LIBRARY OF CONGRESS.
Chap. _ll... Copyright No,
Shelf.
Ja.
837
UNITED STATES OF AMERICA.
ESSENTIALS
OBSTETEICS
BY
CHARLES JEWETT, A.M., M.D., Sc.D.,
PROFESSOR OF OBSTETRICS AND PEDIATRICS IN THE LONG ISLAND COLLEGE HOSPITAL
AND OBSTETRICIAN TO THE HOSPITAL.
ASSISTED BY
/
HAROLD F. JEWETT, M.D.
ILLUSTRATED BY 80 WOODCUTS AND 3 COLORED PLATES
LEA BROTHERS & CO.,
NEW YORK AND PHILADELPHIA
1897.
C
Entered according to the Act of Congress in the year 1897, by
LEA BROTHERS & CO.,
In the Office of the Librarian of Congress. All rights reserved.
DOK.NAN, PRINTER
PREFACE
The object of this volume is to place the Essentials of
Obstetrics within easy grasp of the student. With this
aim in view conciseness and clearness have been consulted,
even at the risk sometimes of being dogmatic, and a sys-
tematic and logical arrangement has been observed. Most
attention has been given to practical topics. Theoretical
discussions, matters of merely historical interest and elabor-
ation of details have in the main been purposely excluded.
Works of this character in the author's experience, have,
within their proper limits, a distinct value in medical
teaching. The pupil in any department of learning suc-
ceeds best by first mastering its elements. To the beginner
cyclopaedic works are confusing. It is seldom that the
average medical student has the necessary mental training
to analyze his subject for himself. This must be done
for him till he is well-grounded in the rudiments. The
foundation well laid, a complete and systematic knowledge
of the subject becomes a matter of comparatively easy
attainment.
vi PREFACE.
If these pages shall be found useful as an introduction
to the more elaborate treatise, and as a guide in following
the didactic and the practical teaching of the college course,
the author's object will have been gained.
Charles Jewett.
330 Clinton Ave., Brooklyn, N. Y.
September, 1897.
CONTENTS.
CHAPTER I.
ANATOMY OF FEMALE GENITAL ORGANS.
PAGES
External genitals — The vagina — Internal genitals . . 13-40
CHAPTER H.
PHYSIOLOGY OF PREGNANCY.
Physiology of the ovum — Effects of pregnancy on the ma-
ternal organism — Signs of pregnancy — Duration of
pergnancy — Hygiene of pregnancy .... 41-88
CHAPTER III.
PHYSIOLOGY OF LABOR.
The mechanical factors of labor — Clinical and mechanical
phenomena of normal labor — Management of labor 89-159
CHAPTER IV.
PHYSIOLOGY OF THE PUERPERAL STATE.
Course and phenomena of the puerperal state — Management
of the puerperal state — Lactation and nursing — The
child — Condition at birth — Management of the newborn
child — Artificial feeding — Disorders of the newborn
infant 160-192
viii CONTENTS.
CHAPTER V.
PATHOLOGY OF PREGNANCY.
PAGES
Diseases of the deciduse — Anomalies of the amnion and the
liquor amnii — Disease of the chorion — Anomalies of the
placenta — Anomalies of the umbilical cord — Pathology
of the foetus — Abortion — Premature labor — Ectopic ges-
tation — Pernicious vomiting and other disorders of
pregnancy 193-223
* CHAPTER VI.
PATHOLOGY OF LABOR.
Anomalies of the mechanism — Anomalies of the expelling
powers — Anomalies of the passages — Anomalies of the
passenger — Anomalies of labor arising from accidents or
disease 224-290
CHAPTER VII.
PATHOLOGY OF THE PUERPERAL STATE.
Puerperal insanity— Galactorrhea— Mastitis — Puerperal in-
fection 291-305
CHAPTER Vlir.
OBSTETRIC SURGERY.
Induction of premature labor — Induction of abortion — Re-
moval of an abnormally adherent placenta — Eorceps —
Version — Csesarean section— Porro operation— Symphy-
siotomy — Embryotomy 306-350
ESSENTIALS OF OBSTETRICS
CHAPTER I.
ANATOMY OF FEMALE GENITAL ORGANS.
For convenience of description the genital organs of the
female may be divided into the external and the internal
genitals, and the vagina, which connects the one group with
the other.
The external genitals of the female together constitute the
'pudendum or the vulva.
External Genitals.
The external sexual organs of the female are the mons
veneris, the labia majora, the labia minora, the clitoris and
the hymen.
The Mons Veneris, or the mount of Venus, is the
fleshy prominence which overlies the anterior aspect of
the pubic bones. Its surface is slightly convex. It is
bounded laterally by the groins, above by the hypogastric
fold, and below it merges into the labia majora. It consists
essentially of fat supported by a reticular framework of
fibrous and elastic tissue. Fibres of elastic tissue, some of
which are derived from the superficial abdominal fascia, run
through the adipose layer in all directions. The round liga-
ment may be traced into the mons on either side. Its
2
14
ESSENTIALS OF OBSTETRICS.
integument, which is somewhat thicker than that of the ab-
domen, becomes invested at puberty with a growth of short,
crisp, curly hair ; it abounds in sebaceous and in sweat-
FlG. 1.
Vulva of the virgin. 1. Greater lip of right side. 2. Fourchette. 3. Small lip.
4. Clitoris. 5. Urethral orifice. 6. Vestibule. 7. Orifice of the vagina. 8. Hymen.
9. Orifice of the vulvo-vaginal gland. 10. Anterior commissure of greater lips.
11. Anal orifice.
glands. The hairy growth extends an inch or more above
the level of the pubic bones. It is a peculiarity of the
female that the hair of the pubic region is limited above by
a sharply denned straight or convex line.
ANATOMY OF FEMALE GENITAL ORGANS. 15
The Labia Majora, or larger lips, are two prominent
rounded folds springing from the mons veneris and ex-
tending downward and backward on either side of the
median line. At full development they lie in contact with
each other in the young nullipara, except when the thighs
are strongly abducted — vulva connivens. When shrunken
from loss of fatty tissue in old age, or from the effects of
childbirth, the labia minora protrude between them — vulva
hians. They are thickest in front, and taper from before
backward. The point of contact in front is spoken of as
the anterior, and that behind as the posterior commissure of
the vulva. There is, however, no true commissure in the
sense of a connecting band at either point.
The covering of the labia majora is skin. The outer sur-
faces, which are of a somewhat darker color than the sur-
rounding integument, are supplied with hair which is most
abundant anteriorly; the inner surfaces resemble mucous
membrane, but are sparsely covered with fine hairs. Both
surfaces abound in sebaceous and in sweat-glands. Their
internal structure consists chiefly of elastic and adipose
tissue, and includes a rich venous plexus. Immediately be-
neath the skin is a layer of smooth muscular fibres anal-
ogous to those of the dartos in the male. Within this is
the pudendal sac. It is made up of elastic fibres, and is
attached by its neck to the external inguinal ring. Its
fundus reaches nearly to the posterior vulvar commissure.
Its cervix contains elastic and adipose tissue. The remains
of the canal of Nuck may sometimes be traced into the
pudendal sac. Each round ligament of the uterus termin-
ates in the corresponding labium. The labia majora are the
analogue of the scrotum in the male.
The Labia Minora, or Nymphae, the smaller lips,
are two thin folds of delicate skin lying between the labia
16 ESSENTIALS OF OBSTETRICS.
majora. They are widest toward their anterior extrem-
ities, narrowing gradually from before backward. When
at rest their inner surfaces are in contact. The outer sur-
faces merge into the labia majora, the inner are continuous
with the vestibule. Anteriorly each subdivides into two
subsidiary folds. The superior folds join in front of the
clitoris to form the prepuce, the inferior unite and are
attached to the under surfaces of the glans to form the frae-
num of the clitoris. Posteriorly they are united by the
fourchette.
In Bush women and in many Hottentots the smaller labia
are hypertrophied, reaching half-way to the knees ; this
overgrown structure is known as the Hottentot apron.
In the virgin the nymphse present the appearance of
mucous membrane ; after long exposure from gaping of the
vulva they look like skin. They are destitute of hairs and
of sweat-glands. Sebaceous glands are found on both sur-
faces. In general the histological characters of the outer
surfaces are those of skin, not of mucous membrane. The
minute anatomy of the inner, surfaces lies between that of
skin and mucous membrane.
The internal structure of the nymphse includes some
bundles of unstriped muscular fibre and a superficial capil-
lary venous plexus, but no fat.
The labia minora are richly supplied with nerve-fibres.
The Fourchette, or Frenulum Vulvae, is a trans-
verse fold of skin immediately in front of the posterior
vulvar commissure. It is scarcely apparent, except when
put upon the stretch by separating the labia. It then ap-
pears as a tense transverse fold between the posterior com-
missure and the hymen. In the nulliparous woman its
distance from the anal orifice is 3 cm. (1 \ inch) ; from
the base of the hymen nearly 1 cm. (J inch).
ANATOMY OF FEMALE GENITAL ORGANS. 17
The Fossa Navicularis is a boat-shaped space which
appears between the hymen and the fourchette when the
labia are separated.
The Rima Pudendi is the median cleft between the labia
of the right and the left sides.
The Clitoris is the analogue of the penis in the male.
It is situated in the median line below the anterior vulvar
commissure. It is a very small cylindrical body, and is
about one inch in length during erection. It is curved with
its convexity outward. Like the penis it has two corpora
cavernosa and a glans, but no corpus spongiosum, and is
imperforate. Continuous with the corpora cavernosa are the
crura by which the clitoris is attached to the ischiopubic rami.
The body is attached to the pubic bones by the suspensory
ligament. It is concealed behind the skin and is enclosed
in a firm fibrous sheath. Its internal structure is made up
chiefly of cavernous tissue. The only visible portion of the
organ is the glans, and this lies partly concealed in the
preputial fold formed by the anterior layers of the nymphre,
as has already been described. The glans during erection
has a thickness of about 5 mm. Its mucous membrane is
richly supplied with nerve-papillae.
Arteries and Vein. It has two arteries, the dorsal and
the profunda, and a dorsal vein. The vascular supply is
from the pudic artery. The dorsal vein empties into the
vesical plexus and communicates freely with all the sur-
rounding venous plexuses.
The nerve-supply is four or five times more abundant
than that of the penis. The clitoris is the chief seat of
voluptuous sensation in the female.
Glands. A few sebaceous follicles are to be found on the
glans.
The Vestibule. This is the triangular surface bounded
18
ESSENTIALS OF OBSTETRICS.
laterally by the labia minora and below by the margin of
the vaginal orifice. Its covering is mucous membrane. At
its apex is the glans clitoridis. At the middle of its base,
or immediately above it, is the meatus urethrae. This ap-
pears as a small tubercle or prominence with a median cleft.
The meatus lies 2 cm. (f inch) below the glans clitoridis,
and 2.5 cm. (1 inch) above the fourchette, in the nullipara.
An intricate plexus of veins immediately underlies the
mucous membrane. This is the 'pars intermedia, so called
from the fact that it connects the opposite vestibular bulbs
with each other and with the veins of the clitoris.
Fig. 2.
The bulbi vestibuli.
The bulbi vestibuli are two leech-shaped masses of veins
about 3.5 cm. in length, and are situated one on either side
ANATOMY OF FEMALE GENITAL ORGANS. 19
of the mesial line behind the labia, opposite the vaginal orifice
and the base of the vestibule. In extent they reach from the
level of the posterior margin of the vaginal orifice nearly to
the clitoris. They lie between the bulbo-cavemosus muscle
and the vaginal wall, immediately in front of the triangular
ligament. They communicate freely with the veins of the
labia, the vagina, the perineum, the glans clitoridis, and with
other neighboring venous plexuses. Each is enclosed in
a fibrous sheath. Their internal structure comprises, in addi-
tion to venous plexuses and connective tissue, some smooth
muscular fibres. The bulbs correspond to the bulbs of the
urethra in the male.
The Vulvo-vaginal Glands, Glands of Bartholin or Duverney.
These are two reddish-yellow bodies varying in size from
a pea to an almond, lying one on each side of the posterior
portion of the vaginal orifice, behind the anterior layers of
the triangular ligament, sometimes behind the posterior layer.
They are partly covered by the lower extremities of the
bulbi vestibuli. Their ducts, about 1.3 cm. (J inch) in length,
run along the inner aspects of the bulbi vestibuli, opening
iust without the base of the hvmen at the sides of the vagi-
nal orifice. The secretion, which is a yellowish tenacious
mucus, is poured out freely under sexual excitement and
during labor.
The Hymen. The hymen appears usually as a septum,
partially occluding the vaginal orifice when the labia are
drawn apart. When at rest it protrudes as a loose fold in
the vulvar fissure. According to Budin, it is a thinned-out
fold of the vaginal v>all. Its most common form is that of
a crescent, situated at the posterior margin of the introitus,
with its concavity looking forward. It may, however, be
annular, or may occupy the entire vaginal orifice, being either
imperforate or cribriform — perforated with holes — or may
20 ESSENTIALS OF OBSTETRICS.
have a single central opening with a fimbriated edge. Its
histological characters are similar to those of the vaginal
wall, yet it has but few muscular fibres. It is usually torn
at the first sexual approaches. An untorn hymen is not,
however, an infallible mark of virginity, nor is a torn one
necessarily evidence that sexual intercourse has been prac-
tised.
The Carunculae Myrtiformes. The carunculse myrti-
formes are the remnants of the hymen torn in labor by the
passage of the child. They appear as minute fleshy tuber-
cles, three or four in number, skirting the vaginal orifice or
at least its posterior margin.
Vessels, Lymphatics, and Nerves of the Pudendum.
Arteries. The arterial supply of the pudendum is de-
rived from the superficial perineal branch of the internal
pudic and from the external pudic artery.
Veins. The veins accompany the arteries. They empty
into the internal pudic and the inferior branch of the small
sciatic.
Lymphatics. The lymphatics go to the superficial inguinal
glands, which in turn communicate with the internal or with
the external inguinal glands.
Nerves. The nerve-supply, which is abundant, is from
the superficial perineal nerve, which is given off from the
pudic, the inferior pudendal nerve, which comes from the
small sciatic, and from the inferior hypogastric plexus of
the sympathetic.
The Vagina.
The vagina is that part of the genital tract between the
uterus and the pudendum. Its direction is nearly parallel
with the plane of the pelvic brim. It terminates below in
AXATOMY OF FEMALE GEXITAL OEGAXS. 21
the hymen or its remnants ; the upper part of the tube,
which surrounds the cervix, is the roof or fornix of the
vagina. The part of the upper extremity behind the cervix
is the posterior, that in front the anterior fornix -; the lateral
portions of the vaginal roof are spoken of as the lateral
fornices. The posterior is deeper than the anterior fornix,
owing to the higher attachment of the posterior vaginal
wall to the cervix.
Relations. As already stated, its upper extremity is
attached to the uterine cervix a little below the middle of
its length, the lower portion of the cervix projecting into
the vagina nearly at a right-angle. The posterior wall for
about one-fourth of its length is in relation at the vaginal roof
with the retro-uterine fold of peritoneum, the cul-de-sac of
Douglas. Its lower end is united with the so-called peri-
neal body: at its middle portion, over about half its length,
it is connected with the rectum by a loose connective tissue.
The upper half of the anterior wall is loosely attached to
the bladder; the lower half is intimately connected with the
urethra, the latter being incorporated in it.
Laterally the fornices are in relation with the bases of the
broad ligaments : below the fornices the vagina is attached
on either side to the levator ani fascia.
The recto-vaginal septum. The united portions of the
rectal and the posterior vaginal walls form the recto-vaginal
septum.
The vesico-vaginal septum is formed by the union of the
posterior wall of the bladder with the anterior vaginal wall.
The urethro -vaginal septum is the partition between the
urethra and the vagina.
The Shape of the vagina when distended is approxi-
mately that of a truncated cone with its larger end up.
When at rest it is a collapsed tube, the anterior lying in
22 ESSENTIALS OF OBSTETRICS.
contact with the posterior wall. Its cross-section in the
adult presents the shape of an H, the limbs of which have
a slight inward convexity. Its orifice, the introitus vagince,
is nearly circular. The vaginal axis is approximately a
straight line.
The Size of the vagina is larger in women who have
practised sexual intercourse than in virgins, and is much
increased in child-bearing women.
The length of the anterior wall in the virgin is 6.3 cm.
(2J inches), that of the posterior wall 9 cm. (3J inches) or
a little more. The walls, however, are extremely distensi-
ble, and in parous women they become permanently en-
larged and relaxed, sometimes attaining the length of 10 to
12 cm. (4 to 4§ inches). The width of the canal at the
widest part is about 4 cm. (If inch) in the virgin; in
women who have borne children it is frequently 7 cm. (2f
inches).
Structure. The vagina has three coats : the external
or fibrous coat ; the middle or muscular coat ; the internal
coat or mucous membrane.
1. The fibrous coat is a prolongation of the recto-vesical
fascia.
2. The muscular coat consists of an inner circular and an
outer longitudinal layer of unstriped muscular fibres. It
is thickest near the vaginal orifice, thinnest in the upper
part of the vagina. A band of voluntary muscular fibres
(the bulbo-cavernosus muscle) encircles the vaginal orifice.
3. The mucous coat is of a light pink color. It presents
two median ridges, one on the anterior and one on the pos-
terior wall. Transverse ridges, cristae, run outward on
either side from the longitudinal ones. The median columns
with the transverse crista are known as the columnae
vaginae. These structures are more marked on the anterior
ANATOMY OF FEMALE GENITAL ORGANS. 23
than on the posterior wall, and on both are most conspicu-
ously developed near the vaginal orifice. They are rarely
found at all above the lower two-thirds of the tube. They
are more or less completely effaced by child-bearing and by
catarrhal inflammation of the vagina. The mucous mem-
brane of the lower portion of the vagina lies in loose folds
when the canal is closed. Its surface is studded with
papillae. The epithelium is of the squamous variety.
The arterial supply of the vagina is chiefly from the
vaginal artery. The upper extremity of the tube receives
branches from the uterine and the lower from the pudendal
artery. These vessels anastomose with one another and
with the vesical and rectal arteries. They all spring from
the anterior division of the internal iliac.
The veins correspond, but they first form plexuses en-
tirely around the canal, one in the external coat and one
in the submucous layer of connective tissue. They com-
municate with the hemorrhoidal, vesical, pudendal and
pampiniform plexuses. None of these veins has valves.
The lymphatics. The lymphatics of the lower fourth of
the vagina join with those of the pudendum, terminating in
the inguinal glands. Those from the remaining portion of
the vagina unite with those from the cervix uteri and
empty into the internal iliac glands.
The nerves are derived from the fourth sacral and the
pudic of the spinal system, and from the lower hypogastric
plexus of the sympathetic.
Glands. The existence of true secreting glands, mucous
glands, is by most anatomists denied. The vaginal secretion
has an acid reaction, due to the presence of an acid-producing
bacillus.
The Urethra. Intimately connected with the lower
portion of the anterior vaginal wall is the urethra. Though
24 ESSENTIALS OF OBSTETRICS.
not a generative organ, it is of obstetric interest, and is
therefore described.
Situation. From the midpoint of the base of the
vestibule the urethra passes backward beneath the pubic
arch to the bladder. In the lower three-fourths of its
length it is embedded in the anterior vaginal wall. It is
supported by the pubo-vesical ligament, and it pierces the
layers of the triangular ligament in the same manner as
does this canal in the male. The portion of the canal
between the layers of the triangular ligament is encircled
by the compressor urethrse muscle. The general direction
of the canal is nearly parallel with the pelvic brim.
Shape. Its shape is straight or very slightly curved,
with its convexity downward and backward. When at rest
its mucous membrane lies in longitudinal folds which are
especially marked at the upper extremity. Its meatus is a
vertical slit ; its vesical end is not funnel-shaped, as some-
times described; the canal terminates abruptly in the bladder.
Size. The length of the urethra is about 4 cm. (If
inch), its average diameter is 6 mm. (J inch). It is largest
at the vesical end, smallest at the meatus, and is very dis-
tensible.
Structure. It has two muscular coats, an outer circu-
lar and an inner longitudinal layer and a mucous membrane.
The epithelium of the urethral mucosa in the low T er por-
tion of the tract is of the squamous type ; toward the upper
extremity it is of the transitional form, like that of the vesical
mucous membrane.
The vascular and the nervous supply are the same as those
of the vestibule. There is a plexus of large veins around
the canal, and another plexus between the two muscular
coats.
Glands. Numerous lacunae and racemose glands are to
ANATOMY OF FEMALE GENITAL ORGANS. 25
be found on the surface of the mucous membrane. There
are two tubular glands, known as Skene's glands, three-
fourths of an inch in length, in the wall of the urethra near
its floor, one on either side of the median line. Their
orifices lie just within the meatus urethrae.
Internal Genitals.
These include the uterus, the Fallopian tubes and the
ovaries.
The Uterus. Situation. The uterus is situated in
the cavity of the pelvis, between the bladder and the rectum,
a little nearer to the sacrum than to the pubic bones. Its
upper border is nearly in the plane of the pelvic brim, its
lower border just above the level of a line drawn from the
lower end of the symphysis pubis to the tip of the sacrum.
The average direction of its long axis is nearly perpendicu-
lar to the plane of the pelvic brim. Its position, however,
is variable within normal limits. A full bladder pushes it
bodily back toward the sacrum and tilts the fundus back-
ward. A distended rectum displaces it forward. The upper
portion of the uterus is in relation with the small intestines.
The latter sink into the upper part of the utero-sacral space
and sometimes into the utero-vesical pouch. Posteriorly
the uterus is separated from the rectum by a fold of perito-
neum, which dips down into the pelvic cavity to the dis-
tance of an inch or more below the cervico- vaginal junction.
This retro-uterine pouch of peritoneum will be more fully
described later. Anteriorly the peritoneum covers about
two-thirds the length of the uterus. That portion of the
lower third of the uterus between the vagina and the peri-
toneum is attached to the bladder by loose connective
tissue. The lower uterine extremity projects into the
26
ESSENTIALS OF OBSTETRICS.
upper end of the vagina to the extent of nearly 1.3 cm. (J
inch). The axis of the uterus forms approximately a
Fig. 3.
Sagittal section of the pelvis, showing relations of generative organs. 1. Body
of the uterus. 2. Cavity. 3. Neck. 4. Cavity of the neck. 5. Intra- vaginal part
of the neck. 6. Vagina. 7. Vaginal orifice. 8. Bladder. 9. Urethra. 10. Vesico-
vaginal wall. 11. Rectum. 12. Rectal cavity. 13. Anus. 14. Recto-vaginal
wall. 15. Perineum. 16. Vesico-uterine cul-de-sac. 17, Utero-rectal cul-de-sac.
18. Pubic symphysis. 19. Small lip. 20. Great lip
ANATOMY OF FEMALE GENITAL ORGANS. 27
right-angle with that of the vagina when the former organ
is in its usual normal position. Laterally the uterus is in
relation with the broad ligaments, presently to be described.
Shape. The uterus is a hollow muscular body. Its
shape is pyriform with its larger end uppermost. It is
slightly flattened from before backward, its posterior and its
upper surfaces are convex, its anterior aspect nearly flat.
Its long axis is straight or slightly curved, with its concavity
forward.
Fig. 4. Fig. 5.
Section of the nulliparous uterus,
showing shape of corporeal and cervi-
cal cavities, etc.
Section of parous uterus, showing
shape of corporeal and cervical cavi-
ties, etc.
measure-
Size. a. Nulliparous uterus. The aven ^
ments of the nulliparous uterus are 2.5 cm. (1 inch) nearly
in thickness antero-posteriorly, 3.8 cm. (1J inch) in width
at the level of the Fallopian tubes, and 6.3 cm. (2J inches)
in length.
b. The parous uterus is approximately 2.5 cm. (1 inch)
thick, 5 cm. (2 inches) wide, and 7.5 cm. (3 inches) long.
28 ESSENTIALS OF OBSTETRICS.
The transverse thickness of the lower end of the uterus, the
cervix, is 3.1 cm. (1J inch). The organ undergoes marked
atrophy after the menopause.
Weight. The nulliparous organ weighs about 28 grams
(1 ounce) ; in the parous woman the weight is 43 grams
(1J ounce).
Regional Divisions. The uterus presents two divisions,
the body and the cervix.
The body is approximately the upper half of the uterus
in the nulliparous, the upper two-thirds in the parous woman.
The isthmus is the slight constriction at the junction of
the body and the cervix.
The fundus is that part of the body above the level of the
Fallopian tubes.
Divisions of the Cervix, a. The infra-vaginal portion,
or portio vaginalis, is that part of the cervix below the
vaginal roof. Its average length in the parous woman is 1
cm., a little less than J inch.
b. The supra-vaginal portion is that part between the
portio vaginalis and the isthmus.. Its length in the woman
who has borne children is 1.5 cm., a little more than J inch.
Uterine Cavity, a. The cavity of the body is somewhat
triangular in shape in the nullipara, its anterior and poste-
rior walls lying practically in contact. It has three open-
ings, one communicating with the cervical canal and one
with each of the Fallopian tubes.
b. The cavity of the cervix is slightly flattened from
before backward, and is laterally elliptical, thus having an
irregular fusiform shape.
The os internum is the upper orifice of the cervical canal,
and is about 2.5 mm. (y 1 ^- inch) in diameter.
The os externum, or os tincse, is the lower orifice, a little
larger than the os internum.
ANATOMY OF FEMALE GENITAL ORGANS. 29
Structure. The mucous membrane of the body of the
uterus is about 1 mm. (^ inch) thick at the fundus and
more than twice that thickness at the centre of the body.
No folds are to be observed in the mucosa of the body of
the uterus except, perhaps, at the mouths of the Fallopian
tubes. Its epithelium is of the ciliated columnar variety,
the cilia, as stated by most anatomists, propelling toward
the tubes. According to recent observations of Hofmeier, 1
the ciliary movement is toward the external os. The mucosa
of the body is firmly attached to the muscular structures.
It abounds in tubular glands, many of which are bifurcated —
the utricular glands. These are slightly tortuous, and, with
few exceptions, extend to the muscularis ; some of them pene-
trate it. They are lined with ciliated epithelium. Their
secretion is alkaline. Dr. A. W. Johnstone ascribes to the
corporeal endometrium a glandular character comparable to
that of the lymph-tissues in the walls of the alimentary
canal and of other adenoid structures.
The mucous membrane of the cervix is thicker, firmer,
and paler than that of the body, and it is united to the mus-
cularis by a distinct submucous layer of loose connective
tissue. On the anterior and on the posterior w^all it presents
a pinnate arrangement of ridges known as the arbor vitce or
palmce plicatce. This consists of a median longitudinal
ridge from which well-marked lateral processes run out-
ward and upward. Upon and between the ridges of the
arbor vita? are numerous racemose glands which are histo-
logically mere inversions of the mucous membrane. In the
upper two-thirds of the canal the epithelium on the crests of
the transverse ridges of the palmse plicatee is ciliated. Else-
where on the free surface it is goblet-shaped, without cilia.
i Centralb. f. Gyn., 1893, No. 33.
30 ESSENTIALS OF OBSTETRICS.
The gland-cells are cuboidal and non-ciliated. The epi-
thelium of the lower third of the cervical canal and of the
entire external surface of the portio vaginalis is squamous,
like that of the vagina. The secretion of the cervical glands
is a clear tenacious mucus having an alkaline reaction.
The muscularis constitutes the greater part of the thick-
ness of the uterine walls. Its fibre is of the unstriped variety.
The muscular wall is usually described as consisting of three
layers ; but this division into strata cannot be made out ex-
cept during gestation, and even then the layers are not dis-
tinctly separable.
The outer layer, which is very thin, consists chiefly of
longitudinal fibres which are continuous with the muscular
layers of the Fallopian tubes, the ovarian, round, and utero-
sacral ligaments.
The middle layer comprises the bulk of the uterine
muscle and is a meshwork of interlacing longitudinal and
circular bundles.
The inner layer, which is made up of circular bundles is
extremely thin. It surrounds the orifice of the Fallopian
tubes and forms a sphincter at the os internum.
The cervix consists mainly of connective tissue. A well-
marked band of circular fibres encircles the cervix at the
vaginal junction.
The peritoneal coat. The uterus is partially enveloped
in a transverse fold of the pelvic peritoneum. The latter
structure invests the upper portion of the uterus, extending
over the entire length of the organ posteriorly and to the
isthmus anteriorly.
The Nulliparous and the Parous Uterus. In the nulliparous
uterus the corporeal cavity is triangular, the fundus nearly
flat, the cervix somewhat conical, and the os externum a
mere dimple. In the parous uterus the cavity is oval, the
ANATOMY OF FEMALE GENITAL ORGANS. 31
fundus dome-shaped, the cervix cylindrical, and the os ex-
ternum a transverse slit, with the lips more or less fissured.
The differences in weight and in size have already been stated.
