 
 
 26 
 
 RIGHT PE°Lvlc WALL. 
 
 -fl 
 
 (? 
 
 External Conjugate, 
 
 62 
 
 1^ 
 
 
 ■f? 
 
 II '« 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 n 
 
 21% post-eISK^elvicwall. 
 
 y^ 
 
 p;: 
 
 LEFT EXTERNAL OBLIQUE, 
 
 f^v 
 
 m 
 
 SACRO-COCC™ EAL CURVE 
 
 ?'i 
 
 If 
 
 Height of Symphysis, 
 
 I's 
 
 O'i 
 
 TRANSVERSE OUTLET, 
 
 5'-* 
 
 IfV 
 
 DIAGONAL CONJUGATE. 
 
 r? 
 
 \Vi 
 
 ";"e°t';?ij"gTal,, 
 
 ?(?r'f| 
 
 ANATOMICAL CONJUGATE. 
 
 n 
 
 11% 
 
 *SjTLE°-f';iljRAU." 
 
 4'^ 
 
 II 
 
 Obstetric Conjugate, 
 
 n 
 
 [(i'i 
 
 CURVE OF SACRUM, 
 
 incRu^td 1 
 
 •n 
 
 
 ^ 
 
 PUBIC ANGLE 
 
 iir| 
 
 GROUP XVIII.— PELVIS DEFORMED BY OSTEOMALACIA. SLIGHT DEGREE. ADULT. 
 (DUPUYTREN MUSEUM.) 
 
 [yi natural size.) 
 
 
 T!? 
 
 " 
 
 
 " 
 
 " 
 
 CIRCUMFERENCE. 
 
 ??5 
 
 ;>;^ 
 
 TRANSVERSE OF INLET, 
 
 /v 
 
 |4 
 
 TROCHANTERS. 
 
 (O'-f 
 
 ?rf' 
 
 RIGHT OBLIQUE INLET, 
 
 
 (% 
 
 Spines, 
 
 P> 
 
 ?5 
 
 LEFT OBLIQUE INLET 
 
 -fV 
 
 \1'i 
 
 Orests, 
 
 10'-' 
 
 ?T4 
 
 RIGHT PE^LvIc V»ALL. 
 
 4'?- 
 
 \% 
 
 Etternal Conjugate, 
 
 rv 
 
 li?? 
 
 LEFT?il.°i<5"wALL, 
 
 f? 
 
 \% 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 8f 
 
 J'l 
 
 pobteriSrT.elvic wall. 
 
 r^ 
 
 
 LEFT EXTERNAL OBLIQUE 
 
 fV^ 
 
 '?! 
 
 SACBO-COCC^VGEAL CURVE 
 
 i? 
 
 l?V 
 
 Height Of Symphysis, 
 
 r-f 
 
 ■+? 
 
 TRANSVERSE OUTLET, 
 
 ^^^ 
 
 P 
 
 DIAGONAL CONJUGATE. 
 
 ■f^rf 
 
 1^: 
 
 "^^'"^"T^JJiYGT.L., 
 
 .?'" 
 
 0, 
 
 ANATOMICAL CONJUGATE, 
 
 \H 
 
 II 
 
 ''alMi^''°^VcK^°" 
 
 -f'/5 
 
 w 
 
 Obstetric Conjugate, 
 
 4 
 
 10 
 
 CURVE OF SACRUM, 
 
 INlRUfED 1 
 
 
 
 
 
 £j 
 
GROUP XIX.— DEFORMED PELVIS. FUNNEL-SHAPED ENLARGEMENT OF THE PELVIC INLET. 
 CONTRACTrON OF PELVIC OUTLET. (DUPUYTREN MUSEUM.) 
 
 (H natural «izc.) ^ 
 
 
 " 
 
 TT 
 
 
 T!? 
 
 fir 
 
 CIRCUMFERENCE. 
 
 ftvi 
 
 $S 
 
 TRANSVERSE OF INLET, 
 
 ?'¥ 
 
 1? 
 
 TROCHANTERS. 
 
 (? + 
 
 ?'\ 
 
 RIGHT OBLiaUE INLET. 
 
 ^'-f 
 
 1^ 
 
 Spines, 
 
 m 
 
 u- 
 
 LEFT OBLIQUE INLET. 
 
 ■><^ 
 
 1+ 
 
 Crests, 
 
 m 
 
 ?rf 
 
 RIGHT I'eIvTc wall. 
 
 ?'4 
 
 f?^i 
 
 External Conjugate, 
 
 n? 
 
 r?o 
 
 
 5^ 
 
 9^ 
 
 RIGHT EXTERNAL OBLIQUE. 
 
 S'-f 
 
 0(^ 
 
 POSTERlSS'^PELVIC WALL. 
 
 f'*' 
 
 1+ 
 
 LEFT EXTERNAL OBLIOUE, 
 
 ,9 
 
 ?^ 
 
 SACR0-C0CC™GE.L CURVE 
 
 T'-f 
 
 1?^ 
 
 Height of Sympliysis, 
 
 ? 
 
 ,-> 
 
 TRANSVERSE OUTLET. 
 
 4 
 
 (0 
 
 DIAGONAL CONJUCATE. 
 
 b 
 
 K'^ 
 
 '™TrE°T':??JcYG°E''ALi. 
 
 S# 
 
 r 
 
 ANATOMICAL CONJUGATE, 
 
 ?^ 
 
 K 
 
 »^J^['°.^';gSTER,OR 
 
 4^ 
 
 II 
 
 Obstetric Conjugate, 
 
 ^* 
 
 l?V 
 
 CURVE OF SACRUM, 
 
 MODERATE 1 
 
 >1 
 
 
 
 
 s^i 
 
 GROUP XX.-RHACHITIC PELVIS. OBSTETRIC CONJUGATE OF THE PELVIC INLET, FOUR 
 CENTIMETRES. FALSE PROMONTORY. CESAREAN SECTION PERFORMED. 
 
 {}{ natural size.) 
 
 
 ■™ 
 
 TIT 
 
 
 " 
 
 " 
 
 CIRCUMFERENCE. 
 
 CO 
 
 ?l 
 
 TRANSVERSE OF INLET. 
 
 4i- 
 
 ui 
 
 TROCHANTERS. 
 
 10-^ 
 
 ?T^ 
 
 RIGHT OBLIQUE INLET. 
 
