K&5 3a iO College of $i)ps;ictan£( anb burgeons; Eibrarp The Students* Quiz Series. A series covering the essential subjects of a thorough medical education, arranged in form of question and answer. By qualified teachers and examiners in New York. Illustrations wherever desirable. Priced at uniform low rate of $1.00, except double numbers on Anatomy and Surgery, which are priced at $1.75 each. ANATOMY (Double Numhpr)—Bj Fred J. Brockway, M.p., Aijst Demonstrator of Anatomy, College of Physicians and Surgeons, New York, and A. O'Malley, M, D., instructor in Surgery, New York Polyclinic. !^1.75o PHYSIOLOGY— By F. A. Manning, M. D., Attending Surgeon, Manhattan Hospital, N.Y. »l,00c CHE^liaTRY ANli PHYSiCS— By Joseph StroTHERS, Ph.B. , Columbia Coll. School xjX iMines^ N. i., 0, W. Wari>, Pu.B., Columbia College Scnool of MineSjH. Y., ana <^nab. H. vViilmarth, M.S., N. Y. $1. HISTOLOGY, PATHOLOGY AND BAC- T£RiiOi.OGY--By Bennett S. Beach, M. 1)., Lecturer on Histology, Pathology ana Bacteriology, New rork Polyclinic. 81.00. watekia medica and therapeu- Tl CS— By L. F. Warner, M. D., Attend- ing Physician, St. Bartholomew's Dispen= sary, N. l". itfl.OO. PRACTECE OF MEDICINE, including Ner- vous Diseases — By Edwin T. Double- day, M.D., Member iS.Y. I'atholo^^ical Society,, and J. I>. Nagel, M.D., Mem- ber N . Y. County Medical Asso n. $1.00. SURGERY (Double Number)— By Bern B. Gallaudet, M. D., Attending Surgeon Bellevue Hospital, N.Y., and Charles Dixon Jones, M.D., Surgpon to York- vilie Dispensary and Hospilal, N. Y. 81 .75. GENITO- URINARY AND VENEREAL DISEASES— By Chas. H. Chetwood, M. D., Visiting Surgeon, Demilt Dispen- sary, Department of Surgery and Genito- urinary Diseases, New York. $1.00. DISEASES OF THE SKIN-By Charles C. Ransom, M. D., Assistant Dermatolo- gist, Vanderbilt Clinic, N. Yo $1.00. DISEASES OF THE EYE, EAR, THROAT AND NOSE— By Frank E. Miller, M. D., Throat Surgeon, Vanderbilt Clinic, N. Y., James P. MacEvoy, M. D., Throat Surgeon, Bellevue Hospital, Out- Patient Department, New York, and J. E. Weeks, M. D., Lecturer on Oph- thalmology and Otology, Bellevue Hos- pital Medical College, New York. $1.00. OBSTETRICS — By Charles W Hayt, M. D., House Physician, Nursery and Child's Hospital, New York. $1.00. GYNECOLOGY— By G. W. Bratenahl, M. D., Assistant in Gynecology, Vander- bilt Clinic, New York, and Sinclair TouSEY, M. D., Assistant Surgeon, Out- patient Department, Roosevelt Hospital, New York. $1.00. DISEASES OF CHILDREN — By C. A. Rhodes, M.D., Instructor in Diseases of Children, N. Y, Post-Graduate Medical School. $iOO. LEA BROTHERS & CO., PUBLISHERS. PHILADELPHIk. Th^ Students' Quiz Scries. OBSTETEICS. A MANUAL FOR STUDENTS AND PRACTITIONERS. BY CHAKLES W. HAYT, M. D., House Physician, Nursery and Child's Hospital, New York. SERIES EDITED BY BERN B. GALLAUDET, M.D., Demonstrator of Anatomy, College of Physicians and Surgeons, New York ; Visiting Surgeon Bellevue Hospital, New York. PHILADELPHIA: LEA BROTHERS & CO. Entered according to Act of Congress, in the year 1892, by LEA BROTHERS & CO., In the OflBce of the Librarian of Congress, at Washington. All rights reserved. T?s-s-3/ //33 Westcott a Thomson, William J. Dornan, Stereotypers and Electrotypers, Philada. Printer, Fhilada. PREFACE. In the writing of this Compend the object sought has been to place before the student the most important matter in the subject of Obstetrics in as condensed a manner as possible. Much has been omitted in the way of theories and obscure or disputed points, which are appropriate only in an extended textbook. Brief manuals have a position of unquestionable value to the student and practitioner, provided the text is clear, accurate, and well proportioned to the importance of the many subjects neces- sary to a practical comprehension of the whole. These requisites have been borne in mind in the preparation of the present volume. In its compilation the following works have been consulted, as well as notes taken at the lectures of Dr. James W. McLane of the College of Physicians and Surgeons, New York City : Char- pentier's Cydrypmdia of Ohstetrica and Gynecology^ Hirst's System of Obstetrics^ Playfair. Winckel, Lusk, and King. The illustrations are taken from Playfair and King. CHAS. W. HAYT. M. D. 571 Lexington Ave., ^ New York City. / CONTENTS. CHAPTER I. FEMALE ORGANS OF GENERATION. PAGE External : Mons Veneris ; Labia Majora ; Labia Minora ; Clitoris ; Vestibule ; Meatus Urinarius ; Hymen ; Vagina ........ 17 Internal: Uterus or Womb ; Fallopian Tubes or Oviducts ; Ovaries . 19 The Pelvis : Formation ; Description of the Pelvis ; DifFerence between the True and False; Diameters; Planes; Difference between the Male and Female ; Ligaments ; Joints of the Pelvis 20 The Breasts : Described 22 CHAPTER 11. THE GRAAFIAN FOLLICLE, OVULATION, AND MENSTRUATION. The Graafian Follicle: Structure; Tunica Propria; Tunica Fibrosa; Zona Pellucida ; Germinal Vesicle ; Germinal Spot ; The Ovule, etc 23 Ovulation and Menstruation : Puberty ; Changes occurring when Pu- berty is Reached ; Nubility ; the Menopause ; Ovulation defined ; Menstruation defined ; Relation between the Two ; Corpus Luteum. 24 CHAPTER III. PREGNANCY. Conception and Generation : The Semen ; Sterility ; Changes occurring in Impregnated Ovumj Changes in Uterine Mucous Membrane; Development of Ovum ; Umbilical Vesicle; Allantois; Amnion; Liquor Amnii; Chorion; Placenta; Umbilical Cord 26 The Foetus : Described at end of First, Second, Third, Fourth, Fifth, Sixth, Seventh, Eighth, and Ninth Months ; Vernix Caseosa ; the Foetal Head ; Functions of Foetus in Utero ; Circulation .... 31 5 f) CONTENTS. PAGE Phenomena of Pregnancy: Changes in Generative Organs; Changes in Pelvis ; Changes in Cutaneous System ; Blood ; Respiratory Apparatus ; Digestive Apparatus ; Urinary Organs ; Osseous Sys- tem ; and Nervous System 36 Signs, Symptoms, and Diagnosis of Pregnancy : Palpation ; Positive Signs ; Difference between First and subsequent Method of Exam- ining the Pregnant Woman ; Duration of Pregnancy 39 Differential Diagnosis of Pregnancy : Death of Foetus in Utero ... 44 Disorders of Pregnancy: Classified; Causes, Diagnosis, Prognosis, Symptoms, and Treatment of each 46 Diseases occurring with Pregnancy 56 Extra-uterine Pregnancy : Tubal ; Abdominal Missed Labor .... 57 Multiple Pregnancy : Superfoetation and Superfecundation 60 Diseases of the Ovum, Foetus, and Decidua : Moles 61 Abortion, Miscarriage, and Premature Labor 66 Hemorrhages of Pregnancy : Accidental ; Placenta Pra^via 69 CHAPTER IV. LABOR. Phenomena : Duration of Labor 74-77 Presentation and Position 78 Mechanism in Vertex Cases 78 Abdominal Palpation 82 Diagnosis of Vertex Presentations 84 Management of Natural Labor 84 Anresthesia. Analgesia 89 The Perineum 91 Episiotomy 93 The Puerperal State 93 Care of the Infant 96 CHAPTER V. UNNATURAL LABORS. Persistent Occipito-posterior Positions 97 Face Presentations 97 Pelvic Presentations > 101 Difficult Breech Presentations 107 Trunk Presentations 109 CONTENTS. 7 PAGE Complex Presentations , „ 113 Prolapse of the Funis , ...... 114 Anomalies of the Forces in Labor , 116 Anomalies of the Soft Parts in Labor 119 Anomalies of the Pelvis in Labor ... = ,.,., 123 Anomalies of the Foetus = .....,...,,.. 132 CHAPTER yi. HEMORRHAGES, INJURIES, AND ACCIDENTS OF LABOR. Hemorrhages during and after Delivery -...».....,.. 135 Inversion of the Uterus 139 Rupture of the Uterus 141 Accidents to Mother, and Sudden Death ..o ......... . 143 CHAPTER VII. OBSTETRIC OPERATIONS. The Induction of Abortion and Premature Labor 145 Version 148 The Forceps: TheVectis; The Fillet 155 Embryotomy and Craniotomy ..... = 161 The Csesarean Section and its Modifications : Laparo-elytrotomy ; Sym- physiotomy; Transfusion; Infusion 164 CHAPTER VIIL PUERPERAL DISEASES. Puerperal Infection 169 Phlegmasia Alba Dolens ..-,..,........ 175 Insanity -....,,...,.,, 176 Affections of the Nipples and Breasts ..... . = .,,.., 178 CHAPTER IX. THE INFANT. Resuscitation of Asphyxiated Infant; Nursing and Weaning; Dis- eases of the Newborn , 181 OBSTETRICS. CHAPTER I. FEMALE ORGANS OF GENERATION. >7ame and describe the external organs of generation. They are organs essentially intended for copulation, and consist of — 1. The Mons Veneris^ which is a firm cushion-hke eminence above the pubes, composed of skin, fat, connective tissue, blood-vessels, and nerves. It has many sebaceous and sweat-glands upon it, and is covered with hair. Its use is as a cushion for the male during copulation and to pre- vent injury from blows. There is no mons until puberty (Fig. 1, /). 2. The Labia Majora are the external or great lips. They are two folds of skin extending from the median line of the mons veneris ante- riorly, to terminate posteriorly in what is called the fourchette, which is situated at the anterior portion of the perineum, and is nearly always torn at the first labor. They are made up of adipose tissue, blood-ves- sels, and nerves, and have both a cutaneous and mucous covering. Deeply within them are situated the vulvo-vaginal glands. In the vir- gin the labia majora are in apposition, but after childbirth they become more or less separated (Fig. 1, a). 3. The Labia 3Iinora, or Nymphae, are the internal or lesser lips. They are two moist folds of mucous membrane seen in separating the labia majora. They arise by two roots. The superior pair are thick and fleshy, and together form the hood or prepuce of the clitoris. The in- ferior pair are thin, and form the frenum of the clitoris. In very young children the nymphae project be.yond the vulva (Fig. 1, &). 4. The Clitoris is a reddish tubercle situated about half an inch be- hind the anterior commissure of the labia majora. It is made up of the glans clitoridis and the two corpora cavernosa, which are separated from each other by a fibrous septum. The nerve-supply is large, and on this account it is supposed to be the chief seat of voluptuousness in the female (Fig. 1, d). ^ 5. The Vestibule is a triangular surface bounded by the nj^mphae on either side and the clitoris above (Fig. 1, c). 2— Obs. 17 18 FEMAI^E ORGANS OF GENERATION. 6. The Meatus Uriimrhis is the external orifice of the urethra, and is situated at the base of the vestibule. Immediately below it is a small tubercle which terminates the superior wall of the vagina. This arrange- ment allows the meatus to be found on examination without exposing ^^r'Cy External Organs of (Jeneratii^n ; a, labium inajus; 6, labium minus; c, vestibule above urethral orifice; d, glans clitoridis; e, preputium clitoridis ; /, mons veneris. the woman. After confinement, however, the swelling of the parts sometimes renders the finding of this tubercle difficult, and makes cathe- t(!rizati()n not easy even though the genitals be exjiosed. For this reason the best and proju'r proc('(lurc is to sei>arate the labia with the thumb and index finger and introduce the catheter by sight. INTERNAL. 19 Y. The^ Hx/mfM is situated at the orifice of the vagina, and is formed from vaginal mucous membrane. It contains a vanable-sized opening through which passes the menstrual fluid. After the first labor three or four eminences are left which are called "carunculse myrtiformes. " 8. The Vagina is a musculo-membranous canal lying wholly within the true pelvis, and extending from the vulvar orifice to the uterus. It is in relation anteriorly with the bladder and posteriorly with the rectum. Its length varies, the anterior wall averaging from 2| to 3 inches, the posterior from 3 to SJ inches. It is made up of three laj^ers— an exter- nal or cellular, middle or muscular, and internal or mucous coat. This latter is thrown into numerous folds or rugae, which become greatly atro- phied in multiparge and the aged, but never entirely disappear. In the virgin the anterior and posterior walls are in apposition. What constitute the internal organs of generation? Describe each. l._ The Uterus, or Womh, is situated in the true pelvis, above the vagina and between the bladder in front and the rectum behind. It is the organ in which the fecundated ovule is developed, and which expels the foetus when the term of pregnancy arrives. The adult nulliparous uterus is about 3 inches long, 2 inches broad at the fundus, and 1 inch thick. Its weight is from 7-12 drachms. It is divided into three re- gions : the fundus, being that part above the Fallopian tubes ; the body, between the tubes and the os internum ; the cervix or neck, extending from the os internum to the os externum. It presents two surfaces and two borders, and is made up of three coats : first, an external or perito- neal ; second, the middle or muscular layer, which consists of unstriped muscular fibre ; and third, an internal lining of mucous membrane (also called musculus granulosus), which terminates below at the internal os. It is held in position by the vagina below, two vesico-uterine ligaments anteriorly, two recto -uterine hgaments posteriorly, two broad ligaments laterally, and two round ligaments passing from the superior angle of the uterus to the labia majora. 2. The Fallopian Tubes, or Oviducts, are two trumpet-shaped tubes from 4 to 5 inches in length, passing from the superior angles of the uterus to the ovaries. Through these ducts the semen is brought in con- tact with the ovule and the ovule is earned into the cavity of the uterus. They also are composed of three coats — an external serous, middle mus- cular, and internal mucous. 3. The Ovaries, the geiTn-producing organs of the female, are two small ovoid bodies situated on either side of the uterus in the poste- rior fold of the broad ligament and at the end of the Fallopian tubes. Their size and weiglit vary with age, but in general the dimensions are Hxf Xi inch, and they weigh about 90 grains. The ovary consists of a spongy, reddish mass called the stroma or medullary portion. This is niade up of connective tissue, muscular fibres, and vessels. Externally, it is thicker, more compact, of a whitish color, and is called the '"tunica 20 FEMALE ORGANS OF GENERATION. albuginea." This is covered by an epithelial layer derived from the peritoneum. THE PELVIS. What is the pelvis, and how is it made up? The Pelvis is a bony basin situated at the lower part of the trunk. It rests below upon the femurs, supports the vertebral column, and forms a canal through which the child passes to be delivered from the uterus of the mother. It is formed of four bones — the sacrum, coccyx, and two innominate bones. Name the ligaments connected with the pelvis. Two anterior sacro-iliac ligaments connecting the anterior surfaces of the sacrum and ilia ; two posterior sacro-iliac ligaments between the sacrum and ilia posteriorly ; two great sacro-sciatic ligaments passing from the sacrum and ilium to the ischium ; two lesser sacro-sciatic liga- ments passing from the ischium to the sacrum and coccyx ; anterior, posterior, and lateral sacro-coccygeal ligaments between the sacrum and coccyx ; anterior, posterior, and superior pubic and subpubic ligaments between the two pubic bones. State what is understood by the true pelvis. The true pelvis is that jiart of the pelvic cavity situated below the ilio-pectineal lines. This is in contradistinction to the false pelvis, which is the broad expanded portion above these lines, and is of practically no importance from an obstetrical point of view. The upper opening of the true pelvis is called the superior strait, inlet, or brim, and is heart- shaped ; the lower opening is called the outlet or inferior strait, is some- what oval, and is bounded by the tuberosities of the ischia, the coccyx, and rami of the pubes. "What are the diameters of the pelvis ? They are measurements taken between various points directly opposite each other, and are three in number: 1st, the antero-post^rior or con- jugate ; 2d, the oblique ; 3d, the transverse. The conjugate at the brim is 4 inches, and is taken from the centre of the promontory of the sacrum to the posterior siu'face of the symphysis. At the outlet this diameter is 5 inches. The measurement here is taken from the tip of the coccyx to the lower border of the symphysis (Fig. 2, 1). The oblique is Al inches both at the brim and at the outlet. At the brim this measurement is taken from the sacro-iliac synchondrosis of one side to the ilio-ixictineal eminence of the other; at the outlet, from the centre of the .ureat sacro-sciatic ligament to the point of junction of the ascendiny; ramus of the ischium with the descending of the pubis (Fig. 2.3). The transverse is 5 inches at the inlet, and is the measurement from a point midway between the sacro-iliac joint and the ilio-pectineal eminence to a con-esponding point on the o])posite side (Fig. 2, 2). At the outlet THE PELVIS. 21 this diameter is 4 inches, and is the distance between the tuberosities of Fig. 2. The Pelvis: 1, Antero-posterior or Conjugate Diameter; 2, Transverse; 3, Oblique. the ischia. (There are a few other measurements sometimes given, but they are of httle importance, and therefore are omitted. ) How many true planes are there in the pelvis ? Name them and give their direction. There are four — two anterior and two posterior " z';2c?/»erZ" planes. The anterior have a direction from above downward, from behind for- ward, and from without inward ; the posterior from above downward, from before backward, and from without inward. What are the differences between the male and female pelvis? The real differences are found in the true pelvis, and are determined 'by the presence of the uterus. Female. Shallow, but capacious. Light in structure, and the points for muscular attachments are much less developed. Subpubic angle 75°. Male. Deep. Bones stronger, heavier, rougher, and more compact. Pelvis more conical. Sacrum less concave. Ischial tuberosities closer together. Subpubic angle more acute, 58°. What alterations take place in the pelvis during pregnancy? The cartilages become softened and swollen and the ligaments relaxed. This makes the pelvis more spacious. 22 THE BREASTS. Fig. 3. THE BREASTS. Describe the mammary glands or breasts. The Mdiuma', or breasts, are two glandular organs connected with the generative apparatus, which secrete the fluid destined to nourish tlie child. They are situated on the anterior and superior part of the chest, in front of the pectoralis major and be- tween the third and seventh ribs. They are conical or hemispherical in shape in the nulliparous woman, but vary greatly both in size and form in w^omen who have nursed. Anomalies in position are sometimes observed. The external surface has three zones: ( 1 ) A white peripheral zone, smooth and soft, reaching from the periphery to the areola. (2) An areolar zone ex- tending to the nipple. This is of a pink or rosy hue in blonds ; in brunettes nearly brown. During pregnancy this zone becomes dark and pigmented. (3) The nipple, or "teat," a large papilla situated at the summit of the gland. The mammae are made up of gland- tissue and fat. Each gland contains fif- teen or twenty lobes sejiaratcd by fibrous septa and by adipose tissue. The lobes are subdivided into lobules, which are produced by the aggregation of acini, in which the milk is formed. As the ducts of the lobes approach the nipple they become widely dilated, so as to form small reservoirs in which milk ig stored. But as they pass through the nipple they again contract. The breast receives a large num})er of both sui)erficial and deep vessels and nerves, and its sympathetic relations with the uterus are very strongly marked, as is shown after delivery by the fact that the nursing of the child produces reflex contractions of the uterus and sometimes severe after-pains. 1, Galactophorous Ducts; 2, Lobuli of tne Mauiinarv (Jland. THE GRAAFIAN FOLLICLESc 23 CHAPTER II. THE GRAAFIAN FOLLICLES, OVULATION, AND MENSTRU- ATION. THE GRAAFIAN FOLLICLES. What are the Graafian follicles? The.y are small spherical vesicles situated in the stroma of the ovary. At the age of about twenty there are some 350,000 to each ovary. From tliis time on they steadily decrease in number. They are formed of two membranes — the external, very vascular and made up of connective tis- sue called the "tunica fibrosa;" the internal, composed of connective Diagram of a Triaugular Portion cut from the stroma of the Ovary: 1, epithelial cover- ing of ovary ; 2, tunica albuginea; 3,3, ovarian stroma; 4, tunica propria of 5, Graafian follicle; 6,6, membrana granulosa; 7, liquor folliculi; S, zona pellucida; 9, yelk; 10. germinal vesicle; 11, germinal spot (King). tissue called the "tunica propria." The inner surface of the latter is lined with a layer of small round nucleated cells, the "membrana granu- losa." These cells become denser at one point, and form the "discus" or "cumulus proligerus." The cavity of the follicle is filled with a clear, viscid liquid, the " liquor folliculi." 24 OVULATION AND MENSTRUATION. Describe the contents of the Graafian follicle. Tlie Graafian follicle contains, besides the liquor folliculi, a small body about y^5 of an inch in diameter, the "ovule." This is surrounded by the cells forming the discus proligerus, and its envelope is a thick, elas- tic, transparent membrane, which has been termed the vitelline mem- brane or zona pellucida. The cavity of the ovule is filled with a granular liquid, the " vitellus," or yelk, in which is found the vesicle of Purkinje, or germinal vesicle, containing the germinal spot. From without inward we thus find — (1) the tunica fibrosa; (2) the tunica propria; (3) the membrana granulosa ; (4) the discus proligerus; (5) the liquor follicuh (these compose the Graafian follicle); (6) the zona pellucida; (7) the yelk ; (8) the germinal vesicle ; (9) the germinal spot, the ovule (Fig. 4). OVULATION AND MENSTRUATION. What is puberty? Paherty is the period of transformation from childhood to youth, and is the time when fecundation is rendered possible. This period varies considerably in different climates and individuals, but averages twelve years in females and fourteen in males. Describe briefly the changes occurring in the female when pu- berty is reached. The pubis becomes covered with hair, the pelvis wider, the thighs broader, and the breasts larger. The character also changes materially. This transformation is indicated by the appearance of two functions car- ried on by the female generative organs — namely, ovulation and men- struation. What is nubility? Niihility is the age when fecundation is rendered possible, and the consequence borne normally without damage. It is generally considered the period of puberty, but this is erroneous, since, thougli puberty must precede it, a girl may be pubescent without being nubile. What is the menopause ? The iMenopaiise, or change of life, is the time when menstruation ceases. Like puberty, the menopause occurs at a very variable period of life, the average being at the forty-third or forty-fourth year, though cases have been known in which menstruation lasted until the sixty-fifth year. The menopause has been known to occur as early as twenty-eight. It does not take place suddenly, but begins by irregularities in the flow in regard to duration, quality, and quantity, and at last the flow ceases altogether. x\t the same time some general ailments appear and the genital organs become atrophied. What is understood by the term " ovulation " ? By Orulatioit we mean the ])lienom(M)a accompanying the formatioti of the ova in the ovary, the rupture of the Graafian follicle, and the dis- OVULATION AND MENSTKUATION. 25 charge of the ovum from the vesicle. This last is followed by the mi- gration of the ovum through the tube, the cicatrization of the Graafian follicle, and the production of the corpus luteum. What does the term "menstruation" mean? Menstruation is the periodical discharge of blood and mucus from the female organs of generation, generally occurring every lunar month, ex- cepting during pregnancy and lactation, when it is usually suppressed. This function is established at puberty and ceases at the menopause. The menstrual blood is acid in reaction, has a slight odor, is prevented from coagulating by the mucus contained in it, and varies greatly in amount in different individuals. The source of the blood is the mucous membrane lining the uterus. The purpose of the menstrual flow is sim- ply to prepare a germ-bed for the reception of the impregnated ovum. What is the relation between ovulation and menstruation? The flow probably begins with the rupture of the Graafian follicle, and continues a variable number of days, ordinarily about four. Undoubt- edly, ovulation may take place without its outward manifestation (men- struation), as many cases are recorded where impregnation has occurred during lactation and before menstruation had been re-established. How- ever, they usually go together. What is the corpus luteum? The Corpus^ Luteitm is a small yellowish mass left in the ovary after the rupture of one of the Graafian follicles. It was once supposed to be a sign of previous impregnation, but is found in unquestionable virgins. Describe the corpus luteum when pregnancy has not taken place. When a Graafian follicle is about to rupture, a short time before the menstrual flow begins, it increases in size and approaches the surface of the ovary until it forms a projection upon it. The distension is due to an increase of its contained fluid. Now, an escape of blood from the distended capillaries of its inner coat occurs, and the follicle ruptures, as does also the ovarian covering ; the ovule passes to the surface of the ovary and into the fimbriated extremity of the Fallopian tube. The internal layer of the follicle now becomes the seat of an hypertrophy due to the development of the cells which compose its tissues. The edges of the rent in the internal layer, on account of this hypertrophy, come in contact ; the external la.yer, being elastic, retracts, and the cor- pus luteum results. The vessels now begin to disappear, the cells to vanish, and the whole mass is reduced to a small cicatrix, which gen- erally disappears in from thirty to forty days (Longet). Describe the corpus luteum when pregnancy has taken place. All of the above changes occur, excepting in a more marked degree. Instead of disappearing in thirty or forty days, as is the case when im- 2fi PREGNANCY. pregnation does not occur, they go until the fourth month of pregnancy, when tliey attain their maximum development and form a corpus luteum which averages ] inch in length and j an inch in breadth. This now commences to atroph}^, and cicatrization becomes complete a few weeks after delivery. CHAPTER III. PREGNANCY. CONCEPTION AND GENERATION. What is conception ? Conception^ impregnation or fecundation, is the act by which the semen or fluid furnished by the male organs of generation unites with the ovule from the female ovary, so that a new being results. This may take place in some part of the Fallopian tube. What must take place for fecundation to occur? There must be a connection of the two sexes by copulation, and there must be ovulation by the female and an emission of semen by the male. Describe the semen, and explain how its ascent to reach the ovule is accomplished. The semen is a white, viscid, dense fluid, having a faint odor, secreted by the testicles of an adult male, and thrown into the urethra by the ejaculatory ducts. It consists of water, albuminous matter, salts of lime and soda, and contains numerous peculiar organisms called spermatozoids. These spermatozoids form the essential fecundating part of the semen, are about (y^oth of an inch in length, and resemble the tadpole of the frog. They are made up of three parts, a head, body, and tail, and are ani- mated by very rapid movements. When placed in proper surroundings they retain their vitality for a considerable time after emission. Exces- sively acid or alkaline fluids and alcohol destroy them ; heat and cold stop their movements; the normal temperature of the body and the menstrual discharge increase these movements. The ascent of the se- men is mainly due to the inherent mobility of the spermatozoids. State some of the most common causes of sterility. In the male : All that hinders or alters the act of copulation ; Absence of ejaculation ; Absence of spermatozoids in the semen, ) n^^ disease ■ Inactivity of the spermatozoids in the semen, j -^ ' ' Abnormal formation of external genitals, | H^j^pJ^'spadias, etc. CONCEPTION AND GENERATION. 27 In the female : Abnormal formation of the genitais ; Displacements of the uterus, obstructing the ascent of the semen ; Vaginal or uterine secretions rendered so strongly acid or alkaline by disease that the spermatozoids are destroyed ; Tubal and ovarian diseases. Describe the changes which take place in the impregnated ovum during its passage to the uterus. As the ovule escapes from the ovary it takes with it some particles of the discus proligerus, which surround it as a thin layer of granular cells. B}'^ friction with the sides of the tube these disappear, and the zona pel- lucida is the outermost covering. It has now advanced some distance along the tube, and becomes invested with a covering of albuminous material. During this time the vitellus or yelk shrinks from its covering and the germinative vesicle disappears. The first indication of impreg- nation occurs when a small, clear vesicle appears in the centre of the yelk. This is called the "vitelline nucleus," and is found in fifteen to thirty hours after fecundation. Now what is called segmentation of the yelk takes place. This consists in a breaking up of the vitellus. First. the vitelline nucleus divides into two nuclei, and then the yelk into two halves. The process continues: the two new cells are converted into four, the four into eight, and so on until a great number are generated. This forms a granular mass which from its resemblance to a mulberry is called the " muriform body " or " morula." A clear fluid then accumu- lates in the centre, expanding the muriform body and pushing tlie cells together until their edges meet, forming an internal lining to the zona pellucida. This is the "blastodermic membrane," and from it the foetus is developed. The ovum is now 2Vth of an inch in diameter, and has occupied about twelve days in its passage from the ovary to the uterus, which it has reached. What changes occur in the uterine mucous membrane to prepare it for the reception of the impregnated ovum ? At each menstrual period the mucous membrane of the uterus be- comes thickened and vascular, and when fecundation has occurred this change is much more marked, until the result is the formation of a dis- tinct membrane which has received the name of the "decidua." This has three divisions: (1) The "decidua vera." lining the entire uterine cavity, and undoubtedly the hypertrophied mucous membrane of the uterus. (2) The " decidua reflexa," which surrounds the ovum, and is probably simply a growth of the decidua vera around the ovum at the point where it lies in the uterus. As the ovum grows this naturally stretches until it eventually (at the fourth month) comes in contact all around with the decidua vera. (3) The "decidua serotina," which is that part of the decidua vera on which the ovum rests. At this point the placenta is developed. Thus it is seen that the three deciduae be- 28 PREGNANCY. come and really are one. Late in pregnancy fatty degeneration of this structure occurs, its adhesions to the uterine wall lessen, and it is thrown off with the placenta after labor, leaving a new mucous membrane lining the uterus. Describe the development of the ovum after it has reached the uterus. The blastodermic membrane divides into three parts: an external, called the "epiblast;" a middle, called the "mesoblast" or "meso- derm;" and an internal, the Fig. 5. External Surface of Epiblast, showing area ger- minativa, area pellucida, and primitive trace. hypoblast " or " entoderm. ' ' At this time a minute elevation, due to an aggregation of cells, and consisting of a slight thick- ening of the membrane, appears. This is the " area germinativa. " In its centre a faint line is seen, "the primitive trace" or "em- bryonic line." Surrounding it are a few translucent cells, which have been called the ' ' area pel- lucida" (Fig. 5). The extremi- ties of the primitive trace thicken and turn upon themselves — one anteriorly, called the cephalic or head fold ; one jwsteriorly, the caudal or tail fold. The body of the embryo is now visible. What organs or parts of the foetus are developed from the epi- blast? The epiblast takes part in the formation of the superficial layer of the skin, hair, nails, organs of special sense, the brain, spinal cord, and amnion. What parts are developed from the mesoblast? From the mesoblast are formed the bony framework, the muscular and vascular system, the muscular and fibrous tissues of the digestive tract, and probably the genito-urinary organs. What is developed from the hypoblast? From the hypoblast is formed the ei)ithelium lining the respiratory and digestive tracts. Describe the umbilical vesicle. The Umbilical Vesicle is a small round sac communicating with the THE ALLANTOIS Fig. 6. Fig. 7. 29 a,a, projecting folds of amnion; z, zona pellucida ; s, epiblast ; »i, hypoblast ; w, umbiliCHl vesicle. a,a, folds of amnion about to join ; p, commencement of allantois. abdominal cavity of the foetus through a constricted portion called the "vitelline duct," and containing a yellowish, oily fluid from which the foetus derives its nourishment during the first few weeks of Fig. 8. life. It attains its greatest development by the end of the fourth week. From this time on it gradually shrinks until by the sixth or seventh week it has entirely disap- peared. It is formed from the internal layer of the blas- todermic membrane. What is the allantois? It is a small vesicle derived from the entoderm and inner stratum of the mesoderm, formed about the twentieth day near the caudal extrem- ity of the foetus, and Ijnng between the amnion and cho- rion. It is connected with the bladder by the urachus, and grows rapidly until it en- tirely lines the chorion. This contains the two umbilical arteries derived from the aorta, and two um- bilical veins, one of which soon disappears. Its caudal part helps to form the umbilical cord. Further Development : o, junction of amniotic folds; p, pedicle of allantois; ?/, umbilical vesicle. 30 PREGNANCY. Describe the amnion. The Amnion is the innermost of the two membranes surrounding the foetus. Externally it is in contact with the chorion, internally with the hquor amnii and foetus. It also forms a covering for the umbilical cord, and is continuous with the integument at the umbilicus of the foetus. It is formed from the ei)iblast, and secretes a fluid which distends its cav- ity. This is called the "liquor amnii," and in it the foetus floats. What is the character of the "liquor amnii"? and what are its uses? It is, in the early months of pregnancy, a clear, transparent fluid, con- sisting of water, albuminous matter, and various inorganic salts. Later it becomes denser and of a brownish color, having a faint odor. It pre- vents injury to the child from blows received on the abdomen of the mother. It also prevents injury to the uterus which the foetus might inflict by its movements. Lastly, it acts as a fluid wedge which dilates the OS during labor and lubricates the parturient canal for the passage of the child. Describe the chorion. The Chorion is the more external of the true foetal membranes. It is a closed sac, formed by the external layer of the blastodermic mem- brane and the zona pellucida. Externally it is in contact with the de- cidua. and internally with the amnion. Its internal surface is smooth and shining, while the external surface is rough, being covered with small villi. What are the chorionic villi? They are small, hollow sprouts springing from the external surface of the chorion and burying themselves in the decidua. At first non-vascu- lar, later (when the allantois has spread itself over the whole of the chorion) each villus receives an artery and vein, which give branches to the subdivisions into which the villi divide. Soon all, excepting those in contact with the decidua scroti na, begin to shrivel up and disappear, until by the end of the eighth week none are left excepting at this site. Occasionally one remains on the surface of the chorion, causing hemor- rhage after the birth of the child. What is the placenta, and how is it formed? The Phicrnfa^ or after-birth, whose function it is to aerate the blood of the foetus, is a soft, spongy, vascular mass, circular in form and thick- est at its centre. It is from to 9 inches in diameter, from 2 to 1 inch thick in the centre, and weighs from 1 to U i)ounds avoirdupois. It begins to be formed at the second month, but docs not reach its full de- velopment until the third month. Its usual attachment is to some part of the uterus near one of the Falloi)ian tubes, thouirh it may be situated anywhere within the uterine cavity. It is formed of I'rom fifteen to twenty tufts or villi, and has two surfaces — an external uterine or ma- THE FCETUS. 31 temal, whicli is rough and in contact with the uterine wall ; and an in- ternal or foetal : this is smooth, and covered by the two membranes, the amnion and chorion. Each tuft is extremely vascular, and its vessels lie in close apposition with the maternal vessels within the walls of the uterus. What is the umbilical cord? The Umbilical Cord is the pedicle attaching the foetus to the placenta. It is^ formed about the fourth week of gestation, and consists of two arteries and one large vein, which pass in a spiral direction from the umbilicus of the child to some portion of the placenta, most frequently about its centre. Surrounding the vessels is a soft, transparent, gelati- nous substance called Wharton's jelly, and around this the amnion. The length of the cord varies: averaging from 18 to 20 inches, it has been found 60 to 80 inches in length, and as short as 6 or 8 inches. In thick- ness it varies from the size of the little finger to that of the thumb or even larger. THE FCETUS. Describe the foetus. 1. At the end of the fourth week it is a small gelatinous mass, curved upon itself and grayish in color. No extremities or head can be seen, and it is so small that it is usually lost in the blood-clots when an abor- tion occurs at this time. 2. At the end of the second month it is from 1 to IJ inches in length. The head is large, forming at least one-third of the embryo. The eyes are marked by two black spots and the ears by slightly projectin.ff rings. The mouth is very large, but small folds of skin have appeared about^it and the eyes, marking the commencement of the lips and eyelids. The limbs are visible, with rudimentary toes and fingers, and the bends at the elbows and knees are present. The spinal column is divided into verte- brae, and the circulatory system is forming. The umbilical cord is, as a rule, straight and inserted into the lower part of the abdomen. Centres of ossification in some of the bones have appeared. 3. At the end of the third month. From now on the embryo is com- monly spoken of as the foetus. It is from 3 J to 4J inches in length, and weighs about 1500 or 1600 grains. The head is still comparatively large and the eyes prominent, though they and the mouth are closed. The neck becomes evident, the fingers distinctly separated, and the integu- ment thin, transparent, and rose-colored, though firmer than it has been. The genito-urinary organs are developed and the sex can be distinguished. The placenta now is distinctly formed. 4. At the end of the fourth month the foetus measures 6 to 7 inches in length, and weighs between 5 and 6 ounces avoirdupois. The chin, which until now has been inconspicuous, becomes prominent. The nails appear, and soft white hairs are found on the head. The umbilicus is just above the pubes. 32 PREGNANCY. 5. At the end of the fifth month the length of body is 8 to 1 inches, and the weight is about 9 ounces. The skin is much firmer, and seba- ceous matter appears on its surface in small areas. The small intestine contains meconium. The umbilicus is some distance above the pubes. 6. At the end of the sixth month the average length is about 12 inches. The weight now is ver}'^ variable, but is in the neighborhood of 1 pound. Eyelashes and eyebrows have begun to appear, and the skin has become darker and firmer. The testicles or ovaries are still in the abdominal cavity. According to some, a child born at this period is viable. 7. At the end of the seventh month the foetus is from 12 to 15 inches long and weighs from 2| to 4'j pounds. The eyelids, which have been closed since the fourth month, now open. The skin is firmer and lighter in color than at the end of the preceding month, and is covered with sebaceous matter. The testicles have descended to the inguinal ring, and may have entered the canal. This is probably the earliest period at which the child can be born with a reasonable chance of surviving. 8. At the end of the eighth month the foetus is from ] 5 to 1 8 inches long and weighs from 4| to 5^ pounds. The nails have reached the finger-tips and the testicles are in the scrotum. 9. At the ninth month, or full term, the foetus weighs, on an average, 6j to 7 pounds, and measures from 18 to 22 inches in length. The cellu- lar tissue is tilled with fat, giving the child a roundness and plumpness which is not observed before term. The hair is fairly abundant and long, and the skin is quite firm, and paler even than at the eighth month. What is the " vernix caseosa " ? It is a greasy, sebaceous deposit covering the entire foetus, and making its appearance first about the sixth month. It consists of matter secreted by the cutaneous glands mixed with dead epithelium. It is alwa3^s more abundant in the axillae and groins, and is said to be of service as a lubri- cant during labor. THE FCETAL. HEAD. Give a description of the foetal head at full term. The head at full term is the hardest and largest part of the foetus, is oval or egg-shaped, and is divided into two parts, face and cranium. The face is composed of fourteen bones, two being single and six double. The cranium, the most important part of the foetus from an obstet- rical point of view, is composed of eight bones — a frontal, occii)ital, eth- moid and sphenoid, two parietal, and two temporal. In the adult these bones are firmly united, wliilu in the foetus they are only so at the base of the skull, being separated at the vc^rtex or vault by membranous intervals, allowing of considerable overlapping during labor (Fig. 9). There are five sutures: (1) the coronal, which separates the frontal from the two parietal bones ; (2) the sagittal, or great suture, running i'rom the root of the nose backward to the lambdoid suture : this sep- THE FGETAL HEAD. 33 Fig. 9. arates the two parietal bones and crosses the coronal suture; (3) the lambdoid (Greek lambda, A), which separates the occipital from the parietal bones : its apex is at the posterior extremity of the sagittal ; (4) and (5) the temporal or squamous sutures, whose names indicate their positions, are un- important, as they cannot be reached during labor. Besides the sutures are two Ibntanelles, an anterior and posterior. The anterior fonta- nelle, or bregma, is the larger of the two. It is diamond-shaped, formed by the crossing of the coronal and sagittal sutures, and has four borders and four angles. Its bounda- ries are the frontal bone anteriorly and the two parietals posteriorly. The posterior or smaller fontanelle is formed by the junction of the sagittal and lambdoid sutures. It is triangular in shape, and ossifies rapidly after birth. Its boundaries are anteriorly the two parietal bones, and posteriorly the occipital. What are the diameters of the foetal skull ? Showing Fontanelles and Su- tures at Crown of Head; A,Ii, biparietal diameter. 1. The longitudinal diameters are- FiG. 10. occipito-mental, 5.4 inches, from the occipital protuberance to the chin; occipito-frontal, 4.6 inches, from the occipital pro- tuberance to the root of nose ; suboccipito - bregmatic, 3.8 inches, from midway between the occipital protuberance and foramen magnum to the centre of the anterior fontanelle. 2. The vertical diameters are — the mento-bregmatic, 4.4 inches, from the chin to the centre of the anterior fonta- nelle ; the trachelo-bregmatic, 3.8 inches, from the bregma to the anterior part of the for- amen magnum. 3. The transverse diameters are — the biparietal, 3.8 inches, from one parietal tuberosity to the other; the bitemporal, 3.2 inches, from the root of one zygoma to the corresponding point on the opposite side ; the bimastoid, 3 inches, from one mastoid process to the other. (These figures are taken from Charpentier, vol. i. pp. 232, 233.) 3— Obs. 1-2, occipito-frontal; 3-4, occipito-mental; 5-6, trachelo-bregmatic; 7-8, frouto-mental. 34 PREGNANCY. NUTRITION OF THE FCE3TUS. How does the child receive its nutrition in utero ? Before the formation of the allantois and umbilical vesicle the ovum derives its nourishment from the cells that form the discus proligerus ; then by the albuminous material covering it. After reaching the uterus the allantois and umbilical vesicle supply it with nourishment until the placenta is formed. As soon as the placenta is formed the foetal nutrition is fully estab- lished, as it acts as an organ of absorption by which nutritious material is carried from the blood of the mother to the foetus. This is proven by the fact that when the placental circulation is interfered with to any great extent the foetus dies. How is respiration carried on in utero ? Before the placenta is formed it is possible that there is no respi- ration, and if there is, the mode in which it is carried on is unknown. After the formation of the placenta by the contact of its vessels with those of the mother, an interchange of gases takes place, by which the carbonic acid of the foetus is given up and oxygen is absorbed. What secretions are carried on in the uterus ? The skin and sebaceous glands secrete the vernix easeosa, the liver secretes bile, the intestines secrete mucus, and the kidneys urine. Describe the foetal circulation. To thoroughly understand the foetal circulation the student must bear in mind the fact that the vascular system differs materially from that in the adult in several respects. The chief differences in the heart are the direct communication between the right and left auricle and the large size of the Eustachian valve. The auricles are connected by a small oval opening covered by a fold which acts as a valve, allowing the blood to pass only from the right to the left auricle. This opening is called the "foramen ovale." The Eustachian valve, passing from the inferior vena cava on to the wall of the right auricle, directs the blood through the foramen ovale into the left auricle. The peculiarities in the arterial system are the communication be- tween the pulmonary artery and descending part of the arch of the aorta by a tube half an inch in length, called the "ductus arteriosus," and the presence of the hypogastric or umbilical arteries, which arise from the internal iliacs, ascend along the sides ol' the bladder, and, pass- ing out of the abdomen at the umbilicus, are continued along the cord to the placenta. The venous system has a communication between the placenta and portal vein through the umbilical vein, and with the inferior vena cava by the "ductus venosus." The vessels in tlu; j)lac('nta lie in close con- tact with the maternal vessels, the walls of Ixithhere being very thin. Oxygen passes from the arteries of the mother into the veins of the NUTRTTIOX OF THE FGETUS. 35 placenta, and CO2 is given up bj^ the latter to the former. Thus the oxygenated blood passes along the cord in the umbilical vein through the umbilicus and to the under surface of the liver. Part here is dis- tributed to this organ, and part passes through the ductus venosus to the inferior vena cava. Thus some of the blood enters the inferior vena cava directly by the ductus venosus, but the greater part passes through the liver to enter that vessel by the hepatic veins. It is thus that the liver is unusually large at an early period of foetal life. The blood from the lower extremities also enters the inferior vena cava, and this mixed blood passes into the right auricle, where most of it, guided by the Eustachian valve, is directed through the foramen ovale into the left auricle. From this it enters the left ventricle, and from the left ven- tricle into the aorta, by which it is distributed mainly to the head and upper extremities, a very small quantity entering the descending aorta. From the head and upper extremities the blood is returned through the superior vena cava to the right auricle : from this it passes into the right ventricle, and from the right ventricle through the pulmonary artery into the ductus arteriosus, and through this into the descending aorta. A small portion of this impure blood goes to the lower extrem- ities, but the greater amount passes into the umbilical arteries to be car- ried to the placenta. What changes occur in the foetal circulation at birth? As soon as the child is born it cries. This inflates the lungs, and con- sequently dilates the pulmonary arteries. The blood now passes in large quantities from the right ventricle into the pulmonary artery, and thence through the lungs, where it becomes arterialized, and is returned by the pulmonary veins to the left auricle. The ductus arteriosus, as soon as the child respires, contracts, and becomes completely closed in from four, to ten daj^s, remaining as a fibrous cord. On account of an adhesion of the valve of the foramen ovale this opening closes. By the tenth day after birth it is usually closed, though in some cases it remains pervious, giving rise to a cyanotic condition of the child. The umbilical arteries between the fundus of the bladder and the umbilicalis become oblite- rated, and remain as fibrous cords. The vein and ductus venosus are completely obliterated a few days after birth, the former becoming one of the ligaments of the liver. What is the attitude of the full-term child in utero ? The body is arched forward, head flexed upon the chest, arms pressed tightly against the sides of the chest, with the forearms flexed and crossed in front. The thighs are flexed on the pelvis and the legs on the thighs. The feet are turned in, inverted, and crossed. In the vast majority of cases the upper extremity, or head, lies in the lower segment of the uterus, while the lower extremity, or breech, lies in the fundus. Motility or motion of the foetus begins as early as the tenth or twelfth week, but the mother is not conscious of the early movements. 