Position of the Uterus. In the upright posture of the
woman the average normal position of the uterus is such
that the body lies nearly in a horizontal plane.
Ligaments of the Uterus, (a.) The broad ligaments.
The pelvic peritoneum dips down posteriorly into the lesser
pelvis, is reflected over one inch or more of the upper part
of the posterior vaginal wall, covers the posterior surface of
the uterus, and passing over the fundus invests the anterior
uterine surface to the isthmus ; thence it is again reflected
upward and over the bladder. The uterus thus lies between
the layers of a transverse fold of peritoneum, the lateral por-
tions of which, stretching from the uterus to the sides of
the pelvis in front of the sacro-iliac joints, form the broad
ligaments. The two layers of each broad ligament are
nearly in apposition, except at their junction with the pelvic
floor and with the pelvic walls. The Fallopian tube is en-
veloped in a subsidiary fold of peritoneum at the upper mar-
gin of the broad ligament. The round ligament directly
underlies the anterior layer. The ovarian ligament runs be-
tween the two layers. There are also included between the
two layers important bloodvessels, lymphatics, nerves, smooth
muscular fibres and connective tissue.
The infundibulo-pelvic, or ovario-pelvic, ligament is that
part of the superior border of the broad ligament on each
side, extending from the Fallopian tube to the pelvic wall.
(6.) The utero-sacral folds are two semilunar folds of
peritoneum enclosing unstriped muscular fibres and connec-
tive tissue, and passing one on each side of the rectum from
the lower portion of the sides of the uterus to the second
bone of the sacrum. In the nulliparous woman they spring
32 ESSENTIALS OF OBSTETRICS.
from the uterus at the level of the os internum ; in the
parous, from points somewhat above the os internum. These
folds are also known as the folds of Douglas, and the space
between them as Douglas's pouch or cul-de-sac. Luschka
terms these ligaments the retractors of the uterus.
(c.) The utero-vesical folds are two folds of peritoneum,
one on either side of the median line, which extend from
the uterus to the bladder, forming the lateral borders of
the utero-vesical space. They contain a few muscular
fibres.
(d.) The round ligaments are two slender, flattened mus-
culo-fibrous cords which spring from the angles of the uterus
in front of the Fallopian tubes, and pass forward through
the inguinal canals to blend with the structures at and im-
mediately below the external ring. They contain unstriped
muscular fibres. Their length is 10 to 12.5 cm. (4 to 5
inches). A small artery and a vein pass through each.
The Arteries. The arteries of the uterus are the two
uterine, the two ovarian and the two funicular arteries, or
arteries of the round ligaments. The uterine artery is a
branch of the internal iliac, the ovarian springs from the
aorta. They pass to the uterus between the folds of the
broad ligament on either side. The uterine artery reaches
the uterus just above the vaginal junction, the ovarian at
the level of the cornua. The former runs up along the lateral
border of the uterus to communicate with the ovarian.
The uterine arteries are remarkable for their free anasto-
moses and their tortuous course. Arterial tufts are given off
at the lateral borders of the organ, whose branches form
spirals within the uterine walls. They end in a meshwork of
capillaries about the utricular glands. Other branches of the
uterine arteries anastomose with those from the opposite
side encircling the uterus. The circular artery surrounds
ANATOMY OF FEMALE GENITAL ORGANS. 33
Fig.
Arteries of the uterus.
34 ESSENTIALS OF OBSTETRICS.
the cervix at the isthmus, uniting the uterine arteries of the
opposite sides with each other.
The artery of the round ligament, which is a very small
one, is a branch of the vesical given off at the internal ab-
dominal ring. It communicates at the cornua with the
ovarian and the uterine artery.
The Veins. The uterine plexus of veins lies immedi-
ately beneath the peritoneal coat of the uterus and extends
between the folds of the broad ligament. It communicates
with large sinuses in the middle muscular coat which are
encircled by muscular bundles. The uterine veins also
anastomose with the vaginal and the vesical plexuses. Their
outlet is the hypogastric vein and the pampiniform plexus.
The Lymphatics. These are very numerous in the body
of the uterus, and they communicate with the lymph-spaces
of the mucous membrane and the muscular coat. They
form an intricate network immediately beneath the perito-
neal coat of the uterus, and communicate with those of the
Fallopian tubes. The uterine lymphatics are fully devel-
oped only during pregnancy. The lymphatics of the body
of the uterus with those of the Fallopian tubes and the
ovaries empty into the lumbar glands. A group which fol-
lows the course of the round ligament ends in the inguinal
glands. The cervical lymphatics unite with those from the
upper part of the vagina and empty into the internal iliac
glands.
The Nerves. These are derived chiefly from the sympa-
thetic system, from the inferior hypogastric and spermatic
plexuses. The uterus also receives filaments from the second,
third and fourth sacral nerves. The uterine nerves termi-
nate in part in the nuclei of the muscle-cells.
The Fallopian Tubes or Oviducts. These are two
narrow tubes, one running outward from each horn of the
ANATOMY OF FEMALE GENITAL ORGANS. 35
uterus and communicating with the uterine cavity. The
outer portion of each tube takes a tortuous course, partially
surrounding the ovary. The length of the tube is from 7.5
to 12.5 cm. (3 to 5 inches), the right a little longer than the
left.
Divisions, (a.) The isthmus is the portion of the tube
next the uterus. It expands gradually as it runs outward
from 2 mm. (j 1 ^ inch) to 4 mm. ( T 3 g- inch) in diameter.
Fig. 7.
Fallopian tube and ovary.
(b.) The ampulla is the dilated portion of the tube next
beyond the isthmus, about 1 cm. (J inch) in diameter. The
fimbriated extremity, pavilion or infundibulum, is the free
trumpet-shaped end of the tube, the margin of which is
fringed with a number of processes (four or five) called
36
ESSENTIALS OF OBSTETRICS.
fimbria? . Here the tube expands abruptly to about 2 cm.
(3J inches) in diameter.
The fimbria ovariea is a special fimbria, a little larger
than the others, which is attached to the ovary.
The ostium uterinum barely admits a bristle, 1 mm.
(^ inch) in diameter.
The ostium abdominale, at which the body of the tube
opens into the pavilion, is of the size of a small goose-quill,
5 mm. in diameter.
Structure. Each tube comprises three layers continu-
ous, respectively, with the corresponding layers of the
uterus :
Fig. 8.
The ovary and oviduct. (The latter opened longitudinally.) 1, 1. Ovary. 2.
Part of the uterus. 3. Ovarian ligament. 4, 4. Oviduct, its walls opened by a
longitudinal incision to show the longitudinal folds of its lining membrane. 5,
5. Pavilion from internal surface. 6, 6. Fimbria attached to the ovary, or tubo-
ovarian ligament. 7, 7. Longitudinal folds. 8. Internal end of the oviduct.
1. The outer or peritoneal coat, continuous with the peri-
toneal fold of the broad ligament. That part of the broad
ligament between the tube and the ovary is termed the
mesosalpinx.
2. The middle or muscular coat, composed of an inner
ANATOMY OF FEMALE GENITAL ORGANS. 37
circular and two outer longitudinal layers of unstriped mus-
cular fibre. The outermost layer, however, is limited to the
uterine end of the tube. The muscular coat contains a rich
plexus of bloodvessels.
3. The inner or mucous coat. Except in the intramural
portion of the tube, the mucous membrane is disposed in
longitudinal folds, which become extremely complex in the
ampulla. There is no distinct submucous layer. It is lined
with ciliated columnar epithelium and is very vascular. The
motion of the cilia propels toward the uterus. According
to Bland Sutton, the mucous membrane of the tubes is pro-
vided with glands.
The arteries of the Fallopian tubes are branches of the
ovarian and the uterine arteries.
The veins open into the pampiniform or ovarian plexus
lying between -the folds of the broad ligament below the
tube.
The lymphatics unite with those from the body of the
uterus and from the ovary, and terminate in the lumbar
glands.
The nerves are derived from the uterine and ovarian
plexuses.
The Ovaries. The ovaries, two in number, correspond
to the testes of the male.
Situations. These organs are situated one on each side
of the uterus 2.5 cm. (1 inch) or more below the level of the
ilio-pectineal line, and the same distance from the uterus ;
yet they have great mobility within normal limits. Each
is set in the posterior fold of the broad ligament, and is con-
nected with the corresponding horn of the uterus by the
ovarian ligament.
Shape. The usual shape of the ovary is a flattened
ovoid ; its free border is convex ; the anterior edge is nearly
3
38 ESSENTIALS OF OBSTETRICS.
straight. This straight border is the hilum. The ovary is
thinnest at the hilum, thickest at the convex border. The
inner end is narrower, pointed, and merges into the ovarian
ligament ; the outer is more obtuse and bulbous. The shape,
however, is variable.
Size. The size is about 3.5 cm. (If inch) in length by
2 cm. (f inch) in width and 1.2 cm. (J inch) in thickness,
but is variable. The average normal weight in the nullipara
is about 6 grammes (85 grains). The size increases during
menstruation.
Structure. 1. External. In early age the external
surface is smooth, like an almond. Later in life, after
puberty, it gradually becomes uneven, acquiring a wrinkled
appearance, owing to cicatrices from rupture of Graafian
follicles. In the young adult subject it has a velvety soft-
ness and a pinkish or grayish-pearly color. In old age it
acquires a cartilaginous hardness and a paler color. The
free surface of the ovary is covered with modified perito-
neum. Its epithelium is columnar and non-ciliated — the
germinal epithelium of Waldeyer.
2. Internal. The stroma is made up of connective tissue
with some unstriped muscular and elastic fibres.
The tunica albuginea is a dense layer of stroma imme-
diately underlying the germinal epithelium of the ovarian
surface.
The zona parenchymatosa is the cortical portion of the
ovary ; it has a grayish color.
The medullary zone, or zona vasculosa, is the portion
about the hilum; it is of a reddish color. Here enter the
bloodvessels, nerves, and lymphatics.
The ovarian ligament is a muscular band about 0.5 mm.
(■£- inch) in width, which extends between the folds of the
broad ligament from the inner end of the ovary to the horn
ANATOMY OF FEMALE GENITAL ORGANS. 39
of the uterus, joining it immediately behind and below the
origin of the Fallopian tube. Its length is about 2.5 cm.
(1 inch). It is made up of connective tissue and smooth
muscular fibres, the latter being continuous with the outer
muscular layers of the uterus.
The arterial supply of the ovary is from branches of the
ovarian artery which enter at the hilum. The veins issue
from the hilum and empty into the pampiniform plexus.
The lymphatics, with those of the tube and body of the
uterus, empty into the lumbar glands.
The nerves are derived from the inferior hypogastric
plexus and the sacral nerves.
Section of ovary magnified to show Graafian follicle and ovum. 1. Surface epi-
thelium. 2. Tunica albuginea. 3, 3. Different parts of stroma. 4. Tunica fibrosa
of follicle. 5. Tunicae propria. 6, 6. Tunica granulosa. 7. Liquor folliculi. 8.
Vitelline membrane of ovum. 9. Vitellus. 10. Germinal vesicle. 11. Germinal
spot.
Graafian Follicles. The Graafian follicles are the sacs
in which the ova are developed. The follicles are deyeloped
40 ESSENTIALS OF OBSTETRICS.
from the germ epithelium of the ovarian surface, and be-
come imbedded in the stroma by the outgrowth of connec-
tive tissue. They are most numerous in the cortical layer.
Each follicle contains generally but one ovum. The number
of rudimentary Graafian follicles at birth is 35,000 or more
in each ovary. At any time during the child-bearing period
ten or twenty Graafian follicles may be found in different
stages of development upon the ovarian surface. The size
of a mature Graafian follicle is ^io *° tV ^ ncn m diameter.
Structure of a Graafian Follicle. The constituent parts of
a Graafian follicle are : 1. The theca folliculi ; 2. The tunica
(membrana) granulosa, a multiple layer of polyhedral epithe-
lium; 3. The discus proligerus, or germinal eminence, a
heaped-up mass of cells of the membrana granulosa at one
side, containing the ovum ; 4. The liquor folliculi, a clear,
albuminous fluid — paralbumin.
The Parovarium. The parovarium consists of a series
of 10 to 20 tubules running between folds of the broad liga-
ment in a slightly downward direction from the o^ary toward
the ampulla of the Fallopian tube. It is the remnant of
the Wolffian body.
CHAPTER II.
PHYSIOLOGY OF PREGNANCY.
PHYSIOLOGY OF THE OVUM.
OVULATION.
Ovulation is the process by which the ovum or egg is
matured and discharged from the ovary. At what intervals
ovulation occurs in the human subject, and in what relation
to the menstrual epoch, are not yet fully determined. Gen-
erally it takes place at about the time of the catamenia.
Ovulation, however, may occur independently of menstru-
ation, and menstruation without ovulation. As a rule, but
a single follicle ruptures at each epoch. Under favorable
conditions both the ova and the spermatozoa may retain
their vitality for several days in the female genital tract.
MENSTRUATION.
Menstruation is a periodic congestion of the female gen-
ital organs, attended with a bloody uterine discharge — the
menses or catamenia. The endometrium undergoes partial
exfoliation and subsequent renewal. Popular terms for
menstruation are the monthly sickness, the courses, or
monthly turns.
The constituents of the menstrual flow are blood and shreds
of endometrium, together with uterine and vaginal secre-
42 ESSENTIALS OF OBSTETRICS.
tions. The amount is from four to six ounces j the
length of the catamenial period is from two to seven days ;
the average duration four days ; the interval between the
menstrual epochs is generally twenty-eight days. Intervals
of several days, more or less than the usual length, however,
are to be considered normal, if constant. The source of the
bloody discharge is the body of the uterus and probably the
Fallopian tubes. Menstruation is usually attended with
some degree of malaise, sacral pain and pelvic tenesmus.
Puberty is the period of sexual maturity, and is marked
in the female by the onset of menstruation.
The age of puberty is usually about the fifteenth or six-
teenth year. It varies with race, climate and other influ-
ences, occurring in exceptional instances as early as the
tenth or as late as the twentieth year of age. It is earlier
in warm than in cold climates, in the better than in the
poorer classes, and in city than in country life. At this
period the girl takes on the physical and mental character-
istics of womanhood.
The Menopause. The menopause is the final cessation of
menstruation and the capacity for child-bearing. Climacteric
and change of life are synonymous terms for menopause.
In most women this period begins at the age of forty-six
years. The change, however, is a gradual one, occupying
two or three years. Variations of ten years or more on
either side of this limit are possible. The anatomical
changes which take place in the sexual ogans are essentially
the reverse of those which characterize the pubescent period.
In extreme old age the uterus is reduced to its infantile
dimensions and the tubes and ovaries are almost obliterated.
As a rule, the menstrual function continues longest in those
in whom it begins earliest. In cold climates the fruitful
period begins late and ends early, and in hot climates it
PHYSIOLOGY OF PREGNANCY. 43
begins early and ends early. At the onset of the menopause
the catamenia recur at irregular intervals, and finally they
cease altogether. The intervals may be shortened or pro-
longed. The flow may be scanty or profuse and prolonged.
Headache, tinnitus aurium, vertigo, hot flashes, palpitation,
dyspnoea, faintness, pruritus and neuralgias are common
nervous disturbances of this period.
Phenomena attending the Rupture of a Graafian
Follicle. Loops of bloodvessels are projected into the
cavity of the follicle, and an increase of the fluid contents
of the sac takes place from the increased vascularity. Ad-
jacent portions of the ovary, and to a certain extent its
entire structure, exhibit a similar increase in vascularity.
The follicle is now apparent as a bright red spot on the
surface of the ovary.
The overlying ovarian structure undergoes absorption
owing to increased pressure of the liquor folliculi. The
distending follicle finally ruptures and discharges its con-
tents, an effusion of blood taking place into the follicle after
rupture.
The ovum is apparently floated into the pavilion of the
tube by a stream of serum which is propelled by the cilia of
the fimbria* ovarica. Its propulsion through the Fallopian
tube is accomplished partly by ciliary motion, and, in the
narrower portion of the tube, partly, perhaps, by muscular
action. Heil thinks other agencies are concerned in the
migration of the ovum into the oviduct, and believes, as was
formerly assumed, that the pavilion of the tube grasps the
ovisac. 1 Rarely, it happens that the ovum migrates across
the pelvic cavity and into the opposite Fallopian tube.
The Ovum. The ovum is primarily a nucleated cell
1 Arch. f. Gyn., 1894, B. xliii. H. 3.
44
ESSENTIALS OF OBSTETRICS.
developed from the germ epithelium which covers the surface
of the ovary. Its diameter at maturity is t Jq- inch.
The constituent parts of the ovum are :
The vitelline membrane ;
The vitellus or yolk, oleo-albuminous matter, containing
shining granules;
Fig. 10.
Section of nearly mature ovum and part of Graafian follicle, a. Membrana
granulosa, b. Discus proligerus. c. Vitelline membrane. /. Vitellus.
The germinal vesicle, which is the nucleus of the cell,
t ^-q inch in diameter, situated to one side of the yolk near
its surface;
The germinal spot, the cell nucleolus, a dark, granular
spot, about so^o inch in diameter, within the vesicle.
The female pronucleus. The germinal vesicle approaches
one pole of the ovum, and two rounded masses, the polar
globules, are successively extruded from the surface of the
egg. The office of these bodies is unknown. The remaining
portion of the germinal vesicle reappears in the centre of the
PHYSIOLOGY OF PREGNANCY.
45
egg, and is now known as the female pronucleus. As will
be seen presently, the fusion of the female with the male pro-
nucleus is the essential fact in fecundation.
The Corpus Luteum. The corpus luteum is the body
formed in the ovary by the changes which take place in the
Graafian follicle after rupture.
The 'corpus luteum of menstruation reaches its full devel-
opment in from two to four weeks, and it becomes reduced
to a mere cicatrix in about two months.
Fig. 11.
Section of human ovary, showing corpus luteum.
The corpus luteum of pregnancy grows for six or seven
weeks, then it remains stationary to the end of the fourth
month ; from that time it retrogrades slowly till term, and
becomes a mere cicatrix by the end of a month after child-
birth. The period of growth, however, and the rapidity of
decline, are not in all cases the same.
CONCEPTION— IMPREGNATION.
Impregnation, or conception, is the fructification of the
ovum by union with the spermatozoon, the fecundating ele-
3*
46 ESSENTIALS OF OBSTETRICS.
ment of the male. Insemination is the act by which the
seminal fluid is deposited in the female genital tract.
The Seminal Fluid. The seminal fluid is a glutinous,
alkaline, albuminous fluid, of a whitish color, heavier than
water, and is the combined product of the testicles, the pros-
tate and Cowper's glands. The quantity ejaculated during
an orgasm is from one to three drachms. Its chemical con-
stituents are water, fats, proteids, calcium and sodium chlo-
rides and phosphates. The proportion of mineral ingredients
is about 3 per cent. Its microscopic elements are epi-
thelium, leucocytes, spermatozoa, and crystals of calcium
phosphate.
The Spermatozoa. The spermatozoa are bodies of mi-
croscopic size resembling tadpoles in shape. The parts of
the spermatozoon are a flattened ovoid head (cell nucleus)
and a long, thread-like tail. The filiform tail maintains a
constant vibratile motion, the result of amoeboid movements
of protoplasm, so long as the spermatozoon retains its fecun-
dating power. The total length of a spermatozoon is -g-J-g- to
4
c
t^
o
'w»
-,
h£
03
-o
E
0J
00
PLATE II,
Evolution of the Placenta and of the Umbilical Cord.
( From Sappey. )
1, 1. Embryo.
2, 2, 2. Amnion.
3, 3, 3. Cavity of Amnion.
4, 4. Digestive Canal.
5, 5. Pedicle of the Umbilical Vesicle.
6, Umbilical Vesicle.
7, 7. Allantoic! Vessels.
8, Pedicle of the Allantois.
9, 9, 9. Chorial Villi beginning to atrophy
10, 10, Villi in relation with the utero-placental
decidna, which hypertrophy.
PHYSIOLOGY OF PREGNANCY. 59
interchange between the foetal and maternal circulation
takes place by osmose through the walls of the foetal villi.
The Umbilical Cord. The umbilical cord is the pedi-
cle which, during gestation, connects the foetus with the
placenta. It is developed from the stalk of the allantois.
Its foetal insertion is at the umbilicus ; the placental is
generally nearly central. (Plate II.)
The usual length of the cord varies from 7 to 60 inches.
Greater variations are exceptionally observed. The average
length is 20 inches. Its diameter is about that of the little
finger of the adult. The tensile strength, at term, varies
from five to twelve pounds.
Structure. The cord contains the remnants of the
vitelline duct and the umbilical vesicle and the umbilical
vessels imbedded in a jelly-like connective tissue, the jelly
of Wharton. It is invested with a sheath derived from the
primitive somatopleure. The covering, though resembling
amnion, is not a process of that structure, as usually assumed.
Bloodvessels. Primarily it has two arteries and two
veins ; subsequently one of the veins disappears. Excep-
tionally there is but one artery. The walls of the arteries
are but little thicker than those of the veins. The vessels
of the cord are arranged in spirals, the vein appearing to be
wound around the arteries. According to recent observa-
tions nutritive capillaries, and also nerves and lymphatics,
are to be found in the cord.
Rate of Development of the Embryo and Foetus.
First Month. 1 The ovum is of the size of a pigeon's
egg ; its diameter is 2 cm. (f inch). Chorionic villi are
present over its entire surface. The length of the embryo
1 Lunar month.
60 ESSENTIALS OF OBSTETRICS.
is nearly 1 cm. (J inch) ; its weight about 1 gramme (15.43
grains). The first rudiments of foetal structure are discern-
ible. The heart, kidneys, liver, extremities, and the eyes,
the oral and anal orifices begin to be formed. The nose
and mouth are one cavity. The heart begins to beat at
the third week. The abdomen is not fully closed. The
spinal canal closes. The members are indicated by
papillae.
Second Month. The ovum is of the size of a hen's egg,
6.5 cm. (2J inches) in diameter; the length of the embryo
is a little more than 3 cm. (1J inch); the average weight, 20
grammes (308 grains). Rudimentary vertebrae appear. The
frontal unite with the superior maxillary processes. Centres
of ossification are present in the inferior maxillary bone, the
clavicle and the sides and bodies of the vertebrae. The
visceral arches are closed, or nearly so. The eyes, nose,
and ears begin to take form. The mouth and nose are
separate cavities. Rudiments of hands and feet appear, but
the fingers and toes are webbed. The umbilical vesicle has
disappeared. The umbilical cord is about 2.5 cm. (1 inch)
in length. Sexual organs are apparent.
Third Month. The ovum is of the size of a goose's egg ;
its diameter is 10 cm. (4 inches) ; the embryo is about 8 cm.
(3 J inches) in length ; its weight 120 grammes (4 \ ounces).
The product of conception now, for the first time, fills the
entire cavity of the uterus. The placenta is nearly com-
plete ; the villi have atrophied over two-thirds of the chorion.
The umbilical cord is 7cm. (2} inches) in length, and its vessels
begin to be twisted. The external parts of the embryo are
distinctly formed. Ossific centres are apparent in most of
the bones. The fingers are separated, also the toes. Rudi-
mentary finger- and toe-nails are present. The cavities are
wholly closed. Sex is determinable by the presence or ab-
PHYSIOLOGY OF PREGNANCY. 61
sence of a uterus. Active foetal movements begin in the
latter part of this month.
Fourth Month. The length of the foetus is 12.5 cm. (5
inches); its average weight is about 235 grammes (8 ounces).
Ossification is established in the frontal and occipital bones.
The sex is distinctly defined. Lanugo appears. Meconium
is present. The placenta is now complete.
Fifth Month. The length of the foetus is 24 cm. (9J
inches) ; its average weight 500 grammes (17 ounces). The
cord is about 30 cm. (1 foot) in length. Its point of inser-
tion, which till the fourth month is still at the symphysis,
now begins to depart from it. The eyelids commence to open.
Beginning ossification is apparent in the ischium. Develop-
ment of hair and nails begins. Vernix caseosa first makes
its appearance. Heart-sounds are audible.
Sixth Month. The length of the foetus is 30 cm. (12
inches) ; its weight is about 1000 grammes (2 pounds and 3
ounces). The umbilical cord is 35 cm. (14 inches) in length.
Ossification in the pubic bones begins.
Seventh Month. The length of the foetus is 35 cm.
(14 inches) ; it weighs 1500 grammes (3J pounds). The
pupillary membrane is disappearing. In boys the testicles
have descended into the scrotum — at least the left one. The
average length of the cord is 42 cm. (16J inches). Ossifi-
cation commences in the astragalus. The foetus is viable,
but its viability is yet feeble.
Eighth Month. The length of the foetus is 40.5 cm.
(16 inches) ; its average weight is 2000 grammes (4 pounds,
6 ounces). The nails are fully developed, but do not project
beyond the tips of the fingers. A child born at this stage
of development is viable. Lanugo commences to disappear
from the face.
Ninth Month. The length of the foetus is 43 cm. (17
4
62 ESSENTIALS OF OBSTETRICS.
inches). The head diameters are 12 mm. to 16 mm. (J to §
inch) less than at term ; the average weight is about 2721
grammes (6 pounds) ; an ossific nucleus first appears in the
lower femoral epiphysis. Lanugo is disappearing from the
body.
Tenth Month. Signs of Maturity. Measurements :
length 45 to 50 cm. (18 to 20 inches) ; suboccipito-breg-
matic circumference 33 cm. (13 inches) ; length of foot 8 cm.
(3J inches). The weight is 3175 to 3288 grammes (7 to 7J
pounds). The eyes are usually open. The face and body are
plump. The child suckles and cries lustily. Lanugo is almost
wholly absent from the body. Vernix caseosa, as a rule, is
present only on the child's back and on the flexor surfaces of
the limbs. The finger-nails overreach the finger-tips, the toe-
nails extend to the end of the bed of the nail. The carti-
lages of the ear and of the nose have become firm. The
cranial bones are hard, and the sutures and fontanelles small.
Centres of ossification are well developed in the lower epiph-
yses of the femurs and in the astragalus : they are begin-
ning to appear in the upper epiphysis of the tibia and in the
cuboid bone. (Plate III.)
FCETAL CIRCULATION.
The peculiarity of the foetal circulation arises chiefly from
the fact that pulmonary respiration is in abeyance during
intrauterine life, the respiratory blood-changes being accom-
plished in the placenta. Only so much blood goes to the
lungs as is needed for their nutrition. From the placenta
the blood passes to the umbilical vein. A part goes directly
to the ascending cava by the ductus venosus, and a part
reaches it indirectly through the liver and the hepatic vein.
Together with the blood from the lower extremities it then
goes to the right auricle, and thence is deflected through
PLATE III.
The Mature Ovum. (After Runge. )
A. Uterine Wall.
B. Placenta.
C. Umbilical Cord.
D. Decidua.
E. Chorion.
F. Amnion.
G. Foetus.
H. Amnial liquor.
PHYSIOLOGY OF PREGNANCY.
63
the foramen ovale into the left auricle by the Eustachian
valve, whence it passes through the left ventricle and into
the aorta. The larger part goes to the arms and the head.
'Pulmonary Art.
Left Auricle
Left Auric. - Vent.
Operang.
Ductus Venosus.
Internal Iliac Arteries.
Diagram of the foetal circulation. (Flint.)
Returning by the descending cava to the right auricle it
goes to the right ventricle, a very small part passing to the
lungs by the pulmonary artery, the larger part reaching the
64
ESSENTIALS OF OBSTETRICS.
aorta through the ductus arteriosus ; a small portion of this
mixed blood goes to the lower extremities, the greater part
being returned again to the placenta by the hypogastric
arteries.
EFFECTS OF PREGNANCY ON THE MATERNAL
ORGANISM.
Changes in the Uterus. Naturally the first effects of
pregnancy are to be found in the uterus. The most notable
clinically are the alterations in the size, shape, and structure
of the uterus.
Size. The growth of the uterus begins immediately on
fixation of the ovum, and is continuous with its growth.
Fig. 23.
Size of uterus at different periods of pregnancy.
In the first two months its development is chiefly in the
lateral and antero-posterior directions. Subsequently the
PHYSIOLOGY OF PREGNANCY. 65
growth is nearly symmetrical. It is mainly due to hyper-
trophy and to hyperplasia of its muscular fibres. In the
later months the enlargement is in part by dilatation.
The thickness of the uterine walls at term is between 4 and
6 mm. (i and J inch). The internal surface is expanded
between conception and full term from 32 or 39 square
cm. (5 or 6 inches), to 2256 square cm. (350 square inches).
The cubic capacity of the uterus is enlarged more than five
hundred times, to 4000 c.c. or more. The weight increases
from 43 grammes (1J ounce) in the pre-gravid state, to 904
to 1133 grammes (2 to 2J pounds) at term.
Dimensions of the Gravid Utei
^US.
Stage of gestation.
Total length.
Width.
12 weeks .