 4 
 
 10 
 
 Spines, 
 
 f> 
 
 ^?? 
 
 LEFT OBLIQUE INLET, 
 
 ?'s 
 
 ? 
 
 Crests, 
 
 !^-^ 
 
 OOI, 
 
 RIGHT I'e°LvIc wall. 
 
 rs 
 
 
 External Conjugate, 
 
 
 \ik 
 
 LEFT pIlvVJ WALL 
 
 ::v 
 
 Ill 
 
 RIGHT EXTERNAUOBLIQUE. 
 
 t7?f 
 
 IT 
 
 post'^eriSS'pelvic wall. 
 
 ? - 
 
 ?> 
 
 LEFT EXTERNAL OBLIQUE. 
 
 Tt* 
 
 U'^ 
 
 SACRO-COCCYGEAL CURVE 
 
 ^'i 
 
 1?? 
 
 Heiglit of Sympiiysis. 
 
 !"-» 
 
 +'e 
 
 TRANSVERSE OUTLET, 
 
 AU 
 
 II 
 
 DIAGONAL CONJUGATE, 
 
 ^J 
 
 (? 
 
 "SiItl"e°t';?SJ"gTali, 
 
 £>J 
 
 
 ANATOMICAL CONJUGATE, 
 
 Ti? 
 
 r 
 
 *SJ"e°t';?aJra",'' 
 
 4'?- 
 
 m 
 
 Obstetric Conjugate, 
 
 Ki 
 
 •+ 
 
 CURVE OF SACRUM, 
 
 FUTTENEHl 
 
 ao 
 
 
 
 PUBIC ANGLE 
 
 """I 
 
GROUP XXI.— RIIACIHTIC PELVIS. OBSTETRIC CONJUGATE, FOUR CENTIMETRES AND A HALF 
 
 CJi;SAREAN SECTION PERFORMED. 
 
 (J^ natural size.) 
 
 
 " 
 
 ™ 
 
 
 " 
 
 fll^ 
 
 CIRCUMFERENCE. 
 
 ?(n 
 
 52 
 
 TRANSVERSE OF INLET. 
 
 2?^ 
 
 -}-| 
 
 TROCHANTERS. 
 
 m 
 
 ocf 
 
 RIGHT OBLIQUE INLET, 
 
 5ff 
 
 9 1 
 
 Spines, 
 
 s'-* 
 
 no 
 
 LEFT OBLIQUE INLET, 
 
 ,Vf^B'2| 
 
 Crests, 
 
 ip'i 
 
 26 
 
 RIGHT PE°Lvlc WALL. 
 
 ?> 
 
 T>f 
 
 External Conjugate. 
 
 i^^i 
 
 16 
 
 leftpILviJwall, 
 
 5^ 
 
 ,S 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 CA 
 
 IT 
 
 POSTER1SST.ELVIC WALL. 
 
 e-^ 
 
 5^ 
 
 LEFT EXTERNAL OBLIOUE 
 
 X'i 
 
 le 
 
 S.CRO-COCCVGEAL CURVE 
 
 ?>+ 
 
 |5^ 
 
 Height of Symphysis. 
 
 2^4 
 
 T 
 
 TRANSVERSE OUTLET. 
 
 V^ 
 
 T 
 
 DIAGONAL CONJUGATE. 
 
 ^'^ 
 
 
 *Si;T!'E°T'^SIJcyGT.L. 
 
 V-> 
 
 T 
 
 ANATOMICAL CONJUGATE. 
 
 ^ 
 
 7's 
 
 "™TrE°T'^i«jRA'L°'' 
 
 45 
 
 (2 
 
 Obstetric Conjugate. 
 
 \H 
 
 n 
 
 CURVE OF SACRUM, 
 
 IKtREA'jEO 1 
 
 ■\.\ 
 
 
 
 
 45^1 
 
 GROUP XXIL— RHACniTIC PELVIS. OBSTETRIC CONJUGATE, FOUR CENTIMETRES. 
 FALSE PROMONTORIES. CESAREAN SECTION PERFORMED. 
 
 (}4 natural size.) 
 
 
 " 
 
 ■J" 
 
 
 n?" 
 
 f^n 
 
 
 iO 
 
 ,^' 
 
 TRANSVERSE OF INLET, 
 
 ^ 
 
 ^ 
 
 TROCHANTERS. 
 
 9'f 
 
 ?^ 
 
 RIGHT OBLIQUE INLET. 
 
 4^ 
 
 lO'V 
 
 Spines, 
 
 S> 
 
 ?? 
 
 LEFT OBLIQUE INLET, 
 
 4 
 
 10 
 
 Crests. 
 
 8^ 
 
 ^1 
 
 RIGHT PeIvIc wall 
 
 T>'i 
 
 ^ 
 
 External Conjugate, 
 
 ^ 
 
 \t% 
 
 LEFT Simc WALL, 
 
 ,^^ 
 
 9^ 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 I?'!' 
 
 m 
 
 POSTERlSS'pELVIC WALL. 
 
 5.^ 
 
 14 
 
 LEFT EXTERNAL OBLIQUE, 
 
 "^^^ 
 
 ^0 
 
 SACRO-MCCySeaL CURVE 
 
 vS-;i 
 
 /3'i 
 
 Height of Symphysis, 
 
 IV 
 
 4- 
 
 TRANSVERSE OUTLET. 
 
 ^ 
 
 ^ 
 
 DIAGONAL CONJUGATE, 
 
 21?- 
 
 ^'4 
 
 ''SutI!e°t';?oJ"g°e''al., 
 
 rL^ 
 
 s^ 
 
 ANATOMICAL CONJUGATE, 
 
 rjr 
 
 :? 
 
 "oiIt?e°t';?aJrau,'' 
 
 5| 
 
 10 
 
 Obstetric Conjugate, 
 
 1'^ 
 
 4- 
 
 CURVE OF SACRUM, 
 
 N(REA(ED 1 
 
 
 
 
 PUBIC ANGLE 
 
 (1 
 
 O'l 
 
GROUP XXIII.— DEFORMED PELVIS. FALSE PROMONTORIES. (HERGOTT.) 
 
 Vide Farabeuf, 31., Spondj'loschise, Spondylolisth&se and Spondj'liz^me. Bulletins de la SoeieU de cJiirurgie, 1S85. 
 