36 PREGNANCY. PHENOMENA OF PREGNANCY. What changes occur during gestation in the pelvis? No changes occur in the bones of the pelvis, but marked aherations in the articulations take place as gestation advances. The interarticular fibro-cartilages imbibe a serous fluid, which softens and relaxes them, so that they allow of some slight separation during the passage of the foetus through the pelvis. This is more marked in the pubic joints. What changes occur during gestation in the vulva? As the end of pregnancy approaches the labia majora become oedem- atous and pigmented, and may contain varices. The nymphas become moist, more freely lubricated, and hyperaemic. The whole mucous membrane of the vulva acquires a dark-red color. What changes occur during gestation in the vagina? It is growing larger for the passage of the head. It begins to lengthen between the third and fourth month on account of the rising of the uterus, but becomes shorter when the organ descends and the foetus "engages." It acquires a violet color and its secretions increase. A purely vaginal leucorrhoea may occur during the first few months of pregnancy. This is perfectly physiological. What changes occur during gestation in the uterus? 1. Changes in Volume. — As soon as the ovum reaches the uterus that organ begins to grow. During the first half of pregnancy it is in active growth, but later it becomes more a distension, due to the pressure of the developing foetus. According to Cazeaux, the uterus at the ninth inonth of pregnancy measures 13.6 inches in its vertical diameter, 9.36 inches in its transverse, and 8.9 inches in its antero-posterior diameter, and weighs nearly 30 ounces. The increase in volume is always at the expense of the fundus and body, as the cervix is not affected at all. ^ 2. Chauf/es in Form. — The form varies with the presentation, posi- tion, and the number of children. If a vertex or breech, it changes from a triangular shape to that of a flattened spheroid from the fif'th to tlie sixth month, and from the sixth to the ninth month it becomes ovoidal or egg-shaped, with the smaller end down. The position of the fundus at the different months varies somewhat, but averages about as given below: At the third month the fundus can just be appreciated above the pubes ; at the fourth month the fundus is about 2] finger- breadths above the symphysis; at the fifth month the fundus is slightly more than midway between the symphysis and umbilicus ; at the sixth month the fundus is even with the umbilicus ; at the seventh month it is nearly 3 finger-breadths above the umbilicus; at the eighth month it is nearly to the ensiform a])))en(lix; aljout the middle of the ninth month it has reached the ensiform appendix, and a week or ten days PHENOMENA OF PREGNANCY. 37 before labor begins it sinks somewhat into the pelvic cavity. This is called "the falling of the uterus." 3. Changes in Consistency. — Instead of being hard and fibrous, as in virgins, it gradually becomes soft and elastic, so that it moulds itself about the foetus, and through its walls can readily be felt the different portions of the child. 4. Changes in Direction. — The uterus changes its direction continually according to the position taken by the woman, until it has risen well out of the pelvis, when its tendency is to lie forward on the abdominal wall. This is in reality an anteversion. There is also a so-called ' ' lateral ob- hquity " of the uterus. The cause of this is unknown, but in most cases it bends to the right side. 5. Changes in its Relations to the Surrounding Organs. — ^While in the virgin the uterus lies between and in relation with the bladder (ante- riorly) and rectum (posteriorly), at full term nearly the entire organ lies against the anterior abdominal wall, only a very small portion touching the posterior surface of the bladder. Posteriorly it is in relation with the rectum and the iliac vessels. 6. Changes in Structure. — We find in the peritoneal coat a simple hypertrophy and a distension as the uterus increases in size. This coat does not become thinned out. In the muscular layer marked alterations take place. The previously small fibres become greatly increased in size in all directions, but especially so in length. There is also a development of new unstriped muscular fibres and of connective tissue.* 7. The Power of Contraction. — Painless,, intermittent contractions constantly occur after the third month. They aid in keeping the foetus in position and help to keep the blood in circulation. 8. Changes in the Uterine Vessels. — As the organ increases in size the arteries and veins grow very large ; at the same time new vessels are formed. 9. The changes in the mucous membrane and formation of the decidua were given on page 27. What changes occur during gestation in the cervix? The first change which occurs in the cervix is a softening, beginning at the OS externum and gradually passing upward, until by the eighth month the entire cervix is soft and ready to dilate, allowing the present- ing part of the child to descend and rest upon the external os. Toward the end of pregnancy the os externum usually, though not always, be- comes patulous, and will admit the tip of the examining finger. In multiparee (women who have borne children) this is always the case ; while the cervix is invariably more or less torn during the birth of the first child, previous to which event such patulency is rare. ■'•■ For a more complete description of the muscular fibres of the uterus during gestation the student is referred to the Cydopsedia of Obstetrics and Gynecology, by Charpentier, vol. i. p. 136. 38 PREGNANCY. What changes occur during gestation in the ovaries, tubes, and ligaments ? The ovaries and tubes rise in the abdominal cavity and become hyper- trophied. Ovulation ceases. The broad and round ligaments increase in size and rise with the growtli of the uterus. What changes occur during gestation in the mammary glands? Soon after impregnation has occurred the breasts begin to enlarge and the veins become more prominent. The areola in brunettes assumes a dark-brown color, in blonds only moderately so, and a few small tubercles appear in the areola. These are called the " tubercles of Montgomery." Around the primary or true areola small dark spots are seen w^hieh con- stitute the so-called secondary areola. Toward the end of pregnancy a few drops of a serous fluid can be squeezed from the nipple : this is the colostrum. What changes occur during gestation in the cutaneous system? Here we find pigmentation occurring in blotches over different parts of the body, and frequently on the face. These usually, but not always, disappear. The labia majora become very dark in most cases, and run- ning ui) the abdomen in the median line from the pubes to the umbilicus is a brown line. As a rule, the pigment is deposited around the umbili- cus, and then the line extends on up the abdomen to the ensiform ap- pendix. In the iliac regions reddish-purple striae are seen. These are ecchymoses caused by tearing apart the small muscular fibres from the rapid distension of the abdominal wall. After labor they acquire a white color, and always remain in the abdominal wall as cicatricial or scar tissue. What changes occur during gestation in the blood? There is an increase in the quantity of water and fibrin, and a decrease in the amount of albumin, iron, and excrement it ious substances. There is also a decrease in the number of red corpuscles. These changes are more marked aftei tae sixth month. The heart becomes hypertrophied, because there is more force needed. The hypertroj^hy is entirely in the left ventricle. Its weight is increased from one-fifth to one-fourth. After childbirth the heart undergoes a retrograde action and regains its normal size. There is an increased tension in the arteries and an en- largement of the superficial blood-vessels, especially of the thighs. What changes occur during gestation in the respiratory appa- ratus ? During pregnancy the chest becomes broader, the antero-posterior and vertical diameters are diminished, and there is a tendency to dyspnoea on the slightest exertion. SIGNS, SYMPTOMS, AND DIAGNOSIS OF PREGNANCY. 39 What changes occur during gestation in the digestive appa- ratus ? The digestive organs are alwaj^s crowded out of their normal position. Pressure on the rectum causes constipation, and hemorrhoids may result. The crowding upward of the stomach may cause vomiting. What changes occur during gestation in the urinary organs ? There are compression and displacement of the bladder, causing an irritability, so that after the sixth or seventh month a pregnant woman is only able to retain her urine for a very short time. A cystitis may also be set up. The urethra is usually displaced, and the kidneys are pressed upon, sometimes enough to cause a congestion which at times results in an albummuria. The urine also shows marked changes, there being an increase in the water, the chlorides, and carbonates, and a de- crease in the phosphates, sulphates, urea, and uric acid. "Kiestein" is almost always found in the urine of a pregnant woman. This is a dejwsit seen when the urine has stood for some time, and it is not always a sure sign of pregnancy, as has been supposed. What changes occur during gestation in the osseous system ? Changes have been noted. These consist in deposits of bone between the_ internal table of the cranial bones and the dura mater. These de- posits are called osteophytes. What changes occur during gestation in the nervous system ? Some changes almost invariably occur. Neuralgic pains over different parts of the body, toothache, and perverted sense of taste or smell are frequently observed. SIGNS, SYMPTOMS, AND DIAGNOSIS OF PREGNANCY. Name the symptoms of pregnancy as nearly as possible in the order in which they occur, including a few points in dia- gnosis. 1st. Suppression of the Menses. — If a woman in perfect health, who has been menstruating regularly, suddenly ceases to do so, with no dis- turbances from it, she is in all probability pregnant. There are many causes for amenorrhoea, but as a rule disagreeable symptoms accompany this malady. On the other hand, women occasionally menstruate regu- larly for several months after impregnation has taken place, and cases have been reported where this function was carried on throughout ges- tation. Then, again, pregnancy has occurred when the function was absent, as during lactation. 2d. Sympathetic Nervous Disturhances. — Some sympathetic disturb- ances constantly occur in most pregnant women. These are apt to be more marked in highlj' neurotic patients or those of a nervous temper- ament. Among them are found itching, tingling, or ' ' peculiar sensa- 40 PREGNANCY. tions" in the breasts, and neuralgic pains over various parts of the body, most frequentl}^ in the face. There maj' be toothache, witli no destructive changes in the teeth, and often the woman who naturally is of a very amiable disposition becomes sensitive, morose, irritable, or despondent. Occasionally a marked tendency to frequent attacks of syncope is developed, but most marked of all are the digestive disturb- ances. There may be a capricious appetite, with longings for the most peculiar articles as food, such as slate-pencils, plaster, chalk, charcoal, etc. But of greater frequency are the nausea and vomiting. This occurs usually on rising in the morning; hence it has been called "morning sickness. ' ' It may be seen soon after impregnation has occurred, but as a rule not until the middle or end of the second month. The cause of this morning sickness has been disputed, but the generally received oi^inion now is that it is purely a reflex disturbance, due to the irritation of the uterine nerves by the pressure of the growing muscular fibres upon them. 3d. Glandular Changes. — Those occurring in the breast and kidney have already been described (pp. 38 and 39). There is one more which deserves mention : this is the activity of the salivary glands. Occasion- ally very severe and annoying ptyalism is seen. This usually ceases spontaneously early in pregnancy. 4th. Other digestive disturbances, as flatulency, heartburn, consti- pation, or sometimes diarrhoea, may occur. 5th. Rrfifonis of rui)ture of the tube arc those of extreme collapse, and with this may be associated severe alxloniinal paiiis, pallor, cold ex- tremities, a small, thready, and raj)id puls(;; vomiting, and possibly coma, accompanied by ''air hunger" and restlessness, may be seen, TUBAL. 59 followed bj' death almost immediatelj' ; or these sj^mptoms may not be so marked, and the patient rallies onl}^ to develop a violent general peri- tonitis, which results in death. How should a tubal pregnancy be treated? If" the case is seen before rupture has taken place, there are several methods of treatment which have been pursued with varied success. One is to destroy" the foetus. This has been done by means of the faradic current, which may be administered ten or fifteen minutes daily for a week or two. Tf the tension is removed and the cyst ceases to en- large, it may be known that the child is dead. Then there is hope that it may remain inert in the tube. Another method of accomplishing the same end is the use of the galvanic current, the negative electrode being introduced into the vagina and pressed up against the tumor, while the positive is placed over the abdomen. Morphine and strychnine have also been injected into the sac to destroy the child, and with success in some instances. Probably the most modern and successful treatment is to do a laparotom^^ and remove the tube. If rujDture has taken place, the only rational procedure is to stimulate the patient and perform a laparotomy, removing the blood, foetus, and tube. Describe the course, symptoms, and treatment of an abdominal pregnancy. This form of extra-uterine pregnancy generally goes to fall term, while the tubal variety never does. The placenta forms on the peritoneum and adhesions are usually set up. The s^'mpathetic disturbances met with in a normal pregnancy are all present. Menstruation may cease, but usually this is not the case, or if it does it ceases only for a short time ; and it may be regular throughout. At times conception may occur again, and the woman bear a child to term in the uterus. Infrecjuent colicky pains are met with, but are not usually as severe as in the tubal variety. On examining the uterus it will be found but shghtly enlarged, though the cervix is soft as in a normal pregnancy. The introduction of a sound shows the uterus to be empty. The foetal heart-sounds will be present and very loud. Palpation reveals the presence of the small parts of the child just beneath the hand. These cases may set up a peritonitis which re- sults in the death of the mother, or they may go on to full term, giving no real marked symptoms at any time. In the latter case a pseudo-labor occurs. Regular uterine contractions take place, lasting for a variable length of time, and the foetus dies. When this occurs a retrograde action begins : the breasts and uterus atrophy, as also do the foetus and pla- centa. The liquor amnii may become absorbed, and the coverings of the foetus are clearly adherent to it, or maceration of the child may occur. Occasionally in the former cases the foetus is carried for years, and even a long lifetime, without causing any symptoms. As a rule, putrefaction results, and a peritonitis or septicaemia is set up, or a secondary' inflam- mation takes place and the foetus is discharged piecemeal through the 60 MULTIPLE PREGNANCY. abdominal wall, vagina, bowel, or bladder, most frequently through the abdominal wall. Treatment. — If the diagnosis has been made certain, the treatment resolves itself into one of two courses : 1. Primary Laparotomy. — If done at all, this should be done when the child is at full term. The statistics in these cases are not at all favor- able, though some good results have been obtained. It maj^ be justifiable in some cases, and when it is done it is with the hope that adhesions may be found between the peritoneum and cyst. The placenta should not be removed, but left to discharge through the wound, a portion of which is left open. If no adhesions are found, the peritoneum must be stitched to the abdominal wall. Cut the cord as near the placenta as possible. The operation is almost invariably followed by septicaemia, but this may be of such a mild form that recovery will take place. 2. Secondary Laparotomy. — If this is decided upon either through choice or necessity, an incision is to be made where the mass points, whether this be through the abdominal wall, vagina, or rectum, and afterward the sac is washed out frequently with some antiseptic solution. Some have recommended the opening of the cyst by caustics when there is reason to believe that adhesions are not present. What is "missed labor"? This term is given to a class of extremely rare cases of utero-gestation in which the foetus is retained in the uterus for a variable length of time beyond term. Labor-pains begin and cease, or may never come on at all; the foetus dies and becomes decomposed, setting up a peritonitis, or it is expelled in pieces ; or, as in abdominal pregnancies, cases are re- corded where decomposition has not occurred, and the foetus has re- mained in the uterus for years, causing no untoward symptoms. The cause or causes of this occurrence are not well understood. MULTIPLE PREGNANCY. What can you say of the frequency of multiple pregnancies ? This varies considerably in different countries and among different races. Statistics have shown it to occur most frequently in Russia, where the proportion of twin to single gestations is about 1 to 50 ; how- ever, the average is from 1 in 80 to 1 in 90 pregnancies. State the causes of multiple pregnancies. They are three in number: (J) Two Graafian follicles mature simul- taneously, and each expels an ovule which becomes impregnated. They may botli come from the same ovary or one from each. (2) One Graaf- ian follicle containing two mature ova which become simultaneously im- pregnated. This is a double-yelked egg, as it were. (3) A single fol- licle, a single ovum, but two nuclei. SUPERFCETATION AND SUPERFECUNDATION. 61 In twin pregnancies are the children likely to be of the same sex? The most frequent combination is a male and female ; the next in frequency is two females ; and the least frequent two males. How are the placentae and membranes arranged in twin gesta- tions ? (1) When two ova become impregnated, each one develops independ- ently, and the result is two separate chorions, two amnions, two placentae, and two cords. Occasionally it happens that the placentae lie very close together, and eventually unite, but a thin line of union can invariably be seen. (2) A single Grraafian follicle, but two ovules. In this case there are two amnions, but only a single chorion. The placentas are usually united, and from this come two cords, (3) One ovule with two nuclei. In these cases there is a single am- nion, a single chorion, and one placenta with two cords. The vessels in these instances are apt to anastomose in the placenta. SUPERFCETATION AND SUPERFEOUNDATION. What is superfcetation ? By this term is meant the impregnation of a second ovule when the uterus already contains one impregnated ovum. This must occur very early in pregnancy, else it is called superfecundation. The fact that it is possible is proven by the occurrence of twins of different nationalities or races being born to one woman. What is superfecundation ? Superfecundation means the impregnation of a second ovule in a uterus containing an ovum somewhat developed. The possibility of this occurrence is proven in two ways: (1) By the fact that in some twin pregnancies one child is apparently at full term, while the other is seem- ingly premature. However, this is not a very good reason, as we know that the growth of two children in utero may not be equally rapid. One seems to take more of the nourishment, as it were. (2) A full-term child is born to a woman, and in a few months she gives birth to another, apparently mature, foetus. DISEASES OF THE OVUM, FCETUS, AND DEOIDUA. What pathological conditions of the decidua are met with ? Acute inflammations are occasionally seen accompanying the infectious diseases. These almost invariably lead to abortion, and are not nearly as frequent as is the chronic condition of endometritis. There are three forms : (1) Chronic Diffuse Endometritis^ which consists in the formation of 62 DISEASES OF THE OVUM, FCETUS, AND DECIDUA. a jiew connective tissue, making a much-thickened decidua if the preg- nancy continues. It very frequently happens that the endometritis ex- ists when impregnation occurs, and in these cases abortion will be very apt to result at an early stage. (2) Polypoid Endometritis. — In these cases there is, besides the thick- ening of the mucous membrane, a growth upon its surface of small, smooth bodies, varying greatly in size and number, called polypoids. Pregnancy may go on to term, and the condition be discovered only after labor, or the growths may be so abundant as to interfere with the nutri- tion of the foetus, causing its death, and abortion results, (3) Catarrhal Endometritis or Hydrorrhoea Gravidarum (?).^ — This is the collection of an aqueous fluid somewhere in the uterine cavity and its discharge by the vagina. The cause is unknown. Many believe it to be a rapid secretion from the uterine glands, and for this reason it has been classed with the forms of endometritis. If this be the case, the fluid collects between the decidua and chorion. Some think the accu- mulation is between the chorion and amnion ; others, that it lies in a sac or cyst between the two membranes. The diagnosis of this condition can only be made from a history of repeated watery discharges, no uterine contractions, and a tightly-closed OS. Treatment is not called for, as neither the pregnancy nor the health of the mother or child is in any way interfered with. THE PLACENTA. Describe placentitis. This pathological condition may be caused by disease of the decidua or of the chrijnic villi. The result is a growth of new connective tissue and vessels, which causes a marked atrophy of the placenta. IMany do not admit that this is an inflammatory disease, but consider it a trans- formation or organization of blood-clots which have formed in the placenta. What other morbid conditions may be found in the placenta? Calcareous deposits are sometimes met with. Tliese vary in size and nunijjer. Occasionally but a few small areas are observed, while in other cases large spots are formed, covering nearly half the maternal surfac-e. Fatty degeneration, which occurs in yellowish -white masses niixed with fibrous tissue, is of quite frequent occurrence. The effect of both the above ui)on the foetus varies greatly according to the extent of the change. Some have thought the latter to be simply a physiological change occurring at term. What alterations in the shape of the placenta may be found? Though usually oval, the i)lacenta may be round or even croscentic in shape. Then there may be formed one or several patches of placental THE CORD. — THE AMNION. 60 tissue entirely separated from the placenta. These are called " placentae succenturiatae. " The}^ are of importance onl}- from the fact that they may remain in the uterus after the placenta is expressed, and thus give rise to hemorrhage, or become decomposed, setting up a septicaemia. THE CORD. What can you say of the pathological conditions of the cord ? Unusually long cords are sometimes met with, but these give rise to no difficulties during gestation, excepting that they are more apt to be- come knotted. Then also there is a greater likelihood of prolapse during labor. Unnaturally short cords are also found. These may cause a pro- longed second stage of labor. Knots of the cord are of infrequent occur- rence, and result from the child in its movements passing through a loop. They are of little practical importance, as they are very rarely tight enough to interfere with the circulation, though cases are recorded where the death of the foetus has resulted from a tight knotting. THE CHORION. Name and describe the only important disease of the chorion. Hydatiform Degeneration or Vesicular Mole. — It is a disease of the chorionic villi, and consists of a cystic degeneration resulting in the forma- tion of small vesicles containing a clear fluid which resembles the liquor amnii. Some believe it to be due to the death of the foetus, others sup- pose it to be caused by syphilis or some other blood disease of the mother. The symptoms are rather obscure, hence the diagnosis is difficult. The increase in the size of the uterus is, as a rule, more rapid than in a normal pregnancy, and no auscultatory signs can be found, nor will it be possible to obtain ballottement. It is usually accompanied by an aqueo- sanguineous discharge, frequently repeated, and perhaps containing small portions of the cysts. Upon the finding of this does a positive diagnosis depend. The treatment consists, as soon as the diagnosis is assured, in imme- diately emptying the uterus. This may be done by the introduction of the fingers into its cavity and removing the mass, or by the use of a curette. In either case an intra-uterine douche must follow. THE AMNION. What is hydramnion ? Hydramnion, or dropsy of the amnion, is an excessive amount of flaid in the amniotic cavity. This disease may be but slightly developed, in which case it gives rise to few symptoms and is of little consequence, but when developed to a marked degree the symptoms are very distress- ing, and often alarming. In many cases the children are stillborn or die 64 DISEASES OF THE OVUM, FCETUS, AND DECIDUA. soon after birth. It does not usually begin before the fifth month, and with the rapidl.y increasing size of the abdomen we are likely to find all the disorders of pregnancy due to a mechanical cause, such as dyspnoea, palpitation, constipation, etc., greatly exaggerated.^ There is usually no difficulty in making a diagnosis. The foetal extrem- ities are felt on palpation only with difficulty, if at all, and the heart- sounds can never be heard distinctly. The abdomen will^ appear large and tense, but the uterine tumor can be mapped out, which is not the case when dropsical effusions in the peritoneal cavity exist. G-enerally the condition requires no treatment. If, however, as occa- sionally happens, the mother's health is endangered, it will be necessary to induce labor. This should be done by puncturint;' the membranes. If labor has begun, three dangers arise from a sudden withdrawal of the fluid : (1 ) A prolapse of the funis ; (2) hemorrhaue from sudden detach- ment of the placenta; (3) syncope, as sometimes hai)pensfrom the rapid withdrawal of fluid from the bladder or the peritoneal or pleural cavities. Thus it is advisable to elevate the hips, that the fluid may pass away more slowly : place the hand tightly against the vulva, introduce only the index finger to the membranes, that the force of the flow may be regulated. Use a small stilette and rupture membranes during an inter- val between the uterine contractions. THE FCETUS. Are the eruptive fevers transmitted from the mother to the foetus ? They all may be, and, although the woman suffering from any of these diseases is likely to abort, it sometimes happens that pregnancy goes on to term. In these cases evidences of i\\Q disease may be found after birth, or labor may come on when the period of viability of the infant is reached, and within a day or two the child be attacked by the disease from which the mother is suffering. From what inflammatory diseases may a foetus in utero suffer? Enteritis, pharyngitis, laryngitis, pleurisy, and i)erit()nitis have all been observed — tlie latter with more frequency, however. It may not be developed until term, when the infant is Ijorn alive and lives for some few hours or days suffering from the disease. Its cavsr^ unless specific, is unknown, but has been attributed to blows on the abdomen, peritonitis, cold, and over-exertion on the part of the mother. What eruptive diseases besides those already mentioned (erup- tive fevers) affect the infant in the uterus ? Si/phif is.— Thla is by far the most frefjucnt disease transmitted by the mother to the foetus. In some cases it cau.ses its death, the mother aborts, and in the child are found evidences of syphilis, or the child may ' MOLES. 65 be born alive, showing specific taint. In still another class of cases an apparently healthy infant is born which in a few weeks develops the disease. These different results are undoubtedly due to the degree of severity of the infection from which the mother is suiFering. When syphilitic children are born alive, they are apt to be small and poorly nourished, and show some form of syphilide, most frequently the pemphigoid. If not found at birth, it will almost invariably develop later. Its seat is on the hands and feet and about the arms. From these points it spreads over the entire body. _ Malarial Poisoning. — Children born in malarial districts are frequently found with enlarged spleens, and cases are related where regular parox- ysms occurred in utero, the frequency varying with the type of the malady. Lead-poisoning and sewer-gas poisoning also afiect the foetus, but as a rule cause abortion. What injuries may the foetus meet with in utero ? Fractures, either from falls or blows received by the mother or from defects of ossification and non-union in the epiphj^ses. Contusions and lacerations are also seen, though rarely. These are the result of injury sustained by the mother. Congenital or Intra-uterine Amputations. — A child may be born with any one or ah of the four extremities absent. It is believed that so- called intra-uterine amputations are caused by constrictions of the extremities by the umbilical cord or bands of false membrane. The latter theory is held by most. MOLES. What are moles ? and what two varieties are seen ? A mole is a fleshy mass of variable size developed in the uterus and receiving its nourishment from this organ. There are two kinds — true and false moles. Describe the true moles.* (1) Hydatid or Vesicular Moles have already been described. (2) Ova J/o/e.§.— These are merely bhghted ova, and often become dis- solved in the liquor amnii and pass away surrounded by blood. On microscopic examination chronic villi may be found. (3) Placentcd 3Ioles.— Thin form is found most frequently after abor- tion. A small portion of the placenta remains in utero, which after a time separates and passes away. Name the classes of false moles.f (1) Sanguineous, which are merely blood-clots. *" All true moles are connected with conception. t False moles have nothing whatever to do with impregnation, and may he found in virgins. 5— Obs, 66 ABORTION, MISCARRIAGE, AND PREMATURE LABOR. (2) Fleshy Moles. — These consist of fibrin, and are simply blood-clots with the serum and coloring matter squeezed out. (3) Decidual Moles. — These are masses of decidual tissue. ABORTION, MISCARRIAGE, AND PREMATURE LABOR. What is abortion or miscarriage ? Abortion or miscarriage consists of the expulsion of the foetus before it is viable. Many consider the period of viability to be the sixth month, others the seventh, so that by some any labor occurring before the seventh month would be called a miscarriage. Up to the end of the third month the ovum is usually expelled entire. After this time the placenta generally comes away after the foetus. What can you say in regard to the frequency of abortion, and is it more common in primiparse than in multiparas ? As an abortion occurring during the early weeks is likely to pass un- noticed, we do not really appreciate the great frequency with which the accident occurs. It has been said that 90 per cent, of the married women who live to reach the menopause have at some time or another aborted. There is much discrepancy of opinion in regard to the fre- quency at different periods of pregnancy ; however, the majority are of the opinion that abortion occurs most frequently between the second and fourth months. It is much more common in multiparae, and is said to be more frequently met with in women who have borne three or four children. How may the causes of abortion be divided ? Name them. I. Maternal; II. Paternal; III. Foetal. I. The maternal causes are — (1) Artificial. — Violent exercise, coitus, hfting heavyweights, cough- ing, vomiting, blows, falls, compression by corsets, the use of a sound, and applications to the cervix. (2) Through the Blood. — Fevers of all kinds, especially the eruptive and those accompanied by high temperature ; syphilis, anaemia, poison of lead, mercury, or sewer-gas, malaria, albuminuria, and the use of medicines. (3) Through the Nenous System. — Shock, convulsions, over-suckling, and many nervous disorders. II. Paternal. — Syphilis and coitus. III. Foetal. — Diseases of the amnion, chorion, placenta, and cord, and anything causing the death of the foetus; placenta praevia. What is the most frequent cause of abortion ? Syphilis produces by far the greatest number of miscarriages, as it may operate through either the father or the mother. What can you say of the mortality resulting from miscarriages ? This depends considerably upon the causes, also somewhat on the ABORTION. SYMPTOMS AND DIAGNOSIS. 67 period of pregnancy. Dangers arise from hemorrhage, local inflam- mation, and septic infection. When the abortion is due to maternal causes or when legitimatel}' done, the mortalitj^ is exceeding]}- small. On the other hand, when criminal!}" done it is very great, as the woman usually places herself in the hands of an inexperienced physician, and very likely keeps on her feet until the pains begin. This, with exposure, makes the mortality as high as 50 per cent. Give the symptoms of abortion ? Early abortions resemble very much a profuse menstruation, and may give rise to no symptoms, or the patient may complain of a sense of ful- ness about the thighs, which is described most frequently simply as a feeling of discomfort. On account of the congestion in and around the uterus there will be a tendency to frequent micturition or defecation. The cervix will be soft and patulous, and possibly the os slightly dilated. When the accident occurs later in pregnancy, there are tico constant symptoms, and their presence, with a history of the case, makes the diagnosis easy. These are _?9ai;i and hemorrhage. The latter occurs first, and is a necessity ; the former is due to uterine contractions. Oc- casionally these may be preceded by a feeling of malaise, headache, cold- ness of the extremities, and a slight rise of temperature, but these symptoms are vague and unreliable. How would you make a diagnosis of a threatened abortion ? A history of the stoppage of menstruation for only one period per- haps, associated with the early signs of pregnancy, a hemorrhage from the uterus, and possibly some pain, would justify one in concluding that abortion was threatened. After the diagnosis of pregnancy is certain the difficulty in recognizing an impending miscarriage is slight. There is a sanguineous discharge, and there maj^ be pain. On examination the uterus is found Ioav, the cervix patulous, the os is perhaps dilated, and the vaginal vault feels tense as though it were on the stretch. How would you make a diagnosis of inevitable abortion ? Unfortunately, the diagnosis of these cases is extremely difficult — un- fortunately, for when an impending abortion becomes inevitable the treatment is materialh" different. If the hemorrhage be free and per- sistent, if there be considerable pain, and on examination the os is found dilated, abortion will usuaUy occur. However, in spite of all this, there are cases where the hemorrhage and pain have ceased, the os has re- tracted, and pregnancy has gone on to full term. The onh- two con- ditions which can be said to render the abortion almost inevitable are the rupture of the membranes and the death of the foetus. Neverthe- less, finding the following conditions present, we maj^ feel pretty sure that abortion is inevitable : viz. severe pain, persistent hemorrhage, and a dilated os. 68 ABORTION, MISCARRIAGE, AND PREMATURE LABOR. How would you make a diagnosis of incomplete abortion ? Ill these cases we get a history of pregnancy, followed by pain, hem- orrhage, and the passage of blood-clots. Upon careful examination the latter are found to contain an ovum considerably advanced, but no pla- centa ; or perhaps some shreds of tissue and membrane are found. The OS will be dilated and the hemorrhage continuing. Passing the finger into the cavity of the uterus, we feel shreds of membrane adherent to its inner surface or a portion of the placenta or perhaps the whole of it. If this is discovered the diagnosis is made certain. How would you make a diagnosis of complete abortion ? When the abortion has been complete the hemorrhage ceases, the uterus contracts firmly, the os closes, and the pain ceases. What is the treatment of the different forms of abortion ? In a case where repeated abortions occur look for a cause. If the patient be syphilitic, treat this condition from the beginning of her pregnancy. Give her Red iodide of mercury, gr. ^ ; Iodide of potash, gr. x. Sig. T. I. d. The iodide of potash may be run up to gr. xx or 3ss, L i d. , without injury. Another good treatment is by inunctions of the oleate of mercury. Where no specific cause is present, but the abortions occur time after time, keep the patient in for the few days during which she should menstruate, and allow her to take no exercise for several days before a!i(i succeeding this time. Do not allow her to have intercourse during the first four to six months, at any rate. Guard against nervous shock, extreme physical exercise, or anything that might irritate or congest the uterus. If a displacement of the uterus is present, restore it to its nat- ural position, and keep it in place by a suitable pessary until its increas- ing size prevents it again becoming displaced. Diseases of the uterus and tubes must be treated before imi)regnation has occurred. Two principles are to be observed in the treatment of all cases of threatened aljortion, unless from a very foul-smelling discharge we know tiie foetus is dead, in which case it should come away. These are abso- lute rest, both mental and physical, and the administration of drugs which will allay nervous sensibility and weaken muscular action. The first is obtained by placing the patient in bed in a darkened room ; the second, by giving opium, chloral, and the bromides. Opium may be ad- ministered hy the mouth, by the rectum, or hypodermically. A very excellent method of administration is in the form of suppositories given per rectum, bearing in mind the fact that women about to abort as a HEMORRHAGES OF PREGNANCY. 69 rule display a marked tolerance of the drug, so that the dose must be large. With the opium we may combine moderate doses of chloral and the bromides. The fluid extract of viburnum prunifolium in .5j doses has been much used of late, and with some good results. If the bleeding stops and pain ceases, you may feel pretty certain that the emergency has passed. However, the woman should be kept in bed eight or ten days longer and at each succeeding menstrual period. As soon as you feel certain that no hope of checking the abortion remains, the treat- ment must be radically altered. The administration of am^ of the above drugs is absolutely contraindicated. If hemorrhage is free, a tampon must be immediately introduced. The best material for this is sterilized cotton made up in small rolls, and just before their insertion immersed in a solution of bichloride of mercury, 1 : 5000. Use a Sims speculum, and begin to pack closely in the vaginal fornices and in front of the cer- vix. After filling the whole canal apply a T-bandage. This jn^y be al- lowed to remain from eight to twelve hours, and upon its removal the ovum will usually be found to come away with it. If not, give a douche of bichloride, and apply another. If the hemorrhage is slight, it will not be necessary to use a tampon. If the ovum has been passed and the hemorrhage continues, place the woman under the influence of ether, give a vaginal douche, dilate the cervix if it be not already di- lated, and with a dull curette clean out the entire uterine cavity, after- ward irrigating it thoroughly with a solution of carbolic acid, 1 : 100, made up with boiled water. The after-treatment of abortion is exactly similar to that pursued after a normal labor at term. What is a premature labor? It is the expulsion of the child after the period of viability is reached, but before full term. Premature labor is conducted, goes through the same stages, and terminates just as a labor at full term, so that a further description of it here is unnecessary. HEMORRHAGES OF PREGNANCY. What forms of hemorrhage are met with during the first three months of pregnancy ? We have (1) hemorrhage from the healthy mucous membrane of the vagina and the cervical canal. This may be of no moment unless it occurs from the upper zone of the cervix, in which case it will very likely lead to abortion. This form of hemorrhage usually takes place during a menstrual epoch, and leads the woman to believe she is menstruating. It is associated with no pain, and is due to a high arterial tension. The treatment consists in lowering the tension by the administration of iodide of potassium in gr. xx doses, t. i. cL, saline laxatives, and the infusion of digitalis. (2) Hemorrhages associated with ulcerations, erosions, and lacerations of the cervix date back before the pregnancy, but seem to be aggravated 70 HEMORRHAGES OF PREGNANCY. by the hyperoemia due to the pregnant condition. The condition is readily recognized by an examination througli the speculum, and the treatment is purely local, consisting in the api)lication of tincture of ido- dine or persulphate of iron. (3) In hemorrhage occurring with primary cancer of the cervix the cervix has an irregular indurated feel and bleeds freely upon the intro- duction of a speculum. There may also be a foul-smelling discharge. This form of hemorrhage, due to malignant growths, is naturally found rather late in life. If the woman be three months pregnant or less, abor- tion should be induced. If further advanced and the growth be localized and over a small area, it may be removed with the galvanic cautery. This is not likely to produce abortion, though it may. When the disease seems more extensive the question of an immediate h\'sterectomy, or waiting until the child is viable and then doing laparotomy, will arise. During the last six months two kinds of hemorrhage are met with : (1) accidental, and (2) that due to an abnormal implantation of the pla- centa, or placenta praevia. This is also called '"unavoidable hemor- rhage. ' ' Define and give the causes of accidental hemorrhage ? An accidental hemorrhage is that due to the premature detachment of a normally situated placenta. Two forms are met with : in one the blood finds its way between the chorion and decidua and escapes through the cervix : this is called the open form. In the other or concealed form the blood does not escape through the os. but collects within the uterus. The separation of the placenta is, as a rule, only partial, and. although there is usually an exciting cause, it generally occurs in women whose constitution has been undermined, perhaps from some chronic disease. It may be the consequence of general disease, such as scarlet fev^, typhoid or typhus fever, and small-pox ; or of local disease, as acute j'ellow atrophy of the liver, nephritis, etc. In the large majority of cases it is the result of undue exertion, blows, falls, strains, liftinir heavy weights, coughing, etc. It is rarely found in primipara?, and almost invariably only during the last two or three months of pregnancy. Give the symptoms and diagnosis of the open form. There may ))e a history of injury, iullowed. though jierhaps not im- mediately, by a moderate or severe hemorrhage, and probably some pain over a localized portion of the uterus. A vaginal examination reveals the fact of a normal feel to the cervix and lower segment of the uterus, and also that this organ is the source of hemorrhage. This, with the history, makes the diatrnosis easy. Give the symptoms and diagnosis of the concealed form. There are extreme collapse, exhaustion, perhaps syncoi)e. ])allid face, cool or cold extremities, disturbed respiration, and a small, rapid, and feeble pulse. Accompanying these there is excessive pain over some portion of the uterus, and in some cases its seat is marked by a promi- ACCIDENTAL. — PLACENTA PP.^VIA. 71 nence caused by the accumulated blood. The localized pain and the tumor are apt to be present when the placental detachment has been central, and the margins, still remaining adherent, keep the blood con- fined to this small area. If the edge is detached, the blood flows out between the membrane and uterine wall, causing a severe pain from over- distension. Cases are recorded where the blood flows into the foetal sac through a rent in its membranes. What can you say of the prognosis, and how would you treat a case of accidental hemorrhage ? When the blood appears externally the prognosis is not very unfavor- able. However, in the concealed form it is very grave. In all cases it is much worse for the child than for the mother. The infant mortality is about 90 per cent. , while the maternal is about 50 per cent. Hemorrhage from the uterus can only cease by a contraction of its muscu- lar fibres, thus closing the orifices of the open vessels; therefore, im- mediately when a case of accidental hemorrhage is seen, whether the os be dilated or not, rupture the membranes and apply an abdominal binder. This latter acts in two ways : first, it prevents the uterine cavity from fill- ing with blood, and secondly, causes contractions of the organ on account of the irritation from its pressure. If* the hemorrhage now ceases, do nothing more. Labor will usually come on within a few hours, and should be conducted as an ordinary case of late abortion. If the hemor- rhage continues, deliver as rapidly as possible. When the cervix is enough dilated to allow of version being performed, turn and deliver. If not, dilate with Barnes' bags. Should the uterus not contract firmly after the birth of the child, and should hemorrhage continue, give an intra-uterine douche of carbolic acid, 1 : 100, or bichlor., 1 : 8000, at a temperature of 120° F. Compound tincture of iodine, Bj~Oj, may be added to the douche should the hemorrhage persist. Then full doses of ergot must be given, though nevej- until the child is horn. The collapse should be treated by warmth to the surface, alcohol and hot water inter- nally, rectal injections of warm water, and ether or alcohol hypoderm- ically if necessary. The after-treatment, as in all cases of hemorrhage, consists in nutritious diet, good hygenic surroundings, and iron internally. PLACENTA PREVIA. . What is placenta prsevia ? The placenta is " prsevia " when situated in the lower segment of the uterus, so that a portion of it lies partially over or completely covers the internal os uteri. When entirely covering the os it is said to be com- plete or central ; when only partially covering the same, it is called mar- ginal, partial, or incomplete placenta praevia. How frequently does placenta prsevia occur? State the causes. The proportion of cases of placenta prsevia is about 1 in 1000 or 1200 pregnancies. It occurs much more frequently in multiparae than prim- 72 PLACENTA PREVIA. iparse, and is more frequent among the poorer classes. This is ex- plained by the fact that women in the lower wallcs of life are obliged to get up too soon after delivery, leaving the uterus in a condition of sub- involution. It is also more often seen in women who have borne children in rapid succession and whose uteri remain abnormally large. Thus the cause seems to be a large uterus, though disease of the endometrium and uterine contractions occurring soon after conception are also given as causes. Describe the symptoms of placenta praevia. vj>Ax^\ui>A |*>x> n^ Hemorrhage is the one important and characteristic symptoms This may occur during pregnancy or not until labor has begun. The quantity of blood lost may be but small at first, and the hemorrhage is spon- taneously arrested, or within a few days or weeks there will be a recur- rence, and each time, if the patient survive the first loss of blood, the quantity is increased. The blood is bright, and the loss is associated with all the general symptoms of hemorrhage. There is no pain, and the flow may, and usually does, occur without any appreciable cause. It many times takes place during what should have been the menstrual period, and usually not until after the sixth month— frequently a few weeks before, or even during, labor. What is the immediate cause of the hemorrhage and the source of the blood? Various theories have been advanced to explain the cause of the hem- orrhage in placenta praevia. By some it is thought there is a loss of pro- portion between the placenta and uterus, and necessarily a separation occurs. This is said by some to be due to a more rapid development of the uterine wall than of the placental tissue (Cazeaux), while others claim that the placenta itself grows more rapidly than the lower segment of the uterus (Barnes) ; others, again, think the hemorrhage due to causes which give rise to accidental hemorrhages, only that these causes are more apt to operate when the placenta is abnormally situated low down in the uterine cavity. The source of the hemorrhage is the lacerated uterine vessels. A little dribbling may take place from the placenta itself, but thrombi soon form in the mouths of these vessels, closing them. Is the prognosis favorable in placenta prasvia ? and would it ever be justifiable to allow a pregnancy to continue where a dia- gnosis had been made? ^ The piynnoiiis is very grave both for the mother and child, but espe- cially so for the latter. Various authors estimate the maternal mortality at from 9 to 30 per cent., and ibr the child 50 to 75 per cent. The evils to tlie mother are both immediate from the loss of blood, and subse- quently i'rom septic troubles. The great liability to this latter is due to several causes: (1) Infection from manipulations; (2) access of air to DIAGNOSIS AND TREATMENT. 73 tlie uterine sinuses; (3) extreme anaemia from hemorrhage; (4) forma- tion of large thrombi, which decompose. It is never justifiable to allow a pregnane}^ complicated by placenta praevia to continue. How would you diagnose and treat a case of placenta praevia ? The diagnosis may be made first by the sudden occurrence of a hem- orrhage from the uterus with no apparent cause and associated with no pain or irregular contour of the abdomen, and secondl}' by the vaginal examination. Upon the introduction of the finger, if the os be dilated, the placenta may be felt as a soft, boggy mass through which the pre- senting part is only indistinctly appreciated. This can be readily differ- entiated from a blood-clot, which is readily broken down by slight pres- sure of the examining finger. On sweeping the finger about close' to the uterine wall the diagnosis of a, central from a marginal attachment may be ascertained. If the cervix is tightly closed, it will be found to have a boggy, cedematous feel ; a scarcely recognizable presenting part is found ; and, though it be associated with difiiculty, the finger can usually be pushed through the os and the placenta felt. Treatment. — Do not adopt an expectant plan and wait, but proceed at once to deliver the woman. Authorities differ on the subject. 3Iany advise, if the child be not viable and if the hemorrhage be shght, using means to check the hemorrhage and allow the pregnancy to continue. These place the woman on a hard bed, apply ice-cloths to the lower part of the abdomen, give acidulated drinks, and keep her at perfect rest. This might be permissible in a hospital case, where the patient is under close and constant observation, but when not under these surroundings it should never be considered, for a hemorrhage might occur at any time and death result before aid could be summoned. When delivery is decided upon, one of several courses may be adopted : (1) Tamponing the vagina ; (2) rupture of the membranes; (3) separa- tion of or boring through the placenta and doing version ; (4) induction of labor by the introduction of a gum-elastic bougie and by tamponing the vagina. Each individual case will suggest the method to be adopted" If the hemorrhage occurs when labor has begun, and the cervix is dilated sufficiently to allow the introduction of two fingers into the uterus, and if the placental attachment be only marginal, introduce the hand into the vagina, pass the two fingers through the cervix, push the edge of the placenta to one side, rupture the membranes, and by combined manipulation do a podalic version. (The bipolar or Braxton-Hicks method of version will be described later.) Pull down a leg and allow the labor to progress. This half breech acts as an efficient tampon, and will check the hemorrhage. If the attachment be central, push the fingers through the placenta and proceed to pull down a leg as before. If the hemorrhage occurs before the os is dilated or before it is dilated enough to allow the introduction of the two fingers, and if it be severe, introduce a vaginal tampon, and allow it to remain six or eight hours ; then remove. By this time the labor-pains will have begun, and the 74 LABOR. cervix will usuall^y be sufficiently dilated to allow of the version being performed. If not, introduce a flexible bougie, and allow it to remain in the uterus until labor is well under way and the cervix sufficiently dilated to permit a version to be done. If the cervix is not dilated, but the hemorrhage ceases, the introduction of the bougie is indicated with- out tamponing, as this excites uterine contraction. CHAPTER IV. LABOR. PHENOMENA. Define the term "labor," and state the most modern theories as to its cause. Labor is the act by which the foetus and its annexes are expelled from the maternal organism. The causei^ are classified as — (1) determining, and (2) efficient. Among the determining causes may be mentioned fatty degeneration of the decidua which occurs at the end of pregnancy. Through this degeneration and separation the nerves over the interior of the uterus become irritated and excite contraction. Another theory is that the extreme distension of the uterus causes its contractions ; still another has attributed it to an ovarian excitement at a menstrual period; and another to a fatty degeneration in the placenta and an accumulation of carbolic acid in the sinuses. However, no single theory has as yet been advanced which is not open to many objections. The efficient causes are two : contractions of the uterus, aided by con- tractions of the abdominal muscles. What is the character of the uterine contractions and the value of the intermittent pains ? The uterine contractions or labor-pains (for the words are used synon- ymously) begin in the lower part of the back, pass around the abdomen, and at times down the thighs. At first occurring at regular but infre- quent intervals, they gradually become stronger and more irequent until, toward the termination of labor, but a very short interval occurs between the contractions. These contractions are absolutely involuntary, but may be influenced by mental impressions. They may be completely checked for a time or their j)ower lessened by the appearance of a stranger in the room, a sudden surprise, or a disagreeable communication. Each con- traction begins and gradually increases to its maximum intensity ; the uterus becomes tense and rigid, then relaxes, and the pain slowly sub- sides. The contractions are said to pass in a wave from the lower zone PHENOMENA. 75 upward by a peristaltic action, then return downward. And they alter- nate in severity : first, a severe, then a moderate contraction. Nature provides for the intermittence of the pains, for no woman could survive an ordinary labor were the contractions continuous. Nor could the child, for pressure upon it and the narrowing of the utero-pla- cental vessels during a contraction so interfere with the circulation that asphyxia and death would result were they not intermittent. During the intervals the patient regains strength and the uterus returns to its oval shape ; respiration becomes more nearly normal ; the pulse, which has been accelerated during the pain, slows; and there is a general re- laxation of the whole muscular system. What signs or symptoms precede the beginning of labor ? Occasionally there are none, but as a rule a few days before labor begins there is the so-called " falhng of the womb." The inferior seg- ment of the uterus sinks down into the pelvic cavity and the fundus re- cedes from the diaphragm. The woman notices that the waist, which has been continually growing larger, becomes smaller, and respiration is easier. On account of this descent bladder irritability is apt to be more marked, and a very frequent desire to micturate is noticed. (Edema of the lower extremities is likely to be aggravated, and if hemorrhoids be present they become very troublesome. A diarrhoea may occur. A few hours before the uterine contractions begin the mucous discharge from the cervix is more abundant, and may be tinged with blood. This is called the ''show," and, if noticed, is a pretty sure sign that labor is not far oiF. On vaginal examination the lower uterine segment is found lower down in the pelvis, the cervix can no longer be felt, and an ex- cessive mucous secretion is observed. What are false pains? They are the pains which occasionally occur near the approach of labor, and may be mistaken for true labor-pains. They are distinguished from the latter by the fact that they are confined to some portion of the abdomen, are very irregular in frequency and severity, and are not asso- ciated with a dilatation of the os, nor is any " show " present. What are the stages of labor ? The course of a labor from the time the first pain begins until the placenta is born has been divided into three stages. The first begins with the true uterine contractions, and ends when the cervix is com- pletely dilated. _ The second begins with the complete dilatation of the OS, and ends with the birth of the child. The third is the period from the birth of the child to the permanent contraction of the uterus after the delivery of the placenta and membranes. What influence have the pains of the different stages upon the physical condition of the mother ? The pains of the first stage of labor are entirely under the control of 76 LABOR. the sympathetic nervous system, are involuntary, and therefore cause little or no exhaustion of the vitality unless very long continued, and even then the exhaustion is owing to the lack of sleep and rest more than to the pains. However, during the second stage the cerebro-spinal system comes into play along with the sympathetic, and during each contraction the woman strains. Now the exhaustion begins, and a very prolonged second stage may give rise to extreme prostration. Describe the first stage of labor. As the painful uterine contractions commence dilatation of the cervix and OS begins. Usually slight and infrequent in the beginning, the pains gradually increase in severity, frequency, and duration, until, as the os approaches complete dilatation, a very short period intervenes between them, and each contraction is severe enough to call forth a cry or a groan from the mother. During this stage the woman is not confined to the bed, but is sitting up or walking about. The amount of pain experienced varies greatly according to the temperament of the patient. In neurotic women it is generally very great. The dilatation may be accompanied by nausea and vomiting which are of a purely reflex character. Usually the secretion becomes more stained with blood as the dilatation of the external os progresses. This may be due to slight lacerations of the os or to more serious tears of the cervix. As a rule, when the dilatation is nearly or quite complete spontaneous rupture of the amniotic sac takes place, and most of the liquor amnii drains away. If a vaginal examina- tion be made at the beginning of labor, the dilatation will be slight, and both orifices of the cervix may be appreciated, but as labor advances the cervix becomes thinner and thinner until nothing but a thin circular ring can be felt. During a contraction this becomes very hard and protrud- ing : through it can be felt the tense hemispherical bag of waters. It occasionally happens that the amniotic sac ruptures prior to or very soon after the beginning of labor. In this case the labor is called a "dry" one, and is usually much prolonged. Describe the second stage of labor. As soon as the os has become completely dilated and retracts over the presenting part the character of the pains alters materially. With each uterine contraction the patient takes a deep inspiration, and involuntarily grasps with her hands the edge of the bed, the bed-clothes, or the hand of some bystander, and, bracing her feet, strains or bears down. In this way the abdominal muscles are brought into play, and with each contrac- tion the presenting part descends into the pelvis. xVs the head passes the ])elvic outlet the vagina dilates and the perineum begins to streteh. With each contraction, which now becomes stronger and more frequent, the tension of the perineum increases and the vulvar orifice expands, ex- posing to view a part of the head. During the intervals between the pains the elasticity of the i>erincal structures pushes the head })ackward and conceals it from view until the succeeding contraction of the uterus STAGES. 77 occurs. Owinir to this recession and advance the dangers of laceration are diminished, as the parts have an opi)()rtunity to become thoroughly stretched ; and this is carried to a marked degree, owing to their great dilatability. The urethra is pushed upward ; the anterior wall of the rectum bulges, and if fsecal matter be present it is expelled. The crown of the head now protrudes farther, and does not recede in the intervals between the pains, and finally, during the height of a contraction, the head slips over the perineum. The shoulders and remainder of the body are soon expressed, and the birth of the child is followed by a sudden flow of amniotic fluid mixed with blood. The contractions now cease for a time, wdien the third stage of labor begins. Describe the third stage. It occasionally happens that immediately the child is born the placenta follows or is forced out of the uterus into the vagina. However, as a rule, the intermittent uterine contractions cease for a short time after the birth of the child, but soon begin again. The muscular fibres retract in all directions, and the placenta becomes separated and eventually ex- pressed. The maternal vessels are naturally torn by this separation, but, owing to firm, tonic contractions of the walls of the uterus and the forma- tion of coagula in the mouths of the vessels, hemorrhage is prevented. What effects has labor upon the mother? The appetite is lessened or wholly absent. The secretion of urine is increased. The perspiration is increased. The temperature is elevated. Mental disturbances, often to a marked degree and very variable in their character, are sometimes present. What effects has it upon the child? During a uterine contraction it is compressed, the placental circulation is interfered with, the foetal heart beats more slowly, and partial asphyxia results. The head is compressed during its passage through the pelvis, and its shape is altered. Meconium is often discharged from the rectum, and the bladder evacuated during or immediately following the birth of the body. What can you say in regard to the duration of labor ? The duration of labor is influenced by many circumstances referable to both mother and child. Age, civilization, mode of living, multiparity and primiparity, as well as the size and presentation of the child, deter- mine the duration. First labors are almost invariably longer than sub- sequent ones, and in old primiparae they are usually very prolonged. The average duration is said to be from twelve to fifteen hours. In primiparae labor may be lengthened to sixty or seventy hours in excep- tional cases. The ratio between the first and second stages is, roughly speaking, 5 to 1. 78 LABOR. PRESENTATION AND POSITION. What is understood by the words "presentation" and "posi- tion " ? By ' ' presentation ' ' is understood the part of the child which offers itself or presents at the superior strait or inlet of the pelvis. There are three recoirnized presentations, all of which are subdivided : (1) those of the head, which are most frequent ; (2) those of the pelvic extreraitj^, next in frequency ; (3) those of the trunk, which are the least frequent. By the term ''position " is understood the relation of the presenting part to, certain fixed points upon, and the diameters of, the superior strait of the pelvis. Why does the head present most frequently ? The head presents in over 90 per cent, of all cases. Explanations for this are numerous, but there are many objections to each. Pajot's law of accommodation is considered one of the best reasons for the great frequency of vertex presentations. It is this : " When one solid body is contained in another, and if the latter is alternately in a state of motion and of repose, and if the surfaces are rounded and smooth, the included body constantly tends to accommodate its shape and dimensions to the shape and capacity of the containing body." The fact that the centre of gravity is situated nearer the head of the foetus, tending to cause this part to lie in the lower segment of the ute- rus, is considered by some the cause. Others consider the reason to lie in the shai)e of the uterus and foetal mass. The large extremities should correspond, and if this is the case the head must lie in the smallest and lowest portion of the womb. MECHANISM IN VERTEX CASES. How many positions of the vertex are there ? Name and de- scribe each. There are four : * (1st) L. 0. A. (Fig. 11). — In this position the occiput is directed toward the front and left side of the mother; the sinciput points pos- teriorly and to the right sacro-iliac joint, and the long diameter of the head lies in the right oblique diameter of the pelvis. (2d) R. 0. A. — In this position the occiput is directed toward the front and right side of the mother, the sincijiut posteriorly and to the left sacro-iliac joint, and the long diameter of the head lies in the left oblique diameter of the i)elvis (Fiir. 12). (3d) 7^. 0. /^.— Tiiis is exactly the reverse of the first. _ The forehead points to the left side of the mother, the occiput to the right sacro-iliac joint, and the long diameter of the head lies in the right oblique diam- eter of the pelvis (Fig. 13). MECHANISM IN VERTEX CASES. 79 (4th) L. 0. P. — This is the reverse of the second position. In it the occiput points to the left sacro-iUac joint, the sinciput to the right side Fig. 11. Fig. 12. L.D.A. R.D.A. of the mother, and the long diameter of the head Hes in the left oblique diameter of the pelvis (Fig. 14). Fig. 13. Fig. 14. R.ap L.O.R Which is the most frequent of the vertex positions? The first position, or L. 0. A. About 70 per cent, of all vertex cases present in this position. The next in frequency is the third, then the second, and the least frequent the fourth. Numerous reasons have been given to account for the greater frequency of the first position, of which the most rational is that the left oblique 80 LABOR. diameter of the pelvis is shorter than the right, position of the rectum. This is owing to the Describe the mechanism of delivery in the first position. For convenience of description the movements are usually divided into stages, though ordinarily these stages gradually run one into another, so that they cannot be made out in actual practice: (1) period of flexion; (2) period of descent or engagement; (3) period of internal rotation of the head ; (4) period of descent and extension ; (5) period of external rotation of the head and internal rotation of the trunk; (6) period of expulsion of the trunk. When labor begins the occiput is at the left ilio-pectineal eminence, and the sinciput at the right sacro-iliac synchondrosis. The back of the child looks forward and to the left side of the mother, and the abdomen backward and to the right. The head is only partially flexed, but as soon as the uterine contractions begin this flexion becomes more marked, and there is substituted for the occipito-frontal diameter (4t inches) the suboccipito bregmatic (31 inches), giving a gain of more than k inch. Fig. 16. Fig. 15. /„,. „ niiiiiiiiM. Extension of the Head. Restitution of the Head. The reas(jn of this flexion is owing to the fact that the vertebral column is not articulated in the centre of the skull, but nearer to tlic oc(Mj)ut, and, meeting equal pressure from below, and the force from above being transmitted through the vertebral column, the sinciput is forced upward. Descent now occurs. The head becomes engaged in the pelvis, and from now on until its birth this movement goes on continually. The important movement of internal rotation now takes place by which the long diam- MECHANISM IN VERTEX CASES. 81 eter of the head becomes adapted to the longest diameter at the outlet of the pelvis. This movement may not occur until the head has reached the perineum and is about to be born. However, it usually takes place higher up, and is due to several causes: First, according to Pajot's law of accommodation (p. 78), the head must accommodate its diameter to the diameter of the maternal pelvis. Secondly, owing to the direction of the inclined planes of the pelvis the occiput is directed forward and the sinciput backward. Thirdly, the perineal influence after the head has reached this body may greatly influence its rotation, if this be not already complete. The head, having now reached the perineum, is born by a process of extension (Fig. 15). The occiput becomes flxed beneath the symphysis pubis and the face sweeps over the perineum. External rotation of the head, or restitution, takes place after extension (Fig. 1 6). The occiput turns toward the thigh of the mother, which correspo^ids to the side of the pelvis which it originally occupied ; in the first position, to the left thigh. The shoulders rotate, so that their long diameter is in the antero-posterior diameter of the pelvic outlet, the anterior or right shoulder becomes fixed under the symphysis, and the left or posterior is born first. The shoulders being born, the body immediately follows. Describe the mechanism of delivery in the second position. In the second position, R. 0. A., the long diameter of the head lies in the left oblique of the pelvis. The movements are exactly the same as in the first position, excepting that the rotation takes place from right to left internally and from left to right externally. Describe the mechanism of delivery in the third position. In the third position, R. 0. P., the occiput is directed backward and to the right sacro-iliac synchondrosis, the forehead forward, and the long diameter of the foetal head lies in the left oblique diameter of the pelvis. The first movement is one of flexion. Then comes descent, which takes place more slowly than in the anterior positions. Rotation now occurs, and is usually prolonged on account of the distance througli which the occiput must pass. It rotates from behind forward, and in this rota- tion naturally turns to lie in the second position before it is completed. Extension,_ restitution, and expulsion of the trunk follow as in the pre- ceding position, restitution taking place so that the occiput points to the right thigh of the mother. Describe the mechanism of delivery in the fourth position. In this position, L. 0. P., the occiput points posteriorly to the left sacro-iliac synchondrosis, and the long diameter of the head lies in the right oblique of the pelvis. _ Flexion takes place, then internal rotation from left to right, during which the head comes to lie in the first position ; extension, restitution, so that the occiput points to the left thigh of the mother, and expulsion now follows. In the third and fourth positions it sometimes happens that flexion 6— Obs. 82 LABOR. does not take place to a sufficient degree, in which case descent occurs without internal rotation. This being the condition of* affairs, the occiput is born over the perineum and the face under the symphysis, not by a process of extension -as in the preceding cases, but by flexion. These are extremely difficult and tedious labors, and will be spoken of more fully later. What is the caput succedaneum ? and how is it formed ? It is an oedematous tumor of variable size developed upon some part of the foetal head during labor. Its situation varies according to the presentation and position, and it is produced by an effusion from the ob- structed venous circulation caused by the pressure upon the head. The swelling occurs on the uncompressed part, and in the first and fourth positions is situated upon the right parietal bone, while in the second and third it is upon the left. In prolonged labors, where the membranes have ruptured early, it is likely to be very large, and may be entirely absent in rapid labors. What alterations take place in the head during labor? It is moulded so that some of the diameters are increased, some de- creased. The occipito-mental and the occipito-frontal are almost always diminished, and the suboccipito-bregmatic may be. This moulding is effected by the overlapping of the bones on account of their incomplete ossification, and by the existence of the sutures and fontanelles. A few days after birth the head regains its normal shape. ABDOMINAL PALPATION. What may be accomplished by abdominal palpation? By abdominal palpation we may discover the position of the fundus of the uterus, the relative amount of liquor amnii, the position and pres- entation of the foetus, and in many cases where abnormalities exist they may be rectified before labor begins. Describe briefly the method of performing palpation. The woman lies on her back on a hard bed. or preferably a table, with her head and shoulders slightly elevated, the legs flexed at the knees and the thighs on the pelvis. The arms should lie extended by the woman's side, and the abdomen exposed from the waist to the pubes. The ac- coucheur stands on the right side of the patient. His hands should be warm, to prevent reflex abdominal muscular contractions. The position of the fundus is first ascertained by j^lacing the hand on the abdomen, immediately above the symphysis, and carrying it upward. Over the uterine tumor marked resistance is encountered, but this ceases above the level of the fundus. We then seek for the presenting part. This is done by placing the hands flatly upon the lateral walls of the ab- donien parallel to the iliac fossne, and slowly depressing them. After having determined the extremity of the foetus which is presenting, we ABDOMINAL PALPATION. 83 seek to find the position of the back by passing the hands, one over the other, ui3ward on each side of the abdominal wall. How is a vertex presentation recognized? By deep downward pressure in the iliac fossae a round, hard, and usually slightly movable mass is felt nearly in the median line. This is the head. If the flexion be marked, it will be noticed that one hand meets with less resistance, and may be depressed more deeply, than the other. This will be upon the side toward which the occiput points, and is due to the ftict that the opposite hand meets with the resistance of the forehead, which on account of the flexion must rise higher out of the pelvis. Passing the hands upward, if the position be either first or sec- ond, the smooth, even, resisting surface of the back is felt on the right or left side extending nearly or quite to the median line, while on the opposite side a non-resisting surface is encountered, and many times some of tlie extremities of the foetus may be distinctly appreciated. If the position be the third or fourth, part of the back can still be felt, but only a small area, and this lying more to the right or left side. Much less resistance is noticed in the median line and on the opposite side, and the small parts are often distinguished over tlie anterior abdomen wall. Where the abdominal muscles are relaxed and palpation made easy, as the hands are passed upward after encountering the head they sink into a slight depression or furrow, the neck, and meet immediately above this the resistance of the shoulder. The breach generally lies in the opposite side of the fundus, from which the occiput points below and Ibrms a rounded though larger and less resisting mass than the head. It may be distinguished from the head by the absence of the furrow spoken of above, and the fact that near it, as a rule, small parts may be felt. How may a breech presentation he recognized by palpation? On depressing the hands in the iliac foss^ we immediately appreciate a different condition than when the head presents. The mass seems broader, less rounded, not so resisting, and, above all, immovable or nearly so. Upon passing upward no furrow is felt, and small parts may even be made out here at the lower segment of the uterus. The back is recognized in the same manner as in normal vertex presentations. AVe then search for the head at the fundus. It almost invariably lies to one side or the other, and may be distinctly felt with its furrow at the neck, and the shoulder lies immediately below. If there be a sufficient quan- tity of liquor amnii — in other words, unless the amount be very much below the normal— by placing the fingers over the head and by a quick movement depressing the abdominal wall, the head is pushed away and returns, striking the fingers with an appreciable shock. This is called cephalic ballottement. This same sensation cannot be gotten with the breech at the fundus. The diagnosis^ of the abdominal presentations and positions by abdom- inal palpation will be spoken of farther along, when these are taken up. 84 LABOR. DIAGNOSIS OF VERTEX PRESENTATIONS. Where is the foetal heart heard most distinctly in the several positions of the vertex ? In the first position the point of maximum intensity of the foetal heart IS a small area situated about midway betv een the umbilicus and the an- tero-superior spine of the ilium on the left side ; in the second position over a corresponding area on the right side ; in the third position, though the point of maximum intensity may be the same as in the second, it is usually found farther around toward the mother\s side. The same may be said of the fourth position, except that it is farther around on the left side, or over the same area as in the first position. In all vertex cases the foetal heart is most distinct at some point hdoic a Une drawn horizontally, so as to divide the uterus into two equal parts. How may the vertex positions he diagnosed by vaginal exami- nation when labor has begun and the cervix is partially dilated? By introducing one, or preferably two, fingers into the vagina and through the cervix, if the membranes are ruptured, they come directly in contact with the parietal bones. Now, by passing backward a narrow membranous interval is felt, which is the sagittal suture. This should be traced by the fingers to determine in which direction it hes. If it passes obliquely from before backward and from the left toward the right, the position must be either the first or the third, but if it passes from right to left, the position will be the second or fourth. The suture is now followed to determine the position of the posterior fontanelle, and, finding this, we know where tne occiput hes. In the two anterior positions, the first and second, the posterior fontanelle is felt anteriorly or nearer the abdomen of the mother, and may be distin- guished from the fact of its being smaller, more triangular-shaped, than the anterior, and running into it the arms of but three sutures are found. These are the sagittal and the two arms of the lambdoid. As a rule, unless the head be very small, the anterior fontanelle cannot be felt, as it lies too high up and too far posteriorly to be reached. This is due to the extreme flexion. In the two posterior positions it is generally pos- sible to feel both fbntanelles. owing to the lack of marked flexion which is usually present in these cases. Here it is necessary to distinguish between the two. and this may be done by feeling the four sutures run- ning into the anterior fontanelles — the sagittal, frontal, and two arms of the coronal. This fontanelle is also much larger than the posterior, and is diamond-shaped. MANAGEMENT OF NATURAL LABOR. What should an obstetrical bag contain? A well-equipped ob.stetrical bag .should contain a stethoscope, a pair of forceps, a set of hydrostatic dilators, a Davidson's syringe, several PREPARATION. 85 flexible rubber catheters and one silver female catheter, a pair of scissors and tape for tying the cord, some small and heavy catgut sutures, several needles, a needle-holder, two glass douche-nozzles, a rubber douche-bag. a hypodermic syringe, and plenty of absorbent cotton. It should also be provided with bottles holding chloroform (5jv or 5vj) ; fluid extract of ergot; pure carbolic acid, 3vj ; a solution of the subsulphate of iron, Jiv ; a small quantity of 3Iagendie's solution of morphine ; a solution of chloral hydrate, gr. x or gr. xv to the drachm ; a solution of ergotin ; ether and brandy for hypodermic use ; and tablets of corrosive sub- limate. In choosing the room for confinement what points should be observed ? It should be large, well ventilated, well lighted, free from sewer-gas or other unwholesome and obnoxious vapors. A room with a southern exposure, containing several windows, is most desirable, on account of the greater abundance of sunlight it aifords. Always, if possible, choose a room containing an open fireplace, and have all unnecessary furniture removed. What can you say in regard to the confinement bed ? Choose a high, narrow cot, and have it situated so that you may get on all sides. It must be away fi'om draughts of air, and in such a posi- tion that good light is secured. The mattress should be firm, smooth, and free from all little irregularities. Over it is placed a rubber pro- tector, and upon this a linen sheet. Under the woman's buttocks a second sheet, folded three or four times, should be placed to absorb the discharges. The coverings over the patient must be so an-anged that they may be easily adjusted or removed if necessary. How should a patient "be prepared for her confinement? If the bowels have not been moved very recently, an enema of one or two pints of warm water and a little soap should be given. The genitals are then to be carefully washed with a solution of bichloride of mercmy, and a warm vaginal douche of the same antiseptic, in the strength of 1 : 5000 or 8000, should be given. An entirely clean set of under- clothing is to be put on, and over this a loose, hght wrapper. What should be ascertained on the first visit to a woman in labor ? First, that everything is in readiness for the birth ; second, that the woman has been properly prepared for her confinement ; third, the presentation and position of the child, the general condition of the woman, and the frequency, character, and strength of the uteriue eon- tractions ; fourth, whether or not the c\iild is living. 86 MANAGEMENT OF NATURAL LABOR. How should the first examination be made ? After tlie pliysician has carefull}' washed and dried his hands he should palpate and auscult the patient's abdomen, and after again re- cleansinir his hands and immersing them for a minute or more in a solu- tion of corrosive sublimate, I : 1000, he should make a careful vaginal examination. If the labor-pains have begun, the lingers must be intro- duced during the interval between the contractions, and should not be withdrawn until the size of the pelvis, the amount of dilatation of the OS, and the presentation of the child have been carefully ascertained. Tliis latter will have been made out on palpation, as will also the posi- tion, but the fjrmer may be confirmed by the vaginal examination. As a rule, the membranes are tense and bulging, owing to which tlie exam- iner is prevented from appreciating the sutures and fontanelles. For this examination the patient should he upon the back. Now, if the presentation be normal, the cervix only slightly dilated, and the patient a primipara, the presence of the physician is unnecessary, and he may with safety leave the woman for an liour or two, but never unless he be within easy reach. Describe the management of the first stage of labor. During this stage the patient should not be confined to the bed, but encouraged to walk about the room or recline in a chair. If the stage be at all prolonged, she must be advised to take food in moderate quan- tities. Beef tea, broths, milk — in fact, any liijht nourishment— should be taken at intervals to prevent exhaustion. A'aiiinal examinations are made only at infrcfiuent intervals, and often enough for the attendant to ascertain the progress of dilatation. The bladder must be carefully watched, and if it becomes distended the catheter j^assed. as a full blad- der retards the labcjr by nearly or completely checking the uterine con- tractions. As the completion of this stage is ai)])roached the pains become more freriuent and severe and their character changes. Each contraction is accompanied by a straining or bearing-down effort, and as a rule the membranes will rupture spontaneously about this time and be fbllinved by a gush of fluid. If the patient has not 3'et lain down, she should be placed upon the bed and a vaLnnal examination now made. If the cervix is found to bo fully dilated, her wrapper must be removed and everything gotten in readiness for the birth. How is the second stage of labor to be managed ? The first thing to ol>serve when the second or jirupulsive stage has been reached is whether or not the membranes are still intact. If so, with the fingers in the vagina we wait until a contraction takes place. Tlu! membranes now become tense, and by sinji)ly jn'c.ssing again.st them with the finger-nail they will usually rupture. If not. by gently .scratch- ing them with the end of a stylet or hair-pin, thoroughly carbolized, the liquor amnii is evacuated. Hot and cold water, ice. the ligature, scissors, and ergot should now be in readiness for use. The position of SECOND STAGE. 87 the patient during the second stage must be left to her selection. In England the established position is upon the left side, with the buttocks close to and parallel with the edge of the bed, while upon the Continent and in this country most obstetricians prefer delivering the woman in the dorsal position. If the choice is left to the physician, this latter position should be selected, as the exposure of the patient is less and the management of the labor much easier for him. During the pains of this stage of labor the patient must be encouraged to ''bear down" or strain ; and this is greatly facilitated by her grasping firmly the sides of the bed or a long towel tied to its foot. When the head has reached the perineum these voluntary efforts on the part of the mother should cease as far as possible. If the stage be at all prolonged, it is advisable that the physician auscult the abdomen occasionally to see if the foetal heart-sounds are still distinct and regular. When the perineum has become completely distended, and just as the head is to pass over it, the patient must be urged to open her mouth and cry out, as this lessens the strong force driv- ing the head against the perineal body, and many times prevents a tear which otherwise would occur. As soon as the head is born the fingers are passed down to the neck and the cord felt for. If it be found coiled about the neck, by making gentle traction upon the placental end it may be slipped over the head, or, when loosened in this way, it may glide down over the shoulders as the body is born. It occasionally happens that it is coiled about the neck two or three times. In these cases it should be ligated in two places and cut between the ligatures. If this becomes necessary, delivery must be hastened by pressure upon the fundus of the uterus and gentle traction upon the child. The head is now supported by the hand, while the eyes and face of the child are carefully cleaned with a soft wet cloth, and the nurse or assistant places a handupon the fundus of the uterus and compresses it firmly as the contractions occur and the body of the child is born. This hand should not be removed until the accoucheur can take the uterus to manage for the third stage. The head being born and restitution having taken place, the shoulders and body usually follow during the next uterine contraction. If the con- tractions are weak and ineffectual, and the child's life is endangered by the delay, gentle traction may be made upon the head or with the fin- gers in the axillae ; but these measures should never be resorted to unless deemed absolutely necessary, and must always be accompanied by a gentle rubbing of the fundus of the uterus. As soon as the child is born the mouth should be carefully wiped out, and after it has cried and the heart-action becomes regular the cord is tied. One ligature, prefer- ably of linen or cotton tape, so that it will not cut through the cord and into the umbilical vessels, is placed about three inches from the umbil- icus, and a second an inch nearer. The cord is then cut between the ligatures, and the end carefully wiped to see that no bleeding is taking place, if a large amount of Wharton's jelly is present, it is often ad- visable to strip the cord. This hastens desiccation, and may be done in 88 MANAGEMENT OF NATURAL LABOR. the following manner : After one ligature has been applied, the cord is f rasped firmly at the umbilicus between the thumb and index finger, t is then cut on the umbilical side of the ligature, and with the fingers and thumb of the other hand the gelatinous matter is gently squeezed out. A second ligature is now applied near the end. Describe the management of the third stage of labor. As soon as the child has begun breathing naturally, the face cleansed, and the cord cut, it should be carefully wrapped up in a soft blanket and removed from the bed to a warm place. A towel is now wrung out of some antiseptic solution and placed over the vulva, and the uterus taken from the nurse by the physician. If at all soft or relaxed, gentle rub- bing causes the uterus to contract. Within a few minutes regular con- tractions will occur at short intervals, and the placenta may be spon- taneously expressed. If after waiting fifteen or twenty minutes this is not the case. Credo's method of expression may be resorted to. This consists in applying gentle friction over the fundus, and during a eon- traction making firm downward pressure, with the fingers extending over its posterior and the thumb its anterior surface. As the placenta escapes from the vulva a dish is held in readiness to receive it, with the blood and clots, and as it passes over the perineum it should be taken in the hand to prevent dragging on the membranes. By making gentle traction upon the placenta in a backward direction the membranes will slip out without tearing. Twisting them into a rope during their withdrawal is not desirable, as it may be, and often is, the means of causing them to tear. As a matter of routine a drachm of the fluid extract of ergot should now be given, as it secures a firm and per- sistent contraction of the uterus and lessens the dangers of post-partum hemorrhage. However, never give ergot until the placenta and mem- branes have been carefully examined and found to be intact. How should the mother now be cared for? A warm douche of a solution of bichloride of mercury, 1 : 5000 or 1 : SOOO, is given, the vulva carefully cleansed with the same solution, and, if the perineum be lacerated, one or more sutures ought to be intro- duced at once. If it is found to be intact, a pad is applied over the vulva and the soiled bedding removed. These vulvar pads may be made of bkuiched gauze or cheese-cloth padded with absorbent cotton, and before their application should be wrung out of a weak bichloride solu- tion (1 : r)()()()). After keeping the hand over the uterus half an hour, or longer if the organ has any tendency to relax, the binder may be applied. This is best made of coarse, unbleached muslin, and should extend from the ensiform cartilage to the middle of the thighs. It is fastened by pinning down the centre and taking gores on the sides to prevent it from slipping out of position. Its advantages, when properly adjusted are numerous and evident. It gives a comfortabU; sui)p()rt to the abdominal walls, which are naturally very lax after childbirth, and ANESTHESIA, ANALGESIA. 89 restores the intra-abdominal pressure. By its constant and even pressure upon the uterus it promotes the invohition of this organ, which is so important for a rapid and complete convalescence, and it prevents relaxa- tion and resulting hemorrhage. It is also said to preserve and restore the figure of the patient. If at the end of an hour the pulse is not over 90, the hemorrhage is not free, and the patient is resting comfortably, she may be left with safety, but should be visited again in the course of six or eight hours. What attention must be given to the child after the mother has been cared for? Now that the mother is attended to, look at the child. See that it is breathing naturally, and then examine the cord and see whether or not it is bleeding. The entire body and scalp of the infant should be smeared with sweet oil or vaseline to facilitate the removal of the vernix caseosa, and the cord dressed. The latter maybe done in this way: In the centre of a piece of soft hnen cut a hole and slip the cord through, wraj) a little absorbent cotton about it, and fold the cloth so that the cord will be against the child's abdomen. _ Now wrap the infant again in a soft blanket and place it in a crib with hot-water bottles or bags about it, and leave it a few hours before bathing. At the end of six or eight hours it may be washed in warm water with castile soap and a soft sponge. Do not place the child in a bath. The cord after each bath is to be dressed in the manner described above, excepting that it is well to dust a mildly antiseptic powder upon it, A powder of 1 part of iodoform and 2 parts of bismuth is efficient, and not irritating. By this treatment desiccation is hastened, and there is much less danger of septic peritonitis from absorp- tion through the umbilicus. After the bath some inert powder is dusted in the axillae, the folds about the neck, and buttocks, and the child dressed. A soft flannel binder or bellj'band is first applied. This extends from the nipples to midway between the umbilicus and symphysis, and must be put on smoothly and loosely, pinning it with safety-pins. Over this a soft shirt is worn, then a flannel petticoat and a long dress. The diaper is preferably made of old cotton cloth, it being soft and non-irritating. In about twelve hours the child should be put to the breast and allowed to nurse for five or six minutes from each. However, the mother has little or no milk for twenty-four or forty-eight hours, and until the end of this time no regularity need be observed in the nm-sing. ANESTHESIA, ANALGESIA. When would you use chloral during labor ? how much would you give ? and what are the dangers connected with its adminis- tration ? Chloral is only of value during the first stage, and here, when used in suitable cases and properly given, it is a drug of unquestionable utility. 90 MANAGEMENT OF NATURAL LABOR. Where the pains come at frequent intervals and are severe, but have httle effect on the progress of the labor, and where the os is thin and rigid and the patient nervous and exhausted, cliloral is indicated. It is frequently given by the rectum suspended in mucilage or milk and the yelk of an egg. A dose of 30 grains may be given, and repeated in three-quarters of an hour if the desired effect is not obtained. By the mouth gr. x well diluted may be given every twenty minutes for three doses, and after waiting an hour the dose may be once repeated. The great danger in the use of chloral is to the heart. Being a decided cardiac depressant, it is absolutely contraindicated in all cases where organic affections of this organ exist. What effect has chloral on a patient in labor? It quiets nerv^ous excitability, and produces a drowsiness, if not sleep, between the pains. It lengthens the interval between the uterine con- tractions, and makes the latter stronger and more regular. Above all, it seems to soften the os and promote its dilatation. When and how should chloroform be given during labor? In the second stage only, and, onl.y in exceptional cases, not until the presenting part has nearly or quite reached the perineum. A convenient method of administration is to fold a towel or napkin six or eight inches square, and n]nm it place about a drachm of chloroform. Holding it with the first two fingers on the moistened surface and the thumb on the oi)i)osite side, the backs of the former are allowed to rest upon the bridge of the patient's nose. In this way fully 90 per cent, of air is inhaled with each inspiration, and no part of the towel comes in contact with the face of the woman. At the beginning of a pain inhalation is commenced, and should cease as soon as the contraction stops. Surgical anaesthesia should not be obtained with chloroform. What are the dangers arising from the use of chloroform ? It acts upon the motor ganglia of the heart, sometimes producing sud- den death. It also acts upon the respiratory centre just as ether does, but to a less marked degree. It sometimes excites rather than quiets the patient, and its administration has to be stopped on this account. It diminishes the contractile power of the uterus, and thus increases the danger of hemorrhage. What advantages has it over ether as an anaesthetic ? Jt i.s more i)leaerineam has not had time to stretch: inexperience on the part of the physician. — may all be causes of perineal lacerations. Then there are some perinea which will always tear, no matter how care- fully the labor may be managed and how favorable the presentation. This is observed in some thick, tense, and often oedematous perinea, which seem to possess no elasticity and begin to tear immediately the head presses upon them. Occasionally eczematous and and other skin affections of the parts about the vulva and rectum render the tissues hard and brittle and favor lacerations. Statistics vary widely as to the percentage of perineal lacerations, but average in primiparae from 18 to 28 per cent, and in multiparte a little less than 4 per cent. It is esti- mated that about one-third of these must tear, no matter how managed. Describe the different degrees of perineal lacerations. (1) Incomplete lacerations are those in which the perineum is torn to the sphincter ani. Accompanying this external laceration there is more or less tearing of the vaginal mucous membrane, and it occasionally ha]v pens that this extends up the posterior vaginal wall nearly to the fornix. 92 MANAGEMENT OF NATURAL LABOR. It is generally confined to one side of the posterior column of the vagina, but may occur on both sides. (2) Complete lacerations are those in which the perineum is completely divided, the sphincter torn apart, and perhaps the laceration may extend for some considerable distance up the wall of the rectum. In these cases the vaginal wall is invariably badly lacerated. Describe the management of the perineum after the head has descended upon it. 1st. In Dorsal Deliveries. — The objects sought for are threefold : First and most important, is to retard the progress of the head, so that the perineum may have time to become fully dilated before its birth. Sec- ond, strive to get complete flexion of the head, so that its shortest diam- eters may pass through the vulva. Third, during its birth relax the perineum as far as possible. These are accomplished in the following manner: When the perineum has begun to bulge outward during a contraction of the uterus, crowd the chloroform. Do not seek to obtain anaesthesia to the surgical degree, but only sufficient to prevent the strong expulsive efforts of the mother. Introduce the first two fingers of the right hand into the rectum and apply the thumb against the descending head. With these two fingers make pressure in two directions on the frontal region of the skull — up- ward and anteriorly. The former increases the flexion ; the latter crowds the occiput forward and tightly under the pubic arch. During a con- traction make direct pressure upon the head with the thumb, to prevent its too rapid descent. Then with the finger and thumb of the left hand crowd back the anterior portions of the labia until the occipital protu- berance is felt to have emerged from under the symphysis. When this has taken place, wait for the pain to subside ; then with the fingers of the right hand slowly extend the head, at the same time making gentle pressure downward and toward the median line with the thumb and two fingers of the left hand, which, being now at liberty, are placed near the posterior termination of the labia majora. This tends to relax the peri- neum. Do not allow the head to be born during a uterine contraction if it be possible to hold it back. 2d. In the Side Deliveinf. — Have the buttocks near the edge of the bed, with thighs and legs well flexed. Place a folded blanket or pillow between the knees to separate them, so as to allow room for manipula- tions with the left hand, which is placed around the thigh and rests upon the child's head. The other hand may rest upon this, and during a pain l)ressure with both is made, so that the descent is as slow as the operator may desire. Chloroform is freely administered as in other deliveries, and the anterior commissure of the vulva is crowded back ; but as ex- tension is about to occur the relaxation may be accom])lished by pushing the perineum forward with the finger and thumb of the right hand placed along its sides. EPISIOTOMY. — THE PUERPEEAL STATE. 93 EPISIOTOMY. What is episiotomy? Episiotomj^ consists in making lateral incisions on each side of the vulva to relieve the tension and prevent spontaneous lacerations in the median line. The incisions are made somewhat anterior to the central raphe, and should be made with blunt scissors during a uterine contrac- tion. _ To be of advantage they must be one-half to three-quarters of an inch in length. After confinement a suture is introduced and union readily takes place. Is episiotomy ever indicated ? It occasionally happens that a case is met with where laceration seems unavoidable. For example, before the perineum has distended nearly enough to allow of the passage of the head the fourchette is seen to tear and the skin covering the perineal body to become tense, and perhaps separate for a short distance midway between the posterior commissure and the anus. In such a case the operation is perfectly justifiable. But it so rarely happens that cases are seen where it can be positively asserted that a tear must take place that this procedure is, as a routine, to be dis- couraged. Should perineal lacerations be repaired immediately? They should in every instance where at all extensive. The internal lacerations of the vaginal mucous membrane should be united by small catgut sutures, and for the deep external sutures silkworm gut, silk, or very heavy catgut may be used. The former is preferable, as it can be made sterile so easily and is convenient to carry. THE PUERPERAL STATE. What is the puerperal state ? Describe the general condition of the mother at its beginning. The puerperal state comprises the period beginning with the comple- tion of the third stage of labor and terminating with the recovery of the patient (Hirst). Soon after the completion of labor there may be a so- called post-partum chill. This is usually of short duration and of no importance. It is probably nervous in origin and due to the exhaustion following labor. The pulse, which has been accelerated during labor, falls soon after, many times considerably below normal, even to 50 or lower. For a time the temperature is somewhat elevated, especially if the labor has been difficult or prolonged. However, within twenty-four hours it should fall to normal or nearly so, and remain there throughout convalescence. There is a general feehng of comfort and well-being and a desire to rest, if not sleep. Describe the changes occuring in the uterus during the puer- peral state. Immediately after confinement the ut'^rus is firmly contracted, and 94 MANAGEMENT OF NATUKAL LABOK. may be felt about midway between the symphysis and umbilicus. As a rule, however, it soon relaxes slightly, some clots come from within its cavity, and twelve or fifteen hours after the delivery its fundus lies on a level with or above the umbilicus. But now the process of involution begins. A fatty degeneration and absor[)tion of the muscular fibres and cells and a growth of new cells occur, so that there is a constant loss in the weight and size of the organ. By the end of six weeks or two months, when this involution is complete, the uterus weighs but slightly more than in its nulliparous condition, while immediately after labor its weight is about 2J pounds. Involution is promoted by giving, for a couple of weeks, small doses of ergot (n^xv-^xx of the fluid extract, t. i. d.). During this process a new decidua is being formed within its cavit^y. The superficial layer is detached and expelled with the placenta and membranes, leaving only fragments behind, which are adherent to the uterus. From these the new membrane is formed, and is complete by the fifth week. Large thrombi form in the uterine sinuses and gradually become organized. A shrinking occurs and a slow obliteration, but it is not until four or five months after labor that this process is complete. The cervix rapidly regains nearly its normal size, though never its virgin shape. The external os is almost hivariably torn, and remains patulous for a considerable time. What are after-pains ? How caused and treated ? After-pains are simply pains due to uterine contraction. They are caused by the efforts nature is making to decrease the size of the uterus and express the foreign bodies in the form of blood-clots which it con- tains. They are almost invariably found in multiparse, though occa- sionally met with in primiparae where the uterus has been over-distended by twins or hydramnion. If care is taken to express all clots and secure firm contraction after labor, in many cases they will be avoided. A mix- ture containing Morphine acetate, gr. i j ; Spts. Mindererus, 3ij ; Fl. ext. of digitalis, lUj, given every three or four hours, is highly recommended to relieve them. Describe the lochia. It is a discharge from the uterus, lasting from two to four weeks after delivery. Abundant at first and of a bright-red color, it gradually de- creases in amount and assumes a paler and eventually a wliite hue. For the first tlircc or four days, oil account of the blood mingled with it, it remains red and is called "lochia rubra." From this time until the eighth or tenth day it is of a very ])alc-red color, and has received the name "lochia alba." It is estimated that during a normal puerperium the THE PUERPERAL STATE. 95 entire lochial discharge amounts to about 3 or 3j pounds. A slight odor may occasional^ be observed in the discharge, but if thorough cleanliness and antisepsis is observed it never becomes marked. What can you say in regard to the care of the bowels and bladder during the puerperium? From two causes it frequently happens that during the first few days there is retention of urine. In some cases it is of purely neurotic origin, and may be readily relieved by applying cloths wrung out of warm water over the suprapubic region. In others it is due to a partial and tem- porary paralysis of the neck of the bladder or to severe contusions and oedema about the urethra and meatus. In these cases it will be neces- sary to use the catheter. For this purpose a soft, flexible rubber catheter should be employed, and the strictest cleanhness and asepsis observed in its introduction. It should be passed every six or eight hours, and always by sight and not by touch. On the second or third day after confinement the bowels, if they have not moved, should be relieved by some gentle laxative. If the patient can take it, nothing is better than a dose of castor oil. There is always a marked tendency to constipation, which may be combated by small doses of cascara sagrada, mild mineral waters, laxative pills, or enemas of soapsuds or glycerin. What care should be given the breasts during this period? Usually in about forty-eight hours milk is found in the breasts. From this time on the child should be nursed regularly. About the third or fomth day it frequently happens that the breasts become full, tense, and somewhat painfril. and there is especial pain in the axillae : added to this there is a general feeling of discomfort and a slight rise of temperature, perhaps to 100° or 100?° F. If the nipples are not eroded or fissured, and if no areas of induration appear, this condition need cause no anxiety. It is simply due to a marked activity of the glands, and lasts only a day or two. From the time the milk appears the breasts must be properly supported either by a binder or in slings. The nipples are to be carefully washed both before and after the child has nursed. For this purpose nothing is more cleanly than a solution' of boracic acid. Avoid all pressure over small areas of the breasts, for there is no more easy way . of setting up a mastitis. What should be the diet of a puerperal, woman ? During the first twenty-four or forty-eight hours the diet should con- sist only of the most easily digested articles of food. 3Iilk. mutton or chicken broth, beef tea. milk toast, and a little bread may be allowed. The patient should receive some nourishment every three or four hours if awake. After the second day any digestible foods may be given. 96 MANAGEMENT OF NATURAL LABOR. Avoid all pastry, cakes, fresh vegetables, ricli desserts, fruits, and sweets while in bed. At the end of a couple of weeks she may resume her usual diet, taking care only to avoid such food as would be likely to cause indigestion. How frequently should the vulvar dressing be changed? and when may a post-partum woman be allowed to sit up ? During the first twenty-four or forty-eight hours the lochial discharge is rather profuse, so that every three or four hours a clean new dressing ought to be applied, taking care to carefully cleanse the vulva and sur- rounding parts with a warm solution of bichloride of mercury, 1 : 5000. After this, and up to the eighth or tenth day, four times in the twenty- four hours is quite sufficient. From day to day, by examining the abdo- men, the size of the uterus can be appreciated. Until the fundus has disappeared below the symphysis, or at least can be felt on a level with the pubis, the patient should be kept in bed. How may a diagnosis of the puerperal state be made ? By the size of the breasts and presence in them of milk or colostrum ; by the flabby, wrinkled condition of the abdominal walls and the large size of the uterus ; by the open and perhaps lacerated cervix ; the cha- racter and amount of the lochial discharge ; the large and relaxed vagina and abrasions about the vulva, or perhaps perineal laceration. CARE OF THE INFANT. Describe the care of the infant the first twenty-four hours of its existence. For a few hours keep it well wrapped up in blankets and warm. Then bathe and dress it, and allow it to nurse for a few minutes from each breast. After this, if it cries and worries, it may be given a little warm water or warm peppermint-water with a medicine-dropper. It should not be allowed to nurse, as it only worries the mother and the child gets no nourishment. How frequently should it be allowed to nurse after the first day? Every two or two and a half hours, beginning at seven in the morning when the mother awakens, and continuing until nine in the evening. During the night, if restless or wakeful, it may be allowed to nurse once or twice. Above all, observe regularity in its feeding, and even though the child be asleep it should be awakened when the hour for its nursing comes around. Always keep it loosely though warmly clad, and in such a position that bright light does not strike the eyes. UNNATURAL LABOES. 97 CHAPTER V. UNNATURAL LABORS. PERSISTENT OOCIPITO-POSTERIOR POSITIONS. State the causes which may operate to prevent anterior rotation of the occiput in posterior positions of the vertex. Incoinplete flexion of the head, so that the chin does not come in con- tact with the sternum, an excessively large head, or a normal head and a justo-minor pelvis, and a very small head and roomy pelvis. (The last class of cases is usually seen in premature labors, and as a rule, though rotation does not occur, the labor is no more difficult than it would be were the occiput anterior.) Describe the management in this class of cases. If complete flexion can be secured, these cases will usually rotate, so our one object in their management is to promote flexion by upward pressure on the sinciput during uterine contractions. At the same time an attempt may be made to aid rotation of the forehead backward by pressing in that direction on the side which looks toward the pubes. Many cases of this kind occur where the rotation takes place very late in the labor, and not until the head is well down upon or bulging the perineum. If the labor is much prolonged, the energies of the mother are becoming exhausted, and no rotation or descent is taking place, the forceps should be applied and the head drawn down to the perineum. The blades should then be removed, and labor allowed to terminate by the natural forces. Usually at this time rotation occurs, and the case is practically the same as an anterior position. If the occiput is born pos- teriorly, the perineum is invariably badly lacerated. FACE PRESENTATIONS. Give the frequency and cause of face presentations. The frequency of presentation of the face varies, according to different authors, from 1 in 150 to 1 in 450 labors, the average being about 1 to 200. The transformation from vertex to face usually takes place during the last few weeks of pregnancy, and may be due to one of a number of difl"erent causes. Uterine obliquity (marked) : doHcho-cephalic child ; tumors of the neck and thorax ; excessive amount of liquor amnii and a small child ; ^ rapid evacuation of the liquor amnii during labor ; hitch- ing of the occiput at the brim of the pelvis, and a lack of proper flexion as the head enters the pehds, — have all been given as causes. Name the positions of the face. The first podtion corresponds to the first position of the vertex. In 7— Obs. 98 UNNATURAL LABORS. it the chin points to the right sacro-ihac sjmiphysis and the forehead anteriorly and to the left— K. M. P. (right mento-posterior, Fig. 17). Fig. 17. Fig. 18. RM.R L.M-R The second position corresponds to the second vertex position. The chin points to the left sacro-iliac symphysis, the forehead anteriorly and to the right — L. M. P. (left mento-posterior, Fig. 18). _ The third position corresponds to the third vertex position. In it the Fig. 19. Fig. 20. L.M.A. R.M.A, chin is directed anteriorly and to the left side, the forehead posteriorly and to the right sacro-iliac symphysis— L. M. A. (left mento-anterior, The fourth position corresponds to the fourth vertex position. The FACE PRESENTATIONS. 99 chin is directed anteriorly and toward the riiiht side of the mother, the forehead posteriorly and to the left sacro-iliac symphysis — R. M. A. (right mento-anterior, Fig. 20). How would you diagnose a face presentation before the mem- branes have ruptured? It is often extremely difficult to make a diagnosis before this time. Pal- pation in the first two positions may lead us to suspect a face, but by it a positive diagnosis cannot be made. After feeling the head, the hands, being passed over the abdomen and considerable pressure made, suddenly sink into the deep sulcus lying between the occiput and shoulders. On vaginal examination the membranes during a pain are more prominent and project farther through the cervix. The hard forehead is felt, and when the membranes are relaxed it is at times possible to appreciate the nose and orbital cavities. How would you diagnose a face presentation after rupture of the membranes ? The only time a mistake can now be made in the diagnosis is when the labor has been prolonged. Under these circumstances the face becomes very much swollen and oedematous, and no landmarks can be appreciated. Ordinarily, the forehead is felt with the frontal, and perhaps the coronal, sutures. Then by passing the fingers down the frontal suture, the root of the nose, the orbits, the superciliary ridges, the nostrils, and the mouth may all be easily recognized. By putting the finger into the mouth the alveolar ridges prove conclusively the presentation, and make the differentiation from a breech possible. Extreme care must be observed not to press roughly against the face and thus injure the features. Give the mechanism in face presentation. In face presentation the mechanism of delivery is nearly the same as in the vertex, only that we must consider the forehead in face to take the place of the occiput in vertpx presentations. Thus we have, as in vertex cases, five periods, constituting the mechanism: 1st, extension; 2d, descent and engagement; 3d, internal rotation; 4th, descent and flexion ; 5th, restitution and external rotation. By the first movement, or that of extension, the occiput is pressed backward and the chin descends lower in the pelvis than the forehead. In this position engagement occurs and descent begins. It is now that the rotation takes place just as in vertex cases, and for exactly the same reasons. By the time the process is completed the face has reached the floor of the pelvis, with the chin anterior and the occiput lying in the hollow of the sacrum. Then begins the fourth movement, or that of flexion. The chin emerges under the pubic arch, and there becomes fixed, allowing the forehead, face, and occiput to successively sweep over 100 tnSTNATURAL LABORS. the perineum. The last movement of restitution now occurs, exactlj'^ as in normal vertex positions, and the mechanism for the shoulders and body is just the same as in vertex cases. Does the face always rotate anteriorly? It does not, and in such cases, if the labor be at term, the child of normal size, and the pelvis not unusuall}'^ large, operative interference of some kind is invariably" necessar3^ In these cases, which, fortunatelj'', are extremely rare, the crown of the head is jammed tightly behind the pubes and the chin lies in the hollow of the sacrum. This places the long occipito-mental diameter in relation with the antero-posterior diam- eter of the pelvic outlet ; and, bearing in mind the fact that the latter is but 5 inches, while the former is 5} inches, and that little or no shorten- ing of this diameter can occur, it will be readily seen how impossible delivery is unless the head is compressed. What can you say of the prognosis and treatment of face pres- entations ? The dangers to the child are much greater than in vertex cases, even though internal rotation occurs. The labor is apt to be prolonged, and the child is subjected to an extreme amount of pressure, which many times causes cerebral congestion or hemon-hage ; so that the mortality, when anterior rotation of the chin occurs, is between 8 and 14 per cent. When this does not occur, it is almost 100 per cent,, as most of these cases require craniotomy. To the mother the prognosis is but slightly graver than in vertex cases. Treatment. — Various methods of treatment have been adopted in face presentations, which in some instances have met with success, in others failure, so that few authors attempt to lay down any fixed rules by which all cases should be treated. If the diagnosis is made before the cervix is completely dilated and before the presenting part has entered the pelvis, we may resort to one of two procedures — convert it into a vertex or do a podalic version. (Unless the chin lie anteriorly, in which case, if we fail in changing to a vertex, the lahor should he left to nature.) A very clear and concise description of the former treatment has been given by Dr. Partridge in a paper read before the New York State Med- ical Society a few years ago. In it he says: "The conditions especially favorable to the operation are an os nearly or quite dilated ; a face not engaged in, or at least capable of being readily lifted from, the pelvic brim ; an unruptured bag of waters ; a capacious vagina. In a majority of labors a stage is reached when there are present these conditions." His method of procedure is to "give chloroform for relaxing the struc- tures of the parturient canal, to quiet the movements of the patient, and to obviate pain." The hand is then introduced into the vagina, and the fingers passed up through the cervix into the uterus. The palms are pas.sed over the occiput and traction made in a downward direction, "llexion PELVIC PRESENTATIONS. 101 may be greatly aided by external manipulation." Continuing, he says that ' ' in some instances in which the membranes are unruptured at the beginning of the operation they remain unbroken at its comj^letion, "showing how simple the operation can be." After flexion has been ob- tained the case must be carefully watched, and any tendency to a return to the face presentation should be checked by applying the forceps and engaging the head. Version, then, is never justifiable when the above can be done, and should only be resorted to after all attempts to engage the head in a flexed position have failed, and then onhj when the cldn points posteriorly. If the case is not seen until the face has entered the pelvis, but one plan of treatment offers itself — namely, that which will secure anterior rotation of the chin if possible. This will almost always take place if marked extension be present ; therefore we should aid this by upward pressure with two fingers on the forehead during each uterine contraction. If this prove unsuccessful, an attempt may be made to secure rotation by placing the fingers in the mouth and drawing the chin forward during a pain. xlnother method of accomplishing the same result has proven success- ful in the hands of some accoucheurs. This consists in introducing one blade of the forceps so as to press upon the posterior cheek. All three methods may be attempted. If failure is encountered, and the chin continues to point posteriorly, the only resource left is to perform crani- otomy. PELVIC PRESENTATIONS. How are breech presentations divided? Into complete or full and incomplete. In the first variety the thighs are flexed upon the pelvis, the legs upon the thighs, the feet are crossed, and are in contact with the buttocks. There are several varieties of in- complete breech presentations : (1 ) Those in which the thighs are flexed on the pelvis, but the legs are extended at the knee, so that the feet lie by the child's face and the buttocks alone present. (2) Cases are met with where the thighs are but slightly flexed and the legs completely so. These constitute knee presentations. (3) The lower limbs are completely extended : these are the so-called footling presentations. (4) Very rarely it happens that one leg is flexed, the other remaining completely ex- tended. The mechanism is exactly the same, no matter how the pelvic extremity presents. State the frequency and causes of pelvic presentations. At full term about 1 labor out of every 60 is breech. In premature labors pelvic presentations are much more freciuent, averaging nearly 1 in 20 labors. One of the most frequent causes of pelvic presentations is premature delivery. Among other causes may be mentioned an excessive amount 102 UNNATURAL LABORS. of liquor amnii, a verj^ large uterus, a small child, a hj^drocephalic child, placenta pr^evia. and all forms of pelvic deformities. How many positions are met with in pelvic presentations? Four. 1st. Left Sacro-anterior (L. S. A.).— The back of the child points Fig. 21. Fig. 22. L.S.A. RS.A. anteriorly and to the left side of the mother, and the long diameter of the hips lies in the left oblique of the pelvis (Fig. 21). Fig. 23. Fig. 24. RS.P L.S.R 2d. Right Sacro-anterior (R. S. A.).— The dorsum of the child points anteriorly and to the right side of the mother, and the long diam- eter of the hips lies in the right obliciue of the pelvis (Fig. 22). PELVIC PRESENTATIONS. 103 3d. Right Sacro-posterior (R. S. P.). — In this position the back of the child points posteriorly and to the right side of the mother, and the long diameter of the hips lies in the right oblique of the pelvis (Fig. 23). 4th.^ Left Sacro-posterior (L. S. P.). — The back of the child points posteriorly and to the left side of the mother, and the long diameter of the hips lies in the left oblique of the pelvis (Fig. 24). Describe the mechanism of delivery in the four pelvic presenta- tions. Unless the pelvis be normal and the child at full term, there will be no mechanisni in pelvic presentations. In the first position we have first a moulding of the breech, occurring with the descent. This is really an act of adaptation. Now, after engagement has taken place, internal rota- tion of the trunk begins. This is due to exactly the same causes as in vertex presentations, and when completed the left hip lies under the symphysis pubis and the long diameter of the buttocks is in conformity with the antero-posterior diameter of the outlet of the pelvis. The next movement is one of lateral flexion. By this the posterior (right buttock) is born oyer the perineum ; then, the descent continuing, the left but- tock is disengaged from under the symphysis, and the limbs, trunk, elbows, and shoulders are born in succession. External rotation of the trunk and internal rotation of the head take place as the body is ex- pressed, and if complete flexion of the head has been maintained, by the time the trunk is born the occiput has rotated from left to right and Hes under the sjauphysis pubis. Here it remains fixed, and in succession the following diameters appear: the occipito-mental the suboccipito- frontal, and the suboccipito-bregmatic. Last of all, the occiput is born. In the second position the movements are exactly the same, excepting that they take place in opposite directions. The internal rotation brings the right hip under the symphysis, and the occiput rotates from right to left, instead of from left to right. In the third position the mechanism is the same, only the rotation must be more extensive to bring the right hip under the symphysis. So also must be the rotation of the occiput, and this takes place just as in the third vertex position. From the foregoing the mechanism of the fourth pelvic position will be readily understood. What are the causes of infant mortality in pelvic presentations ? 1st. Compression of the Cord. — This may occur to a serious degree even before the head has reached the pelvic brim, which is the time at which funic compression is usually considered dangerous. The cord is caught between the trunk of the child and the wall of the pelvis. Even though this does not happen as soon as the head enters the superior strait, the foetal circulation through the cord is interfered with, if not stopped entirely. 104 UNNATURAL LABORS. 2d. Extension of the Head. — This a grave complication, as delivery of an extended head is invariably retarded — often until death of the foetus occurs. 3d. Extension of the Arms. — This also causes delay just at the point when rapid delivery is necessary. 4th. Inspiratory Efforts before the Birth of the Head. — ^By these mucus, blood, and liquor amnii are drawn into the respiratory passages, preventing any possibility of resuscitating the infant. Dubois gives the average of 1 death to 1 1 deliveries. Is the maternal prognosis more grave in breech than in vertex presentations ? It is not. Although the first stage is likely to be prolonged and tedious, the second is usually much more rapid than in vertex labors, so that the entire labor is not unusually long. How may a pelvic presentation be diagnosed before labor has begun ? Pidpation. — As described on page 110, we find a broad mass in the iliac fossae, nearly immovable and resting higher up, out of the pelvis. Small parts of the foetus may be appreciated in the lower segment of the uterus, and above in the fundus the head is found. If cephalic bal- lottement is obtained, the diagnosis of the extremity is certain. Auscul- tation reveals the maximum intensity of the foetal heart-sounds on a level with or above the umbilicus. On vaginal examination, as a rule, nothing can be felt. The breech lies high up and away from the examining finger, though occasionally an extremity can be found. On the slightest pressure this will glide away from the finger as though drawn up by the foetus. Such a sensation would make the diagnosis assured. How may a pelvic presentation be diagnosed after labor has begun ? On palpating and auscultating the same condition of affairs is found as described above. If the membranes be still intact when a vaginal exam- ination is made, little will be discovered, unless the os is dilated, except- ing a peculiar feel to the bag of waters. It is longer and more conical. Now, if we examine when the cervix is more dilated and the membranes ruptured, the diagnosis, as a rule, is very easily made. The finger first comes in contact with a soft, fleshy mass. No sutures or fontanelles are felt, and on passing backward a groove is reached, and beyond a mass similar to the part with which our finger first came in contact is discerned. Following the groove, first in one direction and then in the other, we feel on one side a small osseous point, the coccyx. Pushing farther up- ward, the spinous processes of the sacrum may be distinguished. In the other direction we find the anus, and if the finger can be introduoed this is readily recognized by the contraction of the sphincter and the presence PELVIC PRESENTATIONS. 105 of meconium, which covers the finger. In front of the anus the genital organs are found. If the feet be pressed against the buttocks, they may be felt and the character of the presentation readily determined. The position is recognized by the position of the sacrum. From what must the breech be differentiated? The only presentation with which a breech may be confounded is a face, and then only when the labor has been much prolonged and the parts very oedematous. The mouth is differentiated from the anus by the alveolar ridges in the former and the sphincteric action in tlie latter. Nothing resembling the sacral spines can be felt in a face, and nothing resembling the nostrils in a breech. How would you recognize the foot or knee? The only part the former might be confounded with is the hand. Bearing in mind these points, the mistake will never be made. The toes are shorter than the fingers and placed in a straight line. The thumb can be brought in contact, across the palm of the hand, with any of the fingers ; the great toe cannot. The thumb and first finger may be considerably separated ; the toes cannot. Nothing resembling the mal- leoli or the heel can be found on the hand. Last of all, the hand lies on a straight line with the arm ; the foot is at right angles to the leg. The foot felt (right or left) is determined by finding the great toe, the internal border, and the heel, and by imagining one's own foot in the same position. The knee is appreciated as a smooth, rounded mass with two tuberosities and a deep depression behind. Describe the management of pelvic presentations. In managing a pelvic presentation we seek, first, to keep the mem- branes intact until they reach the perineum if possible, that dilation of the cervix may be complete ; second, to maintain flexion of the head ; third, to hasten delivery after the trunk is born ; fourth, to prevent ex- tension of the arms and head by improper interference. When labor has begun, always remain with the patient and keep her very quiet, that no movement on her part may cause premature rupture of the membranes. If rupture has not taken place when the bag of waters has reached the outlet of the pelvis, it should be artificially ruptured. The foot now appears at the vulva, and/rom this time on the hand of an assistant — preferably, the accoucheur if necessary — should keep up constant pressure over the fundus uteri. As the feet descend, followed by the buttocks, support them with the hand, but do not make any traction. As soon as the genital organs have emerged from the vulva, pass the hand along the child's abdomen, secure the cord, and draw a loop downward. If pulsations are present, allow nature to take its course, raising the body of the child from the bed with each contrac- 106 UNNATURAL LABORS. tion, and keeping uj) firm pressure over the fundus. At the same time encouraire the motlier to bear down, as her efforts will very naturally hasten the delivery. The arms and shoulders are then expelled, and the child lies with its abdomen pointing toward the bed. The cord will now be found pulse- less, and the life of the child at this point depends entirely upon the rapidity of the delivery of the head. Raise the body well up toward the pubes and abdomen of the mother with the right hand, and with the first and second fingers of the left reach up between the symphysis pubes and neck of the child until the occiput is felt, and push down- ward. If delivery is not readily accomplished, traction must be made on the trunk. A short trial at this method will soon show whether or not delivery may be completed. If failure should meet our efforts, there are two more methods which may be tried. One consists in giving the body into the hands of an assistant, and with the first two fingers of the Fig. 25. Delivery of the Head in Breech Cases. left hand introduced over the face of the child downward pressure is made on the two malar bones, aided by the pressure on the occiput (Fig. 25) ; or the forceps may bo used. Tliey sliould always be at hand in breech deliveries, and are applied beneath the abdomen. However, DIFFICULT BREECH PRESENTATIONS. 107 bear in mind that the dehvery must be rai")id to secure a Hvin.g child, and the first method described, if properly done, will almost invariably be crowned with success unless the head is extended. DIFFICULT BREECH PRESENTATIONS. What are the most serious complications met with in breech presentations ? The failure of the head to rotate in the sacro-posterior positions, ex- tension of the head, and extension of the arms. State the management of a sacro-posterior position where in- ternal rotation does not occur. As a rule, this is observed either where a disproportion between the maternal pelvis and foetal head is present, or where the head becomes extended through improper management or interference. Tn either case our efforts are in tico directions : first, to secure and maintain good flexion ; and second, to assist rotation by proper manipulations. The body of the child being supported by the hand of an assistant, upward pressure is made on the occiput by the first two fingers of the right hand. With the fingers of the other hand pressure is made upon the anterior temple during a pain. By these means rotation, as a rule, will take place. In case it does not and the head descends to the pelvic outlet with the occiput lying posteriorly, if flexion be present traction should be made in a backward direction, that the neck may act as the point of rotation and the face emerge first under the pubes. However, if the head be extended the chin will become fixed back of the s^'mphysis, and our traction must be made in a directly opposite direction, allowing the occiput and back of the head to first emerge over the perineum. In case extraction cannot be accomplished beibre the death of the foetus has occurred and the possibility of resuscitation passed, craniotomy may be resorted to as a justifiable and proper means of saving the maternal soft parts from serious injury. How are extended arms to be treated? The arms must be made to pass downward over the chest of the child, but, as direct traction would result in fracturing the delicate bones, we pass two fingers over the shoulder and down toward the elbow as far as possible ; then make gentle pressure. The arm will slip by the face, and by passing the fingers i'arther along the forearm is made to follow in the same direction. When both are extended the posterior is the first to be liberated, as more room for manipulation is found in this part of the pelvis. What is an impacted breech presentation ? Describe its manage- ment. A breech becomes impacted in the pelvis when a marked disproportio: 108 UNNATURAL LABORS. exists between it and the pelvis, even though the attitude of the foetus be normal. In such eases Fig. 26. normal progress of the labor may usuallj'^ be ob- tained by drawing down one of the legs, and thus breaking up the impac- tion. In other words, sub- stitute a half for a full breech. However, when reference is made to an impacted breech we usual- ly understand it to be one in which the limbs, though flexed at the thighs, are extended at the knees. This forms, as it were, a wedge, the small part of which is the breech and the large part the head and feet of the child (Fig. 26). Although impaction does not, as a rule, occur until after the breech is well in the pelvis, treat- ment should be resorted to as soon as the os is well dilated and the condition recognized. In the natural breech the practi- tioner can always feel a foot, heel, or toe, but in these cases he cannot ; and if not, he will, by abdominal j)alpation, discover the feet lying in the fundus of the uterus by the child's head. If the back of the foetus is toward the right side of the mother, the right hand is introduced into the uterus, a foot seized and drawn down. If the back lies toward the left side of the mother, the left hand of the accoucheur is used. The labor is now allowed to progress naturally. For carrying out the above procedures chloroform or ether to the sur- gical degree should be given. Other causes arise where the impaction is found too late in the labor to allow of the hands being passed by the breech and up into the uterus. Two methods for treating these cases are used by diiferent practitioners : one is to apply the forceps to the breech ; this is not advisable. The other is to make traction with an instrument, or with a piece of clotli or the fingers passed over the groin. The best of these three is either the finger or a soft folded cloth. Pelvic fresentatiou with Legs Extended. PRESENTATIONS OF THE TRUNK. PRESENTATIONS OF THE TRUNK. 109 What are the positions of the foetus in transverse presentations ? and which is the most frequent? The term ''transverse presentation" is somewhat misleading, inas- much as the child never lies directly transversely, but always in an Fig. 27. Fig. 28. L. D. A. R. D. A. oblique diameter of the uterus midway between the vertical and the transverse : therefore, the shoulder, elbow, or arm are the parts found presenting. There are four positions — namely, ( 1 ) left dorso-anterior, in Fig 29. Fig. 30. R. D. P. which the head lies in the left iliac fossa and the back points anteriorly (Fig. 27) ; (2) right dorso-anterior. in which the head lies in the right iliac fossa with the back of the child anterior (Fig. 28) ; (3) left abdom- 110 UNNATURAL LABORS. ino-anterior or dorso-posterior, which corresponds to the one first men- tioned, except that the abdomen hes anteriorly and the back toward the mother's baclc (Fig. 29) ; (4) right abdomi no-anterior, in which the head hes in the right ihac fossa and the abdomen points anteriorly (Fig. 30). The most frequent are the two first mentioned, and of these the left dorso-anterior is the one most commonly met with. How frequently do presentations to the trunk occur? According to some, they are found as often as 1 in 125, while others give their frequency as 1 in 250 or 300. State the causes of transverse or shoulder presentations. 31ultiparity ; a too pronounced uterine obliquity ; pelvic deformities, especially a jutting forward of the sacrum ; excess of liquor amnii ; pre- maturity ; deformities of the foetal head ; placenta praevia, or a low im- plantation of the placenta, which prevents the head from lying in the lower uterine segment, — are among the many causes given. Then, also, accidents may occur, which have a decided influence in determining this form of presentation. Falls and irregular pressure over the abdomen may materially aid in determining a shoulder presentation where a tend- ency toward this exists in the way of uterine obliquity and lax ab- dominal walls. How would you diagnose a trunk presentation before the mem- branes have ruptured? Inspection shows an unsymmetrical appearance of the uterine tumor, with a bulging, rounded mass in one iliac fossa. This is especially ap- parent in thin women who have lax abdominal walls. Palpation reveals the absence of any mass occupjnng the inferior uterine segment, but shows the presence of such a mass in one iliac fossa and on the opposite side of the abdomen ; and, lying much lower down than would the breech in vertex or the vertex in breech presentations, is found another mass. The smooth, hard, even surface of the back or the irregular abdominal surface of the foetus can be appreciated as lying in an oblique diameter of the uterus. Auscultation reveals the greatest intensity of the foetal heart-sounds considerably higher up than is the case when the vertex presents. By vaginal examination nothing but a flabby vaginal canal and empty lower uterine segment can be felt. How would you diagnose a trunk presentation after rupture of the membranes? Inspecti(jn, palpation, and auscultation are productive of the same re- sults. In making a vaginal examination, unless some part of the arm or hand are })rolapsed, we feel nothing. As a positive diagnosis nmst be made as early as possible, chloroform or ether should be given, and the hand gradually introduced, cone-shaped, into the vagina. The two fin- gers now being passed through the cervix, the smooth, rounded promi- PRESENTATIONS OF THE TRUNK. Ill nences of the shoulder with its sharp acromion process may be felt. Passing around it, the axilla is recognized, and then the ribs. When the latter are felt the diagnosis is positive. The exact position of the child is ascertained ?jy finding in which iliac fossa the head lies. If this has not been determined by palpation, we will know as soon as the axilla is felt, since it always points toward the feet. We determine the posi- tion of the back through the vaginal examination by feeling the spine of the scapula either in front or posteriorly. In case the elbow lies at the OS, it is readily recognized by the sharply projecting olecranon process lying between the two smaller prominences, the condyles. The method of differentiating the hand from the foot has already been given. Finding a hand projecting from the vulva, how would you de- termine whether it was the right or left hand? Imagine one's own hand placed in the same position as that of the foetus, and we know immediately which it is. Or take hold of it as though to shake hands : if the two palms and thumbs lie in apposition, it must be the right hand; if not, it is the left. The position of the body of the child can also be recognized by the hand, provided we feel sure it is supinated, as its back must point to the back of the child and its palm to the abdomen. Upon what does the prognosis of this form of presentation de- pend? Upon the time when the position is recognized, upon its management, the cause of the presentation, and the facility with which version can be done. For the mother it is exceedingly bad when a deformed pelvis has been the determining cause or when labor has been much prolonged be- fore treatment is undertaken. Churchill estimates a loss of 1 out of 9 mothers in 235 cases. About 60 per cent, of the children are lost. How may these cases terminate? There can be no mechanism to them, but there are two ways possible for them to terminate — namely, by ' ' spontaneous version " or by " spon- taneous evolution. ' ' What is spontaneous version ? This can only occur with a living foetus, and may take place during the latter weeks of pregnancy or after labor has begun. It is the substituting of the vertex or breech, over the cervix, for the shoulder. The probable cause of this very fortunate but rare occurrence is irregular uterine con- traction, and this termination is rendered wellnigh impossible after the membranes have ruptured and the liquor amnii has been evacuated. What is " spontaneous evolution," and when does it occur ? It is the birth of the child folded as it were upon itself (Fig. 31). It can only take place during labor and with a dead foetus, unless under very favorable conditions — namely, an exceedingly roomy pelvis and 112 UNNATURAL LABORS. small child or a premature infant. Under these circumstances living foetuses have been born by spontaneous evolution. Two varieties have Fig. 31 . Spontaneous Evolution. been observed : in one the head is born first ; in the other, the breech. The former can take place only with very premature children. In the COMPLEX PRESENTATIONS. 113 latter the child is crowded tightly down within the pelvis, the presenting shoulder lying behind and the head above the pubes. With the head and shoulders fixed here the body rotates, so that the breech is crowded out of the pelvis over the perineum. The head is the last part of the child to be expelled. Describe the management of shoulder presentations if discerned before labor has begun. These cases should be treated by doing a cephalic version. After the head has been pushed down over the cervix and the breech up in the fundus, a pad is to be applied over the abdomen by the side of the head, and, to hold this in place, an abdominal binder. By these means we pre- vent the slipping back of the head to its former position in one ihac fossa. Describe the management of shoulder presentations after labor has begun. In these cases one of three methods of version must be resorted to — external cephalic version if possible; faihng in this, the bimanual method should be tried, but cases are found where neither will succeed, and in these the internal version must be performed. Faihng in all these, two resources remain : the destruction of the foetus (embryotomy) and a Csesa- rean section. The obstetric operations above spoken of, versions, em- bryotomy, and Csesarean section, will be described farther on. COMPLEX PRESENTATIONS. How would you treat a case where the hand was found pre- senting with the head? It occasionally happens that the hand is drawn back by the child itself. If this does not occur, we attempt to gently force it back during the in- tervals between the pains. The head will now usually descend sufficiently to prevent its again slipping down. However, if it tends to return to the abnormal position, the forceps must be applied and the head en- faged, care being taken not to catch the arm with one of the blades, f the foot is found presenting with the head, the same plan of manage- ment may be pursued. This, however, is of very infrequent occurrence. State the management of a case where the arm lies across the back of the neck. The diagnosis of these cases is very difficult, and, unless by exclusion, can be made only after an anaesthetic has been administered and the hand introduced into the vagina. The obstruction to the descent of the head occurs so high up that by ordinary vaginal examination it cannot be felt. The condition being recognized, the patient may be placed under the influence of chloroform and an attempt made to replace the hand and forearm. This, however, is not likely to prove successful, and podalic version must be resorted to. 8— Obs. 114 UNNATURAL LABORS. What treatment must be pursued when a hand and foot are found presenting? Podalic version. As traction is made on the foot, upward pressure upon the shoulder causes the hand to recede, and a half breech is sub- stituted for the hand and foot. PROLAPSE OF THE FUNIS. What is prolapse of the umbilical cord? and with what pres- entation does it most frequently occur? It is the falling down of a loop of the cord bej^ond the presenting part of the fcetus (Fig. 32). This loop becomes compressed between the presenting part and the walls Fio. 32. of the pelvis, the circulation is interfered with or checked, and asphyxia and death of the foetus result. It most fre- quently occurs with breech or transverse presentations. State the causes and fre- quency of this compli- cation. Any condition which pre- vents the presenting part of the foetus from accurately fit- ting the pelvic brim is condu- cive to prolapse of the funis. Thus we find it most com- monly in contracted pelves and with abnormal presentations. Other important causes are an excessive amount of liquor amnii and early rupture of the membranes, especially if the patient be in an upright posi- tion ; also an unusually long cord and low attachments of the placenta. The frequency is variously estimated by dif- in 300 labors. Prolapse of the Funis. ferent authors as 1 case in 100 to 1 Under what circumstances is the prognosis to the child most favorable ? In cases in which the prolapse occurs in a multipara with a small child and a breech or transverse presentation. At best, less than 50 per cent, of the children are saved, and this mortality is much increased in vertex PROLAPSE OF THE FUNIS. 115 cases occurring In primiparae, especially if the prolapse occurs with the head high up in the pelvis and the child large and at term. How would you diagnose and treat a case of prolapse of the funis ? After the rupture of the membrane the diagnosis is attended with no difficulties. However, if it occurs before the liquor amnii has drained awa3^, it is oftentimes difficult to determine the condition unless the pul- sations can be felt through the membranes. The reason of this is obvious. Being light and soft, the moment the part is touched with the finger it immediately recedes and lies bej^ond our reach. If the condition is found before the membranes are ruptured, the woman should be kept quietly on her back with the hips well elevated, for as long as the membranes remain intact little or no pressure can be exerted upon the cord, at least not until the os is completely dilated. As soon as dilatation is complete two or three fingers should be introduced into the vagina, and a very small puncture of the membrane made, that the escape of the liquor amnii may be slow and the great danger of a large loop of the cord being washed out avoided. Upward pressure upon the prolapsed loop should be tried as soon as the liquor amnii has drained away, and an attempt be made to crowd the head into the pelvis by pressure over the abdomen. If this succeeds and the cord remains in its normal position, and if we find the child's condition good, as will be shown by the foetal heart-sounds, the labor maybe allowed to terminate by the natural forces. Such a favorable termination, however, though the most desirable, can- not always be looked for, and recourse to more active methods of treat- ment must be had. There are four procedures which may be attempted, no one of which is adapted to every case: (1) postural treatment; (2) artificial reposition by instruments; (3) the use of the forceps; (4) version in vertex cases. The method of procedure in the first form of treatment is to place the patient in the knee-elbow position. This elevates the hips, and naturally the cervix; at the same time it lowers the fundus of the uterus ; thus its anterior wall forms a smooth inclined plane down which the cord may pass. Before the rupture of the membranes this method will almost invariably be crowned with success, and it is only necessary to rupture them and allow the woman to carefully turn over upon the back. If the cord again slips down, the same manoeuvre should be repeated, pressure being made upon the abdomen while in the knee-elbow position, that the head may be engaged and prevent the loop from again slipping down. After the escape of the liquor amnii this procedure is not so likely to prove successful. It may be tried, however, and often, if the head can be pushed up, the cord will slip back. The simplest instrument for accomplishing reposition, and at the same time one that is most likely to be at hand, is a gum-elastic catheter. This is prepared by passing the two ends of a narrow piece of tape through the end and drawing them down until they emerge at the eye of the catheter. Allow the loop (an 116 ANOMALIES OF THE FORCES IN LABOR. incli and a half or two inches) to project through the end. This is passed around the cord and shpped over the point of the catheter. Gently drawing down on the ends of the tape which emerge from the open- ing, the cord is firml.y held in position and carried up beyond the he^d by pushing the whole arrangement upward. A^'^^V ^^^ prolapsed portion is well up above the head the catheter alone is withdrawn. The use of the forceps is demanded when, with a roomy pelvis, the cord per- sists in relapsing after being replaced. They should be applied, and as traction is made the cord pushed upward. If after engaging the head the foetal heart shows that the circulation is not interfered with, they may be removed and the labor allowed to terminate naturally. If not, the head must be ra]3idly drawn through the pelvis. It is obvious that this method of rapid delivery should not be attempted unless the pelvis be amply large or the head very small. Version is applicable as a last resort or in cases in which the forceps are inadmissible on account of a small or primiparous pelvis. ANOMALIES OF THE FORCES IN LABOR. PROTRACTED LABOR. State the causes of prolonged labor, and when does the delay occur. Many pelvic deformities and inelasticity of the parturient canal, as well as tumors and foetal deformities, cause prolonged or protracted labors ; but the term is used only in those cases in which the delay is due to a defectively acting uterus. Thus, its walls may be very thin, allowing only weak contractions or perhaps an entire absence of them. This is seen in women marrying too young, as the organ is not fully developed. A conlition of uterine inertia is also frequently seen in multiparae who have borne a large number of children. The organ is, as it were, worn out. Enfeebled constitution and long residence in tropical climates, by enfeebling the nervous powers, cause inertia. Mental conditions, excess oF liquor amiiii, and displacements of the uterus are also causes. The delay, as a rule, occurs in the second stage of labor. However, this is not always the case. A prolonged first stage, if the membranes remain intact, is of little consequence to either the mother or the child, though this is not so if the liquor amnii has drained away, as both the child and the uterus are exposed to constant and oftentimes injurious pressure. State the dangers and symptoms of a prolonged labor. To the child the dangers arise from the ctjnstant and prolonged com- pression of the head, as is shown by the gradual diminution in the fre- quency, strength, and regularity of the foetal heart. To the mother exhaustion comes, as it must with prolonged suffering of any kind. Injury to the soft structures occurs, resulting at times in sloughing and septic infections. The thin uterus, perhaps through interference, per- haps simply through a uterine contraction, ruptures, and death results. PROTRACTED LABOR. 117 Post-partum hemorrhage is of frequent occurrence in these cases, and as a rule is difficult to control. Sym2)to'ms. — Labor perhaps progresses normally until the head has emerged from the os, and then the pains cease or become very infre- quent, irregular, of short duration, and inexpulsive. The pulse, which has been 80 or 90 up to this time, rises to 110 or 120; the patient becomes irritable and very restless. Nausea, vomiting, and a coated tongue, accompanied by a rise of temperature to 100° or 101° F. , now follow. The vagina is hot, dry, and extremely sensitive, and the secre- tions, which have been abundant, are entirely absent. Thirst is intense and a complete loss of appetite is present. If these -symptoms are allowed to continue unrelieved, the vomiting becomes excessive ; delirium occurs, the pulse becomes more rapid, and at last impercep- tible; the temperature rises very high ; the vagina becomes hotter and drier ; and the patient dies with all the symptoms of complete ex- haustion. Describe the management of prolonged labors when delay occurs during the first stage. As has been stated above, it is rare to meet with cases in -^vhich a delayed first stage requires interference ; however, cases will arise where it becomes necessary to resort to treatment of some kind. If labor has been in progress some time, the os is tense and undilated, and the patient irritable, nervous, and wakeful, we should first see that the rectum is emptied by a warm-water or soapsuds enema. A prolonged vaginal douche of a solution of bichloride of mercury, 1 : 10,000, at a tempera- ture of 112° to 116° F., will often alter materially the character and strength of the pains. If more rapid progress does not now occur, chloral hydrate, in gr. x-xv doses every fifteen or twenty minutes until thirty or forty-five grains are taken, will promote dilatation of the os and allow of some sleep between the uterine contractions. Or a hypo- dermic of Magendie's solution of morphine, ■fr^vj to viij, may be given. After a few hours' sleep the patient will awaken refreshed, and labor will now be rapidly completed. As soon as the os is dilated sufficiently to allow of the introduction of the fingers, they should be passed up and swept around the lower segment of the uterus, carefully dissecting the membrane from its walls, as undue adhesion is frequently a cause of tardy or slow dilatation. Often much can be accomplished by the intro- duction of one or two fingers within the cervix, and in the interval between the pains, by gradually stretching it. If all methods meet with failure, recourse may be had to the use of Barnes' hydrostatic dilators. The smallest size is first introduced ; after this is expressed, the second size, and so on until the largest has been used, waiting each time for the natural expression of one before the introduction of a second. In cases where the inertia uteri is due to an over-distended organ from an excessive amount of liquor amnii, the fluid must be evacuated, and in 118 ANOMALIES OF THE FORCES TX LABOR. sucli cases the rupture of the membranes before the dilatation of the os is complete is i)erfectly justifiable. Describe the management of prolonged labors when delay occurs during the second stage. Dilatation of the os is complete, the head enters the pelvis, and here descent ceases. Our first step is to determine the cause of delay — whether it be a weakness of the uterine muscles or a disproportionate head. If the former be the cause, forceps may be used with great suc- cess and perfect safety. Often it will be only necessary to make traction a few times when the pains will return and labor be terminated nor- mally. The second class of cases will be treated of under the head of Obstructed Labor. There are several adjuncts to, or methods of, treating cases of pro- longed labor. The first is the use of oxytocic remedies, or those drugs which, given internally, increase the force of the uterine contractions. The drug which has attained the most widespread reputation as an oxytocic dur- ing labor is quinine. Playfair says : " It has no power in itself to excite uterine contractions, but simply acts as a general stimulant and promoter of vital energy and functional activity." It may be given in doses of gr. XV or XX every twenty minutes until gr. xl or xlv are taken, and often will materially promote the progress of the labor. Ergot has also been used to some extent in these cases, but is absolutely contraindicated. The contractions caused by it are not the regular uterine contractions of a pregnant uterus at term, but rather a constant tonic rigidity, which simply delaj^s labor, and often causes the death of the foetus from the ex- cessive compression to which it is exposed. Strychnine has been used some of late, and with success. Electricity, especially the faradic current, has been used as a promoter of uterine contractions by some, but its utility is very questionable. If applied, the current should be given over each side of the uterus near the fundus. One other adjunct, occasion- ally resorted to, remains to be spoken of This is the so-called manual expression. Its method of application is this : The palms of both hands are applied over the fundus of the uterus, and as soon as a pain begins firm pressure is made in a downward and backward direction. This is extremely ])ainful to the mother, and is rarely attended with any success. Therefore it should not be resorted to excepting under rare circum- stances — namely, a premature child and failure of the uterus to contract when the head is at the pelvic outlet. PRECIPITATE LABORS. What is a precipitate labor ? The so-called })recipitate labor is one which takes place too rapidl5\ It is not of very frequent occurrence, and happens in this way : Just about when labor should begin the woman has one pain, and during the contraction ANOMALIES OF TPIE SOFT PARTS IN LABOR. 119 the child and placenta are horn. This is the true precipitate labor, though we often designate those cases as such in which one expulsive pain, just as the cervix is almost completely dilated, causes the birth of the child ; in other words, cases in which there is no appreciable second stage. State the causes of, and dangers arising from, precipitate labors. Some women are especially afflicted with this form of labor, and the cause is usually a large pelvis, lax parturient canal, non -resisting cervix, and an excessively strongly contracting uterus. The dangers to the child are obviously greater than to the mother. The fact that it may be born at any time and place exposes it to great risks, as well as the danger arising from its falling to the ground if the mother be standing, as is often the case. The dangers to the mother are hemorrhage from rapid delivery or the tearing away of the placenta from its uterine attachment ; inversion of the uterus from the dragging on the cord and placenta ; and perineal lacerations. Is there any method of treating these cases ? If a woman is met with in whom this form of labor has once occurred, she should be kept quietly in the house during the two weeks preceding the expected time of labor. In those cases in which the rapidity occurs during the second stage, chloroform may be administered and the patient cautioned to refrain from all bearing-down efforts. ANOMALIES OF THE SOFT PARTS IN LABOR OBSTRUCTED LABOR. What conditions of the maternal soft parts may cause delayed or prolonged and tedious labors? I. Of the. Uterus and Appemlar/es. — (1) Irregular ante-partum hour- glass contractions ; (2) fibroid tumors; (3) ovarian tumors. II. Of the Os Uteri — (1) Rigidity or spasm of the os ; (2) organic rigidity; (3) occlusion ; (4) cancer; (5) catching of the anterior hp be- tween the presenting parts and pubes. III. In the Vagina. — (1) Atresia; (2) cicatrices; (3) cystocele; (4) rectocele ; (5) rigid perineum ; (6) accumulation of fascal matter in the rectum. IV. At the Outlet. — (]) GEdema of the vulva; (2) thrombosis of the vulva. What is the so-called hour-glass contraction of the uterus ? This extremely rare condition has been described as a constriction of the muscular fibres of the internal os uteri, which is so firm and persist- ent as to cause an almost insurmountable obstacle to the birth of the child. The administration of chloral in full doses is recommended, or complete anaesthesia under chloroform or ether may cause a muscular 120 ANOMALIES OF THE SOFT PARTS IN LABOR. relaxation which will permit of the introduction of the forceps and delivery in this wa}', or the doing of a j^odalic version. Failing in these, Caesarean section must be done. In what situation are uterine fibroids likely to cause the great- est obstacles to delivery? and what is the great danger of fibroids complicating pregnancy? In the lower zone of the uterus or upon the cervix, as they then fill up the pelvic cavity or infringe upon it. and prevent the descent of the foetus. The greatest danger arising from the presence of fibroid tumoi^s is the frequency with which hemorrhage occurs after delivery in these cases. In cases in which the tumor is attached low down, by placing the patient in the knee-chest position it may occasionally be pushed up out of the pelvis, and thus allow of the descent of the head. At other times, when attached to the cervix, it may be possible to remove it by the ecraseur before labor begins if discovered in time. In a majority of cases delivery by the Caesarean section is the only possible method, and the mortality in cases operated upon for this complication has been very high. What can you say in regard to the management of cases in which ovarian tumors complicate pregnancy? If the tumor encroaches upon the pelvic cavity to a degree which in- terferes, to the slightest extent, with delivery, it should be punctured and the fluid withdrawn. If this be not possible, either craniotomy or the Caesarean section must be done. State the causes and treatment of spasm of the os uteri. The rigidity is usually only in the os externum. It is frequently met with in women of a highly nervous temperament and in those cases where the liquor amnii is evacuated at the beginning of labor. A dis- tended bladder or rectum also frequently causes this condition, and as soon as the catheter is passed or the rectum emptied dilatation proceeds normally. Again, we meet with cases where a thick os is the cause of the rigidity. From what has already been said under the treatment of prolonged labors, the management of these cases is obvious. Hot vaginal douches and forcible dilatation with the fingers may both be used, but the remedy par excellence is chloral hydrate. Three most desirable eff'ects are pro- duced by the proper administration of this drug : First, nervous patients become quiet and sleep between the pains; secondly, the frecpienc}' of the contractions is decreased, and they become regular and stronger; thirdly, the os becomes soft and more dilatable. The best method of administration is by the rectum. In what class of cases is organic rigidity of the os met with ? In multiparae who have had extensive lacerations of the cervix with resulting cicatricial masses, and in those cases where a severe endorae- OBSTRUCTED LABOR. 121 tritis or cervicitis has been the cause of the rigidity. As a rule, little or 110 treatment is required, although more rapid progress is made if fre- quent douching is resorted to. What is the cause of occlusion of the os ? and how is it treated ? It is usually the result of an active cervicitis occurring after impreg- nation has taken place. The exudation of the plastic material causes an agglutination of the margins of the os externum. Occasionally, as in the previously described cases, douches will relieve the condition. If not, the patient should be placed in Sims' s position, a speculum intro- duced, and the cervix examined. The position of the os is apparent from a small depression found upon the cervix. With a bistoury two or three small, conical incisions are made at the depression. The finger should then be pushed through the cervix, that we may know the con- dition is relieved, and the labor allowed to progress normally if, as is usually the case, the dilatation progresses as it should. Should pregnancy be allowed to continue if carcinoma of the cervix is present? As soon as such a condition is recognized abortion or premature labor should be induced. All are agreed upon this. If labor begins before the condition is discovered, we should wait a short time to see if dilata- tion progresses to any extent; if not, the cervix is to be incised as already described. Now, if delivery does not occur, we may resort to one of two procedures : craniotomy if the os be sufficiently dilated, or Ci^sarean section ; and, as a rule, in any case the choice lies with the latter. If the cervix is found tightly wedged between the pubes and the head of the child, how would you remove it ? and what are the dangers if it is allowed to remain ? During an interval between the pains the anterior lip is taken between the fingers and thumb and squeezed. This will remove considerable serum from the oedcmatous portion, and during the following pain it can be carefully pushed back over the head. If this proeedure does not suc- ceed, the forceps must be applied and delivery hastened, for prolonged compression of this part results in sloughing and very probably sepsis. Describe the treatment of those cases in which the obstruction occurs along the vaginal canal. (1) Atresiia. — This is a partial closure of the vagina. It may be eon- genital, and is present in the form of a band occluding a portion of the canal. As soon as the head presses against the constriction a nick is made with the knife or scissors, the fingers introduced, and the band torn. Imperforate hymen or thin vaginal septa when met with should be treated in the same way. (2) Cicatnces. — Old and firm cicatrices may be found in the vagina as a result of injuries in former labors, from syphilis, or from severe fevers. Occasionally they may be dilated by the continuous use of Barnes' hy- 122 ANOMALIES OF THE SOFT PARTS IN LABOR. drostatic dilators before labor has begun. If not discovered until labor, as they are made tense by the descent of the head a slight nick should be made with the knife, and dilatation may be accomplished during the birth of the child. Cases of this kind have arisen where craniotomy has been necessary. (3) Cystocde, or prolapse of the bladder and anterior vaginal wall, has given rise to an obstruction, but only in cases where the bladder has been allowed to become distended. As a rule, a soft, elastic male catheter can be passed with little difficulty, and after the withdrawal of the urine the relaxed anterior vaginal wall can easily be pushed beyond the de- scending head. If the catheter cannot be passed, a fine aspirator may be used to puncture the bladder and remove the urine. A few rare cases are on record where with a cystocele a large calculus is present. If the condition is recognized during pregnane}^ — and this is likely to be the case — it should be removed ; if not discovered until labor is well advanced, an attempt must be made to push it out of the pelvis by placing the woman in the knee-elbow position. Failing in this, a vesico-vaginal fistula must be made and the obstruction removed through the opening. (4) Rectocele will never cause an obstruction of any moment unless the bowel be filled with hard f^cal matter. Naturally, in such cases the condition is relieved as soon as the rectum has been emptied. (5) Rigidity of the Perineum may be the result of cicatricial harden- ing after injury during previous labors, but is most often found in pri- mipar?e in whom the pubic arch is narrow. This jDrevents the occiput from fitting snugly under the symphysis, and as a result rupture of the perineum is almost inevitable. When the perineal body begins to bulge, chloroform must be freely administered, and an attempt made to stretoii the right finuer, just under the symphysis; they are then removed, and the distance fnmi the tip of the second finger, which has been in contact with the sacro- vertebral angle, to the index of the left hand is measured. .This gives us the sacro-snbpubic diameter, from which the height of the pubic arch must be deducted. As a rule, this is about l of an inch, which is to be subtracted from the measurement. However, with a broad synqdiysis it will be necessary to deduct :1 of an inch. Wlien no promontory can be Iclt the inference is that labor nuiy take place at term, althouiih ju'lvic deformity may be present, and still we are unable to feel this angle. MALFORMATIONS. 125 Fig What other points should be determined in making the internal examination ? The curve of the pubic arch, which is of considerable importance in recognizing a ''masculine " pelvis. Then by passing the fingers to either side we notice whether or not the same amount of space exists on each side of the sacrum. The curve of this bone must also be determined. In a rachitic pelvis it may be almost flat. How may pelvic deformities be classified? I As those aff'ecting the entire pelvis, j J^^sto-major, ^ ^ ' ( J usto-mmor. 11. Those affecting certain portions of the pelvis, under which are classified the de- formities due to disease — rachitis, osteomalacia, hip dis- ease, etc. Describe the justo-major pelvis. It is one in which all the diameters are equally en- larged. This form of pelvis, as a rule, is not diagnosed, as little if any difficulty during parturition occurs with this class of deformity. The labor is generally rapid, and may even be precipitate. There is likely to be some little in- crease in the irritability of the bladder and rectum dur- ing pregnancy, as the uterus descends farther into the true pelvis, and therefore more pressure is extended upon these parts. In what class of people is the justo-minor pelvis most frequently found ? Describe it. Usually in dwarfs, although it is occasionally met with in well-developed women. It is caused by an arrest in growth, and in these cases all the di- ameters, though in proportion to one another, are shortened, sometimes Method of Ascertaining the Internal Conjugate Diameter. 126 ANOMALIES OF THE PELVIS IN LABOR. as much as an inch or more. Some authors speak of the infantile and undeveloped pelvis as differing from the justo-minor, but it seems as though they might both be classified with the above, as the diameters are in proportion, though all very markedly shortened. The diagnosis of these cases is often not made until labor has begun, and if the amount of contraction be excessive the prognosis is naturally very grave. What is the so-called masculine pelvis ? and how is the deform- ity produced? It is a deep pelvis, narrowed at its outlet by the close proximity of the ischial tuberosities, and hence called a funnel-shaped pelvis. The true conjugate may be normal or even increased in length. The pubic arch is considerably narrowed. Which is the most common variety of contracted pelvis ? The flattened, or that in which the antero-posterior diameter at the brim is shortened. This deformity also occurs in rachitic pelves, but is frequently found unassociated with any disease of the bones. It is pro- duced by a jutting forward and sliding down into the pelvis of the sacrum, and is found chiefly among the poorer classes, who in early life have car- ried heavy weights and done hard work before ossification of the pelvic bones has been completed. Though the conjugate diameter may be con- siderably narrowed, the transverse remains about normal ; and from this fact the differential diagnosis between the simple flattened and the rach- itic i)elvis may be made, for in the latter, though the true conjugate be but slightly shortened, the transverse is very frequently increased in length. Describe the rachitic pelvis. This disease, rachitis, occurring early in life, and producing as it does a shortening and arrest in development of the bones, may give rise to the production of many different deformities, depending upon the influence of the external causes ; for the affection in itself does not cause deform- ity, but renders the bones so flexible that they are easily moulded. The most common variety of rachitic pelvis is the flattened. When this is associated with a backward i)r(jjection of the sym])hysis pubis and a bulging of the iliac bones, we have the "figure-of-eight" deformity (Fig. 34). In the flattened variety the sacrum is short, may be flat or even convex, is depressed, and tipped forward on its transverse axis. The measurement between the anterior sui)erior iliac spines is longer than between the crests, just contrary to what it should be. The pubic arch is increased and the ischial tuberosities sei)arated more than normal. The diameters at the outUit may be ncnirly normal or increased, and the whole [)elvis is shallow. Add to the above a })ackward depression of the symphysis, and the "figure-of-eight" detbrmity is caused. Rachitic MA LFORMATIOXS. 127 women are, as a nile, undersized, with short, curved Hmbs and large, prominent hips. There is often present some spinal curvature, and they Fig. 34. Rachitic Pelvis. usually have a peculiar gait. The head is large and square and the fore- head prominent. Describe the osteomalacic pelvis. Osteomalacia, being a disease of adult life and occurring after the complete development of the bones, the deformities caused by it differ Fig. 35. Osteomalacic Pelvis. markedly from those due to rachitis. As the pelvic bones become soft- ened the weight of the body above and the upward pressure of the 128 ANOMALIES OF THE PELVIS IN LABOR. femora from below cause the deformitj'. The sacrum is depressed and becomes greatly curved, so that the lower and upper pai-ts approach each other. At the same time, this allows the lumbar vertebrae to de- scend and form a projection, narrowing the superior strait. The cotyloid cavities are pushed upward and inward by the femora, and thus both oblique diameters are shortened. The tuberosities of the ischia approach each other, so that the transverse diameter at the outlet is diminished and the rami of the pubic bones come nearly in contact, leaving only a deep fissure in place of the arch (Fig. 35). What is Nagele's pelvis? This is an extremely rare variety of pelvic deformity which received its name from the complete descrip- FiG. 36. tion given of it by N^agele. It is the obliquely oval pelvis caused by an ankylosis of one of the sacro- iliac articulations and a lack of de- velopment of the half of the sa- crum and the ilium on this side. The sacrum is pushed over toward the ankylosed side, and the sym- physis pubis drawn toward the op- posite side. The oblique diameter, which is narrowed, is the one ex- tending from the normal sacro-iliac synchondrosis (Fig. 36) to the ilio-pectineal eminence on the af- Na^et^Tpeivis. fccted side. Describe the transversely-contracted pelvis. This is called the Roberts' pelvis, as it was first described by this writer. It is characterized by comi)lete ankylosis of both the sacro-iliac articulations. The sacrum is also depressed in the pelvis, and the iliac bones flattened, so that there is a marked contraction both at the brim and outlet. It is an extremely rare deformity, but H cases having been recorded. In 6 the Caesarean section was done ; in 2, craniotomy. Describe the pelvic deformity caused by scoliosis combined with rachitis. Scoliosis alone rarely causes sufficient deformity to influence labor to any great extent. Hf)Wover, when complicatiuiz rickets, the extent and severity of the malformation are increased. The internal conjugate is shortened, as well as the oblique diameter at the outlet, and there is a transverse narrowing at the superior strait. There is also an inclination of the sacrum on the side of the lumbar scoliosis. What is kyphosis? and what influence has it upon the pelvis? It is the backward deviation of the vertebral column, and may be con- MALFORMATIONS. 129 fined to one region of the spine or involve nearly its whole length. It may be caused bj" rickets or be due to some local disease, such as caries. The curvature has a tendency to draw the upper part of the sacrum upward and backward, at the same time throwing forward its lower por- tion. The ischial tuberosities are brought nearer together and the jnibic arch narrowed : the result is a deformity in which the antero-posterior diameter at the brim is lengthened, while that at the outlet, as well as the transverse; is shortened. If kyphosis exists with rickets, the de- formity is evel more marked and complex. State the character of the deformity caused by spondylolis- thesis and spondylozemia. It is a narrowing at the brim, sometimes to a very great extent. The cause lies not in the pelvis itself, but by the sinking of the lower lumbar vertebrae into the pelvic cavity ; therefore the narrowing is not of the true conjugate, which remains normal or possibly lengthened, but rather a blocking up of the pelvic inlet. The cause is either a dislocation for- ward of the vertebrge, owing perhaps to disease of the articulations, or the condition known as spond.ylozemia, in which the bodies of the lower lumbar vertebrae are destroyed by caries, allowing those above to sink downward and forward. The deformity is practically the same in either case, though the cause is very diiferent. What other conditions besides those enumerated above may cause deformed pelves? (1) Luxations of either one or both femurs, whether congenital or acquired, may cause deformity. If but one side is aifected, the half of the pelvis corresponding to the injury is less developed, and the pelvis is inchned to this side. The one obhque diameter is diminished. If dis- location be present on both sides, the iliac fossas are pushed closer to- gether, with the result of narrowing the transverse diameter of the cav- ity and increasing that of the outlet. With this deformity there is also an alteration in the planes of the pelvis. (2) Tumors growing upon the bones and obstructing the cavity are of very rare occurrence. Describe the methods of diagnosing a contracted pelvis. In an equally-contracted pelvis the external measurenients will usually show the condition of affairs, and by a digital examination a confirma- tion of the diagnosis is readily made. In the flattened pelvis we get the shortened internal conjugate, with perhaps measurements externally which are normal or nearly so. This is not the case in the rachitic pel- vis, where the external measurements are apt to be considerably altered, as stated above. The transversely-contracted pelvis is determined by finding a shortening of the following diameters : between the crests rind anterior superior spines of the ilia and between the ischiatic tuberosities. Cases due to or associated with spinal curvatures may be diagnosed by the history of the case and an examination of this condition. The posi- 9— Obs. 130 ANOMALIES OF THE PELVIS IN LABOR. tive diagnosis of the obliquely-contracted pelvis is made by letting fall two plumb-lines with the woman in the erect position — one from the symphysis pubis, and one from the sacral spines. In a normal pelvis these will fall in the same plane, while in one obliquely contracted they will deviate considerably. What effects upon pregnancy and labor has a contracted pelvis ? Many times the direct cause of an abortion or miscarriage may be attributed to pelvic deformity. In case this does not occur and the preg- nancy goes on to term, we find the fundus uteri higher than it should be at the period of the pregnancy, the abdominal walls hang forward, and abnormal presentations of the foetus are much more apt to be present than is the case in normal pelves, the greater frequency of face and shoulder presentations being especially marked. Some of the disorders of pregnancy are apt to be much aggravated by deformities. This is especially true of the dyspnoea and circulatory disturbances. In propor- tion to tiie amount of deformity are the risks to both mother and child, and the same may be said in regard to the alterations in the character of the labor. The pains are increased in intensity, depending upon the amount of resistance to be overcome. Labor is prolonged, and before its completion the character of the contractions usually changes, and from being severe, frequent, and regular they become infrequent and irregular, finally ceasing altogether. The os dilates very slowly, owing to the weak pains and the fact that in such cases early ru})ture of the membrane is likely to take place. Then also the cervix is apt to be tliick, as the head has been i)revented from making any pressure upon it by being held above the pelvic brim by the contraction. What can you say of the prognosis to both mother and child in pelvic deformities ? In every case both the mother and child are exposed to more dangers than in delivery through a normal pelvis, but to make a correct prognosis in every case is out of the question. We must be very guarded in our prognosis, and governed entirely by the character and amount of the deformity, the presentation of the foetus, and the period of pregnancy at which the case comes under observation. The greatest danger to the mother is from injury to the soft parts and occasionally to the pelvic joints. Then in those cases where operative interference becomes neces- sary the prognosis is graver. To the child the risks are from prolonged compression, injuries to the head, body, and limbs during birth, and the greater frequency with which prolapse of the funis occurs. Describe the mechanism of delivery in vertex presentations. (1) In generally and equally contracted pelves the occiput is the first part of the head to engage. This becomes jammed down, so that the posterior fontanelle lies low in the pelvis, while the anterior is too high up to be within reach. The resistance now begins. If the contraction MALFORMATIONS. 131 is not too great, delivery will be accomplished in the usual way with a markedly moulded head or craniotomy may become necessary. (2) In a flattened pelvis the head enters the pelvis with it.s biparietal diameter lying in the antero-posterior diameter of the brim : it becomes well flexed, so that the posterior fontanelle comes to lie almost in the centre of the pelvis. In this way descent occurs until the pelvic floor js reached, when internal rotation takes place and delivery is completed in the natural way. The above occurs only in those cases in which the con- traction is not great and the antero-posterior diameter of the brim will allow of the engagement of the biparietal diameter of the foetal head. When the contraction is too great to allow of engagement, flexion does not occur above the pelvis, the bitemporal diameter engages, the head extends, and a brow or face presentation results. (3) In the obliqueb'-contracted pelvis, if the amount of obliquity and the contraction be not too great, the head enters the pelvis in the longer obhque diameter, well flexed. Descent in this same diameter continues until the pelvic floor is reached, when the labor terminates in the natural way. What can you say of the treatment in pelvic deformities ? The treatment resolves itself into one of flve courses — forceps, version, the induction of premature labor, craniotomy or embryotomy, and the Caesarean section. Unfortunately, no hard-and-fast rules applicable to every case can be made, and the course pursued must depend entirely upon the circumstances under which the case is seen. Most authors agree that a live child at full term cannot pass through a pelvis which measures less than 3 inches in the internal conjugate and 4 in the trans- verse, unless it be unusually small. If the case has been under observa- tion from the beginning of pregnancy, and careful pelvic measurements be taken, and if the internal conjugate is not below 2-9- or 2| inches, we should try and carry the pregnancy to a period when a living child might be born, and then induce labor. Nature may complete the delivery after the pains have begun ; and if not, delivery by the forceps is much more likely to give a living child, owing to the softness of the foetal bones and the readiness with which the head may be moulded. The following table, given by Kiwisch and copied from Playfair, may aid very ma- terially in concluding the proper time at which labor should be induced : Inches. Lines. Wlien the sacro-pubic diameter is 2 and 6 or 7, induce labor at the 30th week. 31st " " " 32d " " " 33d " 33d " 34th " 35th " " " 36th " 2 u 8 " 9, 2 11 10 " 11, 3 3 1, 3 u 2 or 3, 3 a 4 " 5, 3 11 5 " 6, 132 ANOMALIES OF THE FCETUS. Barnes says — and his opinion is corroborated by many other authors — that either version or the forceps is appHcable to the pelvis of 3.1 to 3.5 inches in the internal conjugate. Many objections have been raised to the use of the forceps, especially by the German obstetricians, some of which are the difficulties of introducing the blades and the danger of causing injury to the maternal structures. If the head is seized by the occiput and forehead, it is maintained that their compressive action will decrease its long diameter and increase the transverse. All these objec- tions are certainly open to criticism. Many believe it much easier to pull the after-coming head through a contracted brim than to draw the before-coming head down by the for- ceps, and therefore favor version. It is certainly true that version will succeed where the forceps have failed. In pelves between 3 and 3t inches version should be attempted. Between 3^ and 3j either is per- fectly justifiable. Above 3* the forceps should be tried, and if without success version may be done. In all pelves below 3 inches craniotomy or the Caesarean section must be resorted to. The latter is certainly not indicated in pelves measuring more than 2| inches in the internal con- jugate, unless the child be unusually large. ANOMALIES OF THE FCETUS. PLURAL BIRTHS. State the causes of dystocia in multiple pregnancies. Inertia uteri, owing to the excessive distension of the organ, the pres- entation of parts of both children simultaneously, and the interlocking of the two heads in cases where one child presents by the vertex and the other by the breech. Does the management of a normal twin labor differ from that of a single labor ? It does not. As soon as the first child is born and its cord tied and ciit the child should be removed. Then we should wait a short time for the uterine contractions to recur. If they do not come on within a few minutes, the membranes surrounding the second foetus ought to be rup- tured and gentle friction made over the fundus. If this does not pro- duce contractions, the forceps may be applied, provided the head has entered the pelvis, or a version may be done if this is not the case. Either will be comparatively easy, as the parturient canal has been well dilated by the birth of the first child. How would you treat a case in which both heads were found presenting ? By introducing the hand in the vagina and the fingers into the uterus an attempt may be made to push one child up out of the way. The FCKTAL DYSTOCIA. 133 forceps are then applied to the other, that it maybe "engaged," and thus prevent a reeiuTence of the complication. If both heads have entered the pelvis — and such cases are recorded — it will probably be impossible to push one back into the uterus; in which case the forceps might succeed in delivering, though probably perfora- tion would be necessary. In what class of cases does interlocking of the heads occur ? In those cases in which one child presents by the breech and the other by the vertex (Fig. _ ot). The former is born as far as the head, when delay occurs. An exam- ination now reveals the presence of the head of the second fcetus within or at the brim of the pelvis, and the under part of the chins of both infants in contact. We must try to push the second child back, as in the case described above ; or, if this is not possible, the forceps may be ap- plied and an attempt made to draw the head past the body of the first child. If neither means proves successful, decapi- tation of the first child must be resorted to. This can be done by the scissors or ecraseur; the body is then delivered, and after- ward the second head re- moved with the forceps. Fig. 37. Locked Twins. FCE3TAL DYSTOCIA. What are the simplest forms of foetal dystocia? and under what circumstances are they found? (1) An exceedingly large child ; (2) premature ossification of the bones of the skull. These may both be met with in women marrying late in life, though the excessive sign of the child is the more frequent cause of dystocia under such circumstances. Our first recourse is to the forceps, and if delivery cannot be accomplished craniotomy must be done. 134 ANOIMALTES OF THE FOKTTJS. When, as occasionally happens, the delay is of the shoulders and occurs after the birth of the head, traction may be made by drawing on the head or by the introduction of the fingers in the axillae, and will usually be successful. If not, the arms, one after the other, must be disengaged and drawn down. HYDROCEPHALUS. ENCEPHALOCELE. State the method of diagnosing intra-uterine hydrocephalus. Abdominal palpation will often lead us to suspect the condition, if it be present, on account of the disproportion between the head and breech. On vaginal examination after the rupture of the membranes, the head is felt as a large fluctuating mass with enormous fontanelles and broadly- separated sutures. The bones are apt to be very thin, and for this reason the head has been mistaken for a second bag of waters. "What can you say of the prognosis and treatment in these cases ? The prognosis both for mother and child is very grave. The dangers to the mother are from rupture of the uterus and injury to the soft parts. The treatment varies according to the presentation. If the disease is but slightly developed, it may be possible to deliver by the forceps in vertex cases ; and under such favorable circumstances there is likely to be little if any difficulty in delivering the head, provided the child pre- sents by the breech. In most cases, however, craniotomy will be neces- sary. Of course in breech cases the perforation must be made through the occipital bone. Name the congenital tumors of the skull whicli may cause dystocia. Meningocele, which is a tumor over some point of the skull made up of a portion of the meninges protruding through a congenital opening of the bones. This rarely, if ever, causes a delaj^ed labor. Encephalocele is the same as the above, excepting that some brain-sub- stance in addition to the meninges is contained within the tumor. Hijdro-encephalocele contains meninges, brain-substance, and _ fluid. This is the only form of the three which might cause delay in the labor. If .so, it should be punctured and the fluid evacuated. The further progress of the labor will not be materially influenced. Dropsical effusions in the thorax or abdominal cavity, and malignant tumors of the liver, spleen, or kidneys, have occurred with resulting delay, but these cases are extremely rare. MONSTROSITIES. What is an anencephalic monster? One devoid of a brain. The head is extremely small and rests directly HEMORRHAGES, INJURIES, AND ACCIDENTS OF LABOR. 135 upon the shoulders ; the eyes protrude and look almost in an upward direction ; the tongue most frequently' protrudes from the moutli. What forms of double monsters are described ? (1) Two complete foetuses, normally constituted, but united at some point. The fusion may be either back to back, in which case it is at the sacrums; the two heads may be united ; or the union may take i)lace in front, when it generally extends from the umbiHcus to the upper part of the thorax. (2) A single body with two heads. These are made up of two bodies also, but they are so fused that no evidences manil'est themselves exter- nally. The progress and mechanism of dehvery in this class of cases must necessarily vary considerably, depending upon the form of the monster and its presentation. If both heads present, one head may be born, then the other, and afterward the bodies, or mutilation of the infants must be resorted to. In case the two heads attempt to enter the pelvis at tbe same time, and one cannot be pushed back, craniotomy nuist be done, unless the labor is a premature one or the heads are very small. CHAPTER VI. HEMORRHAGES, INJURIES, AND ACCIDENTS OF LABOR. HEMORRHAGES DURING AND AFTER DELIVERY. Do severe hemorrhages ever occur during labor ? and what is the source of the blood if hemorrhage does occur at this time ? They do not, unless from placenta praevia or a low implantation of the placenta. There may be a little flood of blood from lacerations of the cervix or the os. These cease spontaneously, and only occur while dilata- tion is going on or just as the second stage is reached. Or some hemorrhage may occur from abrasions or tears of the vaginal mucous membrane or perineum. These take place as the head passes through the pelvis or escapes from the vulva, and are ver}^ rarely seri- ous. It occasionally happens in extensive injuries or lacerations that some large vessel is ruptured, but the position is such that clamping and hgation, if necessary, may be easily done, so that little if any harm ever results. What is a post-partum hemorrhage? and what three varieties are met with ? A post-partum hemorrhage is a hemorrhage occurring from the uterus 136 HEMORRHAGES, INJURIES, AND ACCIDENTS OF LABOR. after the birth of the child. This may be ( 1 ) immediately after the child is born, but before the third stage is completed ; (2) after the birth of the placenta; (3) some hours after labor is completed. This last variety is called " secondar}^ post-partum hemorrhage." An alarming flow of blood may take place after the child is born from a badly-lacerated cervix, cases even occurring where the circular artery of this part of the uterus has been ruptured. These are not true post- partum hemorrhages, though unless care is taken they might easily be thought such. A vaginal examination reveals the condition, and the treatment con- sists in passing a wire suture through the cervix, so as to close the rent and thus check the flooding. State the frequency and causes of post-partum hemorrhage. It is an extremely frequent complication of labor unless the case be managed properly throughout, under which circumstances it rarely occurs. The one cause is uterine inertia. This may be brought about or pro- duced in many ways. One very frequent cause of inertia is over-disten- sion of the organ from twins or hydramnion. Prolonged labors, from exhausting the muscles ; precipitate labors, in which the uterus is so rapidly emptied that it does not contract; and rapid forceps deliveries, — bring about the same result. A debilitated or exhausted condition of the mother from albuminuria, anaemia, or other diseases, and emotional causes in neurotic women, are also productive of the accident. The causes of secondary hemorrhages may be any of the above, and in addition the retention within the uterus of portions of the placenta, the membrane, or large blood-clots. Any exertion, such as turning quickly upon the side or rising suddenly in bed, may cause it, as well as the free use of cardiac stimulants. Local conditions, in the way of dis- tended bladder or full rectum, have also caused severe hemorrhage, as also the different forms of displacements, especially retroflexion. What are the symptoms ? The flow of blood may occur suddenly and with a profuse gush, or may begin as a slight trickling, which continues onl}' as such or later becomes more profuse. This may be the only symptom if the hemor- rhage is immediately checked. If not. all the signs accompanying the loss of blood follow. The face becomes pale and anxious, the extremities cold, the pulse rapid and feeble ; blindness and possibly sync()])e occur, or perhaps extreme restlessness supervenes and the i)atient throws her- self about on the bed. The so-called "air hunger" is developed, the patient taking short, rapid respirations and crying for air; then a con- vulsion may occur, and in this the woman dies. In ca.ses of secondary liemorrhage we may be deceived in looking on the vulvar pad i'or blood and finding none, and so attribute the symptoms to some other cause. The absence of the flow is owing to the formation HEMORRHAGES DURING AND AFTER DELIVERY. 137 of a clot at the cervix, wliicli prevents the escape of the blood externally, and the onl}- thing found on the dressing is a little clear serum. In an}' case an examination of the abdomen immediately reveals the condition. We find, instead of the hard, rounded uterus, a soft, flabby- feeling abdomen, and are perhaps unable to map out the uterus, or, if we do make it out. it is large- with the fundus high up. What is the treatment ? The treatment should be — (1) Preventive. — From the time the head has emerged from the vulva until at least half an hour or three-quarters of an hour after the placenta has come away, the hand should be kept over the fundus of the uterus to prevent its relaxation. Then, as soon as a careful examination of the l^lacenta and membranes shows them to be intact, a full dose of the fluid extract of ergot (3j-.^ij) should be given as a routine practice in every case, and at the end of three-quarters of an hour the binder applied. The patient must be moved carefully and gently, and. above all, kept from any form of excitement. If the above is carefully carried out in every case, a post-partum hem- orrhage will be an extremely rare occurrence. (2| Curative. — Our energies are all directed toward one thing, and that is to excite uterine contractions. Faihng in this, recourse must be had to the use of styptics. The former is Nature's method of checking and preventing uterine hemorrhage, and unless all the reflex irritabihty of the organ is gone it will be successful. As soon as the placenta is separated from the wall, which occurs dur- ing the last few pains, the muscular fibres contract firmly, completely closing the orifices of the torn utero-placental vessels : thrombi now form in these vessels, and, even though shght relaxation of the womb does occur, no hemorrhage results. Therefore, if we can bring about this condition of afl"airs when it does not take place, we accomplish what Nature has neglected to do. If the hemorrhage takes place before the birth of the placenta, sufiicient friction over the fundus to cause a con- traction and the delivery by Crede's method will generally be immedi- ately followed by a cessation of the flow. However, we find cases where repeated attempts at Crede's method of expression fail, and in such cases the secundines must be removed by the introduction of the hand into the cavity of the uterus. With the umbilical cord as a guide we slowly pass the hand, which has been made thoroughly aseptic, into the uterus, and, reaching the placenta, carefully insert the fingers between it and the uterine wall, and gently dissect it ofl". Extreme care must be taken not to injure the delicate membrane lining the uterus, for it is at times difficult to distinguish between it and the placental tissue. A thorough uterine irrigation should follow any procedure of this kind. If the hemorrhage occurs after the birth of the placenta, immediately attempt to excite contraction by fiiction over the fundus, and give the patient a full dose of ergot, or, better still, a hypodermic of ergotin. 138 HEMORRHAGES, INJURIES, AND ACCIDENTS OF LABOR. While this is being done the nurse or assistant should be preparing a hot douche of carbolic acid, 1 : 80, or bichloride of mercury, 1 : 5000 or 8000, at a temperature of 118° to 120° F., and with a Chamberlin's tube an intra-uterine irrigation is given. The hemorrhage continuing after one or two pints have been used, we should not continue this longer, but re- sort to some other method of causing conti-action ; and one of the sim- plest and at times most effective is ice. iV piece about the size of a walnut is carried up into the interior of the uterus and rubbed about its wall. If the organ does not respond, do not use a second piece, but if a faradic battery be at hand use a current with one pole over tlie fundus, the other in the uterus. The foot of the bed should now be elevated, and compression of the abdominal aorta may be tried before styptics are used if the hemorrhage continues. The aorta can be distinctly felt above the fundus uteri, and may be pressed against the vertebral column by placing the side of the hand erossways over it. This procedure is of very doubtful utility. The three styptics most commonly employed are vinegar, the subsul- phate of iron (Monsel's solution), and tincture of iodine. The first is used by soaking a cloth or piece of gauze in the vinegar, passing it up into the uterus, and squeezing it out. The others should be used only in solution. The strength of the solution of the subsulphate of iron may be about 1 : 4, and of the iodine 1:2; but never employ either unless you are sure of an avenue by which the fluid can escape. To be positive of this, pass two fingers through the cervix, so as to keep it open, and have a hand placed over the fundus of the uterus. Our methods must all be supplemented by treatment directed to the general condition of the mother. Hypodermic injections of ether, whis- key, caffeine, strophanthus, digitalis, etc. may be necessary ; hot bottles should be placed about the patient, the i)illows removed from under her head, and the extremities bandaged. For this purpose ordinary cloth bandages may be used, being applied moderately tight from the toes to the pelvis and from the fingers to the shoulders. These may be left on until the patient rallies somewhat. Absolute quiet must be enjoined, and the hand kept over the fundus of the uterus for several hours at least. Remove all soiled clothing from about the patient without moving her, and after a few minutes give a teaspoonfid of brandy in liot water. If the stomach will retain this, the dose may be repeated every fifteen minutes until the heart begins to respond. If it is rejected, hypodermic and rectal stimulation must be resorted to. For the latter 8 to 16 ounces of liot water containing an ounce of brandy may be given through a rectal tube. At the end of a few hours small quantities of beef juice or mutton broth will usually be tolerated by the stomach. The patient should not be disturbed to change or remove the bed-clothes for at least fifteen or twenty hours. 'IMie treatment of secondary hemorrhage is ))racti('ally the same as that for priniary, excepting that we must bear in mind the fact that this form is generally caused by the presence of some foreign body within the ute- INVERSION OF THE UTERUS. 139 rine cavit.v. Therefore our jBrst procedure will be to carefully remove this, whether it be placental tissue, membranes, or blood-clots, by the intro- duction of the hand. Afterward a douche is given, and as a rule firm contraction results. Always see that the bladder and bowel are empty. In all cases of hemorrhage the loss of blood may be so excessive that transfusion or infusion becomes necessary. The method of doing this will be described later. The after-treatment consists in the administration of a full, nutritious diet, tonics, and iron. INVERSION OF THE UTERUS. What is inversion of the uterus ? It is the partial or complete turning inside out of the large, empty post-partum organ. As a nde. it begins as a shght depression of the fundus, which may remain so or continue to sink until the entire mucous coat is outside and the peritoneal inside. The former is called partial, the latter complete, inversion. If the condition is seen and successfully treated immediately after its oc- currence, it constitutes the so-called acute form, but if allowed to remain in its abnormal condition and adhesions form, it becomes chronic. Be- sides beginning at the fundus, cases are recorded where the inversion has begun at the cervix. State the causes of inversion of the uterus. There are three conditions which favor this accident — namely, uterine inertia, pressure from above, and traction from below. Naturally, a combination of the three might operate at the same time, under which circumstances the unfortunate occurrence would very likely result. When due to accident the causes generally given are traction on the cord while the placenta is still adherent to the uterine wall : a very short cord or one wound about the body of the infant : too rapid a delivery ; delivery in the erect posture : and strong efforts at straining on the part of the woman. Spontaneous inversions also occur. These are due to irregular con- tractions of the uterus. In some cases there is a relaxation or atony of the cervix and lower segment, while the fundus is in a state of active contraction. In others probably the reverse of this is the case : the atony is in the fundus and upper portion of the organ. Describe the symptoms. Pain, shock, and hemorrhage are always present in complete inver- sions. The former is excruciating, often causing the patient to cry out at the top of her voice with the suffering. The shock is due both to the pain and hemorrhage, as well as the withdrawal of the uterus fi'om the abdominal cavity. The pulse becomes rapid and feeble, the face pale 140 HEMORRHAGES, INJURIES, AND ACCIDENTS OF LABOR. and anxious, the extremities cold; there may be vomiting, sj^ncope, con- vulsions, and death, or the acute onset of the sj'mptoms is followed by remission, during which they all improve. How is a diagnosis made ? The above symptoms, occurring immediately after labor, would nat- urally lead one to suspect this condition. On examining the abdomen the hard, rounded fundus is missed, and, rarely, the depression may be felt even through the abdominal wall. A vaginal examination reveals the presence of a rounded tumor, to which the placenta is possibly attached. If only partial inversion exists, the tumor will be ab.sent. The condition is likely to be confounded with but one other — a uterine polypus — and here only when it occurs some days after delivery and comes on insidiously. The introduction of the sound will soon clear up the case. If a polypus be present, it will pass by it and up to the fundus of the uterus, but in a case of inversion it is arrested low down. What can be said of the prognosis ? It is always very grave. The primary dangers are both from shock and hemorrhage, while subsequently sepsis may occur from a sloughing of the uterus in consequence of constriction of its neck. This is more likely to follow if the condition is not relieved at the time of its occur- rence. State the treatment. In every case the immediate restoration of the organ to its normal condition is indicated ; and this is usually attended with little difficulty if no delay occurs in making the attempt. Every minute passed ren- ders reposition more difficult. An anaesthetic should be administered in every case unless the patient's condition is such as to render it dangerous. If there be but a partial inversion and only to a slight extent, direct pressure with the fingers of one hand against the inverted jwrtion, and counter-pressure with the other hand over the abdominal wall, are generally productive of good results. If the inversion be complete, one of three courses of ])rocedure may be adopted: (1) direct uinvard pressure of the uterus grasped in the hand and in the axis of the jiarturient canal ; (2) pressure directly upon the fundus with the fingers made in the shape of a cone or with the fist; (3) Noeggerath's method, which consists in ])lacing the index finger on one side of the uterus near the entrance of the Fallopian tube, and the thumb on the other. First one side is indented and then the other, and when this has been accomplished direct jiressure is made on the centre of the inverted mass until reduction is complete. In all these methods counter-pressure is made with the other hand through the abdominal wall. RUPTURE OF THE UTERUS. 141 After reduction the hand should not be removed from the uterine cavity until firm contraction is obtained and the placenta is dissected from its attachment. The latter must not be removed before the inver- sion is relieved, as severe hemorrhage would likely result. An intra- uterine douche must always follow. If the condition receives no treatment until daj^s or weeks after its occurrence, taxis may still be tried, but is not as likely to meet with success. Failing in all attempts at reposition, extirpation of the organ must be done as a last resort, though cases are recorded where spontaneous reduc- tion has occurred. RUPTURE OP THE UTERUS. What extent of uterine rupture is seen ? There may be rupture of the neck alone, of the body alone, or of both at the same time. The laceration may extend in a longitudinal, transverse, or oblique direction, and it may be complete or incomplete. Incomplete rupture extends only through the muscular wall, while com- plete involves the entire thickness, passing through the peritoneal cov- ering. The usual seat is on the posterior surface, and more frequently on the left side of the median line. What can you say of the frequency and causes of uterine rup- ture? Statistics vary greatly in regard to this most terrible accident of partu- rition. It fortunately is extremely rare, occurring probably not oftener than in 1 in 4000 cases. It io OMly *«ed through it and is visible at the vulva. What is the prognosis? Very grave. Death may occur immediately from shock or hemor- rhage. The child ahnost invariably dies. For the mother the prognosis depends considerably upon the extent of the laceration, and \yhether or not the foetus has escaped into the abdominal cavity. Statistics show about 10 or 15 per cent, of recoveries. State the methods of treatment. J^(>j)hi/l(icfic. — This consists in terminating a labor which is becoming so prolonged as to cause a thinning of the lower uterine segment, and in immediate delivery, either by craniotomy or embryotomy, in case a very thin lower segment is found. All rough or improper manipulations during labor are to be avoided. In case rupture has occurred, one of two courses is to be pursued, depending upon the conditions present (any form of expectant treat- ment is never justifiable): ACCIDENTS TO ^lOTHER, AND SUDDEN DEATH. 143 If the rent be small and the child has not escaped into the abdominal cavit}^ deliver as rapidly as possible. Whichever method offers the g-reatest chance for a speedy delivery should be employed, whether it be the use of forceps, version, craniotomy, or embryotomy. After the birth of the child, carefully and gently remove the placenta and wash out the uterine cavity with warm distilled water. If the foetus has partially or wholly escaped into the abdominal cavity, laparotomy is the only treatment. Remove the child and blood-clots, wash out the abdominal cavity, and sew up the uterus. Some go so far as to recommend laparotomy in every case of ruptured uterus, though the majority are hardly of the opinion that this course is justifiable. The after-treatment consists in stimulants, a light nutritious diet, opium if necessary, and the introduction of a long glass drainage-tube into the uterus and just through the rupture if laparotomy has not been done. At the end of a few days, when adhesions have formed, the uterine cavity, if necessary, may be occasionally irrigated with warm sterilized water. ACCIDENTS TO MOTHER, AND SUDDEN DEATH. Name the injuries which may occur along the parturient canal during labor. (1) Lacerations of the Os Eccternvm. — These almost invariably occur with every labor, and are of no consequence. (2) Lacerations of the Cervix. — These may be slight and confined to one side only (unilateral) ; they may take place on both sides (bilateral) ; or there may be lacerations throughout the entire circumference of the cervix ^stellate). Cases have occurred where a narrow ring of the cervix has been torn away. It rarely happens that any immediate treatment is necessary unless the hemorrhage be profuse, in which case the application of some styptic (subsulphate of iron) will immediately check the flow of blood, and the cervix. may be repaired after the woman has recovered from the effects of parturition. (3) Lacerations of the Vagina. — These never become grave unless occurring in the upper portion of the canal. A few cases are recorded where the rent has taken place in the vault and fornix, causing symptoms similar to those occurring with rupture of the uterus. However, they are extremely rare. Injury farther down should be repaired when labor is completed. (4) Tears of the Vulva will, as a rule, be of little moment unless such injury occurs as to cause thrombosis. This condition has already been described. (5) Injuries to the Petnneum. (6) Injury to the Pelvic Jrn'nts. — This rare occurrence may be the result of violent deliveries, especially when some disproportion exists between the 144 HEMORRHAGES, INJURIES, AND ACCIDENTS OF LABOR. head and pelvis, or it may be the result of pathological changes in the articulations. It consists in a slight tearing apart or loosening of one of the joints, most frequently the pubic. Some pain upon moving about will be the only symptom. The treatment consists in the application of a bandage which will render the joint immovable. Complete rest must be enjoined. State the causes of sudden death during or immediately after delivery. (1) Exhaustion and suffering (very rare) ; (2) air in the uterine sin- uses; (3) mental emotion; (4) affections of the respiratory organs (acute pulmonary congestion and oedema); (5) thrombosis and em- bolism; (6) rupture of the aorta from increased tension, owing to the uterine contraction; (7) diseases of the heart. A few other causes of sudden death at this time have been described, but they are of extremely rare occurrence. Many causes have already been described — inversion and rupture of the uterus, hemorrhage, etc. Is death from emotional causes often seen? It is not, though a few cases are recorded where extreme joy or sor- row has been the cause of sudden death after labor, and in which an autopsy revealed no pathological conditions. State the causes and symptoms of the access of air in the uterine sinuses ? Air enters the uterine sinuses generally from improper management of the patient immediately after labor, though it may be a purely un- avoidable accident. Carelessness in allowing air to pass through the tube in giving an intra-uterine douche, and in carrying the hand into the uterus when this is necessary, is the most frequent way. The symptoms are extreme pallor, dyspnoea, perhaps vomiting, col- lapse, and death. What disease of the heart most frequently causes death at this time? Fatty degeneration alone or associated with dilatation. ltui)ture of the organ may occur from a myocarditis, as well as the above, and is sometimes due to violent straining efforts. What are the usual seats of puerperal thrombosis ? State the causes ? The j)ulnionary arteries and the right side of the heart are the usual seats. The primary causes of thrombosis are some mechanical obstruc- tion, around which coagula form ; an imi)eded or arrested circulation ; and i)athological changes in the blood which render it more easy of coagulation. The fact that at least two of these conditions exist in the puerperal state renders the accident more frequent at this time than under ordi- INDUCTION OF ABORTION AND PREMATURE LABOR. 145 nary circumstances. The blood of the post-partiini woman is very coag- ulable, owing to the increased amount of fibrin already spoken of; then the exhaustion, and perhaps hemorrhage, immediately succeeding labor predispose to thrombosis. The great majority of cases occur after a post- partum hemorrhage. Describe the symptoms. Either a thrombosis of the pulmonary vessels or of the right heart causes practically the same symptoms, though in the latter death is likely to occur more quickly. No premonitory signs occur, and the patient seems to be doing well when she is suddenly attacked with the most violent dyspnoea. The face is either cyanotic or pale, and the struggles to get air are frightful. The pulse is rapid and feeble or en- tirely absent : there is a sense or feehng of impending death, which may occur almost immediately in a convulsion, or the symptoms may improve somewhat. The 2^yognosis is very grave, though cases have recovered and the clot become absorbed. Is there any treatment for this condition? Death generally results too soon to allow of any plan of treatment being carried out. If this does not occur immediately, we should keep the woman at absolute rest and administer stimulants. What can you say of embolism ? It is an obstruction to the circulation, the result of either a detachment of a portion of a thrombus or of a detached vegetation from one of the cardiac valves. The i^ymptoms, if it occur in the pulmonary artery and right heart, are exactly the same as those described above, though their onset may be more gradual. CHAPTER VII. OBSTETRIC OPERATIONS. INDUCTION OP ABORTION AND PREMATURE LABOR. State the most frequent causes demanding the induction of abortion. (1 ) Extreme contractions of the pelvis (below 2 inches) ; (2) encroach- ment of large tumors on the pelvic canal; (3) cicatrices of cervix or vagina not admitting of dilatation ; (4) some cases of cancer of the cer- vix; (5) irreducible retroversion or procidentia of the uterus; (6) fixing of uterus by adhesion ; (7) some uterine tumors ; (8) uncontrollable vom- lO—Obs. 146 OBSTETRIC OPERATIONS. iting with profrressivc emaciation and exhaustion; (9) some cases of albuminuria witli nephritis; (10) some cases of chorea and insanity'; (11) placenta praevia: (12) heart diseases with extreme dyspnoea; (13) C3^stic degeneration of the chorion (McLane). When should premature labor be induced ? Premature labor is anj^ labor occurring after viability of the child, but before full term. Any condition, either of the mother or child, which would render dangerous or fatal the continuance of pregnancy calls for the induction of premature labor. Conditions of the foetus demanding it are (1) an habitually large size of the head or premature ossification of the bones of the skull, as shown by former labors. In this case the woman should be allowed to go nearly to term. (2) Repeated deaths of the foetus in utero during the latter part of gestation. This is caused by some form of degeneration of the pla- centa. (3) Death of the foetus in utero. Conditions of the mother which call for this operation may be anj^^ of those mentioned under the indications for abortion : pelvic deformity, forbidding dehvery at term ; uncontrollable vomiting ; advancing albu- minuria, or jaundice ; eclampsia ; placenta pr?evia ; hj^dramnion, when dyspnoea is urgent ; extensive ascites ; grave diseases of lungs or heart ; tumors, etc. It should always be borne in mind that neither an abortion nor a premature labor should ever be induced without a consultation, unless the case be urgent and no time allowed for calling a consultant. When is the period of viability ? There is a fair chance for a living child after 210 days, though between this time and 230 to 240 days there must be a strong feeling of uncer- tainty. After 250 days we may feel sure of a living foetus. Always count from the last day of the last menstruation. What should be the prognosis when labor is induced ? Always guarded, though depending almost entirely upon the cause demanding the operation. The uterus is not ready to expel its contents ; manipulations are neces- sary ; hence greater risks of hemorrhage and sepsis ; not only these, but the condition of the mother calling for the operation may be such as to add other dangers. For the child it is never very good unless the gestation be near term. What is the best method of inducing abortion ? Puncturing the membranes with a Sims sound. Contractions, as a rule, will soon come on, and the foetus, membranes, and j^lacenta all be expressed. If any of the secundines be retained, the cervix must be more fully dilated, and with a dull curette the entire cavity cleaned out. The fin^^ers are preferable to the curette if the pregnancy has advanced to the fourth month. Bear in mind the fact that absolute cleanliness INDUCTION OF ABORTION AND PREMATURE LABOR. 147 and antisepsis must be observed in the performance of tlie ()i)eration. Tliorough cleansinu' of the i)arts about tlie vulva, a vaginal douche, ster- ilization of the instruments and the hands of the operator and his assist- ants, must precede any manipulation. The after-treatment of abortion is just as it is for labor at full term. Mention the different methods for the induction of labor, and state which are the best. (1) Rupture of the membranes; {2) intra-uterine douches; (3) intro- duction within the uterus of a gum-elastic catheter or bougie ; (4) dilata- tion of the cervix ; (5) vaginal douches ; (6) tamponing vagina ; (7) elec- tricity (either the galvanic or the faradic current) ; (8) use of medicines, cither oxytocics or purgatives. Several others have been used, but are entirely discarded. Among those mentioned, but two should be used, taking as adjuncts some of the others. These are puncture of the mem- branes and the introduction of a flexible bougie. Combined with either of these, vaginal douches, dilatation of the cervix, and tampons may all be of great utility in some cases ; but the use of any of the latter three alone is to be discouraged. Describe the steps to be taken in inducing labor in a case of albuminuria or a contracted pelvis. The methods now to be described are to be pursued in all cases where time is allowed. In some cases of placenta pnievia or eclampsia, as has been mentioned, the immediate rupture of the membranes is indicated : (1) Preparation of the patient and the selection of the time; (2) preparation of the implements, operator, and assistants ; (3) introduction of the bougie ; (4) removal of the bougie. The evening is, as a rule, ])referable for introducing the bougie : as the pains generally will not l)cgin before morning, the labor may be terminated by the following- night, and thus neither patient nor physician loses any sleep. Tlie preparation of the woman consists in giving her a warm vaginal douche of bichloride of mercury, I : 5000, or of carbolic acid, 1 : 60 or (SO, emptying the bowel by an enema, and noticing that the bladder is also empty. She should then be placed so that the buttocks come to the edge of the bed. A gum-elastic bougie (No. 12 American is a desirable size), perfectly new, should be placed either in a solution of carbolic acid, 1 : 20, or of bichloride of mercury, 1 : 1000 (cold), and allowed to be thoroughly immersed for at least half an hour before its introduction. A needle carrying a long piece of silk suture should be passed through the end of the bougie, that it may be easily withdrawn when necessary. Cotton tampons, sterilized, are to be at hand. The hands and arms of the physician and his assistants must be scrubbed with soap and water, washed with alcohol or ether, and submerged for a miiuite or two in the bichloride solution. Everything now being in readiness, a little chloroform is given. The first two fingers of the right hand are introduced to the cervix, and, 148 OBSTETRIC OPERATIONS. using them as a guide, the bougie is passed through the os into the uterus. Very gentle pressure must be exerted, to prevent if possible rupturing of the membranes. If any obstruction be encountered, the bougie should be immediately withdrawn, as it has probably come in contact with the placenta. Now introduce it on the opposite side. At least eight or nine inches are passed into the uterus, one or two tampons introduced to prevent its slipping out, and an aseptic vulvar pad applied. It sometimes happens that the os is too tightly closed to allow of the introduction of the bougie. If such be the case, some dilatation must first be accomplished by the employment of a pair of hard dilators or the finger. A bougie is preferable to the gum-elastic catheter, as it contains no opening or eye through which air or sepsis might get up into the uterus. At the end of a few hours the pains will usually begin, and when the patient is seen in the morning labor may be well under way. Now re- move the tampon. From now on the case is to be managed as one of normal labor, only that the bougie must be withdrawn when the os is about one-half or two-thirds dilated. Is it ever necessary to resort to other methods or means? It is. Though uterine contractions may begin within a couple of hours, cases occasionally go for days without labor beginning. The in- strument should not be allowed to remain longer than twenty-four hours if the desired results do not follow. Remove it and introduce another in some other part of the uterus, or first dilate the cervix with Barnes' bags. This is frequently a very valuable accessory. In case rajiid delivery should become imperative after contractions have begun, the dilators may also be used until the cervix will admit of the application of the forceps. What care should a premature infant receive? It must be carefully wrapped in plain cotton and kept in a warm place. Do not allow a bath to be given for two or three weeks at least. It should bc/^^(/, and not allowed to nurse, as the effort is too exhausting. If possible, a wet-nurse ought to be obtained, and, beginning a few hours after birth, she should squeeze from her breasts a couple of teaspoonfuls of milk, which may be given to the child with a si)oon or medicine- dropper every couple of hours during the night as well as day. VERSION. What is version? Version or tui-ning is the operation by which the position of the foetus in utero is altered, so that some one portion of the body is substituted for the part originally presenting. There are two general varieties : cephalic^ or the substitution of the head for some other part ; and podalic^ or the substitution of the feet for another part. VERSION. 149 How may versions be done ? Either cephalic or podaHc may be clone by o;f6T?ia? manipulations alone, by internaJ manipulations alone, or by external and internal combined. ''Bimanual " means the using of both hands. "Bipolar" means tliat during the operation both poles or extremities of the foetus are acted upon by the two hands. State the indications requiring cephalic version, and what con- ditions are favorable to its successful performance. Malpositions of the foetus are the general indications for this variety of version, and more especially transvei^se or shoulder presentations. It may also be indicated in slight pelvic contractions, where during the last month of gestation the head lies out of the pelvis in one iliac fossa. Some advise its performance in breech presentations. It is contraindi- cated where, from one cause or another, rapid deliver}^ is desired. The conditions which make the operation most favorable are — an un- ruptured amniotic sac : a movaVjle foetus : an opportunity of operating before labor has begun, or at least before the pains have become strong and the os dilated ; a multipara. Describe the method of doing an external cephalic version. The patient is placed upon her back, with the legs flexed at the knees and the thighs on the pelvis. One hand is placed over the head, the other over the breech of the foetus. Gentle downward pressure is made with the one, pushing the head into the pelvis, and at the same time up- ward pressure is made on the pelvic extremity. As soon as the position is rectified place a compress of some kind (a folded towel will answer) over the lower part of the abdomen, where the breech formerly rested, and another at the opposite side of the breech ; then apply an abdom- inal binder. Describe the combined method. The external method having been tried without result, we should then resort to the combined method. 3Iany have been described, but none have met with so much success as the Braxton -Hicks method. Care is taken to see that both the bladder and rectum are empty be- fore proceeding. Ether should be administered to the surgical degree. A warm antiseptic vaginal douche is given and the hands rendered thor- oughly sterile. Then introduce one hand into the vagina and two fingers through the cervix. The shoulder will be felt lying over the os, and this is pushed upward in the direction of the feet. At the same time, with the free hand over the abdomen the breech is pushed toward the median line or the head crowded down into the pelvis. We now have the head between the two hands, and if there is any teixlency to a face presenta- tion it may easily be rectified. If the membranes be intact at the completion of the operation, they 150 OBSTETRIC OPERATIONS. should be ruptured, that the tendency to a return to the abnormal posi- tion be obviated. Is internal cephalic version ever indicated? Only in cases of face presentation TPith the chin posterior. The method of rectifying this condition has already been spoken of under Face Pres- entations. What are the indications for podalic version? Any of those mentioned under Cephalic when this has been tried un- successfully ; placenta prtevia ; some cases of prolapse of the funis ; rup- ture of the uterus ; shoulder presentation with prolapsed arm; eclamp- sia, — in fact, any case in which rapid delivery is necessary, and whei-e this can be accomplished most speedily by securing a foot and extracting. What are the conditions essential to its successful performance ? and when is it contraindicated ? ( 1 ) An OS nearly or com])letely dilated, or at least one capable of dila- tation (soft). (2) Unruptured membranes or a uterus from which the lif}uor amnii has just escaped. (.3) A presenting part that is not wedged into the pelvis, and preferably before engagement has taken place. (4) A ]>elvis roomy enough to allow of the introduction of the hand. Podalic version is absolutely contraindicated in cases where the labor has been so prolonged that the lower segment of the uterus is thinned out. or where, from some cause or other — generally from the improper administration of oxytocics — the uterus is spasmodically contracted over the child. Rupture in either case is almost sure to result. It is also contraindicated with marked pelvic contractions or a vaginal canal of diminished size. What should be the position of the patient? and what should always be in readiness when podalic version is done? The dorsal decubitus is i)r(jbaljly always desirable, the patient lying crosswise in the bed, with buttocks well to the edge. Just as in all obstetric operations, the bladder and bowel should be emptied and a vaLMnal douche given. The forceps must be at hand, in case they are needed for delivery of the after-coming head, and. as the child is likely to be born asph3'xiated, hot and cold water, ice, warm blankets, alcohol, etc. must be in readi- ness, that no delay in its resuscitation may occur. An anaesthetic — preferably ether — should be administered. The choice of the hand to be introduced into the vagina is generally considered oi" httle importance : however, as it may become necessary to introduce it entirely into the uterine cavity, it is advisable to follow this plan : If the abdomen ol' the foetus points to the left side of the mother, the right hand of the operator is used, and vice versa. VERSION. 151 Describe the combined or Braxton-Hicks method. It resolves itself into three stages: (1) The introduction of the hand; (2) the removal of the presenting part and substitution of the leg; (3) extraction. The hand is gently and carefullj^ introduced into the vagina, pressing continually upon the perineum, and not the soft parts under the sym- physis, and the two fingers passed through the cervix. Fig. 38. Braxton-Hicks Method of Version : first step. If the case be a vertex, the fingers are in contact with the crown of the head, and an attempt must be made to push it in the direction toward which the occiput points (Fig. 38). Thus in the first and fourth 152 OBSTETRIC OPERATIONS. positions it is pushed toward the left, and in the second and third toward the right. With the other hand over the abdomen the breech is pushed downward on tlie opposite side. The shoulder will now come within reach, and it is pushed along in a similar manner (Fig. 39) ; at the same time the breech is still further depressed. The membranes, if not al- read}^ so, must now be ruptured, that a knee or foot ma}' be seized and Fig. 39. Version : second step. drawn down into the vagina (Fig. 40). The external hand should then be changed to the cephalic extremity, and upward jiressure made upon this. If the shoulder present, and the arm be not prolapsed, and if the membranes are still intact, we would naturally attempt a cephalic ver- sion. Failing in this, the course of procedure described above would be pursued. VERSION. Fig. 40. 153 Version : third step (beginning). What advantages has this method over the internal? The hand does not have to be introduced into the nterus. This is a procedure alwaj^s accompanied with some considerable risk, not only that there is greater danger of carrying in sepsis, but with the organ in active contraction and its cavity completely filled we add the danger of possible rupture by over-distension. Describe the operation of internal version. This is usually a very easy operation, provided the membranes have but recently ruptured. In vertex cases the hand is introduced into the vagina with a slow, boring motion until the cervix is reached. If this be dilated sufficiently to allow its passage, push the hand through, by the fice and up along the abdomeii of the child. As soon as a uterine contraction begins cease all manipulations and allow the palm of the hand to press firmly against the bell.y of the foetus, that the knuckles may not injure the uterus. As we pass along up, the elbows, arms, and hands are felt, and just above a knee is found. The finger and thumb 154 OBSTETRIC OPERATIONS. Fig. 41 are hooked around this (Fig. 41) and traction made, stopping as soon as the uterus contracts. . i i i As we draw downward upon the leg our manoeu- vres ma\^ be much facil- itated by upward pressure on the child s head, with a hand over the abdomen. If the membranes are intact when the operation is begun, they should be ruptured as the hand is passed through the os. In shoulder presenta- tions the only difference lies in the fact that the feet will not be found as high up. If the arm be prolapsed, a piece of muslin a couple of inches broad should be fastened about the wrist, and made long enough to permit the end to remain outside of the vulva after the child is turned. As traction is made upon this during the delivery of the body and head, the arm is swept over the face, and the unfortunate complica- tion of an extension of this member thus prevented. Tlie operation of turning in these cases does not differ in the slightest from the internal versions. The arm after being snared is not touched, but allowed to slip up into the uterus as the breech descends and the head rises. Which foot should be brought down in doing an internal ver- sion ? and would you ever bring both ? In vertex ca.ses it is i)erfectly immaterial which knee is seized ; simply secure the one most easy of access. In transverse presentations where the back of the child lies anteriorly, many recommend drawing down the upper foot, while some tliink it better to take the lower. It is never advisable to draw down both limbs, unless the os be com- iDternal Version : grasping the foot. THE FORCEPS. 155 pletely dilated, the pelvis roum3^ and the parturient canal large ; and even under these circumstances it is not necessary. How would you proceed in regard to the extraction of the foetus ? From the time the leg has been brought into the vagina the case is to be treated exactly as a breech presentation. If the foetal heart is good and the condition of the mother does not demand immediate delivery, allow this to be accomplished by the natural forces. We always have present a condition of affairs where delivery can be completed within a very short space of time if it becomes necessary ; and as there is more danger of extended head and arms if traction is made, we should not resort to it unless the conditions present demand such interference. What are the dangers of version ? Mention the difficulties often encountered during its performance. To the mother, rupture of the uterus, injury to the organ so that in- flammatory conditions result, and sepsis are the grave dangers. To the child, injury, or even death, may be caused by our manipulations. The difficulty frequently encountered is a failure of the head and shoulders to ascend as the foot is drawn down. Upward pressure over the abdo- men may be sufficient to cause these parts to recede. If not, a noose may be slipped over the ankle and traction made upon this, while with two fingers in the vagina upward pressure is made on the shoulder. Cases now and again occur where all attempts at the hands of the most competent operators fail, and embryotomy or craniotomy becomes necessary. THE FORCEPS. What are the requisites of a good pair of obstetrical forceps ? (1) They should be easy of application and removal. (2) They should retain their hold and not "slip. This will be accomplished if they possess the proper cephalic and pelvic curves. (3) They should be strong and of proper length. (4) They must have as little divergence as possible at the shank. (5) The shoulder should be broad and strong. The ordinary forceps are about 14 inches long, and composed of three parts — blades, shank, and handles. The former may be perfectly solid or fenestrated, and are distinguished as right and left or male and female. There are the so-called axis-traction forceps of Tarnier, as well as many modifications, which differ from the original instrument princi- pally in possessing a curved handle, which is fastened near the base of the blades, and by which ti-action can be made directly in the axis of the pelvic canal. What powers may be exerted by the forceps? (1) Traction.— The amount used must depend entirely upon the con- ditions demanding their use. . 156 OBSTETRIC OPERATIONS. (2) Compression. — A little is always necessary, but it should never be kept up continuously. The forceps are not maintained in apposition with the foetal head by compression on tlie handles, but Ijy pressure exerted upon the blades by the soft parts and pelvis of the mother. (3) Leverage. — This, though perhaps slight, is exerted, or should be, in every forceps delivery. State the difference between "high" and "low" forceps opera- tions. When the instrument is applied with the head at or above the brim of the pelvis, it constitutes the " high operation." When low down or at the pelvic outlet, it constitutes the " low operation." Mention the conditions necessary for their use. (1) The membranes must be ruptured ; (2) the os must be dilated or capable of dilatation ; (3) there must be no obstruction to delivery that we cannot reasonably expect to overcome ; (4) the position of the head must be positively ascertained; (5) the bladder and rectum must be empty. What are the indications for their use? Any condition, either of mother or child, requiring prompt delivery. However, the most frequent cause necessitating forceps delivery is inertia uteri. Describe their application. There are two methods of applying the forceps. One is called the "cephalic application," the other the "pelvic." In the former the operator introduces the blades so that one may lie on each side of the liead, while in the latter they are introduced on the sides of the pelvis without regard to the position of the foetal" head. It is best to adopt a ]ilan whereby these methods may be combined. In other words, if the head lies in the oblique diameter do not introduce the blades at the sides of the pelvis, but one a little posteriorly, the other anteriorly, to an imaginary transverse plane at the outlet. The applica- tion consists — (1) of their introduction ; (2) of their locking ; (3) of trac- tion ; and (4) of the unlocking and removal. The forceps should be boiled or sterilized after each usini!;, that they may be thoroughly clean, and before their ai)plic:iti()n placed in a ])itcher containing a 10 per cent, solution of warm carbolic a(;i(l. The bladder and bowel are emptied, a vaginal douche given, and the patient placed at the edge of the bed, with buttocks at right angles to it. Chloroform to the obstetrical dcigrec; only is generally sufficient in "low operations." The blades are remov(Ml from the solution and their outer surface cov- ered with sterilized or carbolized vaseline or glycerin. The left blade is grasped at the shank between i\w fingers and thumb of the left hand, while the three fingers of the right hand are introduced THE FOECEPS. 157 on the left side of the vagina until they come in contact with the head. Hold the blade at jfirst almost perpendicularly (Fig. 42) ; then pass it Fig. 42. Introduction of First Blade. along the palmar surface of the fingers, gradually depressing the handle as the instrument passes in, until by the time its introduction is complete the handle points in a slightly posterior direction. The handle is now gently held by an assistant, to prevent its expulsion during a contraction or its twisting from position while the right blade is 158 OBSTETRIC OPERATIONS. Fig. 43. Method of Tnf roducing Second Blade. applied. Tntrorlncin.ti the tliree fingers of the left liand on the mother's right side, this is passed in exaetly the same way (Fig. 43). Now takmg the handles with the two hands, they are gently depressed THE FORCEPS. 159 toward the perineum, and the lock slii>s into position. Always see that neither a small fold of the perineum nor any hairs are caught in the lock. In the application of the forceps a good rule to i'ullow is this : Use the greatest gentleness and care in the introduction, and if, this being done, they slip in easily and lock without any difficulty, you may bo sure every- thing is all right and that they are properly applied. If the slightest resistance is met with either in the introduction or the locking, imme- diately withdraw the blades and reapply. Introduce the blades during the intervals between the pains. How should traction be made? Always in the axis of the parturient canal, and intermittently. Allow the arm to rest against the side or front of the chest, and make traction only with the forearm and in this way : With the palm of the hand looking upward, the index finger is applied to one shoulder, the second and third fingers to the other, the shank resting in the crotch between the fingers. When a pain occurs steady traction is made, first in a downward direction, later in a horizontal one, and as the head emerges from the pelvis in an upward direction. The two fingers of the left hand should rest against the descending head to guard against the possi- bihty of a too sudden and rapid descent, or, if it is necessary to exert any compression, this hand may grasp the handles of the instrument ; but as a rule this will not be called for. No oscillatory movement of the handles is necessary. As soon as the contraction ceases discontinue traction. When should the blades be removed? In ordinary vertex cases as the head begins bulging the perineum the forceps should be removed, as there is always danger of laceration if this is not done. The experience of a few forceps deliveries will teach us more in regard to the proper time for their removal than description possibly could. If the maternal condition is such that a short prolongation of the labor might be injurious, deliver the head with the blades still ap- pHed. The same may be said in regard to the foetus. If the heart has stopped beating or is growing slow and irregular, a rapid delivery is in- dicated. The after-coming head in breech cases must be delivered with the for- ceps applied. Describe forceps deliveries with the occiput posterior. In these cases we should never apply the forceps until Nature has been given an opportunity of causing anterior rotation, or at least until the condition of mother or child necessitates their use. The instrument' is applied in exactly the same maimer as already de- scribed, and traction made in the axis of the pelvis until the head has reached the perineum. It will often be found at this time that rotation has taken place within the blades, or, as sometimes happens, the instru- 160 OBSTETRIC OPERATIONS. merit turns with the head. In anj^ case we remove the blades after the head has descended upon the perineum and give Nature another chance. If dehver}' does not take place, they may be reapplied, and now the traction, instead of being made upward, must take place backward toward the perineum, as the face should be born first under the sym- ])h3'sis. Describe the high forceps operation. This is a much more serious and difficult procedure than the low ope- ration, and in a majority of cases version may be much more easily done. However, cases do arise where it seems the only indication. The head will lie either in a transverse or an oblique direction, never directly antero- posteriorly, so that one blade must lie over the occiput and the other by the face as they are introduced in the sides of the pelvis. The cervix will probably be not completely dilated, and the head may lie so high up that it becomes necessary to introduce the whole hand into the vagina, passing two or three fingers within the cervix to rest against the head, which is steadied by the hand of an assistant placed over the abdomen. The blades are applied as in the low operation, though their application is usually attended with much more difficulty. The same precautions are to be taken in locking the instrument. Traction must be made first in almost a backward direction ; and here is where the axis- traction forceps are of great value. Nevertheless, the ordinary instru- ment may be used in these cases, though always with much more diffi- culty. When can the forceps be used in face cases ? and how are they applied ? When the chin points either anteriorly or to one or the other side of the mother — never if posteriorly, for delivery by forceps in such cases is absolutely impossible. Their application, if the fronto-mental diameter lies in conformity with the antero-posterior of the pelvis, is simi)ly in the sides of the pelvis ; but if it lies in an obli(iue or transverse diameter, the blades must be applied to the sides of the child's head and face. Traction to bring the part down on the perineum is generally, as in vertex cases, all that is necessary. If complete delivery nuist be accom- ))lislied, simply bear in mind the mechanism in these cases and apply the force in the proper direction. How should the forceps be applied to the after-coming head in breech cases ? To the sides of the face and skull, beneath the body of the child, if an- terior rotation of the head has taken place. If not. and the chin is caught above the symphysis, the body nnist be raised uj) by an assist- ant, the blades apjAied over the occipital i)ortion of the skull, and trac- tion made in an anterior direction (the handles being lifted toward the child's back], that the occiput may be born first. EMBRYOTOMY AND CRANIOTOMY. 161 If the chin rests beneath the s^'mphj'sis, make the traction away from the back, that the face may emerge under the pubic arch first. Never use forceps to the after-coming head until all other methods of deliver}" have failed. The forceps have been, and are still by some, applied to the breech. This procedure is to be discouraged. What are the dangers of forceps operations ? To the Mother. — In low operations, if properly and carefully done, there is almost no risk, and much less harm can be done by their use than if the foetal head is allowed to rest for a considerable length of time in the pelvic canal. High operations are naturalh" attended with more dan- gers, but even here, if the cases are properly chosen and intelligently treated, the dangers are not great. The unfortunate results attributed to the forceps are injuries to the soft parts and the pelvis. Among the former are lacerations of the uterus, cervix, vagina, and perineum, sometimes the bladder, urethra, and rectum, resulting in inflammatory conditions, fistulse, and sepsis. To the pelvis both fractures of its bones and separation of the joints have occurred. To the Child. — Abrasions of the skin sometimes occur, but are of no consequence unless they are so extensive and deep as to be lacerations. They are usually the result of carelessness or ignorance. Fractures of the cranial bones, cerebral hemorrhages, thrombosis of one of the sinuses, and death have all been caused by prolonged and severe compression. What is the vectis? A short curved blade resembling one of the blades of a pair of short forceps. It was formerly used to promote rotation of the head and aid flexion, but has been entirely discarded. What is the fillet ? It is a loop of cloth, metal, or whalebone which is passed over the occiput or between the chin and thorax of the foetus, so that traction may be made. It is sometimes passed over the groin. It is never used now. EMBRYOTOMY AND CRANIOTOMY. What is understood by these two terms? Embryotomy is applied in general to any operation requiring the de- struction of the foetus, whether this be a simple perforation of the skull ( ' ' craniotomy " ) , perforation with crushing ( ' " cephalotripsy " ) , crushing the base of the skull ( " basiotripsy "), or the_ severing of the head or mutilation of the foetus ("decapitation," " evisceration "). Describe the instruments generally used in doing embryotomy. (1) Perforator. — Many instruments have been devised for perforation 11— Obs. 162 OBSTETRIC OPERATIONS. of the skull, but in a general way they consist either of a trephine with a long handle, sometimes hollow that irrigation may be resorted to and the brain-substance washed out of the skull, or of scissors. Those sug- gested by Smellie or some modification of them are most frequently used. They consist of a long-handled pair of scissors, the blades of which are short and triangular, the apex of the triangle being the point, and the base a projecting shoulder. The outer edge of the blades only is sharpened. (2) Craniodast. — This is a solid, narrow-bladed pair of forceps, so designed that one blade may be introduced through the perforation, the other kept outside of the skull. When both are introduced they are locked like the forceps. The internal blade is small, non-fenestrated, and convex, while the external is larger, fenestrated, and concave. When locked the former lies against the internal concave surface of the skull, while the latter lies against the external convex surfiee. Thus it will be seen two objects may be accomplished — simple traction, or, by a twisting movement, a breaking off of portions of tlie bones. (3) Cephalotribr. — This is a long, solid pair of forceps with a com- pression-screw at the ends of the handles. The blades may or may not be fenestrated, but their inner surfaces are usually serrated, and when applied and compressed come much closer together than do the ordinary forceps. (4) Basiotrihe. — This instrument, first devised by Tarnier, is very complete, and consists of both perforator and cephalotribe combined in one. (5) Crotchet. — This is a sharp-pointed hook which may be fastened on some portion of the skull and traction made upon the handle. It should never be used where other instruments are at hand. State the indications for performing craniotomy. In a general way, disproportion between the head and the parturient canal is the usual cause re(iuiring craniotomy, and this most frequently arises from deformity of the pelvis. The exact amount of contraction where the operation is justified in preference to Caesarean section is such a disputed point that it is impos- sible to lay down any fixed rule to be followed in every case. Some fix the limits of the operation at between V\ and o inches in the internal conjugate, and others between 21 and 2|. We nuist depend, to a large extent, upon the conditions at hand for the performance of the two ope- rations, section or embryotomy. If, in a general way, the chances for the mother seem much better by destroying the foetus, we should not hesitate to resort to this procedure. Other causes, such as hydroceph- alus, impacted face or brow, extended after-coming head, rigid .soft parts of the maternal passages, cancer of the cervix, etc., have already been mentioned. Some recommend the oi)eration in all cases where death of the foetus is positive, but as this is always a questionable point to decide, it is hardly to be recommended. EMBRYOTOMY AND OHANIOTOMY. 163 Describe the operation. After the preparation of the patient, operator, and assistants, which slioiild be just as for forceps operations, the perforator, carefully guarded })y the fin.iicrs to prevent injury to the vaginal wall, is passed up to the head. Here, in vertex cases, it will come in contact with one of the parietal bones, wliile in face or brow presentations it should be intro- duced through the frontal bone, one of the orbits, or the roof of the mouth ; and in case the after-coming head is to be perforated, it must be done back of the ear or to one side of the foramen magnum. Pre- cautions must be taken not to introduce the instrument through one of the sutures or fontanelles, as the overlapping oi" the bones prevents exit of the brain-substance and collapse of the skull. An assistant grasps the foetal head firndy through the abdominal wnll to steady it, and the perforator, held as nearly as possible at right angles to the bone that it may not glide off, is slowly pushed through by a bor- ing motion. When the shoulder of the scissors is reached the handles are separated. This opens the blades, making a long incision in the cra- nium. Closing the instrument again, it is now introduced at right angles to the former incision, and the same manoeuvre repeated. Then push the instrument within the skull as far as the base, and, moving it about, thoroughly break up the brain tissue, and then withdraw it. Many recommend that the skull should now be washed out tlioroughly with some antiseptic solution before ])roceeding further, but this is un- necessary if the destruction of the brain has been carefully done. The completion of the operation consists in reducing the size of the head and delivering. This is preferably done by the cephalotribe, al- though it may be necessary to break up the vault of the cranium some- what with the cranioclast. The blades of the instrument must be deeply introduced, that the base of the skull may be reached, and after apply- ing, the screw on the handles is turned slowly and the bones crushed. Delivery is then accomplished as with the forceps, though it may be necessary to remove and reapply the instrument once or twice during the operation. As a rule, the body will offer no difficulty to delivery, though excej)- tionally further mutilation must be done. What are the indications for, and the method of, decapitating? Impacted shoulder presentation, in which the child is jammed far enough into the pelvis for the neck to be within reach. There are many varieties of instruments in use for decapitating, but tlie one which has gained the greatest reputation is a curved steel hook, the internal edge of which is sharpened. This is passed over the neck, and by a backward and forward movement the head is separated from the body. The wire ecraseur has also been somewhat used, as has also a jmir of blunt scissors. Whatever should be employed must be used with the greatest care, that injury to the maternal structures be avoided. 164 OBSTETRIC OPERATIONS. As soon as completely severed the head is pushed up into the uterus and the bod}' withdrawn by dragging down upon the arm. The head remains to be delivered, and this can generally be done by crowding it down into the pelvis by abd(jminal pressure and applying the forceps, or preferably the cephalotribe. If not, it must be perforated, and under the circumstances the operation is not an easy one. When should evisceration be resorted to? Describe the opera- tion. Occasionally after craniotomy where resistance is encountered in de- livering the body, most frequently in impacted shoulder presentations where the neck lies high up beyond reach. The most dependent part of the thorax is penetrated by a strong pair of scissors, the thoracic viscera broken up and withdrawn in pieces. Next the diaphragm is cut through, and the contents of the abdominal cavity removed. This will allow the body to collapse, and to be born as in spontaneous evolution. It is said that if the spinal column be divided with a strong pair of scissors passed through the opening in the thorax, the delivery is easier, as the child is folded as it were upon itself. For its removal the crotchet or blunt hook may be used. The dangers to the mother of any of the above- described operations are evident, unless the greatest care and antiseptic precautions are ob- served, when naturally they become materially lessened. An intra-uterine irrigation of a bichloride-of-mercury solution, 1 : 5000, followed by a prolonged douche f intra-uterine) of thoroughly sterilized warm water, should be given in every case where either the hand, lingers, or any instrument has been introduced into the uterine cavity. The after-treatment does not differ from that following a normal de- livery. THE CuESAREAN SECTION AND ITS MODIFICATIONS. What is the Caesarean section? It is an operation consistinu in cutting through the abdominal wall and the uterus, and removing the child through the wound thus made. There are several modifications of the operation : (1 ) The Porro, in which the uterus is amputated, with its appendages, at the cervix, after the removal of the child ; and (2) The Porro- M tiller, which is a modification of the above, and con- sists in lifting the uterus out of the abdominal wound, constricting the cervix to prevent hemorrhage, then incising the organ, removing the child, and amputating as in the above. What are the indications requiring the operation? Delbrmities of the pelvis, where the dauiiers of craniotomy would be greater to the mother than laparotomy ; malignant tumors of the cervix or uterus; tumors o})structing the pelvis and rendering delivery in this way impossible ; occlusions of the vagina, rendering delay dangerous or THE CESAREAN SECTION AND ITS MOT IFIGATIONS. 1 65 impossible ; some cases of impacted transverse presentations, with per- haps only slight pelvic deformity ; death of the mother during the latter months of gestation or during labor. Children have been saved where the operation was done soon after death. Is it possible to make a prognosis as to the result? It is not, as the success or failure of the operation must depend upon so many conditions. The general health of the woman, the experience of the operator, the })reparations and surroundings of the patient, and, above all, whether or not the operation is one of election and the time is chosen or one of necessity, make a prognosis favorable or unfavoraVjle as the case may be. If the patient's condition is good, the time for operating properly chosen, and the surroundings favorable, the mortality is not over 25 per cent. The usual causes of death are shock, hemorrhage, exhaustion, peritonitis, metritis, and septicaemia. There is little or no danger to the child. When should the operation be done ? Describe the simple sec- tion. It is now generally admitted that the best time for operating is after labor has begun, for two reasons : First, the uterine contractions prevent hemorrhage ; and secondly, free drainage of the lochia! discharge is ob- tained, as the cervix is somewhat dilated. Some think it is just as well to induce labor near full term ; others prefer having everything in readi- ness and waiting until it normally occurs. Prqmrations.— -The room for the operation should be large, well ven- tilated, and well lighted both by natural and artificial lights, as it may be necessary to operate at night. All furniture is to be removed, and the floors, walls, and ceilings washed with a 1 : 500 solution of bichloride of mercury. As term approaches, provided it has been decided to defer the opera- tion until this time, the patient's bowels must be kept open by the use of laxatives or enemas, and some mildly antiseptic vaginal douche given once daily. As soon as labor begins the abdomen and suprapubic regions must be shaved, thoroughly scrubbed with soap and warm water, afterward washed with alcohol and ether, and then with a solution of bichloride, 1 : 1000. A large folded compress of gauze, sufficient to cover the entire abdomen, is wrung out of the same solution and held in place by an abdominal binder loosely applied. This will not be removed until the first incision is about to be made. Always pass the catheter the last thing before the operation is begun. The anaesthetic to be given is a matter of choice. Many prefer chloroform, as there is much less danger of vomiting after- ward. At least two or three assistants are needed, besides the one ad- ministering the anaesthetic. Plenty of sterilized hot water must be at hand, as well as ice, alcohol, 166 • OBSTETRIC OPERATTOXS. etc.; for resuscitating the child. The instruments, sutures, needles, etc. must be carefully' sterilized and kept subnierued in a :^j per cent, solution of carbolic acid. The operator stands on the patient's right side, one assistant at her left, another at the foot of the table, and if a third be at hand he will pass instruments, needles, etc. Begin the operation when the cervix is slightly dilated. The Operation. — With a scalpel the abdominal incision is made in the median line, to extend from an inch or two above the umbilicus to within the same distance from the symphysis ])ubis. The skin and fascia? arc cut until the peritoneum is reached. All bleeding must now be stopped by clamps, and liuatures if necessary. An opening is then made in the peritoneum, the first two fingers of the left hand passed through it, and, using them as a guide, this is opened throughout the length of the ab- dominal wound with a pair of blunt-pointed scissors. The parts now retract over the uterus, exposing this organ. Towels wrung out of hot water must be placed around the wound, and the as- sistant places a hand on each side of the uterus to steady it and hold it up in apposition with the abdominal wound while the operator opens it. Some rupture the membranes p'!'?' vaghuan at the beginning of the ope- ration, while others do it through the incision. An opening is now made in the median line of the uterus, and the incision extended with scissors, following the same method pursued in dividing the peritoneum. The membranes are ruptured, if this has not already been done, and the child lifted out and given into the hands of an assistant. The cord is then clamped and cut. The placenta may become detached as contraction occurs, or may have to be removed. In either case the cavity of the uterus is sponged out and the sutures introduced. About this time a full dose of ergotin should be administered hypodermically. It sometimes happens in open- ing the uterus that the placenta lies immediately beneath the incision, in which case we may cut directly throuirh it. Hemorrhage will be more profuse, but generally controllable. It rarely becomes so free as to necessitate the use of styptics. The uterine wound is closed by two lines of sutures. Silk, wire, and catgut are all used, but preference is given to the first. The deep sutures are passed through tlie muscular tissue down to the mucous lining, about I to J an infh ai)art. and in each interspace is placed a superficial suture. The abdominal cavity must now be cleansed with sponges, and the wound in the a})dominal wall closed. This may be done either with sil- ver wire or silkworm gut, as after an ordinary laparotomy or ovariotomy. The external dressing consists of dusting the wound with iodoform, cov- ering it with a strip of iodoform yauze, and over this bichloride gauze, absorbent cotton, and a binder to liold the dressing in place. The (ifti'i-'trcafmrut consists in absolute rest in the dorsal position, morphine hypourulent di.scharge. There may be areas of necrotic or ulcerative tissue, and these are sometimes covered by a di|>htherit.ic membrane. Or this membrane may appear on an ai)parently healthy, unabraded surface. Of Endometritis (tnd Metritis. — As a rule, both occur togetlier. The endometrium is swollen, red. and may contain areas of ulceration. The discharge I'rom the uterus is putrid and offensive. The organ itself is enlarged, and its muscular tissue infiltrated with pus, or it may contain gangrenous areas, or be the seat of diphtheritic dei)osits. Of CelluJitis. — Any of the connective tissue about the uterus may be- come the seat of inflanmiation. It is .swollen and infihrated. Some localized peritonitis is generally a.ssociated with it, and adhesions form. It may resolve without the formation of an abscess, but many times does PUERPERAL INFECTION. — SYMPTOMS. 171 not. This abs(;(!ss may point and o])cn in sonic portion of the vagina, in tlie bowcil, or in tho bladfler, or it may open externally in the ,ened. For a peritonitis the uterus shovdd be first thoroughly cleansed. Repeated irrigations are not indicated. Cold externally and opium hypo- dermically or by the rectum are indicated, as in a peritonitis occurring under otlier circumstances. Phlebitis calls for the treatment already described. The nourishment of the patient is often very difficult, owing to the severe vomiting. Peptonized milk, beef juice, and mutton l)roth may all be given. Rectal alimentation may Ijecome necessary. Brandy or wliiskey is indicated from the begimiing. A half ounce every three or i'our hours may be gradually increased as the circulation demand.>5 it. ^ In combination with tlie alcohol, digitalis, strophanthus, caffeine, strychnine, carbonate of ammonium — in fact, any of the cardiac stimulants — may be given. Quinine should be given in 5- or 10-grain doses every four or six hours. Morphine, to relieve i^ain and vomiting as well as the diar- rhoea, is always indicated. It may be given hy))odernii(ally, combined witli atropine. Mustard pastes, iced carbonic-acid water, bismuth, dilute PHLEGMASIA ALBA DOLENS. 175 hydrocj^anic acid, creasote, carbolic acid, may all be tried if vomiting is excessive. To reduce the temperature sponge-baths of cold water, alcohol, and hot water equal parts, or the cold pack, may be used.. In pyaemia the abscesses must be opened, drained, and treated anti- septically as they occur. PHLEGMASIA ALBA DOLENS. What is phlegmasia alba dolens? and when does it usually oc- cur? It is a swelling of one of the lower extremities, owing to the formation of a clot in the veins of the limb, or of the pelvis, and this is an inter- ference with the return circulation, it usually occurs within two weeks after confinement, generally not before the end of the first week. The affection is also called peripheral venous thrombosis, crural phlebitis, milk leg, etc. What is its pathology? This is disputed. Many think it maybe due either to septic infection oris of non-septic origin. In the former case it is believed to occur with a phlebitis, or if it occurs without infection it is the result of detachment of portions of the coagula at the utero-placental site. It occurs more frequently in multiparas and after abortions or severe hemorrhages. Describe the symptoms. Tlie first symptom is an uncomfortable feehng of the limb or pain, usually referred at first either to the groin or popliteal space, Soon it becomes very severe, and slight pressure over any of the venous trunks produces a sharp exacerbation of the pain. The limb now begins to swell, the enlargement beginning in the groin and extending down- ward, or in the calf of the leg, extending upward. The skin acquires a tense, white, shining appearance, and oftentimes the a eins may be felt as hard, cord-like masses under the fingers. Constitutional symptoms may be severe or only slightly developed. There is generally a feeling of malaise, followed by chilly sensations and a rise of temperature to 101°-1()3° F. The pulse is accelerated, and the patient complains of headache, anorexia, thirst, and sleeplessness. In the mild cases the above are but slightly developed, if at all. What are the prognosis and treatment? The x^yognosis is usually very favorable. The acute stage lasts but a few days or a week, when the pain becomes less marked, swelling is di- minished, and by the end of four or five weeks recovery is complete. The limb, however, rarely regains its normal size, but always remains slightly enlarged. Treatment. — Absolute rest and slight elevation of the limb constitute our local treatment. The leg should be wrapped with cotton from the 176 PUERPERAL DISEASES. toes to the hip and slightly elevated. If pain is severe, hot wet cloths may be placed next the skin and cotton over these. General treatment in the way of nourishing food and good hygienic surroundings must be observed. Tonics are indicated after recovery. All active treatment in the way of massage, poultices, bhsters, elec- tricity, depletion, etc. is contraindicated. INSANITY. When may insanity appear during pregnancy and after labor? (1) It may begin at any time after conception, and be but transient, or it may continue throughout gestation and after labor. The usual time of its appearance is about the fourth month. This is called the " insanity of pregnane}'." (2) The so-called puerperal insanity is some form of insanity beginning during the puerperal state. It usually appears within a month after delivery. (3) insanity of lactation, which may occur at any time while the woman is nursing. State the causes. Heredity ; mental impressions ; debility, exhaustion, or anaemia ; septic infection : painful and prolonged labors ; possibly chloroform during delivery; and many nervous disorders, — are all given as causcfi. The many accidents and disorders associated with pregnancy and parturition, such as injuries, mental disturbances, albuminuria, eclampsia, chorea, hemorrhages, etc., may all be determining causes. A large percentage of cases occur in primiparae. Describe the symptoms of the three varieties. That occurring during jn-egnancy usually is melanchoha. It may be only slightly developed, and lasts but a short time, in which case it often- times passes unrecognized. In these mild cases a depression of spirits with insomnia will be the only thing noticed, and generally this is at- tributed to grief, fright, or some other exciting cause. Other cases become more serious from the beginning, many times con- tinuing after delivery and assuming a maniacal tendency. There are marked depression, irritability, sleeplessness, and apprehension, usually of the approaching confinement. The woman becomes sullen and gloomy, her affections change, and interest in all matters is lost. The appearance is just as in melancholia occurring under other circumstances, and there is often a marked tendency to suicide. After delivery the variety met with is most often of the maniacal type. It may follm\s Scries of Pocket Text-books, edited'by Uerx !>. Gallai'DET, M. D. See p. 18. BARNES (ROBERT AND FANCOURT). A SYSTEM OF OB- STETRIC MEDICINE AND SURGERY. Octavo, 872 pages, with 231 illus. Cloth, $5 ; leather, $6. 4 Lea Beothers & Co., Philadelphia and New Yobk. BACON (GORHAM). ON THE EAR. One 12mo. volume, 400 pages, 109 engravings and a colored plate. Cloth, net, $2.00. Just ready. It is thehest manual upon otology, dents of medicine — Cleveland Jour- An intensely practical book for stu- i trial of Medicine. BARTHOL.OW (ROBERTS). CHOLERA; ITS CAUSATION, PRE- VENTION AND TREATMENT. In one 12mo. volume of 127 pages, with 9 illustrations. Cloth, $1.25. BARTHOLOW (ROBERTS). MEDICAL ELECTRICITY. A PRACTICAL TREATISE ON THE APPLICATIONS OF ELEC- TRICITY TO MEDICINE AND SURGERY. Third edition. In one octavo volume of 308 pages, with 110 illustrations. BELL (F. JEFFREY). COMPARATIVE ANATOMY AND PHYS- IOLOGY. In one 12mo. volume of 561 pages, with 229 engravings. Cloth, $2. See Students' Series of Manuals, page 27. BILLINGS (JOHN S.). THE NATIONAL MEDICAL DICTIONARY. Including in one alphabet English, French, German, Italian and Latin Technical Terms used in Medicine and the Collateral Sciences. In two very handsome imperial octavo volumes containing 157-4 pages and two colored plates. Per volume, cloth, $6 ; leather, $7 ; half Morocco, $8.50. For sale by subscription only. Specimen pages on application to the publishers. BLACK (D. CAMPBELL). THE URINE IN HEALTH AND DISEASE, AND URINARY ANALYSIS, PHYSIOLOGICALLY AND PATHOLOGICALLY CONSIDERED. In one 12mo. volume of 256 pages, with 73 engravings. Cloth, $2.75. A concise, yet complete manual, | Concise, practical, clinical, well illustrated and well printed. — Mary- land Medical Journal. treating of the subject from a prac- tical and clinical standpoint. — The Ohio Medical Jonrnal. BLOXAM (C. L.). CHEMISTRY, INORGANIC AND ORGANIC. With Experiments. New American from the fifth London edition. In one handsome octavo volume of 727 pages, with 292 illustrations. Cloth, $2 ; leather, $3. BROCKWAY (F. J.). A POCKET TEXT-r>OOK OF ANATOMY. In one handsome 12mo. volume of about 400 pages, with many illus- trations. Shortly. Lea's Scries of Foe kit Text-books, edited by Bern 15. Gallaudet, M. D. See page' 18. BRUCE (J. MITCHELL). MATERIA MEDICA AND THERA- PEUTICS. New (6th) edition. In one 12mo. volume of 600 pages. Just ready. Cloth, $1.50, net. See Student's Series of Mamuilt, page, 27. PRINCIPLES OF TREATMENT. In one octavo volume. Pre- paring. BRYANT (THOMAS). THE PRACTICE OF SURGERY. Fourth American from the fourth English edition. In one imperial octavo vol. of 1040 pages, with 727 illustrations. Cloth, $6.50 ; leather, $7.50. BURCHARD (HENRY H.). DENTAL PATHOLOGY AND THER- APEUTICS. Handsome octavo, 575 pages, with 400 illustrations. Just ready. Cloth, net, $5.C0; leather, net, $6.00. Lea Beothebs & Co., Philadelphia and New Yobk. 5 BURNETT (CHARLES H.j. THE EAR : ITS ANATOMY, PHYSI- OLOGY AND DISEASES. A Practical Treatise for the Use of Students and Practitioners. Second edition. In one 8vo. volume of 580 pa^es, with 107 illustrations. Cloth, $4; leather, $5. CARTER (R. BRUDENELL) AND FROST ( W. ADAMS). OPH- THALMIC SUP.GEKY. In one pocket-size 12rno. volume of 559 pages, with 91 engravings and one plate. Cloth, $2.25. See Series of Clinical Manuals, page 25. CASPARI (CHARLES JR.). A TREATISE ON PHARMACY. For Students and Pharmacists. In one handsome octavo volume of 680 pages, with 288 illustrations. Cloth, $4.50. The author's duties as Professor student who cannot understand must of Theory and Practice of Pharmacy be dull indeed. The book is full of in the Maryland College of Phar- new, clean, sharp illustrations, which macy, and his contact with students tell the story frequently at a glance, made him aware of their exact The index is full and accurate. — wants in the matter of a manual. National Druggist. His work is admirable, and the i CHAPMAN (HENRY C). A TREATISE ON HUMAN PHYSI- OLOGY. New (2d) edition. In one octavo volume of 921 pages, with 595 illustrations. Just ready. Cloth, $4.25 ; leather, $5.25, net. In every respect the work fulfils its promise, whether as a complete treatise for the student or as an ad- mirable work of reference for the physician. — North Carolina Medical Journal. CHARLES (T. CRANSTOUN). THE ELEMENTS OF PHYSIO- LOGICAL AND PATHOLOGICAL CHEMISTRY. Octavo, 451 pages, with 38 engravings and 1 colored plate. Cloth, $3.50. CHEYNE (W. -WATSON). THE TREATMENT OF WOUNDS, ULCERS AND ABSCESSES. In one 12mo. volume of 207 pages. Cloth, $1.25. One will be surprised at the need at any moment. The sections amount of practical and useful in- devoted to ulcers and abscesses are formation it contains; information indispensable to any physician. — that the practitioner is likely to The Charlotte Medical Journal. CHEYNE (W. W.) AND BURGHARD (F. F.) SURGICAL TREATMENT. In six octavo volumes, illustrated. Volume 1, 299 pages and QQ engravings, just ready. Cloth, $3.00 net. CLARKE (W. B.) AND LOCKTVOOD (C. B.). THE DISSECTOR'S MANUAL. In one 12mo. volume of 396 pages, with 49 engravings. Cloth, $1.50. See Students' Series of Manuals, x^age 27. CLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF THE HUMAN BODY. In one 12mo. vol. of 178 pages. Cloth, $1.25. CLINICAL MANUALS. See Series of Clinical Manuals, page 25. CLOUSTON (THOMAS S.). CLINICAL LECTURES ON MENTAL DISEASES. New (5th) edition. In one octavo volume of 750 pages, with 19 colored plates. Cloth, $4.25, net. Junt ready. ^^"Folsom's Abstract of Laws of JJ. S. on Custody of Insane, octavo, $1.50, is sold in conjunction with Clouston on Mental Diseases for $5.00, net, for the two works. 6 Lea Broth EBfl & Co., Philadelphia, and New Yoek. CLOWES (FRANK). AN ELEMENTARY TREATISE ON PRACTI- CAL CHEMISTRY AND QUALITATIVE INORGANIC ANALY- SIS. From the fourth English edition. In one handsome 12mo. volume of 387 pages, with 55 engravings. Cloth, $2.50. COAIiXiEY (CORNELIUS G.). THE DIAGNOSIS AND TREAT- MENT OF DISEASES OF THE NOSE, THROAT, NASO- PHARYNX AND TRACHEA. In one 12mo. volume of about 400 pages, fully illustrated. Preparing, COATES (W. E., JR.). A POCKET TEXT-BOOK OF BACTE- RIOLOGY AND HYGIENE. In one handsome 12mo. volume of altout ?50 pages, with many illustrations. Shortbj. Lea's Scries of Pocket l\'.vt-books, edited by Bern B. Gallaudet, M. D. See page 18. COATS (JOSEPH). A TREATISE ON PATHOLOGY. In one vol. of 829 pages, with 339 engravings. Cloth, $5.50 ; leather, $6.50. COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY AND PATHOLOGY. With Notes and Additions to adapt it to Amer- ican Practice. By Thos. C. Stellwagen, M.A., M.D., D.D.S. In one handsome octavo' vol. of 412 pages, with 331 engravings. Cloth, $3.25. COLLINS (C. P.). A POCKET TEXT-BOOK OF MEDICAL DIAGNOSIS. In one handsome 12mo. volume of about 350 pages, with many illustrations. Shortly. L^t's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 18. COLLINS (H. D.) AND ROCKWELL (W. H.). A POCKET TEXT-BOOK OF PHYSIOLOGY. In one handsome 12mo. volume of about 300 pages, with many illustrations. In press. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 18. CONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS- EASES OF CHILDREN. Sixth edition, revised and enlarged. In one large 8vo. volume of 719 pages. Cloth, $5.25 ; leather, $6.25. CORNIL (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNO- SIS AND TREATMENT. Translated, with Notes and Additions, by J. Henry C. Simes, M.D. and J. William White, M.D. In one 8vo. volume of 461 pages, with 84 illustrations. Cloth, $3.75. CROCKETT (M. A.). A POCKET TEXT-BOOK OF DISEASES OF WOMEN. In one handsome 12mo. volume of about 350 pages, witli many illustrations. Sliortly. Left's Series of Pocket Te.vt-books, edited by Bern B. Gallaudet, M. D. See page 18. CROOK (JAMES K.) ON MINERAL WATERS OF THE UNITED STATES. Octavo, 575 pages. Just ready. Cloth, $3.50, 9? c^ CULBRETH (DAVID 31. R.). MATERIA MEDIC A AND PHAR- MACOLOGY. In one handsome octavo volume of 812 pages, with 445 illustrations. Cloth, $4.75. CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. Handsome 8vo., 728 pages, with 47 illus. Just ready. Cloth, $3.76, net. Lea Beothees & C!o., Philadelphia and New Yoek. 7 DALTON (JOHN C). A TREATISE ON HUMAN PHYSIOLOGY. Seventh edition. Octavo, 722 pages, with 252 engravings. Cloth, $0 ; leather, $6. DOCTRINES OF THE CIRCULATION OF THE BLOOD. In one handsome 12mo. volume of 293 pages. Cloth, $2. DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual ot Gynecology. For the use of Students and Practitioners. New (3d) edition. In one handsome 12mo. volume of 387 pages, with 150 illustrations. ' Cloth, $1.75, net. Just ready. DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR STUDENTS AND PRACTITIONERS. In one very handsome octavo volume of 5-16 pages, with 217 engravings and 30 full-page plates in colors and monochrome. Cloth, $5 ; leather, $6. From a practical standpoint the ] thoroughly scientific and brilliant work is all that could be desired. A treatise on obstetrics. —J/ecZ. News. DAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second edition. In one 12mo. volume of 287 pages. Cloth, $1.75. DE LA BECHE'S GEOLOGICAL OBSERVER. In one large octavo volume of 700 pages, with 300 engravings. Cloth, $4. DENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYS- TEM OF SURGERY. In contributions by American Authors. Complete work in four very handsome octavo volumes, containing 3652 pages, with 1585 engravings and 45 full-page plates in colors and monochrome. Per volume, cloth, $6.00; leather, $7.00; half Morocco, gilt back and top, $8.50. For sale by subscription only. Full prospectus free on application to the publishers. It is worthy of the position which [ American surgery and is thoroughly surgery has attained in the great practical. — Annals of Surgery. Republic whence it comes. — The ' No work in English can be con- London Lancet. \ sidered as the rival of this. — The It may be fairly said to represent American Journal of the 3Iedical the most advanced condition of i Sciences. DERCU3I (FRANCIS X., EDITOR). A TEXT-BOOK ON NERVOUS DISEASES. By American Authors. In one handsome octavo volume of 1054 pages, with 341 engravings and 7 colored plates. Cloth, $6.00 ; leather, $7.00. Net. Representing the actual status of < The work is representative of the our knowledge of its subjects, and best methods of teaching, as devel- the latest and most fully up-to-date oped in the leading medical colleges of any of its class. — Jour, of Amer- \ of this country. — Alienist and Neu- icon Med. Association. rologist. The most thoroughly up-to-date The best text-book in any Ian- treatise that we have on this subject, guage. — The Medical Fortnightly. — American Journal of Insanity. i DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. Their Classification, History, Symptoms, Pathology and Treatment. Very handsome octavo, 240 ])ages, 46 engravings, and 9 full-page plates in colors. Limited edition, de luxe binding, $4. Net. 8 Lea Brothers & Co., Philadelphia and New York. DRAPER (JOHN C). MEDICAL PHYSICS. A Text-book for Stu- dents and Practitioners of Medicine. In one handsome octavo volume of 734 pages, with 376 engravings. Cloth, $4. DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the twelfth London edition, edited by Stanley Boyd, F. R. C. S. In one large octavo volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. DUANE (AIjEXANDER). THE STUDENT'S DICTIONARY OF MEDICINE AND THE ALLIED SCIENCES. New edition. Com- prising the Pronunciation, Derivation and Full Explanation of Medi- cal Terms, with much Collateral Descriptive Matter, Numerous Tables, etc. Square octavo of 658 pages. Cloth, $3.00 ; half leather, $3.25 ; full sheep, $3.75. Thumb-letter Index, 50 cents extra. DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF GYNECOLOGY. Handsome octavo of 652 pages, with 422 illustra- tions in black and colors. Cloth, $5.00, net ; leather, $6.00, net. Just r*ady. tice of modern gynecology. — Liter- national Medical 3Iagazinc. The book can be safely recom- mended as a complete and reliable exposition of the principles and prac- DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. In one octavo volume of 175 pages. Cloth, $1.50. DUNGLiISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- ENCE. Containing a full explanation of the various subjects and terms of Anatomy, Physiology, Medical Chemistiy, Pharmacy, Phar- macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. By RoBLEY DUNGLISON, M. D., LL. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. Edited by Richard J. Dunglison, A. M., M. D. Twenty-first edition, thor- oughly revised and greatly enlarged and improved, with the Pronuncia- tion, Accentuation and Derivation of the Terms. With Appendix. In one magnificent imperial octavo volume of 1225 pages. Cloth, $7 ; leather, $8. Thumb-letter Index for quick use, 75 cents extra. The most satisfactory and authori- scarcely be measured. — 3Ied. Record. tative guide to the derivation, defini- Pronunciation is indicated by the tion and pronunciation of medical phonetic system. The definitions are terms.— TAeCAaWo^ Seized. Jour/iaZ. unusually clear and concise. The book is wholly satisfactory. — Uni- versity 3Iedical 3Iagazine. Covering the entire field of medi- cine, surgery and the collateral sciences, its range of usefulness can DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- TOLOGY. Octavo, 450 page8,with 363 illustrations. Cloth, $3.25, net. Just ready. The best one- volume text or refer- 1 of published in America. — Virginia ence book on histology that we know I 3Iedical Semi-3Iont]ihj. EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50 ; leather, $4.50. EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for Students and Practitioners. In one handsome 8vo. volume of 576 pages, with 148 engravings. Cloth, $3 ; leather, $4. LsA Beothees & Co., Philadelphia and New Yoek. 9 EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- TATION. In one 12mo. volume of 359 pages, with 63 illustrations. Just ready. Cloth, Net, $2.25. It is written in plain language, and, while primarily designed for physicians, it can be studied with protit by any one of ordinary intel- ligence. The writer has adapted it to American conditions, and his suggestions are, above all, practical. — The New York Medical Journal. ELLIS (GEORGE VEVER). DEMONSTEATIONS IN ANATOMY. Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, $4.25 ; leather, $5.25. E30IET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- TICE OF GYNAECOLOGY. Third edition. Octavo, 880 pages, with 150 original engravings. Cloth, $5 ; leather, $6. ERIOHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- GERY. Eighth edition. In two large octavo volumes containing 2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. ESSIG (CHARLES J.). PROSTHETIC DENTISTRY, ^qq American Text-Books of Dentistry, page 2. EVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. In one handsome 12mo. volume of about 300 pages, with many illustra- tions. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text-books, edited by Been B. Gallaudet, M. D. See page IS. FARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. Fourth American from fourth English edition, revised by Feank WOODBUEY, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE EAR. Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75. FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE. Seventh edition, thoroughly revised by Feedeeick P. Heney, M. D. In one large 8yo. volume' of 1143 pages, with engravings. Cloth, $5.00 ; leather, $6.00. The work has well earned its lead- | The best of American text-books ing place in medical literature. — on Practice. — Amer.lledico-Surgical Medical Record. Bulletin. A MANUAL OF AUSCULTATION AND PERCUSSION ; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. In one handsome 12mo. volume of 274 pages, with 12 engravings. A PRACTICAL TREATISE ON THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE HEART. Second edition enlarged. In one octavo volume of 550 pages. Cloth, $4. A PRACTICAL TREATISE ON THE PHYSICAL EXPLO- RATION OF THE CHEST, AND THE DIAGNOSIS OF DIS- EASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one octavo volume of 591 pages. Cloth, $4.50. MEDICAL ESSAYS. In one 12mo, vol, of 210 pages. Cloth, $1.38. ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, ETC. A Series of Clinical Lectures. In one 8vo. volume of 442 pages. Cloth, $3.50. 10 Lea Beothees & Co., Philadelphia and New York. FOIiSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. Cloth, $1.50. With Cloxiston on Blental Diseases (new edition, see page 6) $5.00, net, for the two works. FOR3IULiARY, POCKET, see page 32. FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New (6th) and revised American from the sixth English edition. In one large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50 ; leather, $5.50. Unquestionably the best book that I This single volume contains all can be placed in the student's hands, that will be necessary in a college and as a work of reference for the j course, and all that the physician busy physician it can scarcely be will need as Avell. — Dominion 3Ied. excelled. — The Phila. Polyclinic. Monthly. FOTHERGELIi (J. MIL.NER). THE PRACTITIONER'S HAND- BOOK OF TREATMENT. Third edition. In one handsome octavo volume of 664 pages. Cloth, $3.75 ; leather, $4.75. FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- bodying Watts' Physical and Inorganic Chemistry. In one royal 12mo. volume of 1061 pages, with 168 engravings, and 1 colored plate. Cloth, $2.75 ; leather, $3.25. FRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. In one handsome octavo volume of 677 pages, with 51 engravings and 2 plates. Cloth, $3.75 ; leather, $4.75. FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- GANS IN THE MALE. In one very handsome octavo volume of 238 pages, with 25 engravings and 8' full-page plates. Cloth, $2. It is an interesting work, and one I tive and brings views of sound which, in view of the large and ^ profitable amount of work done in this field of late years, is timely and well needed. — Medical Fortnightly. The book is valuable and instruc- jjathology and rational treatment to many cases of sexual disturbance whose treatment has been too often fruitless for good. — Annals of Surgery. FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and Treatment. From second English edition. In one 8vo. volume of 475 pages. Cloth, $3.50. GALLAUDET (HERN B.). A POCKET TEXT-BOOK ON SUR- GERY. In one handsome 12mo. volume of about 400 pages, with many illustrations. Shortly, Lea's Scries of Pocket 2'ext-books, edited by liKK.x B. Gallaudkt, M. D. See page 18. GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A Multum in Parvo. In one square octavo volume of 845 pages, with 159 engravings. Cloth, $3.75. GIBBES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. GIBNEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi- tioners and Students. In one 8vo. vol. profusely illus. Preparing. Lea Brothers & Co., Philadelphia and New York. 11 GERRTSH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. By American Autliors. Edited by Frederic II. Gerrish, M. D. In one imp. octavo volume of 015 paffcs, with 950 illustrations in black and colors. JuKtready. Clth, $0.50; llexible waterproof, $7; leath.,$7.50,7/t'«. In this, the first representative treatise on Anatomy produced in America, no effort or expense has been spared to unite an authoritative text with the most successful anatomical pictures which have yet appeared in the Avorld. The editor has secured the co-operation of the pi-ofessors of anatomy in leading medical colleges, and with them has prepared a text conspicuous for its simplicity, unity and judicious selection of such anatomical facts as bear on physiology, surgery and internal medicine in the most compre- hensive sense of those terms. The authors have endeavored to make a book which shall stand in the place of a living teacher to the student, and which shall be of actual service to the practitioner in his clinical Avork, emphasizing the most imjiortant subjects, clarifying obscurities, helping most in the parts most difficult to learn, and illustrating everything by all available methods. GOUL.D (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. New and thoroughly revised American edition, much enlarged in text, and in engravings in black and colors. In one imperial octavo volume of 1239 pages, with 772 large and elaborate engravings on wood. Price of edition with illustrations in colors : cloth, $7 ; leather, $8. Price of edition with illustrations in black : cloth, $6 ; leather, $7. This is the best single volume upon Anatomy in the English language. - azine. University lledical Mag- Gray's Anatomy affords the student more satisfaction than any other treatise with which we are familiar. — Buffalo Med. Journal. The most largely used anatomical text-book published in the English language. — Annals of Surgery. Particular stress is laid upon the practical side of anatomical teach- ing, and especially the Surgical Anatomy. — Chicago Med. Recorder. Holds first place in the esteem of both teachers and students. — llie Brooklyn Medical Journal. Tlie foremost of all medical text- books. — Medical Fortnightly. Gray's Anatomy should be the first work which a medical student should purchase, nor should he be without a copy throughout his pro- fessional career. — Pittsburg 3Iedical Review. GRAY (L.ANDON CARTER). A TREATISE ON NERVOUS AND MENTAL DISEASES. For Students and Practitioners of Medicine. New (2d) edition. In one handsome octavo volume of 728 pages, with 172 engravings and 3 colored plates. Cloth, $4.75; leather, $5.75. An up-to-date text-book upon nervous and mental diseases com- bined. A well-written, terse, ex- plicit, and authoritative volume treating of both subjects is a step in the direction of popular demand. — I'he Chicago Clinical Review. The descriptions of the various diseases are accurate and the symp- toms and differential diagnosis are set before the student in such a way as to be readily comprehended. The author's long experience renders his views on therapeutics of great value. — 2%e Journal of Nervous and 3Ien- tal Disease. 12 Lea Beothees & Co., Philadelphia and New Yoek. GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY AND MORBID ANATOMY. New (8th) American from the eighth London edition. In one handsome octavo volume of 582 pages, with 216 engravings and a colored plate. Cloth, $2.50, net. Just ready. A work that is the text-book of probably four-fifths of all the stu- dents of pathology in the United States and Great Britain stands in of the day — as much so almost as Gray's Anatomy. It is fully up-to- date in the record of fact, and so pro- fusely illustrated as to give to each no need of commendation. The work j detail of text sufficient explanation precisely meets the needs and wishes of the general practitioner. — The American Practitioner and News. Green's Pathology is the text-book The work is an essential to the prac- titioner — whether as surgeon or phys- ician. It is the best of up-to-date text-books. — Virginia3Ied. 3£onthly. GREENE (WJIAAKM H.). A MANUAL OF MEDICAL CHEM- ISTRY. For the Use of Students. Based upon Bowman's Jfedical Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. GROSS (SAI^rUEL D.). A PRACTICAL TREATISE ON THE DIS- EASES, INJURIES AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND AND THE URETHRA. Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN DISEASES. In one handsome 12mo. volume of 350 pages, Avith many illustrations. Shortly. Lea's Series of Poclcet Text-hooks, edited by Bern B. Gallaudet, M. D. See page* 18. HABERSHON fS. O.). ON THE DISEASES OF THE ABDOMEN Second American from the third English edition. In one octavo vol- ume of 554 pages, with 11 engravings. Cloth, $3.50. HALL (WLVFIELD S.) TEXT-BOOK OF PHYSIOLOGY. Octavo about 500 pages, richly illustrated. In press. HA301 Lea Brothers & Co., Philadelphia and New Yoek. 13 HARE (HOB ART AMORY). A TEXT-BOOK OF PRACTICAL THERAPEUTICS, with Special Reference to the Application of Reme- dial Measures to Disease and their Employment upon a Rational Basis. With articles on various subjects by well-known specialists. New (7th) and revised edition. In one octavo volume of 776 pages. Cloth, $3.75, net; leather, $4.50, net. Its classifications are inimitable, I it can be readily used in connection and the readiness with which any- with Hare's Practical Diagnosis. thing can be found is the most won- For the needs of the student and dorful achievement of the art of in- ' general practitioner it has no equal. dexing. This edition takes in all the latest discovered remedies. — The St. Louis Cliniqyie. The great value of the work lies in the fact that precise indications for administration are given. A complete index of diseases and remedies makes it an easy reference work. It has been arranged so that — Medical Sentinel. The best planned therapeutic work of the century. — American Prac- titioner and Neivs. It is a book precisely adapted to the needs of the busy practitioner, who can rely upon finding exactly what he needs. — The National 3Ied- ical Review. HARE (HOBART AMORY) ON THE MEDICAL COMPLICA- TIONS AND SEQUELiE OF TYPHOID FEVER. Octavo, 276 pages, 21 engravings and two full- page plates. Just ready. Cloth, $2.40, net. A very valuable production. One read with great profit. — Cleveland of the very best products of Dr. i Journal of Medicine. Ilare and one that every man can ' HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- TICAL THERAPEUTICS. In a series of contributions by eminent practitioners. In four large octavo volumes comprising about 4500 pages, with about 550 engravings. Vol. IV., just ready. For sale by sub- scription only. Full prospectus free on application to the Publishers. Regular price. Vol. IV., cloth, $6 ; leather, $7 ; half Russia, $8. Price Vol. IV. to former or new subscribers to complete work, cloth, $5 ; leather, $6 ; half Russia, $7. Complete work, cloth, $20 ; leather, $24 ; half Russia, $28. The great value of Hare's System of Practical Therapeutics has led to a widespread demand for a new volume to represent advances in treatment made since the publication of the first three. More than fulfilling this request the Editor has secured contributions from practically a new corps of equally eminent authors, so that entirely fresh and original matter is ensured. The plan of the work, which proved so successful, has been fol- lowed in this new volume, which will be found to present the latest devel- opments and applications of this most practical branch of the medical art. The entire System is an unrivalled encyclopaedia on the practical parts of medicine, and merits the great success it has won for that reason. 14 Lea Brothers & Co., Philadelphia and New York. HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. volume, 669 pages, with 144 engravings. Cloth, $2.75 . A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 12mo. volume of 310 pages, with 220 engravings. Cloth, $1,75. A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. HAYDEN ( JAI>rES R.). A MANUAL OF VENEREAL DISEASES. New (2d) edition. In one 12mo. volume of 304 pages, with 54 en- gravings. Cloth, $1.50, net. Just ready. It is practical, concise, definite j ticularly thorough, and may be and of sufiicient fulness to be satis- i-elied upon as a guide in the man- factory. — Chicago Clinical Review. agemen{ of this class of diseases. — This work gives all of the prac- Northwestern Lancet. tically essential information about It is well written, up to date, and the three venereal diseases, gon- will be found very useful. — Inter- orrhcea, the chancroid and syphilis, national 3Iedical lUagazine. In diagnosis and treatment it is par- ' HAYEM (GEORGES) AXD HARE (H. A). PHYSICAL AND NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- tricity, Modifications of Atmospheric Pressure, Climates and Mineral Waters. Edited by Prof, H, A. Hare, M. D. In one octavo volume of 414 pages,with 113 engravings. Cloth, $3. This well-timed up-to-date volume recognition. Within this large is particularly adapted to the re- range of applicability, physical quirements of the general practi- agencies when compared with drugs tioner. The section on mineral are more direct and simple in their waters is most scientific and prac- I results. Medical literature has long tical. Some 200 pages are given up been rich in treatises upon medical to electricity and evidently embody agents, but an authoritative work the latest scientific information on upon the other great branch of the subject. Altogether this work therapeutics has until now been a is the clearest and most practical aid desideratum. The section on climate, to the study of nature's therapeutics rewritten by Prof. Hare, will, for that has yet come under our obser- the first time, place the abundant vation. — The Medical Fortnightly, resources of our country at the in- For many diseases the most potent telligent command of American remedies lie outside of the materia practitioners. — The Kansas City medica, a fact yearly receiving wider Medical Index. HER3IAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $L25. See Student's Series oj[ Manuals, page 27. HERMANN (L..). EXPERIMENTAL PHARMACOLOGY. A Hand- book of the Methods for Determining the Physiological Actions of Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. volume of 199 pages, with 32 engravings. Cloth, $1.50, Lea Brothers & Co., Philadelphia and New York. 15 HERRICK (JAIMES B.). A HANDBOOK OF DIAGNOSIS. In one handsome 12mo. volume of 429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50. Excellently arranged, practical, microscopical examination to be em- concise, up-to-date, and eminently ployed in each class. The technique well fitted for the use of the prac- titioner as well as of the student. — Chicago 3Ied. Recorder. This volume accomplishes its ob- of blood examination, including color analysis, is very clearly stated. Uranalysis receives adequate space and care. — JVeiv York Med. Journal. jects more thoroughly and com- | We commend the book not only to pletely than any similar work yet the undergraduate, but also to the published. Each section devoted to physician who desires a ready means diseases of special systems is pre- 1 of refreshing his knowledge of diag- ceded with an exposition -of the nosis in the exigencies of professional methods of physical, chemical and life. — 3Iemphis 3Iedical 3[onthly. HILiLi (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one 8vo. volume of 479 pages. Cloth, $.3.25. HIL.L.IER (THOMAS). A HANDBOOK OF SKIN DISEASES. Second edition. In one royal 12mo. volume of 353 pages, with two plates. Cloth, $2.25. HIRST (BARTON C.) AND PIERSOL (GEORGE A.). HUMAN MONSTROSITIES. Magnificent folio, containing 220 pages of text and illustrated with 123 engravings and 39 large photographic plates from nature. In four parts, price each, $5. Limited edition. For sale by subscription only. HOBIiYN (RICHARD D.). A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. In one 12mo. volixme of 520 double-columned pages. Cloth, $1.50; leather, $2. HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, INCLUDING DISPLACEMENTS OF THE UTERUS. Second and revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4..50. HOFFMANN (FREDERICK) AND PO^VER (FREDERICK B.). A MANUAL OF CHEMICAL ANALYSIS, as Applied to the Examination of Medicinal Chemicals and their Preparations. Third edition, entirely rewritten and much enlarged. In one handsome octavo volume of 621 pages, with 179 engravings. Cloth, $4.25. HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- ciples and Practice. A new American from the fifth English edition. Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- ume of lOOS.'pages, with 428 engravings. Cloth, $6 ; leather, $7. A SYSTEM OF SURGERY. With notes and additions by various American authors. Edited by John H. Packard, M. D. In three very handsome 8vo. volumes containing 3137 double-columned pages, with 979 engravings and 13 lithographic plates. Per volume, clotn, $6 ; leather, $7 ; half Russia, $7.50. For sale by subscription only. 16 Lea Brothees & Co., Philadelphia and New York. HORNER (WrLLIA3I E.). SPECIAL ANATOMY AND HIS- TOLOGY. Eighth edition, revised and modified. In two large 8vo. volumes of 1007 pages, containing 320 engravings. Cloth, $6. HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one octavo volume of 308 pages. Cloth, $2.50. HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL METHODS. A GUIDE TO THE PRACTICAL STUDY OF MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav- ings and 8 colored plates. Cloth, $3.00. A comprehensive, clear and re- markably up to-date guide to clinical diagnosis. The illustrations are plentiful and excellent. As exam- ples of the more recent additions to medical knowledge which receive recognition, we mention Widal's test for typhoid and the Neuron theory of the nervous system. — Jlontreal Medical Journal. HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. See Series of Clinical Manuals, p. 25. HYDE ( JA3IES NEVINS). A PRACTICAL TREATISE ON DIS- EASES OF THE SKIN. New (4th) edition, thoroughly revised. In one octavo volume of 815 pages, with 110 engravings and 12 full- page plates, 4 of which are colored. Cloth, $5.25 ; leather, $6.25. This edition has been carefully re- vised, and eveiy real advance has been recognized. The work answers the needs of the general practitioner, the specialist, and the student. — The Ohio Med. Jour. A treatise of exceptional merit characterized by consci'^ntious care and scientific accuracy. — Buffalo Med. Journal. A complete exposition of our knowledge of cutaneous medicine as it exists to-day. The teaching in- culcated throughout is sound as well as practical. — The American Jour- nal of the Medical Sciences. It is the best one-volume work that we know. The student who gets this book will find it a useful investment, as it will well serve him when he goes into practice. — Vir- ginia Medical Semi-Monthly. A full and thoroughly modern text-book on dermatology. — The Pittsburg 3fedical Rettetv. It is the most practical hand- book on dermatology with which we are acquainted. — The Chicago 3Ied- ical Recorder. JACKSON (GEORGE THOMAS). THE READY-REFERENCE HANDBOOK OF DISEASES OF THE SKIN. New (3d) edition. In one 12mo. volume of 637 pages, with 75 illustrations and a colored plate. Just ready. Cloth, $2.50, net. As a student's manual, it may be [ Without doubt forms one of the considered beyond criticism. The 1 best guides for the beginner in der- book is singularly full.— ,SV. Louis matology that is to be found in the Medical and Surgical Journal. j English language. — Medicine. JAMIESON (W. ALLAN). DISEASES OF THE SKIN. Third edition. In one octavo volume of 656 pages, with 1 engraving and 9 double-page chromo-lithographic plates. Cloth, $6. Lea Beothees & Co., Philadelphia and New Yoek. 17 JEWETT (CHARIiES). ESSENTIALS OF OBSTETRICS. In one 12mo. volume of 356 pages, with 80 engravings and 3 colored plates. Cloth, $2.25. Just ready. An exceedingly useful manual for [ ing it in attractive and easily tangi- student and practitioner. The au- ; ble form. The book is well illus- thor has succeeded unusually well trated throughout. — NashvtUe Joar. in condensing the text and in arrang- of Medicine and Surgery. THE PRACTICE OF OBSTETRICS. By American Authors. One large octavo volume of 763 pages, with 441 engravings in black and colors, and 22 full-page colored plates. Just ready. Cloth, $5.00, net ; leather, $6.00, net. A clear and practical treatise upon ' the book abounds. The work is obstetricsby well-known teachers of I sure to be popular with medical the subject. A special feature of i students, as well as being of extreme this work would seem to be the j value to the practitioner. — The excellent illustrations v/ith which | Medical Age. JONES fC. HANDFIELD). CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS. Second American edi- tion. In one octavo volume of 340 pages. Cloth, $3.25. JULER rHENRY). A HANDBOOK OF OPHTHALMIC SCIENCE AND PRACTICE. Second edition. In one octavo volume of 549 pages, with 201 engravings, 17 chromo-lithographic plates, test-types of Jaeger and Snellen, and Holmgren's Color-Blindness Test. Cloth, $5.50 ; leather, $6.50. The volume is particularly rich in \ color blindness, etc. The sections matter of practical value, such as ' devoted to treatment are singularly directions for diagnosing, use of full and concise.— JfecZtca^ Age. instruments, testing for glasses, for \ KING f A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition. In one 12mo. volume of 573 pages, with 223 illustrations. Cloth, $2.50. From first to finish it is thoroughly | cyclopedias. The well-arranged practical, concise in expression, well ; index renders the book useful to illustrated, and includes a statement the practitioner who is in haste to of nearly every fact of importance ' refresh his memory. — Virginia discussed in obstetric treatises or i 3Iedical Seini- Monthly. KIRK (EDWARD C). OPERATIVE DENTISTRY. Handsome octavo of 700 pages, with 751 illustrations. Just ready. See American Text-Books of Dentistry, pa,ge 2. We have only the highest praise tempted. We can heartily recom- for this valuable work. It is replete mend it to the profession. — The in every particular, and surpasses j Ohio Dental Journal. anything of the kind heretofore at- ) KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In one 12mo. volume of 506 pages, with 296 engravings. Just ready. Cloth, $2.00, net. See Student's Series of Manuals, page 27. It is the most complete and con- This work deservedly occupies a cise work of the kind that has yet first place as a text-book on his- emanated from the press. — The 3fed- , tologj.— Canadian Practitioner. ical Age. ) 18 Lea Brothers & Co., Philadelphia and New York. L.ANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. LA ROCHE (R.). YELLOW FEVER. In two 8vo. volumes of 1468 pages. Cloth, $7. LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- BOOK OF OPHTHALMIC SURGERY. Second edition. In one octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. LEA'S SERIEiS OF POCKET TEXT-BOOKS, edited by Bern B. Gallaudet, M. D. Covering the entire field of Medicine in a series of 16 very handsome cloth-hound 12mo. volumes of .350-450 pages each, profusely illustrated. Compendious, clear, trustworthy and modern. The following volumes constitute the series. Coates' Bacteriology and Hygiene. Brockway's Anatomy. Collins and Rockwell's Physiology. IMartix and Rockwell's Chemistry and Physics. NiCHOLS and Vale's Histology and Pathology, Schleif's Materia Medica, Therapeutics, Medical Latin, etc. Mals- bary's Practice of Medicine. Collins' Diagnosis. Potts' Nervous and Mental Diseases. Gallaudet's Surgery. Likes' Genito- urinary and Venereal Diseases. Grtndon's Dermatology. Ballen- ger and Wippern's Diseases of the Eye, Ear, Throat and Nose. Evans' Obstetrics. Crockett's Gynecology, Tuttle's Diseases of Children. For separate notices see under various authors' names, LEA (HENRY C). A HISTORY OF AURICULAR CONFESSION AND INDULGENCES IN THE LATIN CHURCH. In three octavo volumes of about 500 pages each. Per volume, cloth, $3.00. — CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN ; CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINATI- THE ENDEMONIADAS; EL SANTO NiRO DE LA GUARDIA; BRIANDA DE BARDAXI. 12mo., 522 pages. Cloth, $2.50. — FORMULARY OF THE PAPAL PENITENTIARY. In one octavo volume of 221 pages, with frontispiece. Cloth, $2.50. — SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Fourth edition, thoroughly revised. In one hand- some royal 12mo. volume of 629 pages. Cloth, $2.75. — STUDIES IN CHURCH HISTORY. The Rise of the Temporal Power — Benefit of Clergy — Excommunication. New edition. In one handsome 12mo. volume of 605 pages. Cloth, $2.50. AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY IN THE CHRISTIAN CHURCH. Second edition. In one hand- some octavo volume of 685 pages. Cloth, $4.50. LEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY. In one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25. Lea Beotheks & Co., Philadelphia and New York. 19 LIKES (SYLA^AN H.). A POCKET TEXT-BOOK OF GENITO- UEINAEY AND VENEREAL DISEASES. In one handsome 12mo. volume of about 350 pages, with many illustrations. Shortly. Lea's Series of Pochct Text-books, edited by Bern B. Gallaudet, M. D. See page 18. LiOOMIS (ALFRED L.) AND THOMPSON (TT. OILMAN, EDITORS). A SYSTEM OF PRACTICAL MEDICINE. In Contributions by Various American Authors. In four very hand- some octavo volumes of about 900 pages each, fully illustrated in in black and colors. Complete work now ready. Per volume, cloth, $5; leather, $6; half Morocco, $7. For sale by subscription only. Full prospectus free on application to the Publishers. See American System of Practical Medicine, page 2. LUFF (ARTHUR P.). MANUAL OF CHEMISTRY, for the use of Students of Medicine. In one 12mo. volume of 522 pages, with 36 engravings. Cloth, $2. See Student's Series of Manuals, page 27. LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one very handsome octavo volume of 925 pages, with 170 engravings. Cloth, $4.75 ; leather, $5.75. Complete, concise, fully abreast of Practical, systematic, complete and the times and needed by all students '• well balanced. — Chicago Med. Re- and pi-actitioners. — Univ. 3 fed. Mag. corder. An exceedingly valuable text-book. ' LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo volume of 362 pages. Cloth, $2.25. MACKENZIE (JOHN NOLAND). ON THE NOSE AND THROAT. Handsome octavo, about 600 pages, richly illustrated. Prejjaring. ]>IAISCH (JOHN M.). A MANUAL OF ORGANIC MATERIA MEDICA. New (7th) edition, thoroughly revised by H. C. C. Maisch, Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with 285 engravings. Just ready. Cloth, $2.50, net. Used as text-book in every college of pharmacy in the United States and recommended in medical col- leces. — American Therapist. Noted on both sides of the Atlantic and esteemed as much in Germany as in America. The work has no equal. — Dominion 3Ied. 3Ionthly. The best handbook upon phar- macognosy of any published in this country. — Boston 3fed. & Sur. Jonr. 20 Lea Beothees & Co., Philadelphia and New York. MALSBARY (GEORGE E.). A POCKET TEXT-BOOK OF TIIEOEY AXD PRACTICE OF MEDICINE. In one handsome r2mo. volume of about 350 pages. Shortly. Lca^s Series of Pocket Text-hooks, edited by Bern B. Gallaudet, M. D. See page 18. MANTJAIiS. See Students Quiz Series, page 27, StudetiVs Series of Manuals, page 27, and Series of Clinical Manuals, page 25. MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. See Series of Clinical 3Ianuals, page 25. 3IARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. In one 12mo. volume of about 400 pp., fully illustrated. Preparing. MARTIN (WALTON) AND ROCKWELL (WM. H). A POCKET TEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand- some 12mo. volume of about 350 pages, with many illustrations. Shortly. Lea's Series of Pocket Text-hooks, edited by Bern B. Gallaudet, M. D. See page 18. MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For the use of Students and Practitioners. Second edition, revised by L. S. Rau, M. D. In one 12mo. volume of 360 pages, with 31 engrav- ings. Cloth, $1.75. MEDICAL NEWS POCKET FOR^IULARY, see page 32. MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS DISEASES. In one 12mo. volume of 299 pages, with 19 engravings and 2 colored plates. Cloth, $2.50. Of the hundred numbered copies with the Author's signed title page a few remain ; these are offered in green cloth, gilt top, at $3.50, net. The book treats of hysteria, recur- contractions, rotary movements in rent melancholia, disorders of sleep, ' the feeble minded, etc. Few can choreic movements, false sensations speak with more authority than the of cold, ataxia, hemiplegic pain, author. — The Journal of the Ameri- treatment of sciatica, erythromelal- can Medical Association. gia, reflex ocularneurosis, hysteric [ MITCHEL.L (JOHN K.). REMOTE CONSEQUENCES OF IN- JURIES OF NERVES AND THEIR TREATMENT. In one handsome 12mo. volume of 239 pages,with 12 illustrations. Cloth, $1.75. Injuries of the nerves are of fre- quent occurrence in private practice, and often the cause of intractable and painful conditions, conse- quently this volume is of especial interest. Doctor Mitchell has had access to hospital records for tlie last thirty years, as well as to the government documents, and has skilfully utilized his opportunities, —The Med. Age. MORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- graphic plates and 26 engravings. Cloth, $3.25, net. Just ready. IVIULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL- OGY. In one large Svo. vol. of 623 pages, with 538 cuts. Cloth, $4.50. Lea Beothees & Co., Philadelphia and New Yoek. 21 MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL DIAGNOSIS, for Students and Physicians. New (od) edition, thor- oughly revised. In one octavo volume of about 1000 pages, with about 220 engravings and 48 full-page colored plates. In press. Notices of previous edition are appended. We have no work of equal value in English. — University Medical Magazine. His descriptions of the diagnostic manifestations of diseases are accu- rate. This work will meet all the requirements of student and physi- cian. — The 3Iedical News. From its pages may be made the diagnosis of every paalady that afflicts the human body, .including those which in general are dealt with only by the specialist. — North- western Lancet. It so thoroughly meets the precise demands incident to modern research that it has been adopted as a leading text-book by the medical colleges of this country. — North American Practitioner. Occupies the foremost place as a thorough, systematic treatise. — Ohio Medical Journal. The best of its kind, invaluable to the student, general practitioner and teacher. — Montreal MedicalJ our nal. NATIONAL DISPENSATORY. See StUle, Maisch & Caspari, p. 27. NATIONAL FOR]\rLrLAR,Y. See Stille, Maisch & Caspari's National Dispensatory, page 27. NATIONAL IMEDICAL DICTIONARY. See Billings, page 4. NETTLESHEP (E.). DISEASES OF THE EYE. New (5th) American from sixth English edition, thoroughly revised. In one 12mo. volume of 521 pages, with 161 engravings, and 2 colored plates, test-types, formulae and color-blindness test. Cloth, $2.25. Just ready. By far the best student's text-book • English language. — Journal of on the subject of ophthalmology and Medicine and Science. is conveniently and concisely ar- The present edition is the result ranged. — The Clinical Review. of revision both in England and It has been conceded by ophthal- America, and therefore contains the mologists generally that this work latest and best ophthalmological for compactness, practicality and ideas of both continents. — The Phy- clearness has no superior in the sician and Surgeon. NICHOLS (JOHN B.) AND VALE (F. P.). A POCKET TEXT- BOOK OF HISTOLOGY AND PATHOLOGY. In one handsome 12mo. volume of about 350 pages, with many illustrations. In press. Lea's Series of Pocket Text-books, edited by Been B. Gallaudet, M. D. See page 18. NORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXTBOOK OF OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 engravings and 5 colored plates. Cloth, $5 ; leather, $6. A safe and admirable guide, well qualified to furnish a working knowledge of ophthalmology. — Johns Hopkins Hospital Bulletin. It is practical in its teachings. We unreservedly endorse it as the best, the safest and the most compre- hensive volume upon the subject that has ever been offered to the Amer- ican medical public. — Annals of Ophthalmology and Otology. 22 Lea Beothbes & Co., Philadelphia and New Yoek. OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. In one 12mo. volume of 525 pages, with 85 engravings and 4 colored plates. Cloth, $2. See Series of Clinical Manuals, page 25. PARK (ROSWEIili). A TREATISE ON SURGERY BY AMERI- CAN AUTHORS. New and condensed edition. Jii>li shed in a larger edition, comprising two volumes. Volume I., General Surgery, 799 pages, with 356 engravings and 21 full-page plates, in colors and monochrome. Volume II., Special Surgery, 800 pages, with 430 engravings and 17 full-page plates, in colors and monochrome. Per volume, cloth, $4.50 ; leather, $5.50, net. The work is fresh, clear and practi- cal, covering the ground thoroughly yet briefly, and well arranged for rapid reference, so that it will be of special value to the student and busy practitioner. The pathology is broad, clear and scientific, while the suggestions upon treatment are clear-cut, thoroughly modern and admirably resourceful. — Johns Hop- kins Hospital Bulletin. The latest and best work written upon the science and art of surgery. Columbus Medical Journal. The illustrations are almost en- tirely new and executed in such a way that they add great force to the text. — The Chicago Medical Re- corder. The various writers have em- bodied the teachings accepted at the present hour. — The North Amer- ican Practitioner. Both for the student and practi- tioner it is most valuable. It is thoroughly practical and yet thor- oughly scientific. — Medical News. A truly modern surgery, not only in pathology, but also in sound surgical therapeutics. — New Or- leans Med. and Surgical Journal. PARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND SURGERY. 12mo., about 550 pages, fully illustrated. In press. PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- MENT. In one octavo volume of 272 pages. Cloth, $2.50. PARVIN (THEOPHILUS). THE SCIENCE AND ART OF OB- STETRICS. Third edition. In one handsome octavo volume of 677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; leather, $5.25. In the foremost rank among the most practical and scientific medical works of the day. — Medical News. It ranks second to none in the English language. — Annals of Gyne- cology and Pediatry. The book is complete in every de- partment, and contains all the neces- sary detail required by the modern practising obstetrician. — Interna- tional Medical Magazine. Parvin's work is practical, con- cise and comprehensive. We com- mend it as first of its class in thfe English \2d\g\x2igQ.— Medical Fort- nightly. It is an admirable text-book in every sense of the word.— Nashville Journal of Medicine and Surgery. Lea Brothers & Co., Philadelphia and New York. 23 PEPPER'S SYSTP:M of medicine. See page 3. PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's Series 0/ Manuals, page 27. SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. In one 12rao, volume of 530 pages, with 93 engravings. Cloth, $2. See Series of Clinical Manuals, page 25. PIjAYFAIR (W. S.). a TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. Seventh American from the ninth English edition. In one octavo volume of 700 pages, with 207 engravings and 7 plates. Cloth, $3.75 nrt ; leather, $4.75, net. Just ready. In the numerous editions wliich have appeared it has been kept con- stantly in the foremost rank. It is a work which can be conscientiously recommended to the profession. — The Albany Medical Annals. This work must occupy a fore- most place in obstetric medicine as j 3Iedical Fortnightly. a safe guide to both student and I obstetrician. It holds a place among the ablest English-speaking authori- ties on the obstetric art. — Buffalo Medical and Surgical Journal. An epitome of the science and practice of midwifery, which em- bodies all recent advances. — ■ The THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- TION AND HYSTERIA. In one 12mo. volume of 97 pages. Cloth, $1. POCKET FORMULARY, see page 32. POCKET TEXT-BOOKS, see page 18. POIilTZER f ADAM). A TEXT-BOOK OF THE DISEASES OF THE EAR AND AD.IACENT ORGANS. Second American from the third German edition. Translated by OsCAR DODD, M. D., and edited by Sir William Dalby, F. R. C. S. In one octavo volume of 748 pages, with 330 original engravings. Cloth, $5.50. The anatomy and physiology of ment are clear and reliable. We each part of the organ of hearing can confidently recommend it, for it are carefully considered, and then contains all tbat is known upon the follows an enumeration of the dis- subject. — London Lancet. eases to which that special part of A safe and elaborate guide into the auditory apj^aratus is especially 1 every part of otology. — American liable. The indications for treat- 1 Journal of the Sledical Sciences. POTTS (CHARLES S.). A POCKET TEXT-BOOK OF NERVOUS AND MENTAL DISEASES. In one handsome 12mo. volume of about 450 pages. Shortly. Lra's Series of Pocket Text-books, edited by Bern B. Gallatjdet, M. D. See page 18. PROGRESSIVE MEDICINE, see page 32. PURDY (CHARLES W.^. BRIGHT'S DISEASE AND ALLIED AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 pages, with 18 engravings. Cloth, $2. 24 Lea Brothers & Co., Philadelphia and New York. PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. QUIZ SERIES. See Student's Quiz Series, page 27. RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See Student's Series of Ilanuals, page 27. RA3ISBOTHA3I (FRANCIS H.). THE PRINCIPLES AND PRAC- TICE OF OBSTETRIC MEDICINE AND SURGERY. In one imperial octavo volume of 640 pages, with 64 plates and numerous engravings in the text. Strongly bound in leather, $7. REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. In one handsome octavo volume of about 800 pages, richly illustrated. Preparing. REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- ISTRY. New (5th) edition, thoroughlv revised. In one 12mo. vol- ume of 326 pages. Cloth, $2. A clear and concise explanation that the work has met with general of a difficult subject. We cordially favor. This is further established recommend it. — The London Lancet, by the fact that it has been trans- The book is equally adapted to the lated into German and Italian. The student of chemistry or the practi- treatise is especially adapted to the tioner who desires to broaden his laboratory student. It ranks unusu- theoretical knowledge of chemistry, ally high among the works of this — New Orleans Med. and Surg. Jour, class. This edition has been brought The appearance of a fifth edition fully up to the times. — American of this treatise is in itself a guarantee 3Iedico-Surgical Bulletin. RICHARDSON (BENJA3IIN WARD). PREVENTIVE MEDI- CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. New (2d) edition. In one octavo volume of about 800 pages, with about 500 engravings. Shortly. THE COMPEND OF ANATOMY. For use in the Dissecting Room and in preparing for Examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. ROBERTS (SIR \I^ILLIA3f). A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, INCLUDING URINARY DEPOSITS. Fourth American from the fourth London edition. In one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. ROBERTSON (J. MCGREGOR). PHYSIOLOGICAL PHYSICS. In one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2. See Student's Series of Manuals, page 27. ROSS f JAMES). A HANDBOOK OF THE DISEASES OF THE NERVOUS SYSTEM. In one handsome octavo volume of 726 pagee, with 184 engravings. Cloth, $4.50 ; leather, $5.50. SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, with 18_ typical engravings. Cloth, $2. See Series of Clinical Man- uals, page 25. Lea Bkothers & Co., Philadelphia and New Yoek. 25 SCHAFER (EDWARD A.). TPIE ESSENTIALS OF HISTOL- OGY. DESCllIPTiVE AND PRACTICAL. For the use of Students. New (5th) editiou. lu one handsome octavo volume of 359 pages, with 392 illustrations. Cloth, $3.00, net. Just ready. The most satisfactory elementary text-book of histology in the Eng- lish language. — The Boston Med. and Sur. Jour. Nowhere else will the same very moderate outlay secure as thoroughly useful and interesting an atlas of structural anatomy. — The American Journal of the 3£edical Sciences. A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. SCHLEIF (WTLIilAM). MATERIA MEDICA, THERAPEUTICS, PRESCRIPTION AVRITING, MEDICAL LATIN, ETC. 12mo., 352 pages. Cloth, $1.50, 'iict. Just ready. Lea's Series of Pocket Text-books. Edited by Bekn B. Gallaudet, M. D. See page IS. SCHMITZ AND ZUMPT'S CLiASSICAIi SERIES. Advanced Latin Exercises. Cloth, GO cts. Schmidt's Elementary Latin Exer- cises. Cloth, 50 cents. Sallust. Cloth, 60 cents. Nepos. Cloth, 60 cents. Virgil. Cloth, 85 cents. Curtius. 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For separate notices, see under various authors' names. SERIES OF STUDENT'S MANUALS. See page 27. SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- SCOPICAL AND CHEMICAL MP^THODS. New (2d) edition. In one very handsome octavo volume of 530 pages, with 135 engravings and 14 full-page colored plates. Cloth, $3.50. Just ready. In all respects entirely up to date. — Medical Jiecord. The chapter on examination or the urine is the most complete and advanced that we know of in the English language. — Canadian Prac- titioner. This book thoroughly deserves its success. It is a very complete, authen- tic and useful manual of the micro- scopical and chemical methods which are employed in diagnosis. Very excellent colored plates illus- trate this work. — New York Medical Journal. 26 Lea Brothers & Co., Philadelphia and New York. SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory Work for Beginners in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine. New (6th) .j.-x:-_ T_ — o„„ „„i ^ ^'>Q pages, with 46 engravings and 8 edition. In one 8vo. volume of plates showing colors of 64 tests. It is difficult to see how a better book could be constructed. No man who devotes himself to the practice of medicine need know more about chemistry than is contained between Cloth, $3.00, net. Just ready. the covers of this book. — The North- western Lancet. Its statements are all clear and its teachings are practical. — Virginia Med. llonthly. SL.ADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. S3IITH (EDWARD). DIABLE STAGES. LEWIS 1 CONSUMPTION ; ITS EARLY AND REME- In one 8vo. volume of 253 pp. Cloth, $2.25. TREATISE ON THE DISEASES OF IN- Eighth edition, thoroughly revised In one large 8vo. volume of 983 4 full-page plates. Cloth, $4.50; SMITH (J FANCY AND CHILDHOOD. and rewritten and much enlarged pages, with 273 engravings and leather, $5.50. A safe guide for students and phy- sicians. — The Am. Jour, of Obstetrics. For years the leading text-book on children's diseases in America. — Chicago Medical Recorder. SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- oughly revised edition. In one octavo volume of 892 pages, with 1005 engravings. Cloth, $4 ; leather, $5. The most complete and satisfac- tory text-book with which we are acquainted. — American Gynecologi- cal and Obstetrical Journal. One of the most satisfactory works on modern operative surgery yet published. The book is a compen- dium for the modern surgeon. — Bos- ton 3Iedical and Surgical Journal. SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- TOLOGY. In one handsome octavo volume of 462 pages, with en- gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. Just ready. A clear and lucid summary of what is known of climate in relation to its influence upon human beings. — The Therapeutic Gazette. The book is admirably planned, clearly written, and the author speaks from an experience of thirty years as an accurate observer and practical therapeutist. — Maryland Med. Jour. Every practitioner of medicine should possess himself of a copy and study it, and we are sure he will never regret it. — ^S"^. Louis Medical and Surgical Journal. STILLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- MENT. In one 12mo. volume of 163 pages, with a chart showing routes of previous epidemics. Cloth, $1.25. THERAPEUTICS AND MATERIA MEDICA. Fourth and revised edition. In two octavo volumes, containing 1936 pages. Cloth, $10 ; leather, $12. Lea Brothkks & Co., Philadelphia and New Yoek. 27 STILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI (CHAS. JR.)- THE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in the latest Pharmacopoeias of the United States, Great Britain and Germany, with numerous refer- ences to the French Codex. Fifth edition, revised and enlarged, including the new U. S. Pharmacopoeia, Seventh Decennial Revision. With Supplement containing the new edition of the National Formu- lary. In one magnificent imperial octavo volume of about 2025 pages, with 320 engravings. Cloth, $7.25; leather, $8. With ready reference Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 engravings. Cloth, $3.75. A useful and practical guide for all students and practitioners. — Am. Journal of the Medical Sciences. The book is worth the price for the illustrations alone. — Ohio Medical Journal. STIMSON (LEWIS A.). DISLOCATIONS. In with 326 engravings and 20 plates leather, $6.00, net. A TREATISE ON FRACTURES AND one handsome octavo volume of 831 pages, Just ready. Cloth, $5.00, net ; Preeminently the authoritative text-book upon the subject. The vast experience of the author gives to his conclusions an unimpeachable value. The work is profusely il- lustrated. It will be found indis- pensable to the student and the prac- titioner alike. — :Z7te Medical Age. Taken as a whole, the work is the best one in English to-day. — St. Louis Medical and Surgical Journal . Pointed, practical, comprehensive, exhaustive, authoritative, well writ- ten and well arranged. — Denver Medical Times. STUDENT'S QUIZ SERIES. Thirteen volumes, convenient, author- itative, well illustrated, handsomely bound in cloth. 1. Anatomy (double number); 2. Physiology; 3. Chemistry and Physics; 4. Histol- ogy, Pathology, and Bacteriology; 5. Materia Medica and Thera- peutics ; 6. Practice of Medicine ; 7. Surgery (double number); 8. 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For separate notices, see under yarious author's names. 28 Lka Bbothees a Co., Philadelphia and New Yobk. STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. In one 12mo. volume. Cloth, $1.25. SUTTON (JOHN BLAND). SURGICAL DISEASES OF THE OVARIES AND FALLOPIAN TUBES. Including Abdominal Pregnancy. In one 12mo. volume of 513 pages, with 119 engravings and 5 colored plates. Cloth, $3. TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL SURGERY. In two handsome octavo volumes Vol. I. contains 546 pages and 3 plates. Cloth, $3. TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- EASES OF PREGNANCY. From the second English edition. In one octavo volume of 490 pages, with 4 colored plates and 16 engrav- ings. Cloth, $4.25. TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New American from the twelfth English edition, specially revised by Clark Bell, Esq., of the N. Y. Bar. In one 8vo. vol. of 831 pages, with 54 engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50 Jmt ready. To the student, as to the physician, nesses, it strongly behooves them to we would say, get Taylor first, and then add as means and inclination enable you. — American Practitioner and News. It is the authority accepted as final by the courts of all English- speaking countries. This is the im- portant consideration for medical men, since in the event of their being summoned as experts or wit- be prepared according to the princi- ples and practice everywhere ac- cepted. The work will be found to be thorough, authoritative and modern. — Albany Laic Journal. Probably the best work on the subject written in the English lan- guage. The work has been thor- oughly revised and is up to date. — Pacific Medical Journal. ON POISONS IN RELATION TO MEDICINE AND MEDI- CAL JURISPRUDENCE. Third American from the third London edition. In one octavo volume of 788 pages, with 104 illustrations. Cloth, $5.50 ; leather, $6.50. TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT- MENT OF VENEREAL DISEASES. New (2d) edition. In one very handsome octavo volume of about 700 pages, with about 200 en- gravings and 6 colored plates. In press. Notices of previous edition are appended. By long odds the best work on diseases that has in recent years^ ap- venereal diseases. — Louisville Jledi- cal Monthly. In the observation and treatment of venereal diseases his experience has been greater probably than that of any other practitioner of this con- tinent. — NewYork 3Iedical Journal. The clearest, most unbiased and ably presented treatise as yet pub- lished on this vast subject. — The Medical News. Decidedly the most important and authoritative treatise ou venereal peared in English. — American Jour- nal of the Medical Sciences. It is a veritable storehouse of our knowledge of the venereal diseases. It is commended as a conservative, practical, full exposition of the greatest value. — Chicago Clinical Review. The best work on venereal dis- eases in the English language. It is certainly above everything of the kind. — The St. Louis Medical and Surgical Journal. Lea Brothers & Co., Philadelphia and New York. 29 TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- UAL DISORDERS IN THE MALE AND FEMALE. In one 8vo. vol. of 448 pp., with 73 engravings and 8 colored plates. Cloth, $3. NeL The author has presented to the followed, will be of unlimited value to both physician and patient.- Medical News. profession the ablest and most scien tific work as yet published on sexual disorders, and one which, if carefully A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. Including Diagnosis, Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and comprising 213 beautiful figures on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 pages of text. Complete work now ready. Price per part, sewed in heavy embossed paper, $2.50. Bound in one volume, half Russia, $27 ; half Turkey Morocco, $28. For sale hy subscription only. Address the publishers. Specimen plates by mail on receipt of ten cents. TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for the use of Senior Students and others. In one large 12mo. volume of 802 pages. Cloth, $3.75. THOMAS (T. GAILLiARD) AND MUNDE'(PAUL. F.). A PRAC- TICAL TREATISE ON THE DISEASES OF WOMEN. Sixth edition, thoroughly revised by Paul F. Munde, M. D. In one large and handsome octavo volume of 824 pages, with 347 engravings. Cloth, $5 ; leather, $6. The best practical treatise on the subject in the English language. It will be of especial value to the general practitioner as well as to the specialist. The illustrations are very satisfactory. Many of them are new and are particularly clear and attrac- tive. — Boston Med. and Sur. Jour. This work, which has already gone through five large editions, and has been translated into French, Ger- man, Spanish and Italian, is the most practical and at the same time the most complete treatise upon the subject. — The Archives of Gynecol- ogy, Obstetrics and Pediatrics. THOMPSON (SIR HENRY). CLINICAL LECTURES ON DIS- EASES OF THE URINARY ORGANS. Second and revised edi- tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25. THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHRA AND URINARY FISTULiE. From the third English edition. In one octavo volume of 359 pages, with 47 engravings and 3 lithographic plates. Cloth, $3.50. THOMSON (JOHN). DISEASES OF CHILDREN. In one crown octavo volume of 350 pages, with 52 illus. Cloth, $1.75, net. Just ready. TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER- TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. TREVES (FREDERICK). OPERATIVE SURGERY. In two 8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. A SYSTEM OF SURGERY. In Contributions by Twenty -five English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 487 engravings and 2 colored plates. Complete work, cloth, $16.00. 30 Lea Brothers & Co., Philadelphia and New York. TREVES (FREDERICK). SURGICAL APPLIED ANATOMY. In one 12mo. volume of 540 pages, with 61 engravings. Cloth, $2. See Student's Series of 3fanuals, page 27. TUTTLE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES OF CHILDREN. In one handsome 12mo. volume of about 300 pages, with many illustrations. Shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallatjdet, M. D. See p 18. VAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.). PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, or the Chemical Factors in the Causation of Disease. New (3d) edition. In one 12mo. volume of 603 pages. Cloth, $3. The present edition has been not only thoroughly revised throughout but also greatly enlarged, ample consideration being given to the new subjects of toxins and antitoxins. — Tri-Stnte Medical Journal. The work has been brought down to date, and will be found entirely satisfactory. — Journal of the Ameri- can Medical Association. The most exhaustive and most re- cent presentation of the subject. — American Jour, of the 3Ied. Sciences. VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1899. Four styles : Weekly (dated for 30 patients); Monthly (undated for 120 patients per month); Perpetual (undated for 30 patients each week); and Perpetual (undated for 60 patients each week). The 60- patient book consists of 256 pages of assorted blanks. The first three styles contain 32 pages of important data, thoroughly revised, and 160 pages of assorted blanks. Each in one volume, price, $1.25. With thumb-letter index for quick use, 25 cents extra. Special rates to advance-paying subscribers to The Medical News or The American Journal of the Medical Sciences, or both. See p. 32. WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. A new American from the fifth and enlarged English edition, with additions by H. Haktshorne, M. D. In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. WEST (CHARIiES). LECTURES ON THE DISEASES PECULIAR TO WOMEN. Third American from the third English edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- ING. New (4th) edition. In one 12mo. volume of 504 pages, with 502 engravings, many of which are photographic. Just read//. $3.00, net. Notices of previous edition are appended. work of ready reference for sur- geons. — North Amer. Practitioner. The part devoted to bandaging is perhaps the best exposition of the subject in the English language. It can be highly commended to the student, the practitioner and the specialist. — The Chicago Medical Recorder. We know of no book which more thoroughly or more satisfactorily covers the ground of Minor Surgery and Bandaging. — Brooklyn 3Iedical Journal. Well written, conveniently ar- ranged and amply illustrated. It covers the field so fully as to render it a valuable text-book, as well as a Lea Brothers & Co., Philadelphia and New York, 31 WHITLA (T^IililAM). DICTIONARY OF TREATMENT, OR THERAPEUTIC INDEX. Including Medical and Surgical Thera- peutics. In one square octavo volume of 917 pages. Cloth, $4. WIL.LiIA3IS (DAWSON). THE MEDICAL DISEASES OF CHIL- DREN. In one 12mo. volume of 629 pages, with 18 illustrations. Just ready. Cloth, $2.50, net. The descriptions of symptoms are [ diagnoses, prognosis, complications, full, and the treatment recommended : and treatment. The work is up to will meet general approval. Under \ date in every sense. — The Charlotte each disease are given the symptoms, i dledical Journal. WELSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. A new and revised American from the last English edition. Illustrated with 397 engravings. In one octavo volume of 616 pages. Cloth, $4 ; leather, $5. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE. In one 12mo. volume. Cloth, $3.50. WINCKEL. ON PATHOLOGY AND TREATMENT OF CHILDBED. Translated by James R. Chadwick, A.M., M.D. With additions by the Author. In one octavo volume of 484 pages. Cloth, $4. WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated from the eighth German edition, by Ira Remsen, M. D. In one 12mo. volume of 550 pages. Cloth, $3. YEAR-BOOK OF TREATMENT FOR 1892, 1893, 1896,1897 and 1898. Critical Reviews for Practitioners of Medicine and Surgery, In con- tributions by 25 well-known medical writers. 12raos., about 500 pages each. Cloth, $1.50. In combination with The Medical News and The American Journal of the Medical Sciences, 75 cents. YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New (2d) edition. In one 12mo. volume of 592 pages, with 4 engravings. Cloth, $2.50. See Series of Clinical Manuals, page 26. We doubt whether any book on dietetics has been of greater or more widespread usefulness than has this much-quoted and much-consulted work of Dr. Yeo's, The value of the work is not to be overestimated. — Netv York Medical Journal. A MANUAL OF MEDICAL TREATMENT, OR CLINICAL THERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. In studying the different chapters, | surgical specialty and every page one is impressed with the thorough- i abounds with evidences of prac- ness of the work. The illustrations ticality. It is the clearest and most are numerous — the book thoroughly modern work upon this growing de- practical — Medical News. \ partment of surgery. — The Chicago It is a thorough, a very compre- : Clinical Review. hensive work upon this legitimate PEKIODICALS. PROGRESSIVE 3IEDICINE. A Quarter]y Digest of New Methods, Discoveries, and Improvements in the Medical and Surgical Sciences by Eminent Authorities. Edited by Dr. Hobart Aniory Hare. In four abundantly illustrated, cloth bound, octavo volumes, of 400-500 pages each, issued quarterly, commencing March 1st, 1899. Per annum (4 volumes), $10 00 delivered. THE MEDICAL. NEWS. Weekly, $1.00 per Annum. Each number contains 32 quarto pages, abundantly illustrated, crisp, fresh weekly professional newspaper. THE A^IERICAN JOURNAL OF THE MEDICAL SCIENCES. Monthly, S4.00 Per Annum. Each issue contains 128 octavo pages, fully illustrated. The most advanced and enterprising American exponent of scientific medicine. 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