. 12.5 cm. (5 in.)
10 cm. (4 in.)
16 weeks .
. 15 " (6 " )
12.5 " (5 " )
20 weeks .
. 17.5 " (7 " )
15 " (6 " )
24 weeks .
. 21.5 " (8Y 2 " )
16.5 " (6% " )
28 weeks .
. 25 " (10 "
17.5 " (7 " )
32 weeks .
. 29 '• (UV 2 " )
20 '• (8 " )
36 weeks .
. 33 " (13 " )
22.5 " (9 " )
40 weeks .
. 35.5 " (14 " )
25 " (10 " )
Shape. In the first three months the shape of the uterus
is irregularly pyriform ; in the second, the body of the uterus
is a flattened spheroid, its antero-posterior diameter being
the smallest; in the last it is generally egg-shaped, the
fundal being the larger end. Yet the form of the uterus in
the later months is not altogether constant.
Structure. The changes which take place in the mu-
cosa have already been described. The muscular fibres
grow 7 to 11 times in length, 2 to 5 times in thickness ;
there is also some hyperplasia of muscular tissue. At the
internal os there is a preponderance of circular fibres in all
the layers. The peritoneal coat develops in proportion to
the increasing size of the uterus.
The arteries increase in number, length and calibre. By
66 ESSENTIALS OF OBSTETRICS.
the later months of pregnancy the ovarian arteries attain
the size of goose-quills, and the uterine arteries are some-
what larger still. The size of the lateral branches, which
connect the ovarian and the uterine arteries on each side,
exceeds that of the radial artery. The uterine venous plexus
develops into a system of huge sinuses in the middle coat
of the muscularis, and in the subplacental portion of the
inner coat. Some of these vessels attain a diameter of 12
mm. (J inch). The ovarian and uterine veins are propor-
tionately enlarged. The lymph-tubes expand to the size
of goose-quills and the lymph-spaces are expanded. Hyper-
trophy of the nervous structures keeps pace with the general
uterine development.
Changes in the Cervix Uteri. Size. The apparent
shortening of the cervix during pregnancy is due partly to
softening and partly to swelling of the vaginal mucosa and
the loose cellular tissue about the cervix at the vaginal junc-
tion. The cervical enlargement is partly hypertrophic, but is
mainly due to loosening of its structure in consequence of
serous infiltration ; it is progressive to about the end of the
eighth month.
Structure. Softening extends progressively from the
lower border upward ; it involves the entire cervix by the
end of the eighth month. By this time generally the cer-
vical canal has become sufficiently expanded in multipara
to admit the finger, and the head of the child may be
felt through the membranes. In women pregnant for the
first time the os externum is seldom as large as the finger,
even in the later weeks of gestation.
Changes in other Pelvic Structures. The uterine
peritoneum is developed by tissue-growth proportionately
to the development of the uterus itself.
The broad ligaments adapt themselves to the expansion
PHYSIOLOGY OF PREGNANCY. 67
of the uterus partly by the separation of their layers and
partly by growth in the number and size of their tissue-
elements.
The ovaries and the Fallopian tubes lie in contact with
the sides of the uterus by the time it rises out of the lesser
pelvis.
The vagina undergoes hypertrophy during pregnancy.
The width and length of its walls are increased and it be-
comes more vascular.
General Changes. The Heart. According to most
authorities there is a physiological hypertrophy of the left
ventricle of the heart during gestation, which is designed to
meet the increased resistance in the systemic circulation
brought about by the superadded utero-placental circulation.
The pulse-rate is slightly accelerated.
The Blood. The total volume of blood is increased in
the latter half of pregnancy. There are an increase in the
proportion of white globules and a diminution in that of the
red corpuscles and albumin. In the later months there is
more fibrin. The proportion of water is normally little
greater than in the non-gravid state.
The Nervous System. In most gravida? there is a marked
increase in the irritability of the nervous system. Psychic
disturbances, neuralgias and other nervous disorders are
frequently observed.
The Body-weight. As a rule, a considerable gain in
body-weight occurs in the later months, due mainly to in-
creased adipose deposit.
The Thyroid. The thyroid gland is hypertrophied dur-
ing pregnancy, and to a certain degree the enlargement
remains permanent.
Similar changes also occur in the liver, spleen and, prob-
ably, in the kidneys.
68 ESSENTIALS OF OBSTETRICS.
SIGNS OF PREGNANCY.
A. HISTORY.
Suppression of Menses. In a woman of previously regu-
lar menstrual habit, and in the absence of other appreciable
causes of amenorrhoea, the arrest of the catamenia is to be
regarded as strong presumptive evidence of pregnancy.
Other possible causes of suppression must, however, be ex-
cluded. These are :
Anaemia ; Change of climate ;
Tuberculosis ; Tardy menstruation ;
Syphilis ; The menopause ;
Chronic nephritis ; Emotional causes.
Exposure to cold ;
This sign is not in all cases available for diagnosis. Con-
ception may take place during the physiological amenor-
rhoea of lactation or before the menstrual function is estab-
lished. In a few recorded cases pregnancy has occurred
after the menopause. On the other hand, periodical hemor-
rhages simulating menstruation are sometimes observed in
the early months of pregnancy. The bleeding in such
cases generally proceeds from polypi or other lesions of the
cervix, from chronic decidual endometritis or from placenta
praevia, and its occurrence at the end of the menstrual
month results from the influence of the menstrual molimen.
Usually it may be distinguished from menstruation by the
irregularity in the amount and duration of the flow. The
typical menstrual discharge begins and ends gradually, and
in the intervening time is nearly constant in quantity. The
usual length of the menstrual period is four or five days.
Bleeding from other causes seldom presents these charac-
teristics.
PHYSIOLOGY OF PREGNANCY. 69
Nausea is present for a time in the vast majority of preg-
nancies. Usually it begins about the end of the first month 1
and ceases by the end of the third, when the uterus rises
out of the true pelvis. It may subside earlier or last
longer ; in exceptional instances no nausea is experienced
during the entire period of pregnancy.
Generally it is a morning sickness. Sometimes it persists
throughout the day. Pathological causes, such as chronic
nephritis and chronic gastric catarrh, may simulate the
morning sickness of pregnancy, and these must be excluded.
Ptyalism in greater or less degree frequently accompanies
the nausea. Excessive salivation is exceptional.
Hypersecretion of mucus in the mouth and throat during
the early months of gestation is more common. The
tenacity of the secretion and the difficulty of expectoration
have given rise to the term "spitting cotton."
Certain mammary and abdominal signs may be brought
out in the history, such as enlargement, a sense of weight,
fulness and tenderness of the breasts, growth and pigmenta-
tion of the abdomen and quickening.
B. PHYSICAL SIGNS.
1. Mammaey Changes.
(a.) Increased size and fulness of the glands. The milk-
glands are enlarged by growth of the acini, swelling of
the connective tissue and by interlobular deposit of fat.
Development of the gland must be distinguished from over-
lying fat. The gland is readily identified on palpation by
greater density and by its nodular border.
1 By the term month the calendar month is meant unless otherwise specified.
4*
70 ESSENTIALS OF OBSTETRICS.
The fulness and firmness are not always well marked
after mid pregnancy. Rarely no material enlargement is
observed during the entire period of gestation.
(6.) Primary areolae. Important changes take place in
the areolae. They become pigmented, elevated and cedem-
atous. The depth of pigmentation varies according to
the complexion of the patient. It is faintly developed in
blondes, well marked in brunettes, and in the negress is
nearly black. Sometimes it shades into the color of the
surrounding skin at the upper and outer aspects of the
areolae toward the end of the second month. The areolae
acquire a soft, velvety feel and are slightly raised above the
general level of the skin. The most significant of these
changes in the primary areolae, however, is the pigmenta-
tion. (Fig. 24.)
(c.) Montgomery's follicles are sebaceous follicles of the
areolae, ten to twenty in number in each, which have become
hypertrophied during pregnancy. They appear as papu-
lar elevations within the primary areolae. They are best
displayed while the skin is held gently on the stretch.
(Fig. 24.)
(d.) Enlargement of veins. The superficial veins of the
breasts become fuller and more prominent. On slightly
stretching the skin in a good light veins may be seen
coursing across the areolae. (Fig. 24.) Frequently a vein is
seen encircling each primary areola at its margin.
(e.) Milk secretion. Colostrum may be pressed from
the nipples at the end of the third month. In women who
have never borne children its presence affords presumptive
evidence of pregnancy. Yet rarely milk secretion is possi-
ble in virgins, sometimes even in males. The sign is of no
value after the first pregnancy, since milk may usually be
found in the breasts of parous women.
PHYSIOLOGY OF PREGNANCY.
71
To elicit this sign the manipulation should begin over
the ampullae of the milk-ducts at the base of the nipple.
(/.) Secondary areolae. These are faintly pigmented
zones skirting the primary areolae. (Fig. 24.) They are
Fig. 24.
The primary and secondary areolae of pregnancy.
characterized by one or more rows of feebly marked circular
spots just without the primary areolae. The markings are
due to non-pigmented sebaceous follicles. In women never
pregnant before, the secondary areolae are diagnostic when
well made out.
72 ESSENTIALS OF OBSTETRICS.
Date of Appeakance. All the mammary signs, with
two exceptions, may be looked for by the close of the second
month. Colostrum is present at the third, and the second-
ary areolae appear at the fifth month.
Diagnostic Value. In primigravidse the mammary
changes usually afford sufficient evidence for, at least, a pre-
sumptive diagnosis of pregnancy. In women who have
borne children they are not to be relied on since most of
them once developed remain more or less permanent.
The group of mammary signs is rarely complete and those
present are seldom equally well developed.
Breast-changes similar to those of pregnancy may result
from pelvic disease. Pathological conditions of the sexual
organs which may cause reflex mammary changes must,
therefore, be excluded.
2. Abdominal Signs.
1. Inspection, (a.) Flattening. In the second month
of gestation the abdomen is slightly flattened ; the uterus
during this period sinks somewhat lower in the pelvis and
the hypogastrium is therefore a little less prominent.
(b.) Enlargement is apparent after the third month, when
the uterus begins to rise out of the lesser pelvis ; thereafter
it increases with the growth of the uterus till the middle of
the ninth month. Within two weeks or more before term
the uterus usually sinks deeper in the pelvis and the waist-
line becomes perceptibly smaller.
(e.) Pigmentation. As a rule pigmentation of the abdo-
men is limited to a narrow band about 3 mm. (J inch) in
width extending from the pubes to the umbilicus, sometimes
to the ensiform. It is present by the end of the second
month. Pigmentation of the abdomen, like that of the
PHYSIOLOGY OF PREGNANCY. 73
breast, varies in depth and extent of surface with the com-
plexion of the patient. In brunettes a dark circle appears
around the umbilicus, and pigmented patches are observed
over other parts of the abdomen. In blondes entire absence
of pigmentary changes is not infrequent. Deposits of pig-
ment similar to those of pregnancy are sometimes observed
in other conditions of health and disease.
(d.) Umbilical changes. The umbilicus is retracted in
the first three months and becomes protruded in the last two
or three.
(e.) Linese Albicantes, or Striae Gravidarum. These are
irregular whitish, pinkish or bluish lines developed over
the lower half of the abdomen during the later months of
pregnancy. Sometimes they may be observed on the hips
and thighs. The breasts may present similar markings.
Usually they are slightly depressed below the general surface
of the skin. They are due chiefly to partial atrophy of the
skin from tension ; they appear at about the sixth month.
Once formed they remain in greater or less degree perma-
nent. Distention of the abdomen from causes other than
pregnancy may give rise to similar changes.
2. Palpation, (a.) Size of the Tumor. The fundus
uteri lies nearly in the plane of the pelvic brim at the third
month, reaches the level of the umbilicus by the sixth and
the ensiform cartilage at the thirty-eighth week. More
accurate for our purpose than the situation of the fundus
are the width and length of the uterus. For the uterine
measurements at different stages of gestation see table on
page 65.
(b.) Character of Tumor. The gravid uterus is normally
a smooth, symmetrical, pyriform or ovoid, fluid tumor. In
the last trimester, and even earlier, foetal parts may be made
out by palpation.
74 ESSENTIALS OF OBSTETRICS.
(bserver a
premature birth. So insecure is the attachment of the ovum
in the last week or two of gestation that labor is :less
established prematurely in a large proportion of instances.
On the other hand the pregnancy may appear to be pro-
longed when in reality the actual term of gestation has not
exceeded the usual normal limit. It is not infrequently the
case that concej:: tea, not from the end :: the week
following the beginning ;: the last menstrual flow as is
usually assumed, but from some later period in the month.
An error of two or three week in the count is often thus
possible.
Rules and Methods for Predicting the Date of Labor.
(a.) Naepeh:'s rid :e uine calendar months from
the beginning of the last menstrual period and add seven
days. This is a ready method of reckoning approximately
two hundred and eighty days from the be^innin^r of the last
menstruation. For predicting :e of labor it is ^rene-
rally accurate within a week. It is subject) hoi ever, to the
fallacies already pointed out.
Reckoning from the date of quickening is uot reliable.
The period :•: vjiokening is no: jiLstan:. I: varies in
different individuals, and even in the same individual in
different pregnancies. Moreover, the observations :: the
patient in this matter ire :::on fallacious.
(b.) Mensuration of the uterus is not a wholly re-
basis for prediction, since the quantity of liquor amnii v:
in different cases and the sze of the fetus at a given r
of ges:a:i:n is not constant.
•5
8Q ESSENTIALS OF OBSTETRICS.
Situation of the Fundus. The fundus uteri is in the
plane of the brim at the third month, at the umbilicus about
the sixth and reaches the ensiform cartilage at eight and
one-half months. After lightening it sinks to a little lower
level. Accuracy here, too, is vitiated by the causes just
mentioned and also by the fact that the umbilicus is not a
fixed point.
(c.) Mensuration of the Fcetus. The total length of the
foetus is about double that of the foetal ovoid. The latter
may be measured with sufficient accuracy with a pelvimeter,
placing one pole in contact with the head through the
vagina and the other upon the abdomen over the breech,
or using both poles externally. The rate of foetal develop-
ment, however, is not uniform ; and, furthermore, extreme
accuracy of measurement is impossible. Yet this measure-
ment together with the diameters of the head affords fairly
reliable data for estimating the stage of pregnancy.
Length of the Fcetus.
The approximate lengths of the child in different stages
of intrauterine development during the later months of ges-
tation are as follows :
Sixth calendar month, 30 to 35 cm. (12 to 14 inches).
Seventh calendar month, 35 to 40 cm. (14 to 16 inches).
Eighth calendar month, 40 to 45 cm. (16 to 18 inches).
Ninth calendar month, 45 to 50 cm. (18 to 20 inches).
HYGIENE OF PREGNANCY.
The patient should seek the advice of her physician from
the earlv months of gestation. She should consult him on
even slight departures from health and especially during
the later months.
PHYSIOLOGY OF PREGNANCY. 87
Hygienic Requirements are : Exercise in the open air an
hour or two daily, with care to avoid over-exertion and ex-
haustion ; the avoidance, if possible, of all injurious mental
influences ; the observance of regular hours for meals ;
proper quantity and kind of food ; daily bowel movements ;
eight hours sleep daily ; pure air constantly ; a tepid sponge-
bath at least twice weekly in winter, once daily in the sum-
mer months.
The teeth are especially prone to decay during preg-
nancy and special care should, therefore, be given them. :
In case of irritating leucorrhceal secretions a vaginal in-
jection of a quart of water at a temperature of 98° F., or of
a borax solution, gss ad Oj, may be used once or twice
daily. The temperature of the douche should be that of
the body and the injection must be given with the least
possible force lest it provoke abortion.
Clothing. In our climate light flannel underwear is
essential at all seasons ; the outer clothing must be changed
to suit changing temperatures. A rational method of dress
requires no more clothing for indoor use in the winter months
than would be needed at the corresponding temperature in
the summer season. For outdoor use extra wraps are called
for according to the degree of exposure to cold.
The clothing must not be tight, especially about the
breasts and abdomen, and the heavier garments ought to be
suspended from the shoulders.
Care of the Nipples. It is a useful practice to cleanse
the nipples daily with a borax solution, 5ss ad Oj, during
the last two months of pregnancy. They may be anointed
with fresh cacao butter after cleansing, and if they are
small or sunken the patient should be taught to draw
them out with the thumb and fingers. Astringent applica-
tions such as are frequently employed with a view to hard-
88 ESSENTIALS OF OBSTETRICS.
ening the nipples doubtless tend rather to promote cracking
during lactation than to prevent it. The better practice is
to keep them supple by the use of inunctions. The manip-
ulation referred to not only helps to develop the nipples
when this is required but it has the further effect of inuring
them to nursing.
The Urine. The urine should be examined chemically
and microscopically once a week during the last two months,
oftener in case of suspicion of nephritis or of renal insuffi-
ciency. An occasional examination should be made at earlier
periods.
Quantitative tests for urea afford the best evidence of the
functional activity of the kidneys. In all observations of
the urinary excretion the specific gravity and the quantity
passed daily are essential as indicating the extent to which
toxic material is being eliminated. The average normal
quantity of urea daily is about 33 grammes (500 grains) ;
the total solids daily about 66 grammes (1000 grains). The
total solids may be roughly estimated by multiplying the
last two figures in the number indicatiug the specific gravity
by the number of ounces of urine and the product by 1.10.
For the estimation of urea Prof. Bartley's method is recom-
mended. 1
When the urine is scanty the ingestion of a larger quan-
tity of water is indicated.
Marital Relations. Marital relations are to be restricted,
particularly at the menstrual dates. Violation of this rule
is a common cause of abortion and of premature labor. The
nausea of pregnancy is often aggravated by this cause.
1 Medical Chemistry, p. 689.
CHAPTER III.
PHYSIOLOGY OF LABOR.
I. THE MECHANICAL FACTORS OF LABOR.
Three factors are concerned in the mechanism of child-
birth, the powers, the passages and the passenger.
1. The Expelling Powers.
The expelling powers are :
1. The muscular action of the uterus. This is involun-
tary, the motor apparatus of the uterus being chiefly con-
trolled by the sympathetic nervous system. The uterine
contraction is peristaltic, yet practically simultaneous; it
begins at the fundus probably.
2. The action of the abdominal muscles, which is partly
voluntary, partly a reflex involuntary contraction.
In the expulsive stage of labor the contractions of the
abdominal muscles are usually brought into play indepen-
dently of volition. Their force may generally be augmented
by voluntary effort. They have the effect to increase the
intra-abdominal pressure and thus to reinforce the expulsive
action of the uterus.
The chief expellent force is the contraction of the uterus.
Contractions of the muscular elements of the round and of
the broad ligaments take place at the same time with the
uterine contraction. They help to steady the uterus in the
axis of the pelvis.
90 ESSENTIALS OF OBSTETRICS.
The power of the uterine contraction reinforced by that
of the abdominal muscles according to Duncan is 50 to 80
pounds; according to Schatz it is from 17 to 55 pounds.
2. The Passages.
The passages include : 1. The hard parts of the bony
pelvis ; 2. The soft parts, consisting of the uterus, the pelvic
floor and the structures which line the osseous portion of
the birth- canal.
Obstetric Anatomy of the Bony Pelvis.
The Pelvis. The pelvis is a strong, bony basin, whose
cavity is the most important portion of the parturient tract.
The constituent parts of the bony pelvis are the two ossa
innominata, the sacrum and the coccyx.
The joints are the symphysis pubis, the sacro iliac joints
and the sacro-coccygeal joint. A slight mobility of the pubic
and the sacro-iliac joints is usually present in the later
months of gestation. The capacity of the pelvis is thus a
little larger than in the non-gravid state.
Extension of the thighs tilts the upper end of the sacrum
backward and favors the entrance of the head into the pelvic
brim. The escape of the head from the pelvis at a later
stage of the labor is promoted by flexion of the thighs upon
the abdomen, which rotates the lower end of the sacrum
backward.
Recession of the coccyx to the extent of 12 mm. to 25 mm.
(J to 1 inch) occurs during the expulsion of the fcetal head
from the outlet.
The false pelvis or greater pelvis is that portion of the
pelvis above the ilio-pectineal line. It forms with the lower
PHYSIOLOGY OF LABOR.
91
part of the abdominal wall a funnel-shaped approach to the
true pelvis.
The true pelvis or lesser pelvis is the part of the pelvis
below the ilio-pectineal line. It is with this that obstetric
questions are mainly concerned.
The brim, inlet, superior strait, margin or isthmus of the
pelvis is located by the pectineal line and the upper margin
of the sacrum. Usually it is approximately heart-shaped.
Sometimes it is oval or nearly round.
Fio. 27.
Brim of pelvis. 1. True conjugate. 2. Transverse diameter. 3. Oblique
diameter.
Obstetric landmarks at the brim are : 1. The sacral pro-
montory or sacro-vertebral angle ; 2. The sacro-iliac joints ;
3. The ilio-pectineal eminences, which are situated at the
ilio-pubic joint, on the pubic bone ; 4. The symphysis
pubis.
The outlet of the pelvis, or inferior strait, is lozenge-
shaped, and is located by the tip of the coccyx, the subpubic
arch and the ischial tuberosities. It is made up of two
obtuse-angled triangles, whose common base is a line joining
92 ESSENTIALS OF OBSTETRICS.
the ischial tuberosities ; the apex of the one is the summit
of the subpubic arch ; the apex of the other is the tip of
the coccyx.
Fig. 28.
Outlet of pelvis.
Obstetric landmarks at the outlet are : 1. The tip of the
coccyx ; 2. The subpubic arch, formed by the descend-
ing rami of the pubic bones ; 3. The ischial tuberosities ;
4. The ischial spines ; 5. The greater and the lesser
sacro-sciatic ligaments which help to supplement the bony
canal.
The greater sacro-sciatic ligaments spring from the pos-
terior inferior spines of the ilium and from the sides of the
sacrum and the coccyx and are inserted into the inner sur-
faces of the ischial tuberosities.
The lesser sacro-sciatic ligaments lie in front of the
greater. They arise from the sides of the sacrum and the
coccyx and are inserted into the ischial spines. The open
space between the lesser sacro-sciatic ligament and the
ischium is the greater, that between the two ligaments and
the bone is the lesser sacro-sciatic foramen.
The greater sacro-sciatic foramen transmits the pyri-
PHYSIOLOGY OF LABOR. 93
formis muscle, and the gluteal, the sciatic and the pudic
vessels and nerves.
The lesser sacrosciatic foramen transmits the tendon of
the obturator internus muscle and the internal pudic vessels
and nerves.
The cavity of the pelvis is bounded posteriorly mainly by
the sacrum and the coccyx ; anteriorly by the pubic bones
and the ischio- pubic rami ; laterally by the surfaces of the
iliac and the ischial bones.
The posterior wall is smooth, and is concave from above
downward, a fact which favors the descent of the posterior
pole of the foetal head or other presenting part. The depth
of the posterior wall is 12.5 cm. (5 inches) ; if measured on
the curve of the sacrum and coccyx, 14 cm. (5 J inches).
The anterior wall is smooth and concave from side to side.
This favors the lateral rotation of the head in its screw-like
descent through the pelvis At the symphysis pubis the
depth is 4.4 cm. (If inch). The lateral wall is 9 cm. (3J
inches) deep.
The obturator foramen, situated in the anterior wall of
the pelvis, is bounded by the bodies and the rami of the
ischium and pubis. The bony opening is closed by the
obturator membrane, except at the obturator canal. The
canal transmits the obturator nerve and vessels.
Planes of the Pelvis.
1. The plane of the brim cuts the ilio-pectineal line and
the upper margin of the sacrum. In the erect posture of
the woman the average inclination of the brim to the hori-
zon is about 60°.
2. The middle plane cuts the middle of the posterior sur-
face of the pubic symphysis and the upper border of the
third sacral vertebra.
5*
94 ESSENTIALS OF OBSTETRICS.
3. The plane of the outlet cuts the tip of the coccyx, the
ischial tuberosities and the lower end of the symphysis
pubis. The inclination of the plane of the outlet to the
horizon is 11°, the summit of the subpubic arch being
below the level of the tip of the coccyx.
Practically the plane at which the head escapes from the
grasp of the bony pelvis is a plane cutting the lower end of
the sacrum at a point just below the lower end of the
symphysis.
Pelvic Diameters. Internal Diameters, (a.) At the
brim :
1. True conjugate, from the promontory of the sacrum
to the upper end of the symphysis, more exactly to the point
at which the symphysis is crossed by the prolongation of
the linea ilio-pectinea.
2. Diagonal conjugate, from the summit of the sub-
pubic arch to the sacral promontory.
3. Transverse diameter, the greatest transverse diameter
of the pelvic brim ; it terminates in a point midway between
the sacro-iliac joint and the ilio- pectineal eminence on either
side.
4. Oblique diameters, extending from the sacro-iliac
joints, respectively, to the opposite ilio-pectineal eminence;
R. 0. from the right, L. 0. from the left sacro-iliac joint.
(6.) At the middle plane :
1. Antero-posterior diameter, from the upper margin of
the third sacral vertebra to the middle of the posterior
surface of the pubis.
2. Transverse diameters, terminating in points corre-
sponding to the lower margins of the acetabula.
3. Oblique diameters, each from the centre of one greater
sacro- sciatic foramen to the centre of the obturator mem-
brane opposite.
PHYSIOLOGY OF LABOR. 95
(c.) At the outlet :
1. Anteroposterior diameter, from the lower end of the
symphysis pubis to the tip of the coccyx, practically to the
tip of the sacrum.
Fig. 29.
c v. True conjugate, d c. Diagonal conjugate, a s. Axis of brim.
p o. Plane of outlet, h h. Line of horizon.
2. Transverse diameter, the distance between the tubera
ischiorum, the bisischial diameter.
3. Oblique diameters, each from the middle of the lower
edge of the greater sacro-sciatic ligament on one side to the
point of union between the ischium and pubis on the oppo-
site side.
External Diameters. 1. External conjugate diameter,
or diameter of Baudelocque, from the depression or fossa
just below the spinous process of the last lumbar vertebra
to the most prominent point on the surface overlying the
upper portion of the pubic symphysis, nearly parallel with
96 ESSENTIALS OF OBSTETRICS.
the internal conjugate. To locate the spine of the last
lumbar vertebra draw an imaginary line connecting the de-
pressions corresponding to the posterior- superior iliac spines.
The second spinous process above the level of this line is
that of the last lumbar vertebra.
2. Rio-spinal or interspinal diameter, the distance be-
tween the anterior-superior spines of the ilia measured from
the outer borders of the sartorius muscles at their origins.
3. Rio-cristal or intercrislal diameter, in the normal
pelvis the greatest transverse width of the pelvis at the
crests.
Approximate Measurements of the Static or Dried Pelvis.
Internal Diameters.
NTERO-POSTERIOR.
Oblique.
Transverse.
Brim, 4 inches.
4% inches.
5 inches .
Cavity, 4% "
4% "
4^ "
Outlet, 5 " i
4% "
4
These values correspond nearly to 10, 11.5 and 12.5 cm.
At the brim the right oblique diameter is slightly longer
than the left oblique. The average measurements at the
brim are more accurately as follows :
Conjugate. Oblique. Transverse.
10 cm. (4 in.). 12.5 cm. (5 in.). 13.5 cm. (5% in.).
The circumference of the brim is about 40 cm. (16 in.) ;
of the outlet, 33 cm. (13 in.).
Approximate Measurements of the Dynamic Pelvis.
Internal Diameters. The internal diameters are all
reduced 6 mm. (J in.) by the presence of the soft structures
in the dynamic pelvis. The transverse diameter at the
brim is still more diminished by the psoas and iliacus mus-
1 Distance from lower end of symphysis pubis to tip of sacrum 12.5 cm. (5 in.) ;
to tip of coccyx, 9.5 cm. (3% in.) ; when coccyx is pushed back, 11.5 cm. (4% in.).
PHYSIOLOGY OF LABOR.
97
cles, so much so that the oblique is the longest diameter in
the dynamic pelvis.
External Diameters.
External conjugate 20 cm. (8 inches).
Interspinal 25.5 " (10 " ).
Intercristal 28 " (11 " ).
To estimate the internal conjugate from the external
deduct 7 to 12.5 cm. (2| to 5 inches) according to the esti-
mated thickness of the overlying bony and soft parts.
The average external circumference of the pelvis meas-
ured over the symphysis and on a line running just below
the iliac crests and across the middle of the sacrum is nearly
1 metre (about a yard).
Difference between the Male and the Female Pelvis.
Distinguishing Marks of the Female Pelvis.
As a whole : The greater pelvis is wider ; the lesser
pelvis is larger in all its diameters and of shallower depth.
Fig. 30.
Male pelvis.
98 ESSENTIALS OF OBSTETRICS.
The bones are lighter and are more slender. The inclina-
tion of the pelvis is greater.
The hrim. The shape is less triangular. The sacro-
vertebral angle is a little less prominent. The pubic spines
are more widely separated.