 04 mitural size.) 
 
 
 " 
 
 " 
 
 
 " 
 
 rr-t 
 
 CIRCUMFERENCE, 
 
 ?? 
 
 5%\ 
 
 TRANSVERSE OF INLET, 
 
 5^i 
 
 ml 
 
 TROCHANTERS. 
 
 II 'i 
 
 ?9 
 
 RIGHT OBLIQUE INLET, 
 
 \h\'!}A 
 
 Spines, 
 
 10!, 
 
 ?6 
 
 LEFT OBLIQUE INLET 
 
 ^Id 
 
 |3l 
 
 Crests, 
 
 II 
 
 es 
 
 RIGHT PELVIC WALL. 
 
 Xy\ 
 
 m 
 
 External Gorjugate, 
 
 ^'« 
 
 in 
 
 LEFT ?lm J WALL, 
 
 Vi^\\ 
 
 RIGHT EXTERNAL OauQUE, 
 
 d'4 
 
 ao 
 
 POST^RlSStELViC WALL. 
 
 5'4 
 
 9 
 
 LEFT EXTERNAL OBLIQUE. 
 
 9 
 
 25 
 
 SACRO-COCC™ EAL CURVE 
 
 4? 
 
 H'^ 
 
 Height of Symphysis, 
 
 \'-i 
 
 4- 
 
 TRANSVERSE OUTLET, 
 
 $ 
 
 12', 
 
 DIAGONAL CONJUGATE. 
 
 ? 
 
 m 
 
 *S;TLE°T';?Scvi?E''AL.. 
 
 \'i 
 
 i\'i 
 
 ANATOMICAL CONJUGATE. 
 
 A-% 
 
 \<i 
 
 *oJ"e°t™aJra'l°'' 
 
 ^ 
 
 12 V 
 
 Obstetric Conjugate, 
 
 5'< 
 
 9 
 
 CURVE OF SACRUM, 
 
 fLATTENEol 
 
 ■C> 
 
 
 
 PUBIC ANGLE 
 
 96" \ 
 
 GROUP XXIV.— DEFORMED PELVIS. (GUICHARD, OF ,NANTES.) 
 
 (3^ natural size.) 
 
 
 " 
 
 TT 
 
 
 T!? 
 
 " 
 
 CIRCUMFERENCE, 
 
 If) 
 
 m 
 
 TRANSVERSE OF INLET, 
 
 ?1f 
 
 9 
 
 TROCHANTERS. 
 
 n 
 
 ?-^ 
 
 RIGHT OBLIQUE INLET 
 
 4'? 
 
 ir« 
 
 Spines, 
 
 9'-f 
 
 2?^ 
 
 LEFT OBLIQUE INLET, 
 
 ys 
 
 9 
 
 Crests, 
 
 9V 
 
 ?+ 
 
 R,GHt"I'e°LvIc WALL. 
 
 s^ 
 
 T 
 
 External Conjugate, 
 
 fie 
 
 Ifi 
 
 LEFT pIlvVJ WALL, 
 
 ?'* 
 
 8^- 
 
 RIGHT EXTERNAL OBLIQUE, 
 
 T'f 
 
 If^'i 
 
 POST?RlSS^PELVIO WALL, 
 
 $'s 
 
 tJ. 
 
 LEFT EXTERNAL OBLIQUE 
 
 <yy 
 
 }(•' 
 
 SACRO-clcc™EAL CURVE 
 
 j'i 
 
 <? 
 
 Height of Symphysis, 
 
 I'ff 
 
 ?^ 
 
 TRANSVERSE OUTLET. 
 
 ?'4 
 
 6 
 
 DIAGONAL CONJUGATE 
 
 n 
 
 (^ 
 
 ^Sutl°j''<°oIc"'°"m: 
 
 J^^ 
 
 9'i 
 
 ANATOMICAL CONJUGATE, 
 
 4-'s 
 
 m 
 
 ''SjTLE°r';iAjRAU.'' 
 
 Vc 
 
 II 
 
 Obstetric Conjugate, 
 
 4- 
 
 10 
 
 CURVE OF SACRUM, 
 
 fUTTENEcl 
 
 I-"* 
 
 ^ 
 
 ^ 
 
 PUBIC ANGLE 
 
 56" 1 
 
AIDS m OBSTETRIC TEACHING. 
 
 PART III. 
 
 IV. Miscellaneous Models and Aids. 
 
 A FEW metal and leather models, not classifiable under 
 the other divisions of aids, I place under this heading. 
 
 KiG. CO.— Metal pelvia and tripod. Useful for demonst.atmg the mechanism of 
 labor and obstetric operations. (From a photograpii.) 
 
 1. Aluminum Cast of Sagittal Mesial Section of Bony 
 Pelvis.* — The first that we have to ol!er is a vertical 
 mesial section of the female bony pelvis, cast in alumi- 
 num and mounted by means of a hand screw upon a 
 blackboard, and the whole set in a tripod. By means 
 of a narrow nickel band the right half of the pelvic brim 
 is completed, so that the pelvic inlet shows a continuous 
 line without a break. Eotation on a transverse axis al- 
 lows us, by means of the hand screw, to place the pelvis 
 in the position corresponding to the dorsal and upright 
 ones, or at any intermediate angle (see Fig. 1). 
 
 Below the aluminum cast I have outlined perma- 
 
 * Made by the Joljn Reyudcra Company, New York. 
 
 nently in white upon the board a vertical mesial section 
 of the female bony pelvis, in the position corresponding 
 to the dorsal one, and with the diameters and axes of the 
 
 Ftg. 61.— Leather model of the puerperal uterus, with double laceration of the 
 cervix and opening at one ^side closed by tapes. Useful for many demon 
 Btrations. (From a photograph,)'. See Figs. 7. and 8. 
 
 bony inlet and outlet and the axis of the partiirient 
 outlet added; such a combined blackboard and working 
 model, we believe, has never been offered before, and 
 without using it one can scarcely imagine the manifold 
 
 FiQ. 02 — Leather model cf pr.erperal uterus, showing interim 
 graph.) 
 
 and varied uses to which such a combination may be put, 
 as the invention is equally useful in gynascological as 
 well as obstetrical demonstrations. 
 
44 
 
 AIDS IN OBBTETRIC TEACHING. 
 
