The science and art of obstetrics

Preface To First Edition

I have been prompted to prepare this work by a conviction of the existence of an urgent demand for a treatise on the Science and Art of Obstetrics, in our School of Medicine, which should embody the advances recently made, and set forth the distinctive characters of our therapeutics in a rational and practical manner.

Treatment in obstetrical practice in a great measure is mechanical, and does not involve an extensive application of therapeutical resources. Itis true that by the judicious use of homeopathic remedies labor may often be divested of its pathological features ; yet we must beware of expecting too much. We cannot reasonably hope to flex an extended foetal head, to amplify pelvic diameters, to reduce intra-uterine hydrocephalus, to effect version, or to arrest unavoidable hemorrhage by the most carefully affiliated remedy ; and the sooner the sphere of remedial action can be settled, the better for us and the principles which w T e represent. The vantage-ground which we hold consists in our ability to reduce the number of cases demanding interference to a minimum, and to remove from the pathway of the parturient and puerperal woman all unnecessary difficulty and danger.

In preparing a practical and reliable work of this kind, it is always found necessary to draw largel}^ from the writing and experience of others. In doing so, I have endeavored to award due recognition, and have sought to appropriate only the most valuable and practical truths.

Though the matter has been prepared with the greatest care, important omissions and glaring errors will doubtless be discovered, on account of which, in advance, I implore the reader's most gracious forbearance.

To numerous friends I would return my hearty thanks for the many aids and encouragements afforded ; and to my enterprising publishers, for their excellent and energetic performance of the mechanical part of the work.

SHELDON LEAVITT, M.D.

Chicago, October 20, 1882.

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■Hn^aai

Preface To Second Edition

The first edition of this work has been out of print for about three years, during which time I have economized the spare moments, gathered from busy days, in preparing for this edition. So difficult has it been for me to find the necessary time, that, had it not been for the clamor of students, and the encouragement given by brother practitioners of sincerity and judgment, I fear the task would never have been finished. Whether the work, as now presented, will meet the needs, and fulfill the expectations, of those for whom it is intended, or not, they may rest assured that it represents a great amount of labor and earnest effort.

When I came to review the first edition, more than three years ago, so many changes and additions were found needful that I at once resolved again to undertake the drudgery inseparable from a thorough revision of a work of this size. What is herein presented has been fully reduced to manuscript, and reset, hundreds of pages being displaced by entirely new matter, and not a single page being reproduced without change. The size of the work has been augmented by upwards of one hundred pages, the therapeutic hints have been increased in number and perspicuity, recent methods have been introduced, imperfect cuts have been improved and some excellent ones added, until we are able to send out an entirely remodeled and reconstructed book.

I have bestowed unusual pains on the index. Much medical lore lies hidden in text-books for want of suitable facilities for revealing it to the busy practitioner. It has been my aim to make every important subject readily accessible. Furthermore, the names of all authorities mentioned in the work have been indexed, together with the topic in connection with which they appear.

I gratefully acknowledge special help in important details. The appendix consists of an excellent article on Antiseptic Midwifery prepared for the work by Prof. L. L. Danforth, M.D., of New York. The chapter on Puerperal Fever was written by T. Griswold Comstock, M.D., of St. Louis, and the therapeutics vi Preface.

of Syphilis During Pregnancy by Prof. T. S. Hoyne, M.D., of Chicago. Some valuable statistics and wise suggestions were furnished by George B. Peck, M.D., of Providence, and in preparing the index I Avas aided by Prof. F. H. Honberger, M.D., of Chicago. In addition to help so direct, rendered by these well-known gentlemen, I am indebted to Profs. Phil. Porter and George R. Southwick, and others, for valuable suggestions.

Notwithstanding the great care taken in its preparation, I am painfully conscious of numerous defects which mar the book, some of them plainly traceable to my lack of proficiency in literary composition. There are doubtless many glaring omissions in the matter of therapeutics, while again some of my recommendations will not meet the approval of those who regard mere medication as abundantly adequate for all exigencies.