Fig. 31.
The female pelvis.
The cavity is not so funnel-shaped. The sacrum is shorter
and broader and less strongly curved.
The outlet. The subpubic angle is greater — 90°, the
angle in the male being 70°. The depth of the symphysis
pubis is little more than half that in the male.
Obstetric Anatomy of the Pelvic Soft Parts.
The transverse diameter of the hrim is somewhat dimin-
ished by the iliacus and psoas muscles. They encroach
upon the lateral margins of the inlet to the extent of a
quarter of an inch or more on each side. The external
iliac vessels run along the inner borders of these muscles.
In the cavity no muscular structures overlie the median
portion of either the anterior or posterior pelvic wall. On
either side of the median section are the pyriformis muscle
PHYSIOLOGY OF LABOR. 99
posteriorly and the obturator internus anteriorly and later-
ally, too thin to affect the pelvic diameters.
The pyriformis arises by a series of digitations from the
lateral aspects of the sacrum anteriorly and from the upper
portion of the sacro-sciatic ligament, and its fasciculi con-
verge to pass out through the greater sacro-sciatic foramen.
The obturator internus arises from the circumference of
the obturator foramen and the inner surface of the obturator
membrane; its fibres converge to a tendon which passes
through the lesser sacro-sciatic foramen.
The outlet of the pelvis is closed by the pelvic floor or
diaphragm, which is made up chiefly of muscles and fasciae.
The Pelvic Floor. The upper aspect of the pelvic
floor is concave ; its lower, convex from before backward.
It is limited above by the peritoneum, except where that
structure is lifted to be reflected over the pelvic viscera and
their appendages. Its inferior surface is skin.
Its median portion is obliquely traversed by three mus-
cular slits, the urethra, the vagina, the rectum. These
canals are approximately parallel with the plane of the
pelvic brim, except that the end of the rectum turns back-
ward nearly at a right-angle with the vagina.
The posterior vaginal wall and the soft structures behind
it make the sacral segment of the pelvic floor ; the anterior
wall of the vagina and the soft parts in front of it constitute
the pubic segment of the pelvic floor. (Hart.)
Measurements. Coccyx to anus, in the nullipara, 4.5
cm. (If in.) j anus to lower edge of vulvar orifice, in the
nullipara, 3.1 cm. (1J in.); in the parous woman, 2.5 cm.
(1 in.) ; in the primigravida at term, 3.8 cm. (If in.).
Greatest transverse width on the bis-ischial line, 10.7 cm.
(4J in.). Perpendicular thickness of the pelvic floor at the
anus, 5 cm. (2 in.).
100 ESSENTIALS OF OBSTETRICS.
In the nullipara the average projection of the pelvic floor
below a line drawn from the tip of the coccyx to the lower
end of the symphysis is 2.5 cm. (1 in.); in the parous
woman at term, 9.5 cm. (3f in.).
The length of the sacral segment during labor at the
moment of expulsion, coccyx to lower edge of the vulvar
orifice, is 15 to 17.5 cm. (6 to 7 in.).
Principal Component Structures.
Fascial Sheets of the Pelvic Floor. The most im-
portant supporting structures of the pelvic floor are its fascial
sheets. Upon these the strength of the pelvic diaphragm
almost wholly depends.
Recto-vesical or visceral fascia. It will be remembered that
the parietal fascia of the lesser pelvis is continuous with the
iliac fascia*and covers the obturator and the pyriformis mus-
cles. From this is given off a transverse layer which stretches
across the pelvis. This is the recto-vesical fascia. Its line of
attachment to the parietal fascia is the white line, or arcus
tendineus. The white line extends from the ischial spine
to the posterior aspect of the body of the pubis, arching
downward. Its greatest distance below the ilio-pectineal is
about 5 cm. (2 in.).
At the lateral walls of the bladder, the vagina and the
rectum, this fascia divides into four layers (Webster) :
1. Vesical layer. This layer runs upward on each
lateral aspect of the bladder to form the lateral true liga-
ments of the bladder.
2. Vesico-vaginal layer. This layer runs between the
bladder and the anterior vaginal wall.
3. Recto-vaginal layer. This layer extends between the
lower portion of the vagina and the rectum, blending below
with the connective tissue of the perineal body.
PHYSIOLOGY OF LABOR. 101
4. Rectal layer. This layer envelops the lower end of
the rectum posteriorly, being closely attached to its poste-
rior wall.
The anal fascia covers the inferior surface of the levator
ani muscles, presently to be described.
The Triangular Ligament. Across the triangular space
between the ischio-pubic rami and in front of the bis-ischial
line are stretched the two fascial sheets which constitute the
triangular ligament. The deep layer of the triangular liga-
ment blends with the parietal fascia and is in contact with
the inferior surface of the levator ani muscle, fusing with its
fascial sheath. The two layers blend at the bis-ischial line
with each other and with the superficial fascia. The union
of these layers at the bis-ischial line forms the perineal
ledge or ischio -perineal ligament. These three sheets are
sometimes described as the deep, the middle and the super-
ficial layers of the perineal fascia. They are perforated by
the urethra and the vagina. Between the middle and the
superficial layers of the perineal fascia are the superficial
transversus perinei, the bulbo-cavernosus and the ischio-
cavernosus muscles, on either side.
Muscles of the Pelvic Floor. Levator ani. The anatomy
of this muscle, according to Browning, who was the first to
describe it correctly, is as follows : it immediately underlies
the recto-vesical fascia. It consists of three parts. The
first takes its origin from the posterior surface of the os
pubis and from the deep layer of the triangular ligament ;
the second from the white line ; the third from the ischial
spine. The bony origin of the pubic bundle is about
12 mm. (J inch) from the symphysis and 3.5 cm, (1J- inch)
below the upper border of the bone. The entire pubic
bundle is about 12 mm. (J inch) wide and 3 mm. (J inch)
thick at a point just beyond its origin. Its course is nearly
102 ESSENTIALS OF OBSTETRICS.
horizontally backward. Its superficial fibres blend with
those of the external sphincter ani. Of the deeper fibres a
few turn forward into the perineal body. The greater
number take a backward course toward the coccyx, to which
most of them can be traced. Some of the fibres in their
course toward the coccyx lie in close proximity to the
median line, but none are continuous with their fellows of
the opposite side. The pubic bundle as it sweeps by the
vagina is 5 mm. (J inch) away from it.
The part of the muscle which arises from the white line
is thin and membranous and is weakly attached to it.
The direction of its fibres is at first downward, inward and
backward toward the rectum and the rectococcygeal raphe.
They all fall short of the rectum and the raphe, turning
toward the coccyx, most of them reaching it, some first
becoming aponeurotic.
The part of the levator which springs from the ischial
spine forms a small spindle-shaped bundle. Its course is
nearly transverse. The most of its fibres are inserted into
the tip of the coccyx ; a few turn forward upon the recto-
coccygeal raphe.
Nowhere do the fibres of the levator cross the median
line to join those of its fellow on the opposite side.
The anal fascia on the lower and a very thin fascial
layer on the upper surface of the levator constitute its
sheath. These are separable from the contiguous fascial
sheets previously described.
Superficial transversus perinei. Origin, the inner aspect
of the tuberosity and ramus of the ischium : insertion, the
centre of the perineal body.
The deep transversus perinei lies between the deep and
the middle layers of the perineal fascia. It takes origin
PHYSIOLOGY OF LABOR. 103
from the descending ramus of the pubis, and is inserted into
its companion muscle.
Bulbo-cavernosus. Origin, the external sphincter ani and
the perineal fascia at one side of it ; insertion, by three slips,
one into the posterior surface of the bulb, one into the lower
aspect of the clitoris and one into the vestibular mucous
membrane.
Ischio-cavernosus. Origin, the tuberosity of the ischium
and ischio-pubic ramus ; insertion, the crus clitoridis and
an aponeurosis covering the posterior part of the body of
the clitoris.
The sphincter ani externus is made up of two semilunar
bands, each about 3 cm. (f inch) wide, one on either side
of the anus. Origin, the tip of the coccyx and the skin
adjacent thereto; insertion, the tendinous centre of the
perineal body.
The perineal body, so called, is the body of elastic and
muscular tissue between the lower end of the rectum and
the vagina. Its height is 3.7 cm. (1J inch), its transverse
width 3.7 cm. (1J inch), and the length of its base antero-
posterior^ 3.1 cm. (1J inch) in the nullipara.
The Parturient Axis.
The axis of the brim is a line perpendicular to the plane
of the inlet at its central point ; its prolongation passes
through the umbilicus and the tip of the coccyx. It is co-
incident with the axis of the uterus at term.
The axis of the outlet is the perpendicular to the plane
of the outlet at its midpoint. Prolonged it cuts the lower
border of the first piece of the sacrum.
The axis of the outlet of the soft parts, the line of expul-
sion, looks almost directly forward,
104
ESSENTIALS OF OBSTETRICS.
The parturient axis is made up of the axes of the several
planes of the birth-canal. It is an irregular parabola.
Fig. 32.
Axes of the pelvis. A Axis of superior plane. B. Axis of mid-plane. C. Axis
of inferior plane. D. Axis of canal. E. Horizon (Playfair.)
3. The Passenger.
Obstetric Anatomy of the Fcetal Head.
For the obstetrician the foetal head presents two divisions :
1. The cranial vault. 2. The cranial base and face. The
former owing to the semi-cartilaginous character of its bones
and to their mobility is plastic, a fact of importance in
facilitating the passage of the head through the pelvis ; the
latter is unyielding, its bony structures being more highly
ossified and more firmly united. Protection is thus afforded
during labor to the vulnerable structures at the base of the
PHYSIOLOGY OF LABOR. 105
brain. It is with the cranial vault that obstetric problems
have mainly to do.
The cranial vault comprises the parietal, the frontal and
the squamous portions of the occipital and the temporal
bones.
The cranial base is composed of the basilar portion of
the occipital bone, the petrous portion of the temporal bones
and of the entire sphenoid and ethmoid bones.
The Sutures. The sutures are the membranous inter-
spaces between two adjacent cranial bones. Of special ob-
stetric importance are the following :
The sagittal or inter-parietal suture ;
The frontal or inter-frontal suture ;
The coronal or fronto parietal suture;
The lambdoidal or occipito-parietal suture.
The Fontanelles. The fontanelles are the membranous
spaces between the angles of three or four adjacent bones of
the cranium. The fontanelles of obstetric interest are two,
the anterior and the posterior.
The anterior or large fontanelle or bregma is situated
at the anterior end of the sagittal suture. In the vaginal
examination during labor it is identified by the following
characters :
1. It is kite-shaped or quadrangular, its most acute angle
looking forward ; 2. Its average diameter is 2.5 cm. (1 in.) ;
3. Four sutures run into it.
The posterior fontanelle lies at the posterior end of the
sagittal suture. To the examining finger it presents the fol-
lowing distinguishing marks :
1. It is triangular ; 2. It is small, usually a mere de-
pression scarcely perceptible to the finger-tip ; 3. Three
sutures run into it ; 4. Immediately behind it is the squa-
mous or triangular portion of the occipital bone which is
106 ESSENTIALS OF OBSTETRICS.
hinged to the basilar portion by a movable joint of fibrous
tissue.
Protuberances. The foetal head presents five protuber-
ances which are of interest as obstetric landmarks, viz., one
occipital, two parietal and two frontal.
The occipital protuberance is situated on the occipital
bone an inch or more behind the posterior fontanelle.
The parietal protuberance or boss on either side of the
cranium is the eminence at the centre of the parietal bone.
The frontal protuberance is the prominence at the central
portion of each frontal bone.
The Vertex. The vertex is that part of the cranial vault
lying between the fontanelles and extending laterally to the
parietal eminences.
The Occiput. The occiput is the portion of the cranium
behind the posterior fontanelles.
The Sinciput. The sinciput is that portion of the cranial
vault lying in front of the bregma.
Measurements of the Foetal Head.
The biparietal diameter is the greatest transverse width
of the head measured through the parietal eminences ; its
value is 9.5 cm. (3f inches).
The fr onto mental diameter extends from the summit of
the forehead to the centre of the lower margin of the chin.
Its value is 9 cm. (3J inches).
The trachelo-bregmatic diameter is measured from the
neck just above the larynx to the centre of the bregma ; its
value is 9.5 cm. (3f inches).
The occipitofrontal diameter is the distance from the tip
of the occipital protuberance to the root of the nose ; its
value is 11.5 cm. (4J inches).
The occipito-mental diameter is measured from the sum-
PHYSIOLOGY OF LABOR. 107
mit of the occipital protuberance to the centre of the lower
margin of the chin ; its value is 14 cm. (5 J inches).
Fig. 33.
Foetal head viewed from behind. P P. Biparietal diameter. (After Farabeuf.)
The suboccipito-bregmatic diameter is the distance from
the junction of the nucha and the occiput to the centre of
the bregma; its value is 9.5 cm. (3f inches).
The bitemporal diameter is the transverse diameter of
the head between the lower extremities of the coronal
suture ; its value is 8 cm. (3J inches).
The bimastoid diameter is the greatest distance between
the mastoid apophyses ; its value is 7 cm. (2f inches).
Circumference. The suboccipito-bregmatic circumference
is measured over the junction of the nucha and occiput and
over the centre of the bregma ; its value is about 33 cm.
(13 inches), in male — 1.2 cm. (J inch) greater than in female
heads.
108
ESSENTIALS OF OBSTETRICS.
Fig. 34.
Foetal head viewed from the side. F. Occipitofrontal diameter. B. Sub-
occipito-bregmatic diameter. T B. Trachelo-bregmatic diameter. (After Fara-
beuf.)
It will be seen that the principal diameters of the foetal
head, namely, the biparietal (also the fronto-mental), the
occipito-frontal, and the occipito-mental, are approximately
3^, 4J, 5J inches respectively.
Trunk Diameters.
The bisacromial diameter is 12 cm. (4f inches). The bi-
trochanteric is 8.8 cm. (3J inches). The trunk diameters
are much more compressible than are the cephalic.
Presentation, Position and Posture op the Foetus.
Presentation. Definition. By presentation is meant
the relation of the long axis of the fcetal ovoid to the uterine
axis.
PHYSIOLOGY OF LABOR. 109
Varieties :
1. Longitudinal.
A. Cephalic,
a. Vertex ;
b. Face;
c. Brow.
A. Pelvic,
a. Breech ;
b. Feet.
2. Transverse.
a. Shoulder;
b. Arm;
c. Hand.
The presenting part is that part of the foetal ovoid which
offers to the examining finger within the girdle of resistance.
Relative frequency of presentations. In at least 96 per
cent, of all term labors the foetus presents by the cephalic
extremity. Breech or pelvic presentation occurs in 3 per
cent, of term births, lateral in about 1 per cent. The face
or brow is the presenting part in a little less than -f^ per
cent, of cephalic births. The preponderance of cephalic
presentation is mainly due to adaptation ; the foetal mass
tends to accommodate its position to the shape of the uterus.
Position. Position is the relation of the presenting part
to the quadrants of the pelvic brim. These quadrants are
the left anterior, the right anterior, the right posterior and
the left posterior quadrant of the brim. The positions are
named according to the particular quadrant which the lead-
ing anatomical landmark on the presenting part confronts.
For each presenting part there are, therefore, four possible
positions.
Vertex positions are named according to the quadrant
which the occiput confronts. When the occiput looks toward
110 ESSENTIALS OF OBSTETRICS.
the left anterior quadrant the position is left occipitoante-
rior ; when toward the right anterior quadrant the position
is right occipitoanterior, and so on. Face positions are
named in like manner, according to the direction of the
chin ; breech positions with reference to the direction of the
sacrum, and shoulder positions to that of the scapula.
Thus we have the following positions :
Vertex Positions.
Left occipitoanterior — L. 0. A.
Right occipito-anterior — R. 0. A.
Right occipito-posterior — R. O. P.
Left occipito-posterior — L. 0. P.
Relative frequency : 70, 10, 17, and 3 per cent, respec-
tively.
Face Positions.
Left mento-anterior — L. M. A.
Right mento-anterior — R. M. A.
Right mento-posterior — R. M. P.
Left mento-posterior — L. M. P.
Breech Positions.
Left sacro-anterior — L. S. A.
Right sacro-anterior — R. S. A.
Right sacro-posterior — R. S. P.
Left sacro-posterior — L. S. P.
Transverse or Shoulder Positions.
Left scapuloanterior — L. Sc. A.
Left scapulo-posterior — L. Sc. P.
Right scapulo-posterior — R. Sc. P.
Right scapulo-anterior — R. Sc. A.
Note that in shoulder as in other presentations the terms
right and left refer to the mother.
Posture. By posture is meant the relation of the foetal
members to one another. The usual foetal posture during
PHYSIOLOGY OF LABOR. HI
pregnancy and parturition is one of flexion. As an ele-
ment in the labor posture is most important as relates to
the head.
n. CLINICAL AND MECHANICAL PHENOMENA OF
NORMAL LABOR.
Normal labor, as we shall define it, includes only labor
in which all the mechanical factors are normal and which
are otherwise uncomplicated — labors, in other words, having
no element of dystocia. Only vertex births in one of the
anterior positions will be classed as normal.
Stages of Laboe.
The first stage, or stage of dilatation, ends with the com-
plete dilatation or canalization of the utero-cervical zone.
The second stage, or stage of expulsion, ends at the birth
of the child.
The third, or placental stage, includes the expulsion of
the placenta, the complete evacuation and persistent retrac-
tion of the uterus.
Causes of the Onset of Labor.
The causes which determine the advent of labor are not
definitely known. Probable causes are : the loosening at-
tachment of the ovum in the later weeks of gestation ;
distention of the uterus and the consequent reaction of the
uterine muscles; development of the contractile power of
the uterus ; the growing vigor of the foetal movements ;
excess of carbonic dioxide in the blood, acting upon the
motor centres ; increasing irritability of the uterus ; the in-
fluence of the menstrual molimen. The separation of the
decidua begins at the lower uterine segment with the first
112 ESSENTIALS OF OBSTETRICS.
labor pains. The ovum thus becomes in part a foreign
body. This furnishes sufficient stimulus for continued
expulsive efforts.
Phenomena of Beginning Labor.
Signs of the onset of labor are :
Lightening ;
Irritability of the bladder and rectum ;
Increased flow of vaginal secretion ;
The show, a discharge of bloody mucus from the
vagina;
Expulsion of the cervical mucous plug;
Rhythmic uterine pains.
By lightening is meant the sinking of the uterus, which
takes place usually within from ten to fourteen days before
labor actively begins. The uterus sinks more deeply in the
pelvis. The waist-line becomes smaller. As the uterus
settles lower down in the pelvis the pressure on the bladder
and rectum is increased and these viscera are evacuated
oftener than is the usual habit. Lightening, however, is
not observed in all cases.
At the onset of active labor urination and defecation
become still more frequent and there is a profuse secretion
of vaginal and cervical mucus. The vaginal discharge may
be stained with blood — the show. Sometimes the mucous
plug which blocks the cervix during pregnancy is expelled
as a tenacious, jelly-like mass.
The most reliable evidences of beginning labor are the
occurrence of rhythmic uterine pains and contraction of
the uterus with each pain as felt by the examining hand
held upon the abdomen. The first pains are often little
more than a sense of pressure, and are felt in the lumbo-
sacral region. As labor advances they become more pro-
PHYSIOL OGY OF LABOR. 113
nounced, extend in front to the lower abdominal region
and radiate down the thighs.
Labor pains. Labor pains are the painful uterine con-
tractions of labor. The painful character of the contrac-
tions is due to pressure on the nerve-filaments of the uterus
and on the nerve-trunks in the pelvic cavity.
The duration of a pain is thirty to sixty seconds. The
usual intervals between the contractions at the beginning of
labor are twenty to thirty minutes. They gradually shorten
as labor goes on and may be reduced to a fraction of a
minute at the acme of expulsion.
The intensity progressively increases, reaching its maxi-
mum at the expulsion of the head from the vaginal outlet.
1. First Stage : Stage of Dilatation.
Dilatation. Three agencies are concerned in dilata-
tion of the cervix :
1. Traction of the longitudinal muscular fibres of the
upper uterine segment ;
2. Hydrostatic pressure of the bag of waters ;
3. Softening of the cervical structures by serous infiltra-
tion.
The traction of the upper segment of the uterus draws
the lower segment upward over the presenting portion of
the ovum. The dilatation begins at the os internum. With
the first active labor pains the ovum is partially detached from
the lower uterine segment. The internal os expands and
the bag of waters protrudes into the cervical zone with each
pain, receding in the intervals. At first the cervix, becom-
ing somewhat funnel-shaped during the pains, nearly re-
gains its cylindrical form in the intervals. As the labor
advances the os internum is permanently effaced and the
ovum rests against the os externum. From this time the
114 ESSENTIALS OF OBSTETRICS.
progress of canalization is indicated by the size of the
external os.
The bag of waters is the portion of the membranes which
in the course of the labor protrudes downward into the
cervix. It plays an important part in the mechanism of
dilatation. Its contained liquor amnii, the fore-waters,
is partly cut off from that above the head, the hind-waters,
by the ball-valve action of the head as the latter is driven
into the cervix during a pain. The general uterine press-
ure, however, is transmitted in some measure to the fore-
waters. In accordance with the law of hydrostatics the bag
of waters is not only urged downward, but it exerts a cer-
tain amount of expansive force upon the walls of the pas-
sive cervical zone. In vertex presentation the bag of
waters has a watch-glass shape.
When the membranes rupture prematurely the dilatation
of the cervix usually goes on more slowly and is more
painful. The foetal head is not so good a dilator as the
fluid wedge, the bag of membranes. It lacks the active
dilating power and the equable pressure of the bag of
waters. The mechanical disadvantage is still greater in
malpresentations and malpositions, by reason of the greater
inequality of pressure on different parts of the resisting
girdle.
The membranes rupture usually by the time they reach
the pelvic floor, often sooner, or only on interference.
Softening of the cervix, established before labor, is much
increased in course of the first stage. During a pain the
walls of the uterus are everywhere compressed by contrac-
tion upon its contents, except at the cervix. The blood-
vessels of the cervix, unsupported by pressure, become
engorged, and a serous transudation takes place into its
tissues, loosening its structure.
PHYSIOLOGY OF LAB OB.
115
detraction ring. In course of the first stage of labor
the upper uterine segment becomes thickened, retraction of
the muscular structures into that segment taking place with
each pain ; the lower segment becomes correspondingly
thinned. The line of demarcation between the thickened
upper and the thinned lower segment is the contraction
Fig. 35.
The uterus after complete canalization of the utero-cervical zone. CR. Con-
traction ring or retraction ring. oi. Os internum, oe. Os externum.
ring, or, as it may more properly be termed, the retraction
ring. The retraction ring can generally be felt above the
brim by the close of the first stage, and it rises higher in
proportion to the number and strength of the pains.
116 ESSENTIALS OF OBSTETRICS.
Retraction of the pubic segment. The posterior wall of
the bladder and the whole pubic segment of the pelvic floor
begin to be drawn upward during the latter part of the
stage of dilatation. The elevation is marked during the
second stage. The bladder is thus lifted partly out of the
lesser pelvis away from injurious pressure during the birth.
Only a very small portion of the organ rises above the level
of the pubic bones. The length of the urethra remains
unchanged.
The duration is from two or three hours to several days-
The average length of this stage is in primiparse, eleven
hours ; in nmltiparse, seven hours.
2. Second Stage : Stage of Expulsion.
The Mechanism of Labok. The most important
mechanical phenomena of the second stage of labor are
those pertaining to the series of passive movements which
the foetus undergoes in course of its expulsion through the
birth-canal. This succession of movements is usually termed
the mechanism of labor.
The engaging diameters of the head being larger than
those of any part of the foetal mass, the essential mechanical
phenomena of the stage of expulsion are those pertaining to
the birth of the head. To rightly comprehend them it
must be borne in mind that the foetal head is an irregular
ovoid body, which in typical labors tightly fits the passages ;
and that the shape and direction of the parturient tract
change at every point throughout its length. The essential
cause of the head movements is adaptation or accommoda-
tion of the head to the varying shape and course of the
birth-canal. These movements are descent, flexion, rota-
tion, extension ; restitution and external rotation are addi-
tional movements impressed upon the head after its escape
PHYSIOL OGY OF LAB OB. 117
from the passages, in consequence of the spiral motion of
the trunk in course of its descent.
Descent. In the stage of expulsion the uterine contrac-
tions are reinforced by the action of the abdominal muscles.
Hence the bearing-down character of the pains at this period.
Before escape of the waters the expellent force is trans-
mitted to the head through the entire uterine contents. After
rupture of the membranes the propelling force acts directly
upon the foetus. The foetal mass under the general uterine
pressure moves in the direction of least resistance, through
the birth-canal.
The head advances with the pains and recedes in the
intervals, and in normal conditions this advance and reces-
sion continue till the head is well in the grasp of the vulvar
ring.
Flexion. A certain degree of flexion is present primarily.
It belongs to the normal posture of the foetus in utero. The
primary flexion is increased as the descent begins, and for
this reason : the head is so hinged upon the trunk that the
occipitofrontal diameter corresponds to a lever of unequal
arms, the frontal arm being the longer. On engagement
in the utero- cervical zone the resistance, though equal at
the two ends of the lever, acts with greater effect on the
longer or frontal arm, and the chin dips toward the sternum.
Flexion is still more increased when the head encounters
the greater resistance of the bony canal.
The advantage of flexion is apparent. It substitutes the
suboccipitobregmatic diameter, 9.5 cm. (3f inches), for
the occipito-frontal, 11.5 cm. (4 J inches), a gain quite
enough in most cases to make all the difference between a
possible and an impossible delivery. The head undergoes
still further accommodation to the passages by the mould-
ing yet to be described.
<5*
118 ESSENTIALS OF OBSTETRICS.
Rotation. The longest diameter of the pelvis at the
brim which is available for the passage of the head is the
oblique ; at the outlet the longest is the antero-posterior.
The head, therefore, as it descends must rotate about the
axis of the birth-canal to keep its longest engaging diameter
constantly in the longest diameter of the pelvis during its
passage through it.
Rotation of the head is due chiefly to the slope of the
lateral halves of the pelvic floor downward, forward and
inward. In normal labor the occipital pole first lands upon
one lateral half of the floor, and as it descends it is thrust
forward and inward beneath the pubic arch. A firm pelvic
floor, together with efficient labor pains, is, therefore, essen-
tial to forward rotation of the occiput. Flexion, moulding
of the head and the development of the caput succedaneum,
yet to be described, promote rotation by increasing the dip
of the occipital pole. After the occiput has sunk below the
level of the pubic arch its forward rotation is due partly to
the fact that this is the direction of least resistance. Com-
plete rotation is seldom observed. The head is usually
expelled in a position slightly oblique to the median antero-
posterior plane of the parturient outlet.
Extension. After the occiput has escaped beneath the
pubic arch the nape of the neck rests against the subpubic
ligament, and the head, rotating upon the nucha as a pivotal
point, is born by a movement of extension, the vertex, the
forehead and the face successively sweeping over the peri-
neum. The chin, however, does not, as formerly assumed,
leave the sternum till the moment of expulsion. A brief
pause usually follows the birth of the head.
Restitution. Since the shoulders descend in the oblique
diameter opposite that in which the head engages, rotation
of the head during its descent through the pelvis brings
PHYSIOL OOY OF LAB OB. 119
about a certain degree of torsion of the neck. After the
head is born the neck untwists and the head, if left to
itself, takes a position corresponding to that in which it
entered the pelvis. This movement is termed restitution.
It may be utilized as a means of confirming the diagnosis
of position.
External rotation is a still further rotation of the head
which is observed during the expulsion of the body ; it
occurs in consequence of the spiral movement of the trunk
as it traverses the birth-canal.
Birth of the trunk. The shoulders and the breech rotate
to some extent as they descend through the pelvis, but less
perfectly than the head. The rotation takes place in a
direction opposite to that of the head, since the shoulders
and breech come down in the opposite oblique diameter of
the pelvis. The anterior shoulder is expelled first, or it
lodges behind the pubic bones and the posterior shoulder
first appears at the ostium vaginae and escapes over the edge
of the vulvar ring. A gush of bloody water generally ac-
companies the birth of the trunk.
Other Phenomena : Caput succedaneum. The caput
succedaneum is an cedematous swelling developed upon the
presenting part of the foetus after rupture of the membranes.
In cephalic presentation it forms on the part of the head
within the girdle of resistance. The vessels here, unsup-
ported by pressure during the uterine contractions, become
engorged and serous infiltration of the tissues ensues. The
size of the tumor increases with the number and strength of
the pains. Its location differs with the position in which
the head has entered the pelvis. In L. 0. A. positions it
forms on the right, in R. 0. A. upon the left, posterior
parietal region. In R. 0. P. positions it appears upon the
left anterior, and in L. 0. P. upon the right anterior, parietal
120 ESSENTIALS OF OBSTETRICS.
region. The location, however, may be modified when the
head has rested long in the lower portion of the birth-canal
after having undergone partial rotation.
Moulding of the head. Owing to the plasticity of the
cranial vault the adaptation of head to pelvis is in part
accomplished by moulding. Under pressure of the pelvic
walls the engaging diameters of the cranial vault are re-
duced and the head is elongated in the direction of the
passages.
Perineal stage. As the occiput approaches the outlet
of the soft parts the sacral segment of the pelvic floor is
stretched and pushed downward and forward in front of the
advancing head. Its length from coccyx to posterior com-
missure is increased at the moment of expulsion to 13 cm.
(5 or 6 inches). The sphincter ani is relaxed, the anal
orifice gapes widely and feces are usually expelled from the
rectum as the head passes over the pelvic floor. As the
equator of the head escapes from the vulvo-vaginal orifice
the posterior segment of the floor promptly retracts over the
Pulse and temperature. The maternal pulse-rate is some-
what accelerated during the pains. The maternal temper-
ature, particularly in hard labor, is generally a degree or
more above the normal at the termination of the birth.
The foetal pulse-rate is retarded at the height of the
pains, owing to increased arterial tension in the foetus.
The length of the second stage in primiparae is from one
to seven hours — average about two hours ; in multipara,
fifteen minutes to two hours — average about one hour.
3. Third Stage : Placental Stage.
Events. 1. Separation of the placenta; 2. Expulsion
of the placenta and blood-clots ; 3. Retraction of the uterus.
PHYSIOLOGY OF LABOR. 121
Separation of the placenta takes place in the meshy layer
of the decidua ; it is brought about partly by contraction of
the placental site and partly by the extruding force of the
uterine contractions.
Expulsion of the placenta is effected by the extruding
force of the uterine contractions. The after-birth may
present by its amniotic surface or may be expelled edge
first. Its expulsion from the vagina is explained by the
tonicity of the muscular structures in the posterior seg-
ment of the pelvic floor. The placenta drags the mem-
branes after it, gradually peeling them from the uterine
walls.
Retraction of the uterus consists in a thickening and short-
ening of its walls, due in part to rearrangement of the
muscular fibres, in part to thickening and shortening of the
fibres themselves. Normally retraction of the upper seg-
ment is promptly established at the close of labor. It
securely ligates the uterine vessels which have been torn
across by separation of the placenta. The lower segment
remains passive for several hours after the close of labor.
The duration of the third stage varies from a few minutes
to two hours. Its average length is from twenty to thirty
minutes.
The average length of normal labor is in primipar?e twelve
hours ; in multipara, eight hours. Variations from two to
twenty-four hours are not uncommon within normal limits.
III. MANAGEMENT OF LABOR.
Preparatory. The duties of the obstetrician to his
patient especially in the later months of pregnancy are
scarcely less important than those pertaining to the manage-
ment of labor and the post-partum period. The enforce-
122 ESSENTIALS OF OBSTETRICS.
merit of hygienic rules, attention to the general health,
urinary examinations once weekly or oftener during the
last two or three months and instructions with reference to
the care of the nipples are essential to the proper conduct
of the obstetric case. At this period, too, the physician
acquaints himself in so far as possible with the conditions
with which he will have to deal in the subsequent care of
the patient. A month before the expected date of labor a
systematic examination should be made according to the
following plan :
Ante-partum Examination.
Scheme.
History.
General health ;
Character of previous pregnancies, labors, puerperiums,
miscarriages ;
Date of last menses ;
Important data concerning the present pregnancy ;
Character of the vaginal discharge.
Abdominal Examination.
Pendulous abdomen ;
Hydramnios ;
Twins ;
Location of placenta ;
Complicating tumors ;
Presentation, position, and posture of foetus ;
Length of the foetal ovoid ;
Size and hardness of the foetal head ;
Foetal pulse-rate ;
External measurements of the pelvis in primiparse and
in multipara with a history of difficult labors.
PHYSIOLOGY OF LABOR. 123
Vaginal Examination.
Former injuries — pudendal, vaginal, cervical ;
Placenta prsevia;
Obstructing tumors ;
Measurements of the diagonal conjugate and other
diameters of the pelvis in primiparse and in multi-
para whose history excites suspicion of pelvic con-
traction.
Method of Abdominal Examination for Presentation and
Position.
1. Preparation. The patient is placed in the horizontal
posture (supine, with the lower limbs extended) with the
abdomen fully exposed or covered only with a sheet. When
the sheet is used the examination may be conducted through
this covering, or, better, with the hands underneath it. Be-
fore examining the hands of the operator are bathed in warm
water to render the sense of touch more acute, and because
contact of cold hands would excite reflex contractions of the
abdominal and uterine muscles which interfere with the
examination.
2. Locating the dorsal plane and small parts.
This is done by any one or all the following methods :
a. The entire surface of the abdomen is palpated
systematically, using light touches with the palmar
surfaces of the finger-tips.
b. Downward pressure is applied with one hand
on the foetal pole in the direction of the uterine
axis ; this steadies the dorsum and brings it nearer
to the abdominal wall where it can more satis-
factorily be palpated with the other hand. The
child's back is identified by the length and breadth
of the resisting plane. Distinguish from the
124
ESSENTIALS OF OBSTETRICS.
lateral plane by the greater width of the dorsal,
by its convexity and by the absence of a sulcus
between it and the head.
Fig.
Displacing foetus to one side of abdomen for locating dorsal plane.
c. Place the palmar surface of one hand flat on the
median section of the abdomen at the umbilicus,
and press backward toward the spinal column.
The child will be displaced to the side toward
PHYSIOLOGY OF LABOR.
125
which its back lies and the liquor amnii to the
other. Palpating with the other hand, the solid
is readily distinguished from the fluid tumor. (Fig.
36.)
Small parts are felt as nodules which glide freely about
under the touch ; sometimes their outlines may be fully
Fig. 37.
HI ■ mmS
■ If i \ f ■ F
ml .^FBbmw JA f / /
PS
i
Examining lower foetal pole.
traced. Circular rubbing movements with the finger-tips
help to identify them. They are felt on the side opposite
126
ESSENTIALS OF OBSTETRICS.
the foetal dorsum. In full anterior positions of the child's
back the small parts may not be accessible to palpation.
Small parts in the median section of the abdomen indicate
a dorso-posterior position of the foetus.
3. Examining the lower foetal pole. With both hands
over the lower uterine segment just above Poupart's liga-
Fig. 38.
Grasping foetal head with hand over abdomen for locating cephalic prominence.
ments, finger-tips toward the mother's feet, and palmar
surfaces nearly facing each other, the lower foetal pole is
PHYSIOLOGY OF LABOR.
127
caught between the hands. (Fig. 37.) In difficult cases
the following manipulation helps to find the head : bringing
the hands gradually nearer and nearer together, while placed
as above described, move them as if to toss the head sharply
from one hand to the other.
The head feels hard and globular ; there is a lateral sulcus
between it and the trunk ; in primipara (not in multipara)
it is in the pelvic excavation before labor.
The breech alone is smaller, with all its component ele-
ments it is larger, than the head ; it lacks the hard and
globular feel of the head, presents no sulcus and it is
never in the excavation before labor. If small parts can be
felt just beyond either foetal pole that pole is the breech.
The head in either iliac fossa indicates a cross-birth.
Fig.
Locating cephalic^prominence with one hand.
128 ESSENTIALS OF OBSTETRICS.
Cephalic prominence. When the head is in the brim the
cephalic prominence is greatest on the side of the sinciput.
The location of the cephalic prominence affords some aid in
deciding whether the child's back lies to the right or the left.
It is located by grasping the head with one hand held trans-
versely across the suprapubic region (Figs. 38, 39), or by
palpation with both hands (Fig. 40). The hand sinks most
deeply in the excavation on the side opposite the prominence.
Fig. 40.
Locating cephalic prominence by palpation with both hands.
4. Examining the upper foetal pole. With both hands over
the upper uterine segment, finger-tips toward the mother's
face (Fig. 41) and palmar surfaces nearly facing each other,
the foetal poles are differentiated by the signs already given
and by ballottement of the head. The breech lacks the flex-
PHYSIOLOGY OF LABOR.
129
ible attachment to the trunk which characterizes the head,
and it has less mobility by reason of this and of its greater
bulk when taken with all its component parts. Ballotte-
ment of the head when in the lower uterine segment is
possible -only with -excess of liquor amnii.
Fig. 41.
Examining upper fcetal pole.
5. Locating the anterior shoulder. The hands are placed
over the sides of the head and, with firm pressure, moved
toward the breech ; the first obstacle they encounter is the
130
ESSENTIALS OF OBSTETRICS.
anterior shoulder. It can usually be identified by its ana-
tomical characters. (Fig. 42.)
Fig. 42.
Locating anterior shoulder.
Location of the anterior shoulder within one or two
inches of the median line indicates an anterior position of
the child's back ; anterior shoulder several inches away
PHYSIOLOGY OF LABOR. 131
from the median line indicates a posterior position of the
child's back.
6. Locating the foetal heart. The place at which the
foetal heart-tones are heard loudest is called the focus of
auscultation. It is usually an area of about 7 5 cm. (3
inches) in diameter. As a rule it lies nearly over the lower
angle of the left scapula of the foetus, or at least the upper
part of the foetal dorsum. Heart-sounds in the upper
uterine segment indicate a breech, in the lower a cephalic
presentation. The heart, however, is situated nearly mid-
way between the ends of the foetal ellipse. In multipara,
therefore, in whom neither pole sinks into the lesser pelvis
before labor begins, the location of the foetal heart-tones is
of little value for the diagnosis of presentation.
Occasionally the focus of auscultation does not imme-
diately overlie the heart. It may be found at some remote
point owing to firmer contact of the foetus with the uterine
wall at that point.
The location of the foetal heart is especially useful in
distinguishing between right and left and between anterior
and posterior positions of the child's back. Heart-tones to
the left indicate a left, to the right a right, position ; heart-
tones near the median line indicate an anterior, far from it
a posterior, position.
External Pelvimetry- Measurement of the external diam-
eters requires the use of a suitable instrument. A good
portable pelvimeter for external measurements is Schultze's
or Collyer's. (Fig. 43.) Marked asymmetry of the pelvis
is sometimes apparent on external palpation.
Interspinal and intercristal diameters both small indi-
cates general pelvic contraction. Interspinal equal to or
greater than the intercristal indicates antero-posterior flat-
tening. For the external conjugate 7 inches may be taken
132 ESSENTIALS OF OBSTETRICS.
as the average lower limit m normal pelves. Yet variations
of J to 1 inch above or below this limit are observed.
Fig. 43.
Collyer's pelvimeter.
Method of Vaginal Examination and Internal Pelvimetry.
The bladder and the rectum must be empty. Antiseptic
precautions are to be observed as in examinations during
labor. Measure the depth of the symphysis pubis, width
of the subpubic angle, the bisisohial, the sacro-pubic and
the diagonal conjugate diameters and note the size and
shape of the sacrum.
The transverse diameter at the outlet ma} T be measured
externally by taking the distance between the inner aspects
of the ischial tuberosities measured on a line drawn through
PHYSIOLOGY OF LABOR.
133
the anterior margin of the anus. It may be measured in-
ternally with the aid of a suitable instrument, approxi-
mately by the hand.
The antero-posterior diameter at the inferior strait is ob-
tained in a manner similar to that described below for the
diagonal conjugate. It may more readily be measured exter-
nally with a pelvimeter.
The diagonal conjugate is measured as follows : Passing
the index and second finger into the vagina, the tip of the
Fig. 44.
Measuring the diagonal conjugate.
second is placed against the summit of the promontory, the
radial edge of the hand resting against the subpubic liga-
ment. The latter point of contact is marked with the index
finger of the other hand. Withdrawing the hand the dis-
tance between the two points of contact is measured. This
distance is the diagonal conjugate. (Fig. 44.)
The true conjugate is found by deducting 1.3 to 2 cm.
7
134 ESSENTIALS OF OBSTETRICS.
(J to f inch), according to the depth and inclination of the
symphysis pubis, from the diagonal — one-half inch when the
symphysis measures less, three-fourths inch when the sym-
physis measures more, than 4.5 cm. (If inch).
The other diameters are estimated by palpating the walls
of the cavity.
General Preparations for Labor.
The lying-in room. The lying-in room should be a
large, well-ventilated room, with sanitary plumbing, or none
at all, preferably with a southern exposure. The room, the
bedding and the clothing of the patient must be absolutely
clean.
Preparation of the bed. Directions for the nurse.
The mattress should be covered with a muslin sheet, and
that with a rubber sheet large enough to reach across the
bed. A clean muslin sheet is spread over the rubber and
pinned fast to the mattress. Over that is spread a second
rubber covered with a muslin sheet. Two or three fresh
laundered sheets, twice folded, are placed in position to re-
ceive and absorb the discharges. The rubber and the
muslin sheets must be surgically clean.
Labor pad. In place of the folded sheets an aseptic
pad of prepared cotton, cotton-waste, paper-wool or other
absorbent material, covered with cheese-cloth, may be used
to receive the discharges. It ought to be two and a half to
three feet square. A large Kelly rubber pad may be sub-
stituted for the absorbent pad.
Obstetric Armamentarium. For general practice the
obstetric bag should be equipped with obstetric forceps, a
pelvimeter, a soft- rubber catheter, a hypodermic syringe, a
fountain syringe, a uterine douche-tube of glass, needles,
PHYSIOLOGY OF LABOR. 135
needle-forceps, aseptic sutures, hand brushes, a Sims' specu-
lum, a sponge-holding forceps, a volsella, a curette and a
yard of aseptic gauze.
It should also contain four ounces of Squibb's chloroform,
an ounce of Squibb's ergot, a few drachms of chloral, mor-
phia tablets gr. J, fluid extract of veratrum viride and
antiseptic tablets of the biniodide or bichloride of mercury,
or either of the following powders.
R . — Hydrargyri biniodidi,
Potassii iodidi. — M.
Chart, no. viii.
S. One to a quart of warm water, as an antiseptic solution.
R. — Hydrargyri bichloridi,
Acidi tartarici. — M.
Chart, no. viii.
S. One to a quart of warm water, as an antiseptic solution.
The nurse should have ready a half dozen clean
sheets, a dozen recently laundered towels, a dozen pieces
of cheese-cloth 45 cm. (18 inches) square, for wash-cloths ;
two or three pieces of unbleached muslin for binders,
a little over a meter long by 50 cm. wide (1J by J
yard) ; two surgically clean rubber sheets wide enough to
reach across the bed (table oil-cloth may serve when
economy requires) ; scissors, two dozen shield-pins of
medium size ; a bed-pan of earthenware or of agate iron-
ware, two or three clean hand-basins of like material, a
slop-jar, one or more new hand-brushes, plenty of hot and of
cold water, a yard of strong linen bobbin, one-sixteenth of
an inch in width, for tying the navel cord ; a woollen
blanket to wrap the child in, an infant's bath-tub and a
bath-thermometer, Castile soap, an ounce package of aseptic
cotton for the navel dressing ; the child's clothing.
Hand-brushes, scissors, cheese-cloths and the ligature for
136
ESSENTIALS OF OBSTETRICS.
the funis should be wrapped in a towel and sterilized by
steam or by boiling at the beginning of labor. They are
kept enveloped in the towel until wanted for use. Similar
care should be taken with all other appliances that other-
wise might directly or indirectly be the source of infection
to mother or child.
Antisepsis.
Antiseptic Agents.
1. Dry heat at 284° F. — exposure in an oven for half
an hour may serve for utensils.
2. Boiling for ten minutes, or steaming for half an hour.
Boiling is best done in water to which 1J per cent, of
sodium carbonate, c. p. (washing soda), has been added. The
soda removes greasy matter and tends to prevent metallic
instruments from rusting, and boiling in the solution is a
much more efficient germicide than boiling in plain water.
3. Chemical antiseptics.
Mercuric iodide solution, 1 : 2000.
R . — Hydrargyri biniodidi j
Potassii iodidi i
Aquae* ....
Mercuric chloride [sublimate) solution
R. — Hydrargyri bichloridi
Acidi tartarici .
Aquae ....
Chlorinated soda solution, 1 : 10.
R . — Liquor sodae chloratae
Aquae ....
Creolin solution, 1 : 1000.
R.— Creolin ....
Aquae ....
aa
1 : 2000.
gr. vijss.
Oij.— M.
gr. vijss.
gr. xl.
Oij.— M.
^ix.— M.
Sijss.
Oij.— M.
The water should previously he sterilized by boiling.
PHYSIOLOGY OF LAB OB. 137
Carbolic solution, 1 : 20. 1
R.— Acidi carbolici) ^ z;~~
>-.... act ^jlSS.
Glycerini i
Aquge Oij . — M.
Peroxide of hydrogen in full strength, or diluted with
one or two or four volumes of water, is a useful antiseptic.
It has the advantage of being non-poisonous.
Practical Bides for Antisepsis.
Non-metallic utensils may be disinfected with any of the
foregoing agents ; heat is the most efficient.
Metallic instruments are best sterilized by boiling in the
If per cent, soda solution. Baking for ten minutes in an
oven at a temperature a little below 300° F. is effective,
but it injures the edges of cutting instruments. 2
In sterilizing by steaming or boiling instruments may
for convenience in handling first be wrapped in a towel.
Cloths, bed-linen, etc., are best sterilized by steaming.
Flowing steam is most active. Dry heat does not pene-
trate dressings well.
When the chemical solutions are used exposure for at
least a half hour is desirable.
The obstetrician should wear a sterilized operating-gown
to cover his clothing and prevent contact of his hands and
arms therewith.
Technique of Hand- cleaning.
(a.) Filrbringer method.
1. The nails are kept short and cleaned dry.
2. The hands and forearms are scrubbed thoroughly with
1 Approximately.
- The spores of the bacillus tuberculosis are killed by dry heat only after an
exposure of three hours to a temperature of 2S4° F,
138 ESSENTIALS OF OBSTETRICS.
soap and hot water and a hand-brush for not less than five
minutes, giving special attention to the finger-tips and the
free edges of the nails and using two or three changes of
water.
3. The soap is rinsed off with sterilized water.
4. The hands and forearms are held in one of the mer-
curial solutions (1 : 2000) for five minutes.
As an additional precaution the hands may be wet well
with alcohol (80 per cent, or more) before immersion in the
antiseptic solution. This helps to remove fatty matter and
by dehydrating the skin makes the antiseptic sink more
deeply.
Hand-brushes should be steamed for ten minutes or boiled
in the soda solution for the same length of time.
(b) Permanganate method.
Steps 1, 2 and 3 as in a.
4. Immerse for two or three minutes in a warm saturated
solution of permanganate of potassium in boiled distilled
water, using plenty of friction.
5. Remove the permanganate stain by immersing in a
warm saturated solution of oxalic acid made with sterilized
water.
6. Rinse with sterilized water.
7. Immerse for five minutes in a mercuric iodide or
chloride solution, 1 : 500.
With this method the hands may be rendered sterile to
culture-tests.
(iv.
3iv.
gr. v.
To prepare the whey add a grain or two of pepsin dis-
solved in a teaspoonful of water to a pint of milk at the
temperature of 115° F. After the curd separates strain off
the whey.
Milk Laboratories,
A recent advance in infant-feeding which has met with
gratifying success in some of our larger cities is the milk
laboratory. The physician writes a prescription for the
food mixture very much as he does for medicine. The pro-
portions for the essential ingredients in the formula, albu-
minoids, fat, and sugar, are adjusted to the requirements of
the individual case. The food mixture supplied daily from
the laboratory is prepared according to the prescription, which
is modified by the physician as occasion requires.
The following formula, suitable for a healthy, full term
infant, one week old, illustrates the method of prescribing.
H . -Albuminoids 0.75. 1
Fat 2.00.
Milk-sugar 5 .00.
Lime-water 5.00.
Mix. Sterilize at 167° F.
Send 10 bottles of 1J ounce each.
In weak albuminoid digestion the proportion of albu-
minoids is reduced to the minimum, 0.20 per cent., and
gradually increased to the point of tolerance. A like modi-
1 The numerals in the formula represent percentages. It is understood that
the rest of the 100 parts is made up with water.
PHYSIOLOGY OF THE PUERPERAL STATE. 183
fication is prescribed in case of the fat or the sugar should
either of these and not the proteid element be found to be
the source of the digestive disorder.
The following table shows the quantities of food and the
percentages of albuminoids, fat, sugar, etc., required at
different periods of the first year, as deduced from the ex-
perience of the milk laboratories of New York and Boston.
Age.
Premature infants .
Full term healthy infants
1 week
2 weeks
3 "
1 month
2 months
Stomac
capaci
;h Albumin-
ty. oids.
Fat.
Sugar.
2-6 dra
as. 0.20-0.50
1.00-1.50
3.00-5.00
1
z. 0. 75
2.00
5.00
IY2'
1.00
2.50
6.50
2 '
1.00
3.00
6.50
2%<
1.00
3.50
7.00
3%'
1.25
4.00
7.00
4 '
1.50
4.00
7.00
4K'
1.75
4.00
7. CO
5 '
2.00
4.00
7.00
5K'
2.25
4.00
7.00
6 '
2.50
4.00
7.00
ey 2 '
2.75
4.00
7.00
7 '
3.00
4.00
6.50
■%'
3.50
Perhaps
4.00
some cere*
5.50
il jelly
8 '
4.00
4.00
4.00
sy 2 i
' Cow's milk
Lime-
water.
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
5.00
Twelve to Eighteen Months.
The child may take four or five feedings daily of whole
milk, with barley or oatmeal gruel or bread jelly in the
proportions of one of the latter to seven of the former, and
184 ESSENTIALS OF OBSTETRICS.
Pasteurized. Two or three ounces of uncooked beef-juice,
moderately seasoned, may be given daily ; it may be mixed
with the milk or be given separately. It must be prepared
at least twice a day and kept on ice. Care must be taken
that the beef is fresh.
After the child has sixteen teeth the simpler kinds of
food requiring mastication may be added, such as oatmeal
and milk, or wheaten grits, thoroughly cooked, or stale
bread and milk. Scraped beef or soft-boiled eggs can be
allowed two or three times weekly.
Eighteen Months to Two Years.
The number of feedings may be four or five daily. A
little fine-cut meat, such as tender beef, lamb or chicken,
may be added to the midday meal if the child is robust.
Milk should be the chief reliance for feeding till the
child has all its teeth and may constitute a part of its food
for several years longer. Milk, beef -juice and the fari-
naceous preparations above mentioned afford an ample
dietary for the entire period of infancy. Proprietary foods
for infants are not to be recommended.
DISORDERS OF THE NEWBORN INFANT.
Constipation.
Treatment. Regulate the digestion and the feeding.
Enough cream may be added to the food to raise the pro-
portion of fat to 4, 5 or 6 per cent. This alone frequently
overcomes the constipation in bottle-fed infants. Even a
moderate excess of fat, however, is not in all cases well borne.
Suitable laxatives are the following :
R. — Sodii phosphatis gr. x.
Sacchari lactis gr. x. — M.
PHYSIOLOGY OF THE PUERPERAL STATE. 185
This may be given at one dose in a teaspoonful or two of
water or of syrup of manna.
R.— Ext. sennse fluid, deoclorat. (N. F.) . . ^ss.
Potassii et sodii tartratis . . . . 3j-
Glycerini £ss.
Aquse ad ^iv.— M.
Dose, a teaspoonful, p. r. n.
Phillips' milk of magnesia is an eligible laxative for
infants. The dose is a teaspoonful.
Useful rectal measures are the injection of equal parts of
glycerin and water, 5\j, sweet oil, 5iv, or warm water, Sj.
The use of a suppository of soap or cacao butter or a
glycerin or gluten suppository generally provokes immedi-
ate action of the bowels. Yet glycerin suppositories may
prove too irritating to the rectum for continued use.
Indigestion.
Symptoms. Flatulence, sour, green and curdy stools,
vomiting an hour or more after nursing or feeding, restless-
ness, disturbed sleep, colic, failure of the normal gain in
weight.
Treatment. Regulate the nursing or feeding. The
food is almost invariably the source of the trouble. Look
to the health and habits of the mother. It is sometimes
useful to dilute the mother's milk by giving the child
a teaspoonful or two of warm water with the nursing.
Frequently the first thing needed is to relieve the stomach
of its contents by lavage. In acute indigestion four to five
-^-grain doses of calomel may be useful. Pepsin, gr. j,
in warm water, 5j, with each feeding may be given with
benefit, for a time, in certain forms of indigestion.
186 ESSENTIALS OF OBSTETRICS.
Colic.
Treatment. Remove the cause, which is to be found
in faulty digestion, by regulating the feeding.
For the pain choral is almost a sovereign remedy. The
dose is gr. j in water, 5j, or in syrup of vanilla and water,
aa 5ss, repeated once to three times daily, p. r. n. ; warm
applications to the abdomen and warm rectal injections, oj,
are useful palliatives. The curative treatment must consist
mainly of measures addressed to the digestive disorder.
Simple Diarrhoea.
Treatment. Look to the feeding and the digestion.
All feeding may sometimes be suspended for several hours
to advantage. A mild laxative may be indicated to remove
irritating material ; then bismuth subnitrate, gr. iij to v,
may be given after each diarrhoeal movement. Should this
fail add camphorated tincture of opium, ffiiij to vj, to each
dose of the bismuth.
Thrush.
Symptoms. The mucous membrane of the mouth is
studded with white patches, due to the presence of a fungus.
The patches resemble milk-curds in appearance, but are dis-
tinguished from them by their firm adhesion and by the
detection of the mycelia and spores of the parasite under
the microscope.
Treatment. To destroy the fungus sop the patches
every two hours with a saturated solution of boric acid or
with a solution of sodium sulphite, one drachm to the ounce.
For the stomatitis which persists after destruction of the
fungus use a half-saturated solution of potassic chlorate, or
better, as being less toxic, sodic chlorate, as a mouth-wash.
The child must not be permitted to swallow any of these
PHYSIOL OGY OF THE P UEBPEBAL ST A TE. 187
solutions. The accompanying -gastrointestinal disorders are
to be treated as in other cases.
Intertrigo.
Treatment. Keep the parts clean, with care to do no
mechanical violence to the skin by too much friction. Use
as an infant powder lycopodium and oxide of zinc, equal
parts, dusted on the affected surfaces after cleansing, p. r. n.
Talcum powder is a useful application.
Cephalhematoma.
Cephalhematoma is an extravasation of blood, usually be-
tween the pericranium and the cranial bones • rarely it occurs
internally. After a few days a hard ridge develops at the
margin of the tumor owing to periosteal inflammation.
Its situation is most frequently over one parietal bone ;
exceptionally it is the site of the caput succedaneum.
Prognosis. In the internal form the prognosis is grave
if cerebral symptoms develop. The external variety, as a
rule, terminates in subsidence of the tumor in about three
months.
Treatment. If the swelling grows it may be firmly
strapped after shaving the head. If pus forms early inci-
sion is indicated. Otherwise no treatment is considered
advisable by most authorities. The writer has practised the
evacuation of the blood within a few days after birth by a
small incision. The tumor must first be shaved and the
strictest asepsis be observed. A firm antiseptic compress is
applied and held in place with a roller bandage. When the
incision has been delayed for one or two weeks a longer in-
cision may be required owing to the presence of blood-clots.
Should the hemorrhage persist after opening the tumor it
may be controlled by pressure.
188 ESSENTIALS OF OBSTETRICS.
Preputial Adhesion.
In male children the adhesion of the foreskin to the glans,
which is usually physiological in newborn children, may
cause irritability of the bladder and other reflex disturbances.
In such cases the preputial orifice should be very gently
dilated and the adhesion broken up till the foreskin can be
fully retracted. Nicking the foreskin with scissors in the
median line on the dorsum may be required to permit re-
traction. Drawing back the prepuce, it is liberated from
the glans by the aid of a smooth, blunt, stiff probe ; a dress-
ing of vaselin or of bismuth powder together with daily
retraction will prevent re-adhesion.
Icterus.
Icterus occurs in a large proportion of newborn infants.
It begins from the first to the fifth day after birth, most fre-
quently on the third or fourth. The pathology is in dispute.
The icterus is probably due to destruction of red blood-
corpuscles and consequent excessive formation of bile pig-
ment in the liver. It is observed most frequently in pre-
mature and feeble infants and after difficult labor.
The conjunctivae and the urine may or may not be stained.
In well-marked cases the stools are clay-colored. In the
mild form the icterus disappears within six or eight days ;
in the more severe it may last for two weeks or more.
Treatment. As a rule none is required. In persistent
cases attention to the digestion, keeping the bowels open
by enemata, or, if need be, by the use of a mild laxative,
as sodium phosphate, constitute the treatment.
In persistent icterus with increasing discoloration, and
especially with the presence of sepsis and high temperature,
treatment is generally futile.
PHYSIOLOGY OF THE PUERPERAL STATE. 189
Ophthalmia.
Cause. In the vast majority of cases the cause is infec-
tion from the genital tract of the mother by the gonococcus
of Neisser. It generally begins on or before the third day.
Prognosis. The prognosis for the sight is grave in the
absence of timely treatment. Twenty-five per cent, of all
cases of total blindness in asylums are due to this cause.
Almost without exception under skilfully conducted manage-
ment the suppuration is promptly controlled and the sight
is not impaired permanently.
Treatment. Prophylactic. Disinfect the maternal pas-
sages before and during labor in case of gonorrhoeal secre-
tion. Cleanse and dry the child's eyes immediately after the
head is born. Instil one or two drops of a 2 per cent, solu-
tion of nitrate of silver into each conjunctival sac shortly
after birth. (Crede.) The prophylactic use of Crede' s solu-
tion is the rule in hospital practice. The eyes of every
child are treated with the nitrate of silver solution within a
few minutes after birth. A similar precaution may well be
observed in private practice. It should never be omitted
when the mother is known to be the subject of leucorrhoeal
discharges. When properly employed the immunity is prac-
tically absolute. Should the use of the silver solution be
followed by much serous oozing the latter may be promptly
relieved by a single application to the conjunctivae of a one-
grain solution of atropine, one drop in each eye.
Curative. At the onset of the inflammation cold ice-
water compresses are useful in the absence of corneal com-
plications.
Cleansing. Removal of the pus every hour or two by
irrigating or bathing with a warm saturated boric-acid solu-
tion is essential.
9*
190 ESSENTIALS OF OBSTETRICS.
Silver- nitrate. After free discharge is established brush
the conjunctival surfaces after cleansing once or twice daily
with a 2 to 4 per cent, aqueous solution of nitrate of silver.
This is continued till the discharge loses its purulent char-
acter. Frequent cleansing with the boric-acid solution must
still be practised till all discharge ceases. Anointing the
edges of the lids with vaselin favors drainage by preventing
the lids from becoming glued together. The nurse should
be drilled in the method of manipulating.
As a rule the advice of an oculist should be had. 1
Umbilical Infection.
The cause is uncleanliness in the care of the umbilical
wound. The infecting organism is most frequently the
streptococcus. The septic process may result in a mere
local ulcer or in umbilical phlebitis and septicaemia. In
the latter event the termination is fatal usually by convul-
sions. Pus may be present in the umbilical vessels from
infection through the navel even when the wound has
healed promptly. Cellulitis of the abdominal walls and
peritonitis are frequently observed. Septic processes in
remote organs are common comolications.
Treatment. In local sepsis frequent antiseptic cleans-
ing of the wound surface and dressing with aristol, bismuth
powder or iodoform and bismuth suffice. The peroxide
of hydrogen is a good antiseptic for disinfecting the wound
surface. It is non-poisonous and practically non-irritant.
Inunctions of quinine and the use of stimulants by the
1 In New York State a midwife or nurse who may be cognizant of any inflam-
matory affection in the eyes of an infant under her care is required by law to
report the fact in writing, within six hours, to the Health Officer, or to some
legally qualified practitioner of medicine in the city, town or district in which
the parents reside.
PHYSIOLOGY OF THE PUERPERAL STATE. 191
stomach help to increase the resisting power. In systemic
infection treatment is futile.
Tetanus Neonatorum.
The disease begins toward the end of the first week. The
cause is infection, generally of the navel, with the tetanus
bacillus.
The symptoms are those of surgical tetanus. The ter-
mination is almost invariably fatal within two or three
days.
Treatment. As far as possible all sources of peripheral
irritation should be removed. Feeding is maintained by the
stomach-tube passed through the nostrils, using pre-digested
milk, or, this failing, by rectal injections. The drug treat-
ment consists in the use of potassium bromide, gr. iv every
two to four hours, or of chloral, grain j every hour, p. r. n.
These remedies must be given by a stomach-tube or by a
rectal tube. Sulphonal, gr. iij every two hours, by the
rectum, has been used with success. The value of the serum
treatment is still sub judice.
Umbilical Hemorrhage.
Umbilical hemorrhage may proceed from faulty ligation
of the cord, syphilis, sepsis, acute fatty degeneration with
hemoglobinuria or hemophilia. The hemorrhage usually
begins within a week or a little more after birth. Eighty
per cent, of the children die.
Treatment. In simple cases re-ligate the cord and
apply a compress, or lift the umbilicus, transfix with a
harelip-pin and apply a figure-of-eight ligature. In cases
dependent on a dyscrasia treatment is generally futile.
192 ESSENTIALS OF OBSTETRICS.
Mastitis.
Swelling of the breasts is frequently observed in newborn
children during the first week. As a rule it calls for no
treatment. If pus form, which is very rarely the case, it
should be evacuated.
A Bloody Genital Discharge.
A bloody genital discharge is sometimes observed in
female children the first few days after birth ; no treatment
is required.
CHAPTER V.
PATHOLOGY OF PREGNANCY.
DISEASES OF THE DECIDILE.
Acute Endometritis. Acute endometritis may be
present in the course of acute febrile disease. It is often
attended with hemorrhage and frequently results in abortion.
Chronic Diffuse Endometritis. The causation is not
fully understood. The anatomical changes in the decidua
are mainly hypertrophic. It occasionally gives rise to
abortion.
Catarrhal Endometritis. Catarrhal endometritis is
attended with a discharge of watery mucus from the uterus —
hydrorrhcea gravidarum ; it is most common in the later
months of pregnancy. Sometimes the fluid collects between
the chorion and the decidua and is discharged in gushes.
Rarely the uterus becomes excessively distended by the
accumulated fluid. The inflammation affects most fre-
quently the vera ; it may also involve the reflexa. It is
attended with hypertrophy of the connective tissue and of
the glandular elements. Exceptionally it terminates in
abortion or premature labor.
In this condition the hyperplasia of the uterine mucosa,
which is normal to the early months of pregnancy, is exag-
gerated and is continued to the later months of gestation.
It affects all the elements of the decidua and results in a
greatly increased thickness of this structure. Hemorrhage
194 ESSENTIALS OF OBSTETRICS.
frequently occurs into the decidua. Cysts have been
observed. The cause is a persisting endometritis which
may be of the septic, syphilitic or gonorrhoeal type.
When the process is rapidly developed it is attended
with hemorrhages into the decidua or with partial separa-
tion of that structure ; abortion or premature labor is the
rule.
Debility and ansemia frequently result from hydrorrhoea.
The discharges are to be distinguished from liquor amnii,
from urine and from leuchorrhceal secretions.
Treatment. The treatment is to be addressed mainly
to the resulting debility and anemia. The arsenate of iron
or other hematinic and general tonics are indicated.
Cystic Endometritis is distinguished by the formation
of retention cysts due to obstruction of the gland-ducts by
proliferation of interglandular connective tissue. Here, too,
there is hydrorrhoea.
Polypoid Endometritis is rarely met with. It is charac-
terized by polypoid growths upon the ovular surface of the
decidua, in addition to the lesions of simple diffuse endo-
metritis. The pathological changes are generally limited
to the decidua vera. Rarely, however, they involve the
serotina. The placental villi may undergo hypertrophy or
myxomatous degeneration. Death of the foetus and abor-
tion usually result.
ANOMALIES OF THE AMNION AND THE LIQUOR
AMNII.
Oligohydramnios. The quantity of amnial liquor at
term is normally about two pints. Oligohydramnios is a de-
ficiency of liquor amnii. Extreme scantiness of the amnial
liquor may be attended with adhesions between the amnion
PATHOLOGY OF PREGNANCY. 195
and the foetus and with the formation of amniotic bands.
Intra-uterine amputation of foetal extremities and develop-
mental faults sometimes result from these amniotic bands.
Harelip, cleft palate, navel-cord hernia, and spina bifida
are frequently produced by this agency. Oligohydram-
nios is one of the causes of club-foot.
Hydramnios or Polyhydramnios may be defined as an
excess of liquor amnii over 4 pints. In extreme cases the
quantity may reach 30 to 50 pints.
Polyhydramnios occurs much more frequently in multi-
parae than in primipane. It is usually present to some
degree in twin pregnancies. Excess of liquor amnii may
exist in one foetal sac and deficiency in the other. Great
excess of the amnial liquor is often attended with malforma-
tion of the foetus. It begins most frequently in the latter
half of pregnancy and is observed once in about three
hundred pregnancies.
Causes. Among the causes assigned are maternal
anasarca, abnormal persistence of the vasa propria (a capil-
lary network of the subplacental chorion immediately
underlying the amnion, and which is normally present in
the early months of gestation), excessive secretion of urine
by the foetus, exudation of the foetal skin, amniotitis, decid-
ual disease, deficient resorption of liquor amnii. Foetal
syphilis is a possible cause.
Diagnosis. The more important physical signs are ex-
cessive size and permanent tension of the uterine tumor,
suprapubic oedema, preternatural mobility of the foetus.
In extreme amniotic distention the cervix is obliterated.
Hydramnios is distinguished from ascites, ovarian cyst and
twins, by palpation and auscultation of the tumor and by
the history. The differential diagnosis will be found dis-
cussed under the topics referred to.
196 ESSENTIALS OF OBSTETRICS.
Pkognosis. The prognosis is unfavorable to the child,
owing to premature birth, dropsical affections, malforma-
tions and malpresentation, which are common in hydram-
nios. The foetal mortality is 25 per cent. For the mother
the prognosis is generally good.
Treatment. In case of alarming symptoms from over-
distention puncture of the membranes, with care to guard
against syncope from too rapid escape of the liquor amnii,
is permissible. On the birth of the child precautions may
be needed against post-partum hemorrhage. Special care
must be taken to promote retraction of the uterus after
delivery.
DISEASE OF THE CHORION.
Cystic Degeneration of the Chorion, Vesicular Mole,
Hydatidiform Mole, may be defined as " an hypertrophy
and myxomatous degeneration of the chorial villi, attended
with the formation of cysts." The cysts vary in size from
that of a millet-seed to a grape — they may reach the size of
a hen's egg. Each cyst springs from another and not from
a common stalk. They may be many thousand in number
and the total mass as large as the mother's head. Very
rarely the villi perforate the uterine wall, leading to rupture
of the uterus and peritonitis. The cyst content is a clear
watery fluid containing albumin and mucin. The degenera-
tion begins most frequently in the very first weeks of gesta-
tion. In twin pregnancies one or both ova may be affected.
It is met with most frequently in women who have borne
children, sometimes in more than one pregnancy in the
same individual. It occurs once in something more than
two thousand pregnancies.
Etiology. Of the etiology little is known. The cause
apparently resides in the ovum. Endometritis, syphilis
PATHOLOGY OF PREGNANCY. 197
and absence or deficiency of allantoic vessels, commonly
assigned as causes, probably have no part in the etiology.
Diagnostic Signs. Signs of pregnancy ;
Abdominal enlargement out of proportion to the stage of
gestation ; the uterus is too large the first three months, later
it is sometimes too small ;
Absence of ballottement, of the foetal heart, of foetal
parts and of foetal movements ;
Uterus usually doughy ;
Sero-sanguineous discharge ;
Expulsion of cysts, rarely noted ;
Detection of the cysts by direct exploration of the uterine
cavity. The disease is rarely recognized till after the third
month.
Prognosis. The maternal mortality is 10 to 15 per
cent. Immediate causes of death are hemorrhage, sepsis
and rupture of the uterus. Except in rare cases of partial
degeneration the embryo invariably dies and disappears by
absorption. The degenerated ovum may be retained for
many months, usually it is expelled before the sixth.
Treatment. If no evidence can be found that the foetus
is living the uterus should be emptied. The cervix is to be
dilated and the evacuation of the uterine cavity begun with
hand or dressing-forceps. This must be done cautiously,
since the uterine wall is often extremely thin. Curettement
is practised after considerable retraction has taken place.
The uterus is washed out with a hot, mild antiseptic douche
and its cavity swabbed with tincture of iodine. Ergot is
given, if required, to make the uterus contract.
ANOMALIES OF THE PLACENTA.
Placenta Membranacea. A placenta membranacea is
a broad, thin placenta with persistence of the villi over the
198 ESSENTIALS OF OBSTETRICS.
entire surface of the chorion. Abnormal adhesion is common
with this anomaly.
Placenta Praevia. The placenta is prsevia when its
attachment encroaches upon that portion of the uterus
which is subject to dilatation during the first stage of
labor.
Placenta Succenturiata. Subsidiary 'placenta. This
term is applied to a wholly or partially independent pla-
cental cotyledon. The anomaly is usually single, sometimes
multiple.
Cysts of the placenta are of frequent occurrence. The
cysts are small and are seated beneath the amnion. They
are probably developed from the chorial villi.
Syphilis. The syphilitic placenta is larger and paler
than normal, and yellowish in patches. In syphilis of
paternal origin the foetal structures of the placenta are
affected ; when the disease is of maternal origin the decidua
is involved; in the tertiary stage gummata are present.
Syphilis of the placenta is always dangerous, and may be
fatal, to the foetus.
(Edema may be present in hydramnios, in occlusion of
umbilical veins or in maternal anasarca.
Apoplexy. Extravasations of blood into the placenta
may occur at one or several points. Hemorrhages in the
early months of pregnancy occur near the foetal surface, in
the later months near the maternal surface of the placenta.
The causes are placentitis, general infectious diseases, ne-
phritis, pelvic congestion, traumatism. Extensive effusions
of blood result in the death of the embryo or foetus and con-
sequent abortion or premature labor. Small extravasations
are generally tolerated with no apparent ill-result. Small
blood-collections may be found partially organized, or may
become fatty or calcareous.
PA THOL OGY OF PBEGNANG Y. 199
Myxomatous Degeneration usually involves only a part
of the placenta. (See Vesicular Mole, page 196.)
Fatty Degeneration may result from endometritis, pla-
cental hemorrhage or chronic inflammation of the placenta.
Death of the foetus may ensue.
Placentitis may affect the whole, rarely a portion only,
of the placenta. Placental inflammation may result from
an endometritis existing at the time of conception, or from
syphilis or acute sepsis. The normal placental structure
is replaced by fibroid tissue. There are hypertrophy and
sclerosis of the decidua. Abnormal adhesions of the pla-
centa are attributed to this cause.
Calcareous Degeneration is common and is unim-
portant.
White Infarcts are very commonly observed in the pla-
centa. They are dense whitish or yellowish masses varying
in size from one to two or three centimetres in diameter.
They are of no pathological importance when small and few
in number. When numerous and extensive they may cause
the death of the foetus. They have their origin in local
degeneration of the decidua.
ANOMALIES OF THE UMBILICAL CORD.
Length. Excessive length of cord may predispose to
prolapse, to torsion, to knots, or to coils about the foetus
and to obstruction in the funic vessels. A short cord may
lead to premature separation of the placenta during labor.
Excessive Torsion of the umbilical vessels may cause
partial occlusion. It is sometimes accompanied with serous
effusion into the peritoneal cavity of the foetus and with
cedematous swelling of the cord. In most cases torsion of
the cord itself is developed only after the death of the foetus.
200 ESSENTIALS OF OBSTETRICS.
Knots rarely occur. They result from the passage of the
foetus through a loop of the cord. They are seldom tight
enough to endanger the foetus.
Hernia. Hernial protrusion of omentum or intestinal
loops may take place into the cord. It results from imper-
fect closure of the abdominal walls at the umbilicus, and is
usually accompanied with other errors of foetal develop-
ment.
Cysts are frequently observed in the sheath of the cord.
They are due to liquefaction of mucoid tissue or of blood
extravasations.
Coils about the foetus, especially the neck, are of fre-
quent occurrence. Sometimes an arm or a leg is thus
encircled. Rarely is the circulation impeded either in the
funis or the girdled member. Extensive coilings may give
rise to the dangers of short cord.
Coiling of the cord about the neck of the child may
sometimes be recognized during pregnancy by depressing
the abdominal walls of the mother opposite the child's neck;
the foetal pulse-rate is retarded when the cord is pressed
upon.
The insertion may be eccentric, marginal or velamen-
tous. In the latter anomaly the vessels pass for a greater
or less distance between the membranes to the edge of the
placenta. As the vessels are more or less separated and
unprotected they are liable to be torn during labor. Such
an accident almost surely results in the death of the child
unless it is promptly born.
When the insertion of the cord is marginal the placenta
is sometimes termed a battledore placenta.
PATHOLOGY OF PREGNANCY. 201
PATHOLOGY OF THE FOETUS.
ANOMALIES OF DEVELOPMENT.
The principal anomalies of foetal development are briefly
the following -}
(a.) Hemiteria. Literally, half monstrosity. Under
this head are included dwarfs and giants, microcephalia,
sternal fissure, spina bifida, club-foot, supernumerary digits,
double uterus, double vagina, supernumerary ribs, etc.
(b.) Heterotaxia. Under this head are included trans-
position of viscera, hernial protrusion, imperforate rectum,
vagina, oesophagus, etc., persistent foramen ovale, persistent
ductus venosus, persistent ductus arteriosus, etc, webbed
fingers or toes, harelip, cleft palate, epispadias, hypospadias,
hermaphrodism.
(c.) Teratism. 1. Ectromelic monster. Having one
or more aborted extremities.
2. Symelie monster. Having its lower limbs partly or
wholly united.
3. Qelosomatic monster. Having partial or complete even-
tration.
4. Exencephalic monster. In this anomaly the brain is
malformed and protruding from the cranial cavity.
5. Pseudencephalic monster. Here the cranial vault
and the larger part of the brain are absent.
6. Anencephalie monster. The cranial vault and the
entire brain are wanting.
7. Cyclo cephalic monster. A monster in which the nose
is wanting and the eyes are partially fused into one.
8. Otocephalic monster. The ears meet or are fused in
the median line.
1 In part after Norris.
202 ESSENTIALS OF OBSTETRICS.
9. Omphalositic monster. This monster is one of twins
which has a parasitic existence in utero. Its nourishment
is derived from the companion foetus, and it is incapable of
living independently after the cord is divided. The anomaly
owes its origin to the fact that the circulation of one foetus
has overpowered and reversed that of its companion.
10. Double monster. Two foetuses united.
Varieties : (a.) Sternopagus, joined at the sternum ;
(b.) Isehiopagus, joined at the pelvis ; (c.) Cephalopagus,
joined at the head; id.) Xiphopagus, joined at the xiphoid
cartilage.
Syncephalic. The heads partly fused, the bodies sepa-
rate.
Monocephalic. The heads completely fused, the bodies
separate.
Synsomatic. The bodies are partially fused, the heads
separate.
Monosomatic. The bodies are wholly fused, heads sepa-
rate.
Double Parasitic Monster. One foetus is attached as a
parasite to the other, or inserted or included in it.
DISEASES OF THE FCETUS.
The foetus is subject to many of the infectious and other
general diseases of post-natal existence. Well-known ex-
amples are variola, typhoid fever, pneumonia, syphilis, scar-
latina, measles, rachitis, valvular disease of the heart, serous
effusions, etc.
FCETAL DEATH.
Diagnosis. Signs of foetal death are :
Recession of the signs of pregnancy ;
Uterus doughy ;
PA THOL G Y OF PBEGNANO Y. 203
Peptonuria :
Acetonuria :
Cervical temperature not above the vaginal :
Absence of foetal heart-tones;
Absence of active foetal movements — examine by ab-
dominal palpation and by the bimanual ;
Absence of the choc foetal ;
Looseness and crepitation of cranial bones.
The mother frequently experiences periods of illness and
a sense of weight in the abdomen.
In most cases of suspected death of the foetus repeated
examinations will be required to decide the question. The
diagnosis of death of the ovum is especially difficult in the
early months of development before the period when in the
living foetus the heart can be heard or active movements
felt.
The recognized causes of intra-uterine death, such as
mechanical violence, maternal toxaemia or profound anaemia,
syphilis, etc.. should be sought for.
Habitual death of the foetus, in a great majority of cases,
is the result of syphilis in one or both parents. The most
important signs of foetal syphilis to be found by post-mortem
dissection are osteochondritis, between the diaphysis and
epiphysis of the long bones, especially at the lower end
of the femur, enlargement of the liver, often to one-twelfth
or even one-eighth the body-weight, enlargement of the
spleen.
Changes in the Foetus after Death in Utero.
The dead fcetus carried in utero undergoes either absorp-
tion, mummification, maceration or putrefaction.
Absorption. This occurs usually when the fcetus dies in
the first two months of gestation. The embyro in course
204 ESSENTIALS OF OBSTETRICS.
of a few days after its death becomes liquefied and ab-
sorbed.
Fleshy Mole. Sometimes when the ovum is carried in
utero for a long period after the death and absorption of the
embryo the uterine contents are reduced to a dense mass
of placental structure and organized blood-clot known as a
fleshy mole. This may be retained for many weeks.
Mummification takes place only when the foetus has
died in the middle or later months of development. The
soft structures become dried and shrunken and the skin
assumes a yellowish-gray color. The placenta undergoes
somewhat similar changes. A foetus papyraceus is a mum-
mified twin foetus which after death in utero has become
flattened by the pressure of its living companion. The
head in such cases is frequently pressed into the shape of a
meniscus lens. •
Maceration. In maceration of the foetus the tissues
become softened and sometimes swollen and the abdomen
is distended. The epidermis is exfoliated and the serous
cavities contain blood and serum. The odor is sickening,
but not putrefactive.
Putrefaction takes place only when the foetus is carried
for a time in utero after the membranes have ruptured.
The connective tissues become emphysematous, the abdomen
distended and the body emits a putrefactive odor. The
uterus sometimes is tympanitic and the mother suffers more
or less from septic absorption.
Treatment in F(etal Death. The uterus should be
emptied immediately the diagnosis of foetal death can be
positively established. The presence of a dead foetus in
utero is always injurious to the health and may become
dangerous to the life of the mother.
In the first three or four months of pregnancy the method
PATHOLOGY OF PREGNANCY. 205
to be pursued is the same as for the induction of abortion.
In the later months labor is induced as in other cases of
advanced pregnancy.
ABORTION.
Frequency. It is estimated that not far from 20 per
cent, of pregnancies end in abortion. This estimate is
doubtless too small if abortions from all causes are included.
Owing to the influence of the menstrual molimen sponta-
neous abortions occur most frequently at the end of the
menstrual month. In a large proportion of cases they take
place at the second month, and are comparatively infrequent
after the third.
Causes. In considering the etiology of abortion it must
be borne in mind that the security of attachment between
the ovum and the uterus differs greatly in different cases.
Influences quite sufficient to bring about the expulsion of the
ovum in one pregnancy may have no such effect in another.
The provoking causes of abortion may be grouped under
two heads: 1. Those which act by first causing the death
of the foetus. 2. Those which act independently of the death
of the foetus. In the great majority of cases abortion results
from the death of the foetus.
1. Death of the foetus may occur from: Malformation,
disease, mechanical violence, maternal toxaemia or excessive
anaemia, pathological conditions of the chorion, the amnion,
the cord, the decidua.
2. Causes acting independently of the death of the foetus
are atrophy or hypertrophy of the endometrium, placenta
praevia, oxytocics, reflex irritation of the uterus, e. g., from
mammary or from rectal stimuli, epileptiform convulsions
from uraemic or other causes, carbon dioxide poisoning,
10
206 ESSENTIALS OF OBSTETRICS.
placental apoplexies, pelvic adhesions, uterine myomata,
cancer of the uterus, misplacement of the uterus, over-dis-
tention from hydramnios or from multiple pregnancy, direct
interference, falls or blows, hyperemia of the pelvic organs
from circulatory obstruction in the lungs or liver, from
valvular heart disease, from violent muscular exertion, or
from sexual excesses, etc., resulting in hemorrhage into the
placenta.
Diagnosis. Symptoms. The symptoms of beginning
abortion are : Hemorrhage, pelvic tenesmus, rhythmical
uterine pains.
Physical Signs. The physical signs are effacement of
the os internum, dilatation of the cervix and partial pro-
trusion of the ovum from the uterine cavity.
The physical signs establish the diagnosis of inevitable
abortion. They imply a degree of separation of the ovum
from the lower uterine segment too great to permit the
farther continuance of the gestation. Severe rhythmical
pains with hemorrhage almost surely forebode the expulsion
of the ovum. Not only should a thorough physical ex-
amination of the pelvic organs be made in every case of
suspected abortion, but blood-clots and other material cast
off from the genital passages should be inspected. Other-
wise the ovum when expelled enveloped in a mass of coagu-
lated blood may escape observation. Clots are best examined
by breaking them up under water.
Abortion in the first weeks of gestation is not always
easily distinguished from dysmenorrhoea or simple uterine
hemorrhage. Here the diagnosis will depend mainly on
the evidence of pregnancy as shown by the shape, size and
consistence of the uterus, and on the presence of foetal struc-
tures in the genital discharges. Free hemorrhage with
expulsion of large blood- clots is significant of abortion.
PATHOLOGY OF PREGNANCY. 207
Prognosis. There is no mortality in properly conducted
abortions, yet many deaths occur from mismanagement.
The principal sources of danger are hemorrhage and septi-
caemia. Hemorrhage contributes to the fatal issue, though
it is rarely the immediate cause of death. The danger of
sepsis is especially imminent in incomplete abortion. The
presence of necrotic material in the uterus is a serious
menace to life. It is a potent cause of pelvic inflammation
in cases which escape a fatal termination.
Treatment, (a.) Prophylaxis in habitual abortion.
The preventive treatment of abortion is addressed chiefly to
the cause.
Syphilis in one or both parents, retroversion of the
uterus and endometritis are the most frequent causes of
habitual abortion. Syphilis is treated as in other cases. It
is not always possible to save the ovum by treatment begun
after conception.
Retroversion is corrected and its recurrence is prevented
by the use of a suitable pessary till after the third month.
Endometritis is best treated by curettage in the interval
between pregnancies. It is important to guard against
overexertion, mechanical violence and the causes of pelvic
congestion, especially at the menstrual dates. Rest in bed
during the menstrual epochs and abstention from sexual
intercourse should be enjoined till the critical period has
passed.
(b.) Arrest of threatened abortion. Enforce absolute rest
in the recumbent position. The patient should not be per-
mitted to rise for any purpose till all symptoms of abortion
have subsided. Uterine rest is maintained by the use of
opium, gr. ij, or its equivalent, p. r. n. A four-grain pill
of extract of viburnum prunifolium is useful as an adjunct,
even as a substitute for opium. Misplacements of the
208 ESSENTIALS OF OBSTETRICS.
uterus must be corrected. Exclude vesicular degeneration
of the chorion and death of the embryo or foetus, in either
of which conditions the uterus should be evacuated.
( child, 175
Nipples care of, during pregnancy,
87
treatment of sore, 294
Normal labor, clinical and me-
chanical phenomena of, 111
Nursing the newborn child, 176
Nymphse, anatomy of, 15
OBSTETRIC position, 143
surgery, 306
of the abdomen. 332
Occipito posterior position, 240
Occiput, definition of, 106
Oligohydramnios, 194
Ophthalmia of newborn child, 189
Os externum uteri occlusion of, as
a cause of dystocia, 238
Ovaries, anatomy of, 37
Oviducts. See Fallopian tubes.
Ovulation, 41
Ovum, anatomy of, 43
development of impregnated, 47
physiology of, 41
PARAMETRITIS, puerperal,
symptoms of, 298
treatment of, 304
Parovarium, 40
Parturient axis, 103
Passages, anomalies of, as affecting
labor, 228
laceration of, 150
obstetric, anatomy of, 90
Passenger, anomalies of, as causes
of dystocia, 240
as a factor of labor, 104
Pasteurizing, methods of, 179
Pathology of pregnancy, 193
Patient, obstetric, aseptic prepara-
tion of, 139
ante-partum, examination of,
122
examination of, during labor,
140
Pelves, deformed, 228
Pelvic deformity, diagnosis of, 234
-floor, anatomy of, 99
fascial sheets of, 100
lacerations of, 150
treatment of, 151
muscles of, 101
prevention of lacerations of,
146
signs of pregnancy, 77
soft parts, obstetric anatomv of, 98
Pelvimetry, 131, 234
external, 131
internal, 132
Pelvis, brim of, 91
differences between male and
female, 97
flattened and generallv con-
tracted, 230
funnel-shaped, 230
justo-minor, 230
kyphotic, 230
measurements of, 96
Nsegele oblique, 231
narrowing of, from bonv tumors,
233
obstetric, anatomy of bony, 90
ordinary oblique-ovate, 232
osteomalacic, 233
outlet of bony, 91
planes of, 93
356
INDEX.