 With a supply of puppets, models of uteri, and col- 
 ored chalk at our disposal, there is scarcely an obstetric 
 or gynajcological condition that will not admit of a con- 
 cise ocular demonstration. 
 
 Fig. 03.— Reproduction in nibljrr of a plaster cast, tnlcen from Nature, of tlie 
 buttocks and vulva. Useful for demonstrating the mechanism and manage- 
 ment of the second stage of labor. (From a photograph.) 
 
 The metal pelvis (Fig. 70) can, with advantage, be 
 used, in conjunction with the present sagittal section 
 of the pelvis, in many ways that will readily suggest 
 themselves to the demonstrator. If desired, the same 
 tripod will answer for both contrivances. 
 
 Fig. G4.—E-xtemal genital organs. Ni 
 plaster cast ; from a photograph.) 
 
 Copper-plated 
 
 Fig. 1 shows the model and blackboard mounted 
 upon the tripod, and Figs. 2 to 6 indicate a few of the 
 many ocular demonstrations that may be given with it. 
 
 3. Complete Metal Pelvis.* — The complete metal pel- 
 
 vis, mounted upon a tripod, has already been described 
 and figured in a paper upon obstetric manikins * but I 
 take the opportunity of reproducing it here (Fig. 60). 
 
 Its utility is attested by the fact, as the instrument 
 maker informs us, that it has been supplied to many 
 of the medical schools of this country and Canada, f 
 
 3. Leather Model of Puerperal Uterus-l — Such a sim- 
 ple and inexpensive model as that depicted in Fig. 61 
 
 Fig. (55.— Vagino-perineal laceration involving the right lateral sulcus. Two 
 internal, or vaginal, and two external, or perineal, sutures in place ready to 
 be tied. (Copper-plated plaster cast ; from a photograph.) 
 
 can readily be made to do duty in various kinds of 
 demonstration. It is constructed of chamois leather, 
 lined with canvas, and may be opened along one lateral 
 half, the opening being closed with tapes (Fig. 62). 
 
 * Edgar. The Manikin in the teaching of Practical Obstetrics. New 
 York Medical Journal, December 27, 1S90. 
 
 f The following is the original description : For demonstrating the 
 mechanism of labor before a large class — the application of the forceps, 
 cranioclast, cephalotribe, and other obstetric instruments ; the various 
 methods of performing version ; the different methods of manual e.x- 
 traction, whether by tlie head, shoulders, breech, or lower extremities — 
 the gmi-metal pelvis, covered with leather and mounted upon a tripod, 
 lias proved itself exceedingly useful (Fig. 60). 
 
 The pelvis is practically indestructible, and i.s so mounted (Fig. 80) 
 upon the upright of a tripod as to permit of rotation in an entire circle 
 in a horizontal plane, which allows the pelvic outlet or inlet to be directed 
 to any point desired. 
 
 Besides complete rotation in the plane of the horizon, partial rotation 
 upon a transverse axis is also easily and quickly secured, and a simple 
 device (Fig. 60), in the shape of a small wheel at the side, enables one 
 to fix the planes of the pelvis (represented by cardboard if need be) at 
 any desired angle with the horizon. 
 
 If desirable, for greater convenience and accuracy, a simple scale 
 m.'iy be added at the side, which will enable one to read off at a glance 
 the angle produced. A movable coccyx permits recession during the 
 passage of the foetus, and a spring throws it back again to its true posi- 
 tion. A false sacrum, controlled by a thumbscrew passing through the 
 true sacrum, enables one to illustrate contraction of the pelvis in its 
 antero-posterior diameter, or to fix the presenting part nf the puppet or 
 foc^tal cadaver in any desired position. 
 
 :); Made by the John Reynders Company, New Yorlv 
 
AIDS m 0B8TETBI0 TEAOHINO. 
 
 45 
 
 The cuff of the partly cut away vagina is represented 
 by a piece of leather, and the cervix made to show a bi- 
 lateral laceration, extending in each instance as far as 
 the uterovaginal junction. 
 
 The whole roughly resembles the puerperal uterus 
 at the beginning of the puerperium. 
 
 This uterus can be utilized in a variety of ways: alone 
 to show manual expression of the placenta; in conjunc- 
 tion with the metal pelves to demonstrate the axis of the 
 puerperal uterus and puerperal canal and Crede's method 
 of placental expression, or with any ordinary manikin, 
 to illustrate the technics of various puerperal obstetric 
 procedures. With this simple model, together with 
 some gauze, volsella forceps, dressing forceps, needles, 
 ligatures, curettes, and a speculum, the student may be 
 made familiar with that manual training necessary to 
 ligate the bleeding points in a deeply lacerated cervix; 
 to pack safely the puerperal uterus with gauze to con- 
 trol hjemorrhage or secure drainage; to use properly the 
 puerperal curette, so as to reach safely the fundus with 
 the cautious upstroke, and to clear it of debris with the 
 more forcible clean downward sweep, not neglecting to 
 clear the eornua at the same time. 
 
 id 6. ^LL lures 
 
 I^enSaUu'es 
 
 i, 60.— VaffiuO'Perineal laceration involving both lateral sulci. Three inter 
 nal, or vaginal, and two external, or perineal, Butures in place ready to be 
 tied. (Copper-plated plaster cast ; from a photograph.) 
 
 In order that the student shall acquire this manual 
 training, it has been our custom to place the proper in- 
 struments in his hands and require him to carry out the 
 
 procedures above referred to. His handling of the cu- 
 rette is then criticised; the model is opened and the 
 
 ur&J 
 
 Per. futures 
 
 Fig. 67. — Vagino-perineal laceration in' 
 and perinjenm to the sphincter an 
 external, or perineal, sittures in pla 
 ter cast ; from a photograph.) 
 
 )lviDg right po.«tero-lateral vaginal wall 
 
 Four internal, or vaginal, and three 
 
 i ready to be tied. (Copper-plated plas- 
 
 manner of the gauze packing inspected, and if he has 
 failed to reach the fundus with the gauze, his fault ex- 
 plained to him. So also the ligature in the cervical 
 laceration is looked to, and the student's errors in technic 
 corrected. 
 
 I have intended in this model to supply to the stu- 
 dent the means and the opportunity to acquire that kind 
 of manual training in certain obstetric procedures which 
 may never occur to him until he is in active practice, 
 and, moreover, the manual training that will save the 
 physician's first eases of confinement much that would 
 otherwise be but crude and experimental, if not actually 
 dangerous, treatment. 
 
 Fig. 7 represents the use of the leather uterus in 
 a manikin. The uterus, drawn down into the vulva by 
 means of two volsella forceps, and is held by an assistant; 
 with blunt-pointed dressing forceps the student proceeds 
 to pack the uterus with gauze from a glass receptacle, the 
 fingers and palm of the left hand being used as a trough 
 to guide the gauze directly from the glass tube into the 
 uterine cavity, thus avoiding all contact with adjacent 
 unclean tissues. 
 
 Fis. 8 illustrates the uterus drawn down in the 
 
46 
 
 AIDS m OBSTETRIC TE AGEING. 
 
 same manner, and the student with, needle and holder 
 applying a ligature to a bleeding lacerated cervix. 
 
 —Laceration of right postero-iateral vaginal wall, perinseum, and ante 
 rior rectal wall througli the sphincter. Four rectal sutures and one silver 
 wire suture, the latter tranefixins torn ends of sphincter muscle and 
 encircling apes of rectal laceration, in place and ready to be tied. (Copper- 
 plated plaster cast ; from a photograph.) 
 
 Deep ^ i Iver /^uZure' 
 
 FiQ. 69.— Rectal sutiu-es of Fig. 08 tied and cut short in rectum. Silver-wire 
 sphincter suture and four vaginal sutures in place and ready to be tied. 
 (Copper-plated plaster cast ; from a photograph.) 
 
 4. Ritiier Perinasum and Vulva. — In Fig. 63 is 
 shown a rubber pelvic floor taken from Nature. A plas- 
 
 ter cast in this model was first taken from the living sub- 
 ject, this in turn cast in iron, and from this latter rubber 
 
 Pig. 70.— Vaginal 
 
 to be tied. (Copper-plated plaster cast ; from a photograph.) 
 
 models were made. It supplies the place of the ordinary 
 manikin for class-room, chnic, or ward demonstration. 
 
 A tLulsted 
 
 Pig. 71.— Perineal sutures of Fig. 70 tied. Ends of deep silver suture transfix- 
 ing sphincter muscle twisted Ends of rectal sutures hidden by closed anus. 
 Vaginal sutures seen to the right. (Copper-plated plaster cast ; from a pho. 
 tograph.) 
 
 and has the additional advantage of being readily por- 
 table and capable of being kept perfectly clean. 
 
AIDS m OBSTETRIC TEAGEINO. 
 
 47 
 
 V. JUledro-plated Plaster Models. 
 
 Experience has taught us that the papier-mache 
 method is not applicable for very small objects where 
 minuteness of detail is required. I refer more particu- 
 larly to the non-pregnant uterus, the pregnant uterus in 
 the early months, conditions of the cervix, lacerations of 
 the vagina and pelvic floor. We have therefore hit 
 upon a method of illustration which has given the great- 
 est satisfaction, and secures for us a model which is 
 comparatively light, practically indestructible, and 
 leaves nothing to be desired in accuracy of detail, as the 
 original and permanent model is a plaster cast taken 
 from Nature. 
 
 If, for example, a reproduction of the multiparous 
 uterus is desired, as soon as possible after its removal 
 from the cadaver a model in plaster of Paris is taken of 
 it. From this model, subsequently, any number of casts 
 or models may be reproduced. These are allowed to 
 dry thoroughly, and are then sent to an electrotyper, 
 who, at a trifling expense, throws a layer of copper over 
 the plaster cast, and afterward the model can be col- 
 ored in any desired manner. In this way were obtained 
 the smaller uteri represented in Figs. 10 and 11, and the 
 several degrees and varieties of perineal lacerations arti- 
 ficially produced upon the cadaver and represented in 
 Figs. 64 to 71. 
 
 We need not confine ourselves to plaster as regards 
 copper-plating, as bone, composition, and clay may be 
 subjected to the same process. All the models of pelvic 
 deformity (groups 1 to 24) were treated in the same way 
 for the sake of strength and durability. 
 
 1. Lacerations of Vagina, Perinceum, and Anterior 
 Rectal Wall. — My aim in this direction has been to pro- 
 duce a series of models that shall illustrate the ordinary 
 degrees of vaginal, perineal, and rectal lacerations pro- 
 duced during childbirth. To this end at first I confined 
 myself to plaster casts taken from the living subject 
 at the completion of the puerperium. This proved 
 unsatisfactory, however, because of contraction and 
 distortion of the parts in question, so that the series 
 herein offered represents plaster casts of artificially pro- 
 duced lacerations with the knife upon the cadaver. The 
 positive mold being taken in plaster of the injury pro- 
 duced, a second positive in glue was taken from this, 
 and then negative plaster casts taken from the glue posi- 
 tive and copper-plated. These latter are then completed 
 by the insertion of sutures by means of an ordinary drill. 
 
 This series includes (1) a cast of the nulliparous geni- 
 tals, showing the fourchette, from which the subsequent 
 casts, with injuries, were secured (Fig. 64); (2) a vagino- 
 perineal laceration involving the right lateral vaginal sul- 
 cus, -with sutures for repair in position (Fig. 65); (3) va- 
 gino-perineal laceration, involving both lateral sulci, with 
 sutures for repair in position (Fig. 66); (4) vagino-peri- 
 neal laceration, involving right postero-lateral vaginal 
 wall and perinasum to the sphincter ani, with sutures 
 for repair in position (Fig. 67); (5) laceration of right 
 
 postero-lateral vaginal wall, perinaeum, and anterior rec- 
 tal wall through the sphincter, sutures for repair of rec- 
 tal wall, and suture, including sphincter, in place (Fig. 
 68); (6) rectal sutures tied and cut short, wire. sphinc- 
 ter suture ready to be tied, vaginal sutures in position 
 (Fig. 69); (7) vaginal sutures tied, external perineal 
 sutures in position (Fig. 70); (8) external perineal su- 
 tures tied (Fig. 71). 
 
 2. Pelvic Deformity. — The subject of pelvic deform- 
 ity has always been one of the dryest and most uninter- 
 esting to the student, and one of the most difficult for 
 the instructor to teach. Little more than a temporary 
 impression is made by diagrams, verbal and printed de- 
 scriptions, and by perhaps an occasional cUnical demon- 
 stration of some form of pelvic deformity, so that at 
 graduation, and even later in the pupil's professional ca- 
 reer, the various deformities, whether they be congeni- 
 tal or produced by rhachitis, osteomalacia, ankylosis, or 
 adventitious causes, too often escape notice until the pa- 
 tient is perhaps well in the first stage of labor. We have 
 always believed that the best, if not the only satisfactory 
 method for the pupil to acquire an intelligent apprecia- 
 tion of this subject is to place in his hands the various 
 deformed pelves, and with the normal type in view be- 
 fore him require the student to point out the departures 
 from the normal in the deformed pelvis. This can readi- 
 ly be made a stepping-stone to the causes of such abnor- 
 mities, the diagnosis and prognosis of the same, and 
 the treatment appropriate to meeting the condition in 
 pregnancy or labor. Commencing with the moderate 
 deformities, the more marked and rarer conditions can 
 then be gradually approached. So in the obstetric cliniCj 
 hospital ward, or the dispensary, examination of preg- 
 nancy, varieties of pelvic deformity, with their prognosis 
 and treatment, can be brought home to pupils in a man- 
 ner never before thought possible, if at our command 
 we possess a series of deformed pelves from which one 
 resembling, if not exactly corresponding to, the abnor- 
 mity can be chosen. Heretofore this want we have 
 been unable to meet in the recitation room or hospital. 
 The limited number of specimens of pelvic deformity to 
 be found in any single college or hospital museum are 
 practically non-accessible to the student or practitioner, 
 and surely are too valuable and fragile to allow of re- 
 peated handling and study. 
 
 Eecently Tramond,* of Paris, has completed a series 
 of twenty-two deformed pelves. 
 
 This collection consists of twenty-two plaster models, 
 with artificial ligaments added, being correct repro- 
 ductions of the originals now in possession of private in- 
 dividuals or of the museums of Paris. 
 
 The series offers examples of the principal malforma- 
 tions, and there are in addition two pelves of normal con- 
 formation — namely, the male and female types, 
 twenty-four models in all. 
 
 * Maison Vasseur, 9 rue de I'Ecole de M6deoine. 
 
48 
 
 AIDS IN OBSTETRIC TEA CHIN 0. 
 
 In a number of the titles of the pelves herein given is 
 included the owner of the original or the museum where 
 found. Such a collection has been of great help to us for 
 several years past, and had we not hit upon some means to 
 render the models more durable, would not at the pres- 
 ent writing be presentable. To meet the wear and 
 tear of repeated handling and demonstration, we 
 have had these pelves sent to an electrotyper and 
 a thin film of copper thrown over them. This cop- 
 per-plating does not, to any extent, change the pro- 
 portions of the original pelves, but renders them prac- 
 tically indestructible, and a coat of paint will easily 
 restore the original natural appearance. Very slight ad- 
 ditional weight is added, and the plated model can be 
 cleansed and thus rendered free from suspicion for clini- 
 cal or bedside demonstration. 
 
 Believing this series of deformed pelves to be of value 
 not only to the teacher of obstetrics but to the general 
 practitioner and surgeon as well, I have made it a basis 
 of study, making complete measurements of each pelvis, 
 offering a photograph of the pelvic inlet and outlet of 
 each, an outline of a lead cast to show the vertical mesial 
 section, with the lumbo-sacro-coccygeal curve, the incli- 
 nation and shape of the symphysis, and the relations of 
 the anatomical, obstetric, and diagonal diameters of the 
 pelvic inlet, and also the sacro- and coccygo-pubic diame- 
 ters of the outlet. 
 
 Of the three conjugates appearing in each vertical 
 mesial section, I have emphasized the obstetric by draw- 
 ing here a heavier line, and it is well to state at this point 
 that we define the obstetric conjugate as the available 
 antero-posterior diameter of the pelvic inlet. 
 
 DISCUSSION OF THE PAPER, 
 
 "AIDS IN OBSTETRIC TEACHING," BY THE 
 
 AMERICAN GYNAECOLOGICAL SOCIETY, 
 
 New Yorh, May 26, 1896. 
 
 Dr. A. H. BuoKMASTEE, of Charlottesville, Va. — 
 I wish to express my admiration of these beautiful casts, 
 and also to call attention to a practical method of re- 
 producing casts from the living as well as the dead sub- 
 ject. It is by the use of iiarafrin, mid T think ilint il 
 has some advantages over Ihr iin'lhnd whirli llic doclor 
 described. The method is iml oi-igmal willi myscir. Imt 
 was used in 1880 or 1881 by Dr. Tetamore, of Long 
 Island College, for maldng some beautiful casts, of the 
 brain. It is a very simple one. The paraffin can be 
 applied with a fine eamel's-hair brush, and when care- 
 fully used it causes the patient but slight pain. When 
 a sufficient amount of paraffin has been used it is re- 
 moved, and at a later period is backed with plaster. 
 Into this paraffin cast the plaster is run, and you have 
 a perfect reproduction of the condition. The decussa- 
 tion of the pyramids can be perfectly shown by this 
 method. I made some casts four or five years ago just 
 before operation, and then made casts at a later period 
 in order to show the results of restoration of the pelvic 
 
 floor. I think that this method has some advantages 
 over that described in the paper. I would like to urge 
 its adoption generally. 
 
 Dr. EoBEET A. Murray, of New York. — We have 
 all been intensely interested by Dr. Edgar's casts of the 
 pelvis, and also those of the child which is to go tlirough 
 the pelvis. When I was connected with the Universitj' 
 Jledical College, and gave cases to the third-course stu- 
 dents to deliver, it seemed to me that the important 
 points were two: 1, the size of the pelvis; 2, the size of 
 tlie child. Now, if you will notice the statistics in Ger- 
 many, you will find that the average weight of the child 
 is about six pounds and a half. In New York, with the 
 more perfect nutrition of the child, due to the better 
 nutrition of the mother, and in all our States, the 
 child is usually larger than in Germany, Italy, and 
 France. That is, it is ordinarily not six pounds, 
 or six and a half, but seven pounds and a half. 
 Now, we do not have in New York, nor in Chi- 
 cago, nor in any of the cities of the Union, the deformed 
 pelvis that we ordinarily see in the Italians, in the Ger- 
 mans, and in the French, who come here. Why? Be- 
 cause our people have had more perfect nutrition. They 
 have not had to work when the pelvis was imperfectly 
 formed. They have had sufficient nutrition, and nutri- 
 tion of a land to develop the pelvis. So that we have 
 not the pelvis which is deformed absolutely, but one 
 which is small relatively to the child which is to pass 
 tlirough it. It becomes a question of mechanics, wheth- 
 er the child can pass through the pelvis. We have very 
 seldom a cordiform pelvis, seldom a Roberts's pelvis. 
 We do not have a pelvis in which the coccyx tump up 
 at the outlet, with marked contraction at the ou. 
 and in which laceration of the periuEeum through the 
 sphincter is likely to take place. 
 