In conclusion I reaffirm my implicit confidence in the efficacy of the indicated remedy for the correction of abnormal conditions which may reasonably be expected to respond to mere medication.

SHELDON LEAVITT, M.D. 148 Thirty-seventh Street, Chicago, May 1, 1S92.

LIST OF ILLUSTRATIONS.

1. The Right Os Innominatum. (Outer Surface), 2

2 The Right Os Innominatum. (Inner Surface), .... 3

3. The Anterior Surface of the Sacrum, 5

4. Section of the Symphysis Pubis, 7

5 Section Through the Left Sacro-iliac Articulation, .... 8

6. The Articulated Pelvis, 11

7. Showing the Diameters of the Superior Strait, ..... 12

8. Showing the Diameters of the Outlet 13

9. Plane of Outlet, 15

10. Horizontal Planes, . . . . 16

11. Axis of Parturient Canal, 16

12. Inner Surface of the Left Half of the Pelvis, 17

13. Male Pelvis, 18

14. Female Pelvis, 19

15. Lateral View of Erectile Structures, 21

16. Vulva of the Virgin, 22

ic' [ Figures Showing Different Forms of Hymen 23

19. Vascular Supply of Vulva, 25

20. The Vagina, 27

21. Section of Female Pelvis, 28

22. Relations of Vagina, Perineum and Rectum, 30

23. Muscles of the Perineum, 31

24. Full View of External and Internal Generative Organs, . . .32

25. Normal Position of the Uterus with Empty Bladder, ... 34

26. Anterior View of Virgin Uterus, . . 35

«o' - Median Section of Virgin Uterus, 37

29. Muscular Fibers of Unimpregnated Uterus, . . . . .38

30. External Muscular Fibers of the Uterus, 39

31. Inner Muscular Fibers of the Uterus, 40

32. Section Showing Glandular Structure of the Uterus, . . ' 42

33. Arterial Vessels in a Uterus Ten Days After Delivery, . . .43

34. Nerves of the Uterus, 44

35. Uterus with Double Cavity and Slight Deviation of Form, . . 45

36. Uterus Septus Bilocularis, 45

37. Double Uterus and Vagina, 46

38. Ovary and Fallopian Tube, 48

39. Longitudinal Section of Ovary, 50

40. Part of Vertical Section Through Ovary of Bitch, .... 5]

41. Diagrammatic Section of Graafian Follicle, . . . . 52

42. Uterine and Utero-ovarian Veins, 53

43. Section of Pelvis Showing the Pyramidal Muscles 54

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■■HBU viii List of Illustrations.