Pelvis, Eoberts', 232
simple flat, 229
spondylolisthetic, 232
Perineal body, 103
Peritonitis, puerperal, symptoms
of diffuse, 299
treatment of, 303
Phlegmasia alba dolens, symptoms
of, 299
treatment of, 304
Physiology of labor, 89
of the puerperal state, 160
Placenta and membranes, examina-
tion of, at close of labor, 150
anatomy of, 56
anomalies of, 197
degeneration of, 199
white infarcts of, 199
delivery of, 148
development of, 58
manual extraction of, 149
previa, 198-273
causes of, 273
physical signs of, 274
symptoms of, 274
treatment of, 275
removal of abnormally adherent,
315
syphilis of, 198
Placental stage managementof, 148
Polyhydramnios, 195
Porro operation, 339
indications for, 339
steps of, 339
Position of foetus, 109
Post-partum chill, 160
hemorrhage, 280
causes of, 281
diagnosis of. 281
treatment of, 281
secondary 283
visits, 163
Posture of foetus, 110
Powers, expelling, 89
anomalies of, 224
Pregnancy, abdominal signs of, 72
care of nipples in, 87
changes in cervix uteri in, 66
uterus in, 64
clothing in, 87
duration of, 84
Pregnancy, ectopic. See Ectopic
gestation,
effects of, on maternal organism,
64
general changes in, 67
hygiene of, 86
hygienic requirements in, 87
mammary changes as signs of, 69
multiple, 83
origin of, 83
nausea as a sign of, 69
pathology of, 193
pelvic signs of, 77
physical signs of, 69
physiology of, 41
ptyalism as a sign of, 69
pulsation of uterine artery as a
sign of, 80
signs of, 68
suppression of menses as a sign
of, 68
temperature of cervix uteri as a
sign of, 80
Premature labor, indications for,
306
induction of, 306
methods of, 307
Presentation, breech, 247
brow, 246
face, 242
methods for converting, into
vertex, 245
of foetus, 108
shoulder, 256
transverse, 256
vertex See Normal labor.
Presentations, complex, treatment
• of, 259
i Prolapsus funis, 264
diagnosis of, 265
prognosis of, 265
treatment of, 265
Protuberances of foetal head, 106
Ptyalism in pregnancy, 222
Pruritus vulvae in pregnancy, 223
Puberty, 42
Pubic segment of pelvic floor, re-
traction of, during labor, 116
Pudendum, anatomy of, 13
lymphatics, and nerves
of, 20
INDEX,
357
Puerperal infection, 295
diagnosis of, 297
etiology of, "296
special manifestations of, 297
symptoms of special lesions in
298
treatment of, 301
insanity, 291
causes of, 291
prognosis of, 291
treatment of, 291
state, condition of uterus in, 161
course and phenomena of, 160
management of, 163
pathology of, 291
physiology in, 160
pulse-rate in, 160
temperature in, 160
Pysemia, puerperal, 300
treatment of, 304
RECTOCELE as a cause of dys-
tocia, 237
Retention of urine after labor, 165
Retraction ring, 115
of uterus at close of labor, 121
Sutures of foetal head, 105
Symphysiotomy, 340
after-treatment of, 345
indications for, 340
method of operating in, 341
results of, 340
space gained in, 340
Symphysis pubis, separation of,
283
TRANSVERSE presentation,
1 256
causes of, 256
diagnosis of, 257
treatment of, 258
Transversus perinei, 102
Triangular ligament, 101
Trunk, delivery of, 147
Tumors, maternal, as causes of
dystocia, 238
foetal, as causes of dystocia, 263
Twins, 260
arrangement of membranes and
placentas in, 84
diagnosis of, 260
interlocking, 261
OEMINAL fluid, 46
O Septicaemia puerperal See
Puerperal infection,
pure, symptoms of, 300
Serous effusions into foetal cavities
as a cause of dystocia, 263
Shoulder presentation See Trans-
verse presentation.
Signs of pregnancy, 68
summary of diagnostic, 81
Sinciput, definition of, 106
Somatopleure, 49
Souffle, funic, 75
uterine, 75
Spermatozoa, 46
Sphincter ani externus, 103
Splanchnopleure 49
Stages of labor, 111
Subinvolution of uterus, 166
Sudden death in childbed, 305
Superfecundation, 84
Superfoetation, 84
UMBILICAL cord, anatomy of,
59
anomalies of, 199
hemorrhage in newborn child,
191
infection in newborn child, 190
Uretero-pyelitis in puerperal pe-
riod, symptoms of, 301
treatment of, 305
Urethra, anatomy of, 23
Urine, observation of the, during
pregnancy, 88
Uterus, anatomy of, 25
arteries of, 32
cavity of, 28
changes in, during pregnancy,
64
developmental anomalies of,
239
gravid, dimensions of, 65
shape of, 65
size of, 64
358
INDEX.
Uterus, intermittent contractions
of, in pregnancy, 74
inversion of, 267
diagnosis of, 268
etiology of, 267
treatment of, 268
involution of, after labor, 161
subinvolution of, 166
ligaments of, 31
lymphatics of, 34
nulliparous and parous, 30
position of, 31
regional divisions of, 28
rupture of, 269
diagnosis of, 271
etiology of, 270
prognosis of, 271
treatment of, 271
Uterine tumor of pregnancy,
changes in, 78
YTAGINA, anatomy of 20
t purplish color of, in preg
nancy, 77
Vaginal examination in second
stage of labor, 144
Varices of lower extremities in
pregnancy, 223
Veins, mammary, enlargement of,
during pregnancy, 70
Version, 326
bipolar, 328
external, 328
indications for, 327
internal, 331
Vertex of foetal head, definition
of, 106^
presentation. See Normal labor.
Vesicular mole, 196
Vestibule, 17
Villi, chorial, 53
Vomiting of pregnancy. See Preg-
nancy, nausea of,
pernicious, 219
etiology of, 219
treatment of, 220
Vulvar dressing at close of labor,
158
Vulvo-vaginal glands, 19
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PROSTHETIC DENTISTRY. Edited by Charles J. Essig, M.D.,
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983 engravings. Cloth, $6 ; leather, $7. Net. Just ready.
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OPERATIVE DENTISTRY. Edited by Edward C. Kirk, D.D.S. ,
Professor of Clinical Dentistry, Department of Dentistry, University
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AMERICAN SYSTEMS OF GYNECOLOGY: AND OBSTET-
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ASHHURST (JOHN, JR.). THE PRINCIPLES AND PRACTICE
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ASBTWELL (SAMUEL). A PRACTICAL TREATISE ON THE
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A SYSTEM OF PRACTICAL MEDICINE BY AMERICAN
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ATTFDELD (JOHN). CHEMISTRY; GENERAL, MEDICAL AND
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scientific chemical nomenclature has Medical Review.
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BELLAMY (EDWARD). A MANUAL OF SURGICAL ANATOMY.
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BILLINGS (JOHN S.). THE NATIONAL MEDICAL DICTIONARY.
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BRYANT (THOMAS). THE PRACTICE OF SURGERY. Fourth
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BUMSTEAD (F. J.) AND TAYLOR (R. W.). THE PATHOLOGY
AND TREATMENT OF VENEREAL DISEASES. See Taylor on
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BURNETT (CHARLES H.). THE EAR : ITS ANATOMY, PHYSI-
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BUTLIN (HENRY T.). DISEASES OF THE TONGUE. In one
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PRINCIPLES OF HUMAN PHYSIOLOGY. In one large octavo
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CASPARI (CHARLES JR.). A TREATISE ON PHARMACY.
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CHAMBERS (T. K.). A MANUAL OF DIET IN HEALTH AND
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CHAPMAN (HENRY C). A TREATISE ON HUMAN PHYSI-
OLOGY. In one octavo volume of 925 pages, with 605 illustrations.
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CHARLES (T. CRANSTOUN). THE ELEMENTS OF PHYSIO-
LOGICAL AND PATHOLOGICAL CHEMISTKY. In one hand-
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CHEYNE (W. WATSON). THE TREATMENT OF WOUNDS,
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CHURCHDLL (FLEETWOOD). ESSAYS ON THE PUERPERAL
FEVER. In one octavo volume of 464 pages. Cloth, $2.50.
CLARKE (W. B.) AND LOCKWOOD (C. B.). THE DISSECTOR'S
MANUAL. In one 12mo. volume of 396 pages, with 49 engravings.
Cloth, $1.50. See Students' Series of Manuals, page 27.
CLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF
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CLINICAL MANUALS. See Series of Clinical Manuals, page 25.
CLOUSTON (THOMAS S.). CLINICAL LECTURES ON MENTAL
DISEASES. New (4th) edition. In one octavo volume of 736 pages,
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^^Folsom's Abstract of Laws of U. S. on Custody of Insane, octavo,
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CLOWES (FRANK). AN ELEMENTARY TREATISE ON PRACTI-
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SIS. From the fourth English edition. In one handsome 12mo.
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COATS (JOSEPH). A TREATISE ON PATHOLOGY. In one vol.
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COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY
AND PATHOLOGY. With Notes and Additions to adapt it to Amer-
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handsome octavo vol. of 412 pages, with 331 engravings. Cloth, $3.25.
CONDD3 (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS-
EASES OF CHILDREN. Sixth- edition, revised and enlarged. In
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CORNEL (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.
CULBRETH (DAVID M. R.). MATERIA MEDICA AND PHAR-
MACOLOGY. In one handsome octavo volume of 812 pages, with
445 illustrations". Cloth, $4.75. Just ready.
A thorough, authoritative and
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Lancet.
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It is one of the most valuable works
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CULVER (E. M.) AND HAYDEN (J.R.). MANUAL OF VENE-
REAL DISEASES. In one 12mo. volume of 289 pages, with 33
engravings. Cloth, $1.75.
Lea Beothees & Co., Philadelphia and New Yoek. 7
DAI/TON (JOHN C). A TREATISE ON HUMAN PHYSIOLOGY.
Seventh edition, thoroughly revised and greatly improved. In one
very handsome octavo volume of 722 pages, with 252 engravings.
Cloth, $5 ; leather, $6.
DOCTRINES OF THE CIRCULATION OF THE BLOOD. In
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DAVENPORT (F. EL). DISEASES OF WOMEN. A Manual of
Non-Surgical Gynecology. For the use of Students and General Prac-
titioners. Second edition. In one handsome 12mo. volume of 314
pages, with 107 engravings. Cloth, $1.75.
DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR
STUDENTS AND PRACTITIONERS. In one very handsome
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plates in colors and monochrome. Cloth, $5 ; leather, $6. Just ready.
This work must become the prac-
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A work unequalled in excellence.
— The Chicago Clinical Review.
Decidedly one of the best text-
books on the subject. It is exception-
ally useful from every standpoint. —
Nashville Jour, of Med. and Surgery.
From a practical standpoint the
work is all that could be desired. A
thoroughly scientific and brilliant
treatise on obstetrics. —Med. News.
DAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second
edition. In one 12mo. volume of 2S7 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 15S5 engravings and 45 full-page plates in colors and
monochrome. Just ready. Per volume, cloth, $6 ; leather, $7 ; 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 i 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 Medical
the most advanced condition of j Sciences.
DERCUM (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 i The work is representative of the
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the latest and most fully up-to-date oped in the leading medical colleges
of any of its class. — Jour, of Amer-
ican Med. Association.
The most thoroughly up-to-date
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— American Journal of Insanity.
of this country. — Alienist and Neu-
rologist.
The best text-book in any lan-
guage. — The Medical Fortnightly.
DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS.
Their Classification, History, Symptoms, Pathology and Treatment.
Very handsome octavo, 24*0 pages, 46 engravings, and 9 full-page
plates in colors. Limited edition, de luxe binding, $4. Net.
8 Lea Brotheks & 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 PEACTICE 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 (ALEXANDER). THE STUDENT'S DICTIONARY OF
MEDICINE AND THE ALLIED SCIENCES. New edition. Com-
prising the Pronunciation, Derivation and Full Explanation of Medi-
cal Terms. Together with much Collateral Descriptive Matter, Numer-
ous Tables, etc. In one square octavo volume of 658 pages. Cloth,
$3.00; half leather, $3.25; full sheep, $3.75. Thumb-letter Index for
quick use, 50 cents extra. Just ready.
Medical students are here provided | The book is brought accurately to
with full information concerning date. It is a model of conciseness,
every word they will meet in acquir
ing their professional education.—
Nat. Med. Revietv.
Far superior to any dictionary for
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3Iedical Record.
The standard dictionaiy for medi-
cal students. — Charlotte Med. Jour.
the medical student that we know of. The best student's dictionaiy. —
— Western Med. and Surg. Reporter . I Canada Lancet.
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.
DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI-
ENCE. Containing a full explanation of the various subjects and
terms of Anatomy, Physiology, Medical Chemistry, 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.
Just ready. 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- Pronunciation is indicated by the
tative guide to the derivation, defini- ' phonetic system. The definitions are
tion and pronunciation of medical unusually clear and concise. The
terms. — The Charlotte Med. Journal, book is wholly satisfactory. — Uni-
Covering the entire field of medi- versity Medical Magazine.
cine, surgery and the collateral j The volume is entitled to be called
sciences, its range of usefulness can \ an encyclopaedia rather than a dic-
scarcely be measured. — Med. Record. ; tionary. — Brooklyn Med. Journal.
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.
Lea Beothebs & Co., Philadelphia and New Yoek. 9
ELLIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY.
Being a Guide to the Knowledge of the Human Body by Dissection.
From the eighth and revised English edition. In one octavo volume
of 716 pages, with 249 engravings. Cloth, $4.25 ; leather, $5.25.
EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC-
TICE OF GYNAECOLOGY, for the use of Students and Practitioners.
Third edition, enlarged and revised. In one large 8vo. volume of 880
pages, with 150 original engravings. Cloth, $5 ; leather, $6.
ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR-
GERY. A new American from the eighth enlarged and revised Lon-
don edition. In two large octavo volumes containing 2316 pages, with
984 engravings. Cloth, $9 ; leather, $11.
ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. Just ready.
See American Text-Books of Dentistry, page 2.
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.
To those who desire a concise
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mends itself in the highest degree.
It is just such a work as is needed
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American Practitioner and News.
FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND
PRACTICE OF MEDICINE. New (7th) edition, thoroughly revised
by Feedeeick P. Henry, M.D. In one large 8vo. volume of 1143
pages, with engravings. Cloth, $5.00 ; leather, $6.00.
The work has well earned its lead-
ing place in medical literature. The
element of treatment is by no means
neglected; in fact, by the editor a
fresh stimulus is given to this neces-
sary department by a comprehensive
study of all the new and leading the-
rapeutic agents. — Medical Record.
The leading text-book on general
medicine in the medical schools of
the United States. — Norihivestern
Lancet.
The best of American text-books
on Practice. — Amer .Medico-Su rgical
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
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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 Brothers & Co., Philadelphia and New York.
FOLSOM (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 Clouston on Mental Diseases (new edition, see
page 6) $5.50 for the two works.
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
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The leading text-book used by
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minion Med. Monthly.
For physician, student, or teacher
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ology. — Virginia Medical Monthly.
FOTHERGILL (J. MILNER). THE PRACTITIONER'S hand-
book OF TREATMENT. Third edition. In one handsome octavo
volume of 664 pages. Cloth, $3.75 ; leather, $4.75.
To have a description of the
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a great convenience to many thought-
ful but busy physicians. The prac-
tical value of the volume is greatly
increased by the introduction of many
prescriptions — New York Med. Jour.
POWNES (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.
Just ready.
It is an interesting work, and one tive and brings views of sound
which, in view of the large and pathology and rational treatment to
profitable amount of work done in many cases of sexual disturbance
this field of late years, is timely and whose treatment has been too often
well needed. — Medical Fortnightly, fruitless for good. — Annals of
The book is valuable and instruc- 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.
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 MOR-
BID HISTOLOGY. In one very handsome octavo volume of 314
pages, with 60 illustrations, mostly photographic. Cloth, $2.75.
Lea Brothers & Co., Philadelphia and New York. 11
GIBNEY (V. P.). OETHOPEDIC SURGERY. For the use of Practi-
tioners and Students. In one 8vo. vol. profusely illus. Preparing.
GOULD (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. Just ready.
This is the best single volume
upon Anatomy in the English
language. A thorough knowledge
of the subject is acquired without
consulting other books. As a work
of reference for the surgeon or prac-
titioner it has no superior. — Uni-
versity Medical Magazine.
This edition has been revised to
adapt it thoroughly to the require-
ments of teachers and students of
the present day. The illustrations
in Gray's Anatomy have always
been one of its especial features ;
each bone, ligament, muscle, nerve,
artery and tissue has been appro-
priately labelled, and in late editions
have appeared in colors where
essential. Gray's Anatomy affords
the student more satisfaction than
any other treatise with which we
are familiar. — Buffalo 3Ied. Journal.
The most largely used anatomical
text-book published in the English
language. — Annals of Surgery.
Gray's Anatomy, in spite of the
efforts which have been made from
time to time to displace it, still holds
first place in the esteem of both
teachers and students. — The Brook-
lyn Medical Journal.
Particular stress is laid upon the
practical side of anatomical teach-
ing, and especially the Surgical
Anatomy. — Chicago Med. Recorder.
The 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 Medical
Review.
This new edition of Gray is a
matchless treatise upon Human Ana-
tomy. Medical students and prac-
titioners desiring a complete library
on anatomy will make no mistake
in purchasing Gray. — Tri-State Med.
Journal.
GRAY (LANDON 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.
We have here what has so often
been desired — an up-to-date text-
book upon nervous and mental dis-
eases combined. A well-written,
terse, explicit, and authoritative vol-
ume treating of both subjects is a
step in the direction of popular de-
mand. — The Chicago Clinical Re-
view.
" The word treatment," says the
author, "has been construed in the
broadest sense to include not only
medicinal and non-medicinal agents,
but also those hygienic and dietetic
measures which are often the physi-
cian's best reliance." — The Journal
of the American Medical Association.
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.
— The Journal of Nervous and Men-
tal Disease.
detail of text sufficient explanation.
The work is an essential to the prac-
titioner — whether as surgeon orphys-
ician. It is the best of up-to date
text-books. — Virgin ia Jled. Mon th ly.
12 Lea Brothers & Co., Philadelphia and New York.
GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY
AND MORBID ANATOMY. New (7th) American from the eighth
London edition. In one handsome octavo volume of 595 pages, with
224 engravings and a colored plate. Cloth, $2.75.
A work that is the text-book of of the day — as much so almost as
probably four-fifths of all the stu- j Gray's Anatomy. It is fully up-to-
dents of pathology in the United | date in the record of fact, and so pro-
States and Great Britain stands in j fusely illustrated as to give to each
no need of commendation. The work
precisely meets the needs and wishes
of the general practitioner. — The
American Practitioner and News.
Green's Pathology is the text-book
GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM-
ISTRY. For the Use of Students. Based upon Bowman's Medical
Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75.
GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS-
EASES, INJURIES AND MALFORMATIONS OF THE URINARY
BLADDER, THE PROSTATE GLAND AND THE URETHRA.
Third edition, thoroughly revised and edited by Samuel W. Gross,
M. D. In one octavo vol. of 574 pages, with 170 illus. Cloth, $4.50.
HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN,
comprising those of the Stomach, (Esophagus, Caecum, Intestines
and Peritoneum. Second American from the third English edition.
In one octavo volume of 554 pages, with 11 engravings. Cloth, $3.50.
HAMILTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR
DESCRIPTION AND TREATMENT. Second and revised edition.
In one octavo volume of 598 pages, with 72 engravings. Cloth, $4.
HAMILTON (FRANK H.). A PRACTICAL TREATISE ON FRAC-
TURES AND DISLOCATIONS. Eighth edition, revised and edited
by Stephen Smith, A. M., M. D. In one handsome octavo volume of
832 pages, with 507 engravings. Cloth, $5.50 ; leather, $6.50.
Its numerous editions are convin- I cent revision make it a work thor-
cing proof of its value and popular- oughly in accordance with modern
ity. It is preeminently the authority practice theoretically, mechanically,
on fractures and dislocations. The aseptically. — Boston Medical and
additions it has received by its re- j Surgical Journal.
HARD A WAY (W. A.). MANUAL OF SKIN DISEASES. In one
12mo. volume of 440 pages. Cloth, $3.
HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE
USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. In
one octavo volume of 566 pages, with 191 engravings and 13 full-page
colored plates. Cloth, $4.75. Just ready.
This book is one of the best of its observer, will pay more attention to
kind we have ever had the pleasure the simple yet indicative signs of
to peruse. It is a great triumph of disease, and he will become a hetter
the author to encompass such an diagnostician. Tlietwoinoispensable
enormous number of practical points indexes— Index of Diseases, and In-
in a work of convenient size. Its dex of Symptoms, Organs and Terms
great practical utility is sugg-ested make the work especially valuable as
by the title. The logical sequence of a clinical manual. This is a compan-
the book is to lead to a diagnosis ion to Practical Therapeutics, by
from a study and grouping of individ- the same author, and it is difficult to
ual symptoms. Anyone who reads conceive of any two works of greater
this book will become a more acute -practical utility. — Medical Review.
Lea Brothers & Co., Philadelphia and New York. 13
HARE (HOBART 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 (5th) and revised edition. In one octavo volume of 740 pages.
Diagonal cloth, $3.75 ; leather, $4.75.
Five editions in as many years
constitute a remarkable record for
any book, and, futhermore, an evi-
dence that medical teachers and
practitioners appreciate a work
closely adapted to their require-
ments. Professor Hare is well
known as a progressive and able
nection by means of references, so
that a knowledge of any subject
treated is easily gained. Ease of
reference is, moreover, provided for
in the highest degree by the alpha-
betical arrangement of the book and
by the two full indexes. Practi-
tioners will find the Therapeutical
therapeutist and teacher, and his Index, in which all the remedial
ability in both directions is attested | measures are listed with brief anno-
in the highly original plan of this J tations under the headings of the sev-
work, as well as in its execution. His [ eral diseases, most suggestive and ser-
purpose has clearly been to bring a viceable. Like preceding issues, the
knowledge of the remedial agents into present edition has been revised to
close relation with a knowledge of; the latest date. — Columbus Medical
disease. The book consists essentially j Journal.
of two parts, the first being a treatise It is a book precisely adapted to
on therapeutics, both medicinal and the needs of the busy practitioner,
non-medicinal ; the second being a who can rely upon finding exactly
treatise on disease, its symptoms, j what he needs. — The National Med-
varieties, treatment, etc. The two i ical Review.
parts are brought into direct con- 1
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, 820 ; 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.
Prescriptions indicative of the manner in which particular drugs are admin-
istered are frequently inserted, with the aim of making the work as helpful
as possible ; and especial care is devoted to such precision of detail as
will render it a safe guide in the use of the newer and less familiar agents.
This volume will therefore be indispensable to the many thousands of
subscribers to the original work, and it will be of no less value by itself,
since it reflects the whole position of each subject. The entire System is
an unrivalled eucyclopcedia 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 ; half bound, $3.
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 ( JAMES R.). A MANUAL OF VENEREAL DISEASES.
In one 12mo. volume of 263 pages, with 47 engravings. Cloth, $1.50.
Just ready.
It is practical, concise, definite i ticularly thorough, and may be
and of sufficient fulness to be satis- j relied upon as a guide in the man-
factory. — Chicago Clinical Review. ■ agement of this class of diseases. —
This work gives all of the prac- Northivestem 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, i national Medical Magazine.
In diagnosis and treatment it is par- 1
HAYEM (GEORGES) AND 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 j recognition. Within this large
is particularly adapted to the re- | range of applicability, physical
quirements of the general practi-
tioner. The section on mineral
waters is most scientific and prac-
tical. Some 200 pages are given up
to electricity and evidently embody
the latest scientific information on
the subject. Altogether this work
is the clearest and most practical aid
to the study of nature's therapeutics
that has yet come under our obser-
vation. — The Medical Fortnightly.
For many diseases the most potent
remedies lie outside of the materia
medica, a fact yearly receiving wider
agencies when compared with drugs
are more direct and simple in their
results. Medical literature has long
been rich in treatises upon medical
agents, but an authoritative work
upon the other great branch of
therapeutics has until now been a
desideratum. The section on climate,
rewritten by Prof. Hare, will, for
the first time, place the abundant
resources of our country at the in-
telligent command of American
practitioners. — The Kansas City
Medical Index.
HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In
one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See
Student's Series of 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 12rao,
volume of 199 pages, with 32 engravings, Cloth, $1,50,
Lea Brothers & Co., Philadelphia and New York. 15
HERRICK (JAMES 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,
concise, up-to-date, and eminently
well fitted for the use of the prac-
titioner as well as of the student. —
Chicago Med. Recorder.
This volume accomplishes its ob-
jects more thoroughly and com-
pletely than any similar work yet
published. Each section devoted to
diseases of special systems is pre-
ceded with an exposition of the
methods of physical, chemical and
microscopical examination to be em-
ployed in each class. The technique
of blood examination, including color
analysis, is very clearly stated.
Uranalysis receives adequate space
and care. — New York Med. Journal.
We commend the book not only to
the undergraduate, but also to the
physician who desires a ready means
of refreshing his knowledge of diag-
nosis in the exigencies of professional
life. — Memphis Medical Monthly.
HILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS
DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25.
HLLLIER (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 PD3RSOL (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.
HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS
USED IN MEDICINE AND THE COLLATERAL SCIENCES.
In one 12mo. volume 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 POWER (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.
HOLDEN (LUTHER). LANDMARKS, MEDICAL AND SURGI-
CAL. From the third English edition. With additions by W. W.
Keen, M. D. In one royal 12mo. volume of 148 pages. Cloth, $1.
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 100S 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, cloth, $6 ;
leather $7 ; half Russia, $7.50, For sale by subscription only,
16 Lea Beothees & Co.. Philadelphia and New Yoek.
HORNER (WILLIAM 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.). LECTUKES ON THE STUDY OF FEVER.
octavo volume of 308 pages. Cloth, $2.50.
In one
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 (JAMES 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.
Just ready.
Almost every page of this edition
has been carefully revised, and
every real advance has been recog-
nized. The work answers the needs
of the general practitioner, the
specialist, and the student, and is
a happy example of the fact that
such an apparently wide range of
adaptation can be given within the
compass of a volume of convenient
size and price. — The Ohio Med. Jour.
A treatise of exceptional merit
characterized by conscientious care
and scientific accuracy. — Buffalo
Med. Journal.
Those who wish the latest views
may confidently consult its pages. —
University Med. Magazine.
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 Medical Review.
All new facts based on path-
ological and bacteriological re-
searches have been considered in
detail, and in every way this book
represents the Dermatology of to-
day. It is the most practical hand-
book on dermatology with which we
are acquainted. — The Chicago Med-
ical Recorder.
JACKSON (GEORGE THOMAS). THE READY-REFERENCE
HANDBOOK OF DISEASES OF THE SKIN. New (2d) edition.
In one 12mo. volume of 589 pages, with 69 illustrations and a colored
plate. Cloth, $2.75. Just ready.
The specialist will find it a prompt
and ready source of knowledge on
all points of terminology, symptoms,
varieties, etiology, pathology, diag-
nosis, treatment and prognosis of
dermal affections. Tables of differ-
ential diagnosis and standard pre-
scriptions will be found scattered
through the text, and the work ends
with an appendix of well-tried
formulae. The series of illustra-
tions is rich and instructive. — Mem-
phis Medical Monthly.
The text is clear and sufficiently
full. The subject of treatment in-
cludes all the newer methods and
remedies of proved value. It is a
thoroughly satisfactory and clear
expression of cutaneous diseases. —
American Journal of the Medical
Sciences.
The work is fair and accurate, full
and complete, and it embodies the
recent additions to our information.
Above all, it is eminently practical.
The reviewer has found it a good
book for students, and believes it is
equally good for the practitioner. —
Chicago Clinical Review.
Lea Brothees & Co., Philadelphia axd New Yoek. 17
JA3ILESON (W. ALLAV . 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.
JEWETT (CHARLES). ESSENTIALS OF OBSTETEICS. In one
12mo. volume of 356 pasres, with 78 en?ravinsrs and 3 colored plates.
Cloth, $2.25. Just ready.
JOXES (C. HANDFLELD\ CLINICAL OBSERVATIONS ON
FUNCTIONAL NERVOUS DISORDERS. Second American edi-
tion. In one octavo volume of 340 pages. Cloth, $3.25.
JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE
AND PRACTICE. Second edition. In one octavo volume of 549
?ages, with 201 engravings. 17 chromo-lithographic plates, test-types of
aeeer and Snellen, and Holmgren's Color-Blindness Test. Cloth,
$5.50 ; leather, $6.50.
The continuous approval mani-
fested toward this work testifies to
the success with which the author
has produced concise descriptions
and typical illustrations of all the
important affections of the eye. The
volume is particularly rich in mat-
ter of practical value, such as direc-
tions for diagnosing, use of instru-
ments, testing for glasses, for color
blindness, etc. The sections devoted
to treatment are sinsularlv full, and
at the same time concise, and couch-
ed in language that cannot fail to be
understood. This edition likewise
embodies such revisions and changes
as were necessary to render it thor-
ouehly representative, and moreover
it has been enriched by the addition
of 100 pages and 75 engravings. All
told, there are 201 engravings, ex-
elusive of 17 handsomely colored. —
The Jledical Age.
KING LA. F. A.). A MANUAL
In one 12mo. vol. of 532 pages, wi
It is just such a work as the obstet-
rician turns to in time of need with
the assurance that he will in a mo-
ment refresh his memory on the sub-
ject. A vast amount of knowledge
is expressed in small space. — The
Ohio Medical Journal.
This is undoubtedly the best man-
ual of obstetrics. Six editions in
thirteen years show not only a de-
mand for a book of this kind, but
that this particular one meets the
requirements for popularity, being
clear, concise and practical. The
present edition has been carefully
revised, and a number of additions
OF OBSTETRICS. Sixth edition.
th 221 illus. Cloth, $2.50.
and modifications have been intro-
duced to bring the book to date. It
is well illustrated, well arranged ;
in short, a model manual. — The Chi-
caqo Medical Recorder.
For clearness of diction it is not
i excelled by any book of similar na-
ture, and by its system of captions
and italics it is abundantly suited to
the needs of the medical student.
! The book is undoubtedly the best
manual of obstetrics extant in Eng-
lish. — The Philadelphia Polyclinic.
The most valuable manual for stu-
t dents that is published. — Xational
Jled. Review.
KIRK (EDWARD CM. OPERATIVE DENTISTRY. Handsome
octavo of 700 passes, with 751 illustrations. Just ready. See American
Books of Dentistry, -page 2.
The work is essentially a new departure. Since the subject was last
treated in text -book form the high specialization devoted to it has resulted
in a development beyond the power of any single mind to represent.
Accordingly Professor Kirk has secured the assistance of gentlemen of
recognized authority in the various departments, and as a result the
student now has at command the best and most modern knowledge pre-
sented in the form which facilitates to the utmost its assimilation.
18 Lea Brothers & Co., Philadelphia and New York.
KLEIN (E.). ELEMENTS OF HISTOLOGY. Fourth edition. In
one pocket-size 12mo. volume of 376 pages, with 194 engravings.
Cloth, $1.75. See Student's Series of Manuals, page 27.
It is the most complete and con-
cise work of the kind that has yet
emanated from the press, and is
invaluable to the active as well as
to the embryo practitioner. The
illustrations are vastly superior to
those in most works of its class. —
The Medical Age.
The clear and concise manner in
which it is written, the absence of
debatable matter, and of conflicting
views, the convenient size of the
book and its moderate price, will
account for its undoubted success. —
Medical Chronicle.
This work deservedly occupies a
first place as a text-book on his-
tology. — Canadian Practitioner.
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.
PNEUMONIA. In one 8vo. volume of 490 pages. Cloth, $3.
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.
LAWSON (GEORGE). INJURIES OF THE EYE, ORBIT AND
EYE-LIDS. From the last English edition. In one handsome octavo
volume of 404 pages, with 92 engravings. Cloth, $3.50.
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.
Complete work just ready.
CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN
CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMIN ATI
THE ENDEMONIADAS ; EL SANTO NINO DE LA GUARDIA
BRIANDA DE BARDAXI. In one 12mo. volume of 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, thoroughlv 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.
LEE (HENRY) ON SYPHILIS. In one 8vo. volume of 246 pages.
Cloth, $2.25.
LEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY.
In one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25.
LEISHMAN (WILLIAM). A SYSTEM OF MIDWIFERY. Includ-
ing the Diseases of Pregnancy and the Puerperal State. Fourth edi-
tion. In one octavo volume.
Lea Beothees & Co., Philadelphia and New Yoek. 19
LOOMIS (ALFRED L.) AND THOMPSON ("W. GDLMAN,
EDITORS). A SYSTEM OF PEACTICAL MEDICINE. In
Contributions by Various American Authors. ' In four very hand-
some octavo volumes of about 900 pages each, fully illustrated in
black and colors. Vols. I. and II., just ready. Vols. III. and IV.,
in active preparation. 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.
LUDLOW (J. L.). A MANUAL OF EXAMINATIONS UPON
ANATOMY, PHYSIOLOGY, SURGERY, PRACTICE OF MEDI-
CINE, OBSTETRICS, MATERIA MEDICA, CHEMISTRY, PHAR-
MACY AND THERAPEUTICS. To which is added a Medical For-
mulary. Third edition. In one royal 12mo. volume of 816 pages, with
370 engravings. Cloth, $3.25 ; leather, $3.75.
LUFF (ARTHUR P.).
Students of Medicine,
engravings. Cloth, $2.
MANUAL OF CHEMISTRY, for the use of
In one 12mo. volume of 522 pages, with 36
See Student's Series of Manuals, page 27.
LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one
very handsome octavo volume of 925 pages, Avith 170 engravings.
Cloth, $4.75 ; leather, $5.75.
An excellent treatise on the prac-
tice of medicine, written by one
who is not only familiar with his
subject, but who has also learned
through practical experience in
teaching what are the needs of the
student and how to present the facts
to his mind in the most readily
assimilable form. The practical and
busy physician, who wants to ascer-
tain in a short time all the necessary
facts concerning the pathology or
treatment of any disease will find
here a safe and convenient guide. —
The Charlotte Medical Journal.
Complete, concise, fully abreast of
the times and needed by all students
and practitioners. — Univ. Med. Mag.
Au exceedingly valuable text-book.
Practical, systematic, complete and
well balanced. — Chicago Med. Re-
corder.
Represents fully the most recent
knowledge. — Montreal Med. Jour.
LYONS (ROBERT D.). A TREATISE ON FEVER,
volume of 362 pages. Cloth, $2.25.
In one octavo
MA1SCH (JOHN M.). A MANUAL OF ORGANIC MATERIA
MEDICA. New (6th) edition, thoroughly revised by H. C. C. Maisch,
Ph. G., Ph. D. In one veiy handsome 12mo. volume of 509 pages, with
285 engravings. Cloth. $3.
The best handbook upon phar-
macognosy of any published in this
country. — Boston Med. c0 Sur. Jour.
Noted on both sides of the Atlantic
and esteemed as much in Germany as
in America. The work has no equal.
— Dominion Med. Monthly.
Used as text-book in every college
of pharmacy in the United States
and recommended in medical col-
-American Therapist,
New matter has been added, and
the whole work has received careful
revision, so as to conform to the new
United States Pharmacopoeia. — Vir-
ginia Medical Monthly.
This standard text-book is a
work of such well-tried merit that it
stands in no danger of being super-
seded. — Amer. Druggist and Pharm,
Record.
20 Lea Brothers & Co., Philadelphia and New York.
MANUALS. See Student's Quiz Series, page 27, Student's 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 Manuals, page 25.
MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For
the use of Students and Practitioners. Second edition, revised by L.
S. Ratt, M. D. In one 12mo. volume of 360 pages, with 31 engrav-
ings. Cloth, $1.75.
MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS
DISEASES. In one 12mo. volume of 299 pages, with 19 engravings
and 2 colored plates. Just ready. 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.
There is no question as to the in-
terest of the clinical pictures pre-
sented in this volume. Many rare
examples of spurious troubles
(hysteria) are given and irregular
types of other "nervous " affections.
The study of these types, from the
author's clear notes and deductions,
will be of value to the student of
neurology.— The Chicago Clinical
Review.
This is a book by a master and if
we mistake not it will prove a very
popular one. The book treats of
hysteria, recurrent melancholia, dis-
orders of sleep, choreic movements,
false sensations of cold, ataxia,
hemiplegic pain, treatment of sci-
atica, erythromelalgia, reflex ocular
neurosis, hysteric contractions, ro-
tary movements in the feeble
minded, etc. Few can speak with
more authority than the author. —
The Journal of the American Medi-
cal Association.
MITCHELL (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 the last
thirty years, as well as to the
government documents, and has
skilfully utilized his opportunities.
This work will doubtless take a
prominent place in medical litera-
ture among the special monographs
which throw light into obscure
places and contribute to the advance
of medical science. — The Med. Age.
MORRIS (HENRY). SURGICAL DISEASES OF THE KIDNEY.
In one 12mo. volume of 554 pages, with 40 engravings and 6 colored
plates. Cloth, $2.25. See Series of Clinical 31anuals, page 25.
MORRIS (MALCOLM). DISEASES OF THE SKIN. In one
square 8vo. volume of 572 pages, with 19 chromo-lithographic figures
and 17 engravings. Cloth, $3.50.
MULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL-
OGY. In one large 8vo. vol. of 623 pages, with 538 cuts. Cloth, $4.50.
Lea Bkothees & Co.. Philadelphia axi> Nbw Yoke:. 21
MUSSER JOHN H. . A PRACTICAL TREATISE ON MEDICAL
DIAGNOSIS, for Students and Physicians. 2s ew 2d edition, thor-
oughly revised. In one octavo volume of 3 s with 177 engi v-
ings and 11 full-page colored plates. Cloth. $-5 ; leather. $6. Just
ready.
"We have no work of equal value with only hy the specialist. The
iu English. — University M
Magazine.
Every real advance that has been
made in this rapidly progressing
department of medicine is here re-
corded. There is no half knowledge.
His descriptions of the diagnostic
manifestations of diseases are accu-
rate. This work will meet all the
requirements of student and physi-
cian. — The Medical yews.
Erom its pages may be made the
diagnosis of everv maladv that
early demand for the new edition
speaks volumes for the book's popu-
larity. — North wester ■ L
It so thoroughly meets the precise
demands incident to modern research
that it has been already adopted as a
leading text-hook by' the medical
colleges of this country. — North
American Practitioner. -
Occupies the foremost plat
thorough, systematic treatise.— Oh io
Me d lea I Jo ur nal.
The best of its kind, invaluable to
afflicts the human body, including the student, general practitioner and
those which in general are dealt teacher. — M. Meal Journal.
NATIONAL DISPENSATORY. See Stille, Maiseh & Caspari. p. 27.
NATIONAL FORMULARY. See Stille, Maiseh & C v atonal
Dispensatory, page 27.
NATIONAL MEDICAL DICTIONARY. See Billings, page 4.
NETTLESHTP E. . DISEASES OE THE EYE. Fourth American
from fifth English edition. In 'me 12mo. volume of 500 pages,
with 164 engravings, test-types and formula? and color-blindness test.
Cloth, .>:
Four large American editions
testify to thefact that it is a favorite
text-book in American coIIt.
well as to the extent of its use
among practitioners in general and
special branches. Its popularity as
a reference-book is due to the prac-
tical nature of its text and to the
inclusion of test-types, color-blind-
ness tests and a collection of
formula?. It is safe to predict that
this handy volume will become more
than ever a favorite with all classes
of readers. — Pacifie Med. Journal.
NORRIS \VM. F. AND OLIVER CHAS. A. . TEXT BOOK OF
OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357
engraving.- and 5 colored plates. Cloth. $o : leather.
We take pleasure in commending
the "Text-book" to students and
practitioners as a safe and admir-
able guide, well qualified to furnish
them~ as the authors intended it
should, with •'" a working knowl-
edge of ophthalmology."' — Johns
Hopkins Hospital Bulletin.
The first text-book of diseases of
the eye written by American authors
for American colleges and students.
Every method of ocular precision
that can be of any clinical advantage
to the eveiy-day student and the
scientific observer is offered to the
reader. Rules and procedures are
made so plain and so evident, that
any student can easily understand
and employ them. It is j^ractical in
its teachings. "SVe unreservedly en-
dorse it as the best, the safest and the
most comprehensive volume upon
the subject that has . offered
to the American medical public. —
Annals of Ophthalmology and Oto-
logy.
22 Lea Bbothees & Co., Philadelphia and New Yoek.
OWEN (EDMUND). SUKGICAL 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 (ROSWELL). A TREATISE ON SURGERY BY AMERI-
CAN AUTHORS. In two handsome octavo volumes. Volume I.,
General Surgeiy, 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.
Complete work just ready.
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.
Its special field of application is
in practical, every-day use. It well
deserves a place in every medical
man's library. — The Pittsburg Med-
ical Review.
The illustrations are almost en-
tirely new and executed in such a
way that they add great force to the
text. It gives us unusual pleasure
to recommend this work to students
and practitioners alike. — The Chi-
cago Medical Recorder.
The various writers have em-
bodied the teachings accepted at
the present hour and the methods
now in vogue, both as regards
causes and treatment. — The North
American 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.
PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS
CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT-
MENT. In one octavo volume of 272 pages. Cloth, $2.50.
PARVEV (THEOPHTLUS). 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 eveiy de-
partment, and contains all the neces-
sary detail required by the modern
practising obstetrician. — Interna-
tional Medical Magazine.
In breadth and scope the work is
adapted to the needs of the advanced
scholar and specialist. The con-
sideration of every subject is in
reality brought up to the hour when
the copy went to print. — Medicine.
Parvin's work is practical, con-
cise and comprehensive. We com-
mend it as first of its class in the
English language. — Medical Fort-
nightly.
Parvin's classical work now oc-
cupies the front rank of modern
text-books. It is an admirable text-
book in every sense of the word. —
Nashville Journal of Medicine and
Surgery.
PAVY (F. W.). A TREATISE ON THE FUNCTION OF DIGES-
TION, ITS DISORDERS AND THEIR TREATMENT. From the
second London edition. In one 8vo. volume of 238 pages. Cloth, $2.
Lea Beothees & Co., Philadelphia and New Yoek. 23
PAYNE (JOSEPH FRANK). A MANUAL OF GENERAL
PATHOLOGY. Designed as an Introduction to the Practice of Medi-
cine. In one octavo volume of 524 pages, with 153 engravings and
1 colored plate.
PEPPER'S SYSTEM OF MEDICINE. See page 3.
PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's
Series of 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 12mo. volume of 530 pages, with 93 engravings. Cloth, $2.
See Series of Clinical Manuals, page 25.
PIRRIE (WILLIAM). THE PRINCIPLES AND PRACTICE OF
SURGERY. In one octavo volume of 780 pages, with 316 engravings.
Cloth, $3.75.
PLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND
PRACTICE OF MIDWIFERY. Sixth American from the eighth
English edition. Edited, with additions, by R. P. Haeeis, M. D.
In one octavo volume of 697 pages, with 217 engravings and 5 plates.
Cloth, $4 ; leather, $5.
In the numerous editions which
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- 1 bodies all recent advances. — ■ The
most place in obstetric medicine as Medical Fortnightly.
a safe guide to both student and '
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-
PL AYF AIR (W. S.). THE SYSTEMATIC TREATMENT OF
NERVE PROSTRATION AND HYSTERIA. In one 12mo. vol-
ume of 97 pages. Cloth, $1.
POLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE
EAR AND ADJACENT ORGANS. Second American from the
third German edition. Translated by Oscae Dodd, M. D., and
edited by Sie 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 i 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 that 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 apparatus is especially every part of otology. — American
liable. The indications for treat- 1 Journal of the Medical Sciences.
POWER (HENRY). HUMAN PHYSIOLOGY. Second edition. In
one 12mo. volume of 396 pages, with 47 engravings. Cloth, $1.50.
See Student's Series of Manuals, page 27.
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 Beothees & Co., Philadelphia and New Yoek.
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 Manuals, page 27.
RAMSBOTHAM (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, thoroughly revised. In one 12mo. vol-
ume of 326 pages. Cloth, $2. Just ready.
A. clear and concise explanation
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The book is equally adapted to the
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— New Orleans Med. and Surg. Jour.
The appearance of a fifth edition
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ally high among the works of this
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fully up to the times. — American
Medico- Surgical Bulletin.
REYNOLDS (J. RUSSELL). A SYSTEM OF MEDICINE. Ed-
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three large 8vo. vols., containing 3056 closely printed double-columned
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RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI-
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ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF
MODERN SURGERY. In one octavo volume of 780 pages, with
501 engravings. Cloth, $4.50 ; leather, $5.50.
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 WILLIAM). 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 (JAMES). A HANDBOOK OF THE DISEASES OF THE
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SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES,
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uals, page 25.
Lea Brothers & Co., Philadelphia and New York. 25
SCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL-
OGY, DESCRIPTIVE AND PRACTICAL. For the use of Students.
New (4th) edition. In one handsome octavo volume of 311 pages,
with 325 illustrations. Cloth, $3.
Nowhere else will the same very I The most satisfactory elementary
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useful and interesting an atlas of | lish language. — The Boston Med. and
structural anatomy. — The American Sur. Jour.
Journal of the Medical Sciences.
A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition.
In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25.
Just ready.
SCHMITZ AND ZUMPT'S CLASSICAL. SERIES.
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VIRGIL. Cloth, 85 cents; half bound, $1.
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SCHOFD3LD (ALFRED T.). ELEMENTARY PHYSIOLOGY
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SCHRED3ER (JOSEPH). A MANUAL OF TREATMENT BY
MASSAGE AND METHODICAL MUSCLE EXERCISE. Trans-
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SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi-
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SERIES OF CLINICAL MANUALS. A Series of Authoritative
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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 METHODS. In one very handsome
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This is a very much-needed book, in the full detail of the technique as
A most excellent arrangement con- to mode of securing, preparing and
sistsin the Differential Table of the examining specimens. — The Yir-
More Important Diseases, or of the ginia Med. Semi-Monthly .
fluid, secretion or excretion, under Will adequately supply a well-re-
consideration — the table being at the cognized deficiency. — British Med.
end of each subject discussed. An- Journal.
other excellence of the book consists I
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. Fifth
edition. In one 8vo. volume of 501 pages, with 44 engravings and 8
plates showing colors of 64 tests. Cloth, $3.25. Just ready.
the covers of this book. — The North-
western Lancet.
Its statements are all clear and its
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SL.ADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT-
MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25.
It is difficult to see how a better
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SMITH (EDWARD).
DIABLE STAGES.
CONSUMPTION; ITS EARLY AND REME-
In one 8vo. volume of 253 pp. Cloth, $2.25.
SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN-
FANCY AND CHILDHOOD. New (8th) edition, thoroughly revised
and rewritten and much enlarged. In one large 8vo. volume of 983
pages, with 273 engravings and 4 full-page plates. Cloth, $4.50;
leather, $5.50.
The most complete and satisfac-
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cal and Obstetrical Journal.
It truly is the most evenly bal-
anced, clear in description and
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books published in this country on
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A treatise which in every respect
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subject. — American Medico-Surgical
Bulletin.
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.
dium for the modern surgeon. — Bos-
ton Medical and Surgical Journal.
One of the most satisfactory works
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SOLL.Y (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
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— 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.— St. Louis Medical
and Surgical Journal.
STDLLE (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
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Cloth, $10; leather, $12.
Lea Brothers & Co., Philadelphia and New York. 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-
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with 320 engravings.
Thumb-letter Index.
Cloth, $7.25 ; leather, $8. With ready reference
Cloth, $7.75 ; leather, $8.50.
Recommended most highly for the
physician, and invaluable to the
druggist. — Therapeutic Gazette.
It is the official guide for the Med-
ical and Pharmaceutical professions.
— Buffalo Med. and Sur. Jour.
The readiness with which the vast
amount of information contained in
this work is made available is indi-
cated by the twenty-five thousand
references in the two indexes. — Bos-
ton Medical and Surgical Journal.
Should be recognized as a national
standard. — North Am. Practitioner.
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. Just ready.
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.). A TREATISE ON FRACTURES AND
DISLOCATIONS. In two handsome octavo volumes. Vol. I., Frac-
tures, 582 pages, 360 engravings. Vol. II., Dislocations, 540
pages, 163 engravings. Complete work, cloth, $5.50 ; leather, $7.50.
Either volume separately, Cloth, $3 ; leather, $4.
STUDENT'S QUIZ SERIES. A New Series of Manuals in question aria
answer for Students and Practitioners, covering the essentials of medical
science. Thirteen volumes, pocket size, convenient, authoritative,
well illustrated, handsomely bound in limp cloth, and issued at a low
price. 1. Anatomy (double number); 2. Physiology; 3. Chemistry and
Physics ; 4. Histology, Pathology and Bacteriology ; 5. Materia Medica
and Therapeutics ; 6. Practice of Medicine ; 7. Surgery (double num-
ber); 8. Genito-Urinary and Venereal Diseases ; 9. Diseases of the Skin;
10. Diseases of the Eye, Ear, Throat and Nose; 11. Obstetrics; 12.
Gynecology; 13. Diseases of Children. Price, $1 each, except Nos.
1 and 7, Anatomy and Surgery, which being double numbers are priced
at $1.75 each. Full specimen circular on application to publishers.
STUDENT'S SERIES OF MANUALS. A Series of Fifteen Man-
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Treves' Manual of Surgery (monographs by 33 leading surgeons), 3
volumes, per set, $6; Bell's Comparative Anatomy and Physiology, $2;
Robertson's Physiological Physics, $2 ; Gould's Surgical Diagnosis,
$2; Klein's Elements of Histology (4th edition), $1.75; Pepper's
Surgical Pathology, $2 ; Treves' Surgical Applied Anatomy, $2 ;
Power's Human Physiology (2d edition), $1.50 ; Ralfe's Clinical
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$1.50. The following is in press : Pepper's Forensic Medicine.
For separate notices, see under various author's names.
28 Lea Brothees & Co., Philadelphia and New York.
STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY
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SUTTON (JOHN BliAND). SURGICAL DISEASES OF THE
OVAEIES AND FALLOPIAN TUBES. Including Abdominal
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and 5 colored plates. Cloth, $3.
— TUMORS, INNOCENT AND MALIGNANT. Their Clinical
Features and Appropriate Treatment. In one 8vo. vol. of 526 pp., with
250 engravings and 9 full-page plates. Cloth, $4.50. Just ready.
TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL
SURGERY. In two handsome octavo volumes. Vol. I. contains 546
pages and 3 plates. Cloth, $3. Vol. II., preparing.
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 octavo volume of about 800
pages, with about 75 engravings. Cloth, $4.50; leather, §5.50 Just recall).
Notices of previous edition are appended.
No library is complete without j The editor has given to two pro-
Taylor's Medical Jurisprudence, as fessions a reference-book to be relied
its authority is accepted and un
questioned by the courts. — Buffalo
Medical and Surgical Journal.
upon. — The American Journal of the
Medical Sciences.
TAYLOR (ALFRED S.). ON POISONS IN RELATION TO
MEDICINE AND MEDICAL JURISPRUDENCE. Third Ameri-
can from the third London edition. In one octavo volume of 788
pages, with 104 illustrations. Cloth, $5.50 ; leather, $6.50.
TAYLOR (ROBERT TV.). THE PATHOLOGY AND TREAT-
MENT OF VENEREAL DISEASES. In one veiy handsome octavo
volume of 1002 pages, with 230 engravings and 7 colored plates.
Cloth, $5.00 ; leather, $6.00. {Net.) Just ready.
By long odds the best work on
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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. — Neiv York Medical Joe rnal.
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 on venereal
diseases that has in recent years ap-
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.
The student or practitioner will
find in this book a most full, com-
plete and trustworthy guide on all
points connected, with this subject.
— The Montreal Medical Journal.
Lea Beothees & Co., Philadelphia and New Yoek. 29
TAYLOR (ROBERT W.). A PE ACTIO AL TREATISE ON SEX-
UAL DISORDERS IN THE MALE AND FEMALE. In one
8vo. vol. of 416 pp., with 73 engravings and 8 colored plates. Cloth,
$3. Net. Just ready.
A work handling sexual diseases in a scientific and practical manner.
The same practicality which has made the author's Pathology and Treat-
ment of Venereal Diseases the recognized authority will secure for this
new volume equal favor. It will afford the general practitioner as well
as the specialist the best methods of treating a very large class of cases.
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, balf Russia,
$27 ; half Turkey Morocco, $28. For sale by 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. GAILLARD) 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 tmd 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 FISTULA. From the
third English edition. In one octavo volume of 359 pages, with 47
engravings and 3 lithographic plates. Cloth, $3.50.
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. Price per volume, cloth, $8.
Complete Work just ready.
A MANUAL OF SURGERY. In Treatises by 33 leading sur-
geons. Three 12mo. volumes, containing 1866 pages, with 213 engrav-
ings. Price per set, $6. See Student's Series of Manuals, page 27.
30 Lea Brothers & Co., Philadelphia and New York.
TREVES (FREDERICK). THE STUDENTS' HANDBOOK OF
SURGICAL OPERATIONS. In one 12mo. volume of 50S pp., with
94 illustrations. Cloth, $2.50.
SURGICAL APPLIED ANATOMY. In one 12mo. vol. of 540 pp.,
with 61 engravings. Cloth, $2. See Student's Series of Manuals, p. 27.
INTESTINAL OBSTRUCTION. In one 12mo. volume of 522
pages, with 60 illus. Cloth, $2. See Series of Clinical Jfanuals, p. 25.
TUKE (DANIEL HACK). THE INFLUENCE OF THE MIND
UPON THE BODY IN HEALTH AND DISEASE. Second edition.
In one 8vo. volume of 467 pages, with 2 colored plates. Cloth, $3.
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. Just ready.
The work has been brought down I The present edition has been not
to date, and will be found entirely , only thoroughly revised throughout
satisfactory. — Journal of the Ameri-, hut also greatly enlarged, ample
cam Jledical Association. consideration being given to the new
The most exhaustive and most re- j subjects of toxins and antitoxins. —
cent presentation, of the subject. — j Tri-State Medical Journal.
American Jour, of the Med. Sciences. '
VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1897.
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 bv H. Hartshorne, M. D.
In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11.
WELLS (J. SOELBERG). A TREATISE ON THE DISEASES OF
THE EYE. In one large and handsome octavo volume.
WEST (CHARLES). 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 (3d) edition. In one 12mo. vol. of 594 pages, with 475
engravings, many of which are photographic. Cloth, $3. Just ready.
We know of no book which more
thoroughly or more satisfactorily
covers the ground of Minor Surgery
and Bandaging. — Brooklyn Medical
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
work of ready reference for sur-
geons. — Xorth 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,
Lea Brothers & Co., Philadelphia and New York. 31
WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR
THERAPEUTIC INDEX. Including Medical and Surgical Thera-
peutics. In one square octavo volume of 917 pages. Cloth, $4.
WILSON (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.
WEVCKEL 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 1897. A Critical Review for
Practitioners of Medicine and Surgery. In contributions by 24 well-
known medical writers. 12mo., 488 pages. Cloth, $1.50. In combi-
nation with The Medical News and The American Journal
of the Medical Sciences, 75 cents. See page 32.
To repeat the praises bestowed on the hands of a practical and recog-
previous issues is not to do full jus- nized authority. The whole field of
tice, as every year shows improve- medicine is in this way traversed,
ment and advances which make the and a critical estimate formed of all
work one of increasing utility to the that is substantial and meritorious
physician. The work this year con- ! in recent progress. — The Physician
sists of twenty-five chapters, each in I and Surgeon.
YEAR-BOOKS OF TREATMENT FOR 1891, 1892, 1893 and 1896,
similar to above. Each, cloth, $1.50.
YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New
(2d) edition. In one 12mo. volume of 592 pages, with 4 engravings.
Cloth, $2.50. Just ready. See Series of Clinical Manuals, page 26.
work of Dr. Yeo's. The value of
the work is not to be overestimated.
— Neiv York Medical Journal.
We doubt whether any book on
dietetics has been of greater or more
widespread usefulness than has this
much-quoted and much-consulted
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, I surgical specialty and every page
one is impressed with the thorough- \ abounds with evidences of prac-
ness of the work. The illustrations j ticality. It is the clearest and most
are numerous — the book thoroughly i modern work upon this growing de-
practical — Medical Neivs. partment of surgery. — The Chicago
It is a thorough, a very compre- ! Clinical Review.
hensive work upon this legitimate
fll^dical Periodicals and Combinations.
jHE student cannot begin too early in his course a habit of reading
current medical literature. In this way he will best acquire an
intelligent interest in the vital questions of his profession, secure
a vast fund of information which will constantly supplement the
knowledge gained from text-books, and become familiar with the
approved methods of calling public attention to such additions as he may
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THE MEDICAL NEWS (Weekly, $4.00 per Annum).
The News contains each week twenty-eight quarto pages, comprising
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tres, and news items of interest. Published for fifty years, The News is
familiar with the needs of medical men and the best methods of meeting
them.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
(Monthly, $4.00 per Annum).
The American Journal is a medical magazine affording, in the 128
pages of each issue, ample space for elaborate original articles on important
medical discoveries, discriminating reviews on valuable medical literature,
and classified summaries of progress. According to the highest literary
authority of the profession, ' ' from this file alone, were all other publica-
tions of the press for the last fifty years destroyed, it would be possible to
reproduce the great majority of the real contributions of the world to
medical science during that period."
COMMUTATION RATE.
Taken together, The Journal and News form a peculiarly useful
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in the progress of medical matters shall escape attention. To lead every
reader to prove this personally the commutation rate has been placed at the
exceedingly low figure of |7.50.
SPECIAL COMBINATION OFFERS.
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LEA BROTHERS & CO., Publishers, iJftSSJ^SSBll:^
Yck.
32
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