 If, then, the student of midwifery would have ab- 
 solute knowledge of his case, he must have knowledge 
 of the child which is to pass through the pelvis, as well 
 as of the characteristics of that pelvis. Now, how are 
 we to determine that relationship between pelvis and 
 foetus? The student may study these casts. He may 
 learn to do version. He may learn how to apply forceps. 
 He may learn the different characteristics of the pelvis, 
 and I must congratulate Dr. Edgar on the very happy 
 way in which he makes those different deformities of 
 ihe pelvis evident to the student. Ordinarily the stu- 
 dent only knows that the male pelvis differs from the 
 female. But here we have it shown absolutely, so that 
 tlic student knows about the male and female pelvis, 
 about the pelvis which is contracted at the inferior strait, 
 the spondylolisthetic pelvis, etc. And until there is a 
 diameter reduced belowr two inches and three quarters 
 he (Iocs iKit almudon the hope of delivering tlirough 
 I he iialiir.il ( hiiiiiu']. He also learns to determine what 
 is llic si/.c o( tlic child's head as he feels it above the 
 pubes. He then knows wdiether he has to do a sym- 
 physeotomy, a Ca!sarean section, or, if he introduces 
 forceps and extracts the child, whether he will be likely 
 to save it. He knows all that, and that is why I con- 
 gratulate my friend Dr. Edgar for demonstrating these 
 things to students before they have had the opportunity 
 to examine and estimate the size of the pelvis during 
 the state of pregnancy. 
 
 Dr. A. P. A. King, of Washington, D. C— In the 
 evolution and development of any science, and in the 
 teaching of any art. new necessities are constantly aris- 
 ing. Now the necessity has arisen in the teaching of ob- 
 stetrics, in the absence of clinical teaching, to fumi.sh 
 
AIDS IN OBSTETRIC TEAOEINO. 
 
 49 
 
 a substitute. It is very fortunate tliat when these ne- 
 cessities arise tliere also occasionally appears a man oi; 
 originality and intelligence to grapple with the new 
 necessity and to provide the means of overcoming it. 
 Dr. Edgar, with his intelligence and originality, has 
 arisen in this country to furnish a substitute for the ne- 
 cessity of clinical teaching, and he has done it, or has 
 begun it at least, in a most admirable manner. I think 
 that we are all extremely grateful to him for the ad- 
 vance he has made in this substitute for clinical teach- 
 ing. 
 
 Now, I have only one or two ideas to suggest. One 
 is that in the absence of bedside teaching, which after 
 all is the only real method of teaching obstetrics, this 
 substitution of models is the best that we can do. It 
 is of the greatest importance that the student's fingers 
 should be educated, and, if Dr. Edgar would exercise 
 his ingenuity, I think that he might devise a model 
 which every student should buy — just as he now buys 
 a pelvis or a skeleton to learn anatomy — a device con- 
 taining a model of the foetal head susceptible of being 
 moved around in every direction, having the exact ana- 
 tomical construction of the foetal head. This the stu- 
 dent may carry with him to his room, and educate 
 his fingers, just as he would educate his muscles 
 with dumb-bells every morning, so that he will 
 become absolutely familiar with the sutures, fonta- 
 nelles, and general anatomical structures of the fcetal 
 head. 
 
 Another idea which would suggest itself has occurred 
 to me for many years. I do not know whether it is prac- 
 ti'-al or not, but in a large lecture room, like those in 
 _ ,me of the schools here in New York, where seven or 
 eight hundred matriculants are collected in a large am- 
 phitheatre, how little they can see in a case of labor, 
 or by a small model, like Dr. Edgar's! If Dr. Edgar 
 would exercise his originality and ingenuity he might 
 devise a very large pelvis, eight or ten times as big as 
 this one, and then hire a newsboy, eight or ten years 
 old, anoint him with vaseline, have the pelvis elastic so 
 as to avoid the danger of strangling him, and demon- 
 strate before these enormous classes the mechanism of 
 labor. 
 
 There is one other suggestion. It is a lamentable 
 fact that while most universities are so richly endowed 
 in most of their departments, in nearly all these insti- 
 tutions the medical school is the very last department 
 to receive endowments. Now, it is a curious thing that 
 while hundreds of thousands of dollars are given many 
 universities to build laboratories, gymnasiums, dormi- 
 tories, and nearly everything else, it is very seldom that 
 we get a donation for a medical institution. In New 
 York there are exceptions, as the Sloane Maternity, 
 and some others, but most universities have no provision 
 of this sort. I wish that this society coixld make itself 
 heard through this country in impressing the necessity 
 for raising money to estalDlish maternity hospitals for 
 teaching obstetrics. Until we accomplish this of course 
 we can never compete with the great schools of Europe 
 ■ — in Vienna, in Dublin, and other cities — where actual 
 clinical material is provided, and which is really the only 
 proper method of teaching next to the use of Dr. Ed- 
 gar's admirable models and manikins. 
 
 Dr. Edward Reynolds, of Boston. — I have known 
 for some years that Dr. Edgar was doing pioneer work 
 for all of us in this direction, and I have iDeen extremely 
 interested to see his collection of models. There is not 
 much that one can say in the discussion of such a paper, 
 
 but I sincerely hope that Dr. Edgar is going to elaborate 
 his system of models in the direction of providing stu- 
 dents with more and more exact exhibitions of the 
 mechanism of labor. 
 