44. Supernumerary Mammae, ..... 55

45. Mammary Gland, ■ . . .56

46. Spermatozoa, 62

47. Bifurcation of the Tubal Canal, .'..,■ 63

49. [ Successive Stages of Segmentation of the Yolk, .... 64

51. External Surface of the Ovum, with A rea Germinativa, . . .65

to" [ Progressive Development of the Ovum, ... .66

54. Showing Amnio-chorial Pocket of False Waters, . - . .67

55. Human Embryo at the Third Week, 68

56. Formation of the Decidua Reflexa First Stage, . . . .69

57. Formation of the Decidua Reflexa, completed, .... 69

58. Flap of Decidua Reflexa Turned Down, Disclosing the Ovum, . . 70

59. Placental Villus, Magnified 71

60. Foetal Surface of the Placenta, 72

61. Uterine Surface of the Placenta, 72

go" [ Specimens of Placentae Succenturiatae, 73

64. Section of Uterus and Placenta at Fifth Month, .... 74

65. Ovum and Embryo, 76

66. Ovum of Seven Weeks, . . 76

67. Ovum at Five Months, . . .77

68. Diagram of Foetal Circulation, 80

69. The Vertex, 82

70. Posterior View of the Cranium, . 82

71. Lateral View of the Cranium with Indicated Diameters, . . 83

72. Attitude of the Foetus in Utero, 85

73. The Foetal Ovoid, 88

tf4. Situation and Surroundings of the Foetus in Utero, ... 89

75. Height of Cervix and Fundus at Different Weeks of Pregnancy, . 92

76. Cervix at the Fourth Month of Pregnancy 93

77. Cervix at Fifth Month of NPregnancy, . . . . . . .94

78. Cervix at the Close of the Eighth Month, . . . . 94

79. Cervix of Multipara who Died at the Eighth Month, . . .95

80. Cervix at a Period Beyond the Seventh Month, .... 96

81. Appearance of the Areola, . . .97

82. Lateral View at the Sixth Month, 98

83. Lateral View at the Ninth Month, 98

84. Pendulous Abdomen, .......... 99

85. Striae of Pregnancy, 100

86. Tracing of Normal Pulse of a Pregnant Woman, . . . . 101

87. Bimanual Examination in Pregnancy, 109

88. Palpation of Foetal Trunk, 120

89. Palpation of Foetal Cranium, 120

90. Palpation of Foetal Cranium, 121

91. Locations of the Foetal Heart-sounds, 122

92. Location of Foetal Heart-sounds in First Position of the Vertex, . 123

93. Location of Foetal Heart-sounds in First Position of the Face, . 123

List of Illustrations. ix

94. Location of Fcetal Heart- sounds in First Position of the Breech, 123

95. Location of Fcetal Heart-sounds in Dorso-anterior Position of Trans-

verse Presentation, 123

96. Location of Fcetal Heart-sounds in Twin Pregnancy, . . . 123

97. Size of Uterus at Various Periods of Pregnancy, .... 133

98. Abdominal Pregnancy, 141

99. A Lithopsedion, 142

100. Interstitial Pregnancy, . . 143

101. Tubal Pregnancy, 144

102. Tubal Pregnancy, 145

103. Pregnancy in Rudimentary Horn of Uterus, 146

104. Ovum with Imperfectly-developed Decidua Reflexa, . . . 161

105. Uterus, with Basis of a Fibrinous Polypus After an Abortion, . 167

106. The Ovum Forceps, 178

107. Leavitt's Uterine Curette, 179

108. Leavitt's Placenta Hook, 182

109. Hypertrophied Decidua Laid Open : Ovum at the Fundus, . 186

110. Hydatidiform Mole, . .189

111. Hydatidiform Mole (Placental Origin), 189

112. Fatty Degeneration of the Placenta, 194

JJJ I Knots of the Umbilical Cord, .200

115. Torsion of the Cord, .201

116. Intra-uterine Amputations, 204

117. Acephalic Foetus, 205

118. Pygopagi, 207

IIq [• Monosomata, 207

121. Relative Size and Inclination of the Uterus at the Close of Gesta-

tion, 257

122. Retroflexion of the Gravid Uterus, 258

123. Soft Rubber Catheter, 260

124. The Uterine Mucous Membrane, . .309

125. Showing Various Stages of Dilatation, 321

126. Section of a Frozen Body at the Termination of the First Stage of

127. The Parturient Canal, 323

128. Dilating Os with Protruding Membranes, 326

129. Dilating Os with Protruding Membranes, 326

130. Dilating Os with Protruding Membranes, 327

131. Dilating Os with Protruding Membranes, 327

132. Section Showing Foetus, Inclosed in its Membranes, with Expand-

ing Os, 328

133. Descending Head Dilating the Os, 329

134. The Uterus and Parturient Canal, . 330

135. Distension of the Perineum, 331

136. Showing Movements of the Sacrum, 332

137. Normal Mode of Separation and Expulsion of the Placenta, . 334

138. Mode of Separation and Expulsion when Traction is Made on the

Cord, 334

■san x List of Illustrations.