 I believe that in obstetrics it is peculiarly important 
 to graduate students with a clear and definite, even 
 though limited, set of ideas; that in the emergencies 
 which test the results of our obstetric teacliing it is far 
 better for them to meet their cases with a concise and 
 definite knowledge of one method of dealing with the 
 emergency, rather than to be taught the pros and cons 
 and wherefores without end. I believe that in order to 
 fit men to deal with abnormal labor promptly and effi- 
 ciently, a large portion of the time devoted to obstetrics 
 must be given to careful drill in the mechanism which 
 underlies the whole subject, and without which there 
 is no possibility of its proper comprehension. Dr. Edgar 
 is showing us the way to teach students the mechanism 
 of labor, for I believe with him most heartily that there 
 is no possibility of teaching subjects of three dimensions 
 clearly by the use of plates of two dimensions, or by 
 mere words. We must have models in three dimensions, 
 and I for one look forward to Dr. Edgar's future work as 
 likely to furnish us all with an easy means of good 
 teaching, which we have not to-day. 
 
 Dr. Edwahd p. Davis, of Philadelphia. — Dr. Ed- 
 gar seems to me to have represented better than has 
 been done abroad some work which has been done by 
 others, and then to have added several distinct and 
 purely original and most meritorious things. The 
 leather uterus reminds me of the rubber uterus of 
 Winckel, by which the palpation of the foetal cadaver 
 can be in a measure learned. With wax casts we are 
 more or less familiar, but to my mind the best things 
 that Dr. Edgar has given us are this tripod with its 
 aluminum half-pelvis, and also his method of plaster 
 illustration of lacerations of the parturient tract. 
 
 If I mistake not. Dr. Edgar has not done himself 
 full justice in the idea of the tripod, as he uses, I think, 
 a pelvis of metal and a tripod in which he places the 
 fcEtus in the position of normal labor when illustrating 
 his lectures, so that this is but a part of his work in that 
 line. 
 
 These illustrated lacerations are certainly better 
 than any which have before come under my observation. 
 They represent in a clean and exact way an actual re- 
 production of the lesion and the method of treatment. 
 
 Referring to what has been said of the value of edu- 
 cation in three dimensions, there is certainly no better 
 way of teaching the mechanism of labor than by giving 
 to each student a pelvis and head with normal dimen- 
 sions, and educating his finger to recognize the relative 
 proportion of the one to the other. When thrown upon 
 his own resources he may be without the means of ac- 
 curate measuremeiit, but the finger which recognizes the 
 fact that the head does not engage in the ^ dlvis is the 
 safe finger for obstetric practice, and that can be taught 
 by placing the normal head in a model of a pelvis suffi- 
 ciently deformed to prevent engagement of the head. 
 That is one thing which the student must know, or he 
 will apply forceps to the disaster of the mother and 
 child. 
 
 There remains a way for further advancement in 
 illustrating obstetrics in a most interesting direction — 
 namely, that of the Roentgen rays for photographing, 
 or skiagraphing, the living pelvis and uterus. The time 
 of exposure now necessary has been reduced to about 
 one minute, but the one element which has baffled us 
 
50 
 
 AIDS IN OBSTETRIC TEACHINO. 
 
 in obstetrics is the fact tliat the fcetus is in almost con- 
 stant motion, and it has so far been impossible to clearly 
 skiagraph the living foetus. When the time of exposure 
 shall be so reduced that the fcetal movements shall offer 
 no serious obstacle we may hope that Dr. Edgar will 
 supplement his admirable work with skiagraphy. 
 
 Dr. ]<]dgar. — There is very httle left to say. With 
 regard to Dr. Buckmaster's remarks, I would imagine 
 that paraffin would do very well, but in my hands it has 
 not given the same success as plaster. Plaster has cer- 
 tainly taken in all the depressions and elevations in a 
 satisfactory manner, as is shown by the casts of the 
 vaginal and perineal lacerations. 
 
 In reply to Dr. Murray, I do not know whether 
 he misunderstood the paper, but I did not at all mean to 
 imply tliat tlie models and methods a-ef erred to were to 
 take the place of clinical instruction. They were only 
 to act as adjuncts and aids to such instruction. 
 
 I want to thank Dr. King for his kind words, and 
 T would like to repeat to him that all this paraphernalia 
 is meant to be used in maternity hospitals as well as in 
 the lecture room. I might say that there are two peri- 
 ods in the student's career when these adjuncts come 
 into play: during the second year, when he is prepar- 
 ing for obstetric work, and later, when he is in the ma- 
 ternity service and is seeing cases of confinement, in 
 order to illustrate more graphically parts out of sight 
 In reply to Dr. King's suggestion, I would say that I 
 have such a pelvis, which is three times the size of this 
 
 one (normal pelvis), but I could not get it into the cab, 
 consequently it remains at the foundiy. I have not yet 
 secured the newsboy, but Mr. Reynders is preparing a 
 piippet which is exactly three times the size of one of 
 these which you see — i. e., three times the normal size. 
 
 Again, in connection with Dr. King's remarks, I 
 would like to say that we do have an abundance of clini- 
 cal teaching here in New York; that the students from 
 all the principal medical schools are required now to 
 take a two weeks' course and to confine a number of 
 patients. They take it in the most practical way im- 
 aginable; that is, they actually confine the women. 
 They live in the hospital, and during the intervals be- 
 tween the confinements they attend the operations or 
 clinics going on in the institution. 
 
 I would like to have referred further to the mechan- 
 ism of labor, as Dr. Eeynolds has suggested, but the 
 time was so limited that I was unable to do so'. The 
 primary idea was to show the posture of the child, inter- 
 nal rotation, extension, and flexion: that is, to give an 
 ocular demonstration of the mechanism of labor. Some 
 of the remarks I was compelled to leave out (they will 
 apjiear in the ]:iublished paper) which apply more par- 
 ticularly to the mechanism of labor. 
 
 I wish to thank Dr. Davis for his kind words. I did 
 not refer to the full model of the pelvis, which he spoke 
 of, because it had already been presented to the New 
 York Obstetrical Society. The tripod is interchange- 
 able. 
 
 East Thirty-foueth Street, N"ew York. 
 
 
COLUMBIA UNIVERSITY LIBRARIES 
 
 This book is due on the date indicated below, or at the 
 expiration of a definite period after the date of borrowing, as 
 provided by the library rules or by special arrangement with 
 the Librarian in charge. 
 
 DATE BORROWED 
 
 
 
 DATE DUE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C2a(042)M5 
 
 ( 
 
 
 
Ed32 ' 
 B.Q524 
 
 "^^"^ thod of te^^L=_=