139. The Vaginal Touch, 341

il? I Showing the Difference in Involved Diameters Between Flexion 14 2 \ an( i Extension of the Head, 353

143. Method of Supporting the Perineum with the Woman in the

Lateral Decubitus 356

144. Method of Perineal Protection During Forceps Delivery, . . 360

145. Distension and Threatened Rupture of Perineum, .... 362

146. Showing Ligatures of the Umbilical Cord, and Point of Section, 364

147. The Square Knot, 365

148. Delivery of Placenta by Expression, 369

149. Delivery of the Placenta by the Mixed Method, . . . .369

150. Rotation of the Placenta During Delivery to Make the Trailing

Membranes Stronger, 370

151. Inversion of Placenta from Traction on the Cord, . . . 371

152. Marginal presentation of the Placenta, .... . . 372

153. Suturing Lacerated Perineum, 376

154. Section Showing Suturing Completed, 377

155. Allis' Ether Inhaler, 387

156. Esmarch's Inhaler, 389

157. First Position of the Vertex, 392

158. Second Position of the Vertex, 392

159. Third Position of the Vertex, 392

160. Fourth Position of the Vertex, 392

161. First Position of the Face, 393

162. Second Position of the Face, ........ 393

163. Third Position of the Face, . . 393

164. Fourth Position of the Face, 393

165. First Position of the Breech, . . . j 394

166. Second Position of the Breech . 394

167. Third Position of the Breech, 394

168. Fourth Position of the Breech, 394

169. Second Position of Footling Presentation, ..... 395

170. Fourth Position of the Feet, ........ 395

171. Third Position of Transverse, .... .' . . .395

172. Second Position of Transverse, . . , . 396

173. Fourth Position of Transverse, 396

174. First Position of the Vertex, . 396

175. First Position of the Breech, ........ 396

176. Second Position of the Vertex, 397

177. Second Position of the Breech, . . . . . .397

178. First Position of the Vertex, . 404

179. Showing Lateral Obliquity of the Head, 405

180. Leverage Action of the Head, 406

181. External Rotation of the Head, .407

182. Head Approaching the Outlet in the First Position, . . .408

183. Showing Various' Movements of the Head in First Position of the

184. Second Position of the Vertex, . . . . . . . 409

185. Third Position of the Vertex, ........ 410

List of Illustrations. xi

186. Fourth Position of the Vertex, 410

187. Showing Proper Rotation of the Head in Fourth Position of the

188. Occipito-posterior Termination of Third Position of the Vertex, 412

189. Outline of Foetal Head After an Ordinary Labor, .... 415

190. Outline of Head Four Days After Birth, 415

191. Form of Head After Difficult Vertex Labor, 416

192. Face Presentation at the Outlet 419

193. Engagement of the Head in Face Presentation, .... 420

194. Showing Proper Rotation of the Head in Second Position of the

Face, 421

j^' [Diagrams Illustrating Schatz's Method of Converting Face into

197 \ ^ er tex Presentations, 424

. 425

. 426

. 428

. -429

. 430

. 431

. 432

. 433

. 434

. 436

. 437

198. Mento-posterior Termination of Labor, .

199. Outline of Head : Brow Presentation, . "200. Movements of the Breech in First Position, .

201. Expulsion of the Trunk in Breech Presentation,

202. Delivery of Posterior Arm in Head-last Cases,

203. Third Position of the Breech, ....

204. Delivery of the After-coming Head,

205. The Forceps Applied to the After-coming Head,

206. Shape of the Head in Breech Presentation, .

207. Second Position of the Breech, ....

208. Breech Raised Above the Brim of the Pelvis,

209. Position of the Hands in Performing Vagino-abdominal Version, 438

210. Method of Performing External Version After Displacement of

the Breech, 439

211. Position of the Foetus when Version is Complete, .... 440

212. Dorso-anterior Position of the Foetus in Transverse Presentation, 445

213. Dorso-posterior Position of the Foetus in Transverse Presentation, 445

214. Transverse Presentation with Shoulder Wedged in the Brim, . 447

215. Spontaneous Expulsion, . . . . 448

216. Spontaneous Expulsion. Second Stage, . . . . 449

217. Use of the Fillet with Running Noose, 452

218. Cystocele Complicating Labor, 472

219. Multiple Fibroid Developments on the Gravid Uterus, . . . 474

220. Labor Impeded by Uterine Polypus, 475

221. Labor Obstructed by Ovarian Tumor, 476

222. Flattened (Rachitic) Pelvis, .. . . . . . .478

223. Malacosteon Pelvis, . . 479

224. Obliquely-distorted Pelvis, . . 480

225. Flattening of the Sacrum, 481

226. Exaggerated Sacral Curve, 481

227. Robert's Pelvis, 482

228. Spondylolisthetic Pelvis, 482

229 Pelvic Exostosis, 483

230. Manual Pelvimetry, 487

231. ) Change of Cephalic Form, from Molding, in Difficult Head-last

HUH xii List of Illustrations.

233. Transverse Diameters of the Head as Viewed from Above, . 496

234. Molding of Head at the Brim in Difficult Cases of Extraction After

Version, 498

235. Twins Lying Laterally, One Presenting by the Vertex and the

Other by the Breech, 502

236. Twins, One Anteriorly and the Other Posteriorly, .... 502

237. Twins, the Inferior Presenting by the Breech, and the Other by

the Shoulder, 503

238. Twins, the Inferior Presenting by the Dorsum, and the Other by

the Vertex, 503

239. Twins, Both Lying Transversely, One Above and the Other Below, 504

240. Head-locking, 505

242. Double Monster, 507

243. Double Monster United Anteriorly, ■ . 508

244. Pelvic Presentation with Hydrocephalus. Tapping through Spinal Canal, 511

245. Mode of Perforating the Head in Pelvic Presentations, . . . 512

246. Dorsal Displacement of the Arm, 513

247. Varieties of Placental Attachments, 516

248. Central Placenta Previa, . . 519

249. T Bandage to Hold Tampon, 526

250. Prolapse of the Umbilical Cord, 539

251. Inclination of the Uterus, in the Dorsal Posture, Favoring Descent

of the Cord into the Pelvis, 542

252. Postural Treatment of Prolapse of the Cord, .... 543

253. Manual Reposition of the Cord, 544

254. Reposition of the Cord with Forceps, . . . . . . 545

255. Bimanual Compression of the Uterus, 572

256. Irregular Uterine (Hour-glass) Contraction, with Retention of the

Placenta, 580

257. Incipient Inversion, . 581

258. Showing Commencement of Inversion at the Cervix, . . . 581

259. Complete Inversion of the Uterus, . . . . . . . 583

260. Schultze's Method with Asphyxia, . 588

261. Schultze's Method with Asphyxia, 589

9gg' j- Combined Method of Turning, . .598

264. Combined Method of Turning, 599

5 fifi ' t Internal Podalic Version, ........ 600

^oo' - Internal Podalic Version, 601

269. Use of Running Noose on the Foot, . . . . . 602

270. Turning by the Noose, 603

271. Chamberlen's Forceps, 606

272. Stone's Short Forceps, 606

273. Knox's Short Forceps, ... ..... 606

List of Illustrations. xiii

276. Leavitt's Forceps, ' . . . .608

277. Tarnier's Axis-traction Forceps, 609

278. Leavitt's Forceps Applied to the Head Above the Brim, showing

how Traction can be Made in the Axis of the Plane of the Pelvic Brim, 609

279. The Forceps at the Brim, by the Pelvic Mode, .... 610

280. Introduction of the First Blade, 613

281. Imperfect Seizure of the Head Above the Brim, .... 614

282. Showing How the Head is Usually Seized in the Cephalic Applica-

tion, 615

283. Folding Yectis, 620

284. Taylor's Blunt Hook, 621

285. Soft Eubber Catheter, ......... 622

286. Manner of Holding Catheter, . . . . . . . .623

288. Blot's Perforator, 624

289. Blunt Hook and Crotchet, . .625

290. Thomas's Craniotomy Forceps, 625

291. Use of Craniotomy Forceps, 626

292. Simpson's Cranioclast, . .627

293. Lusk's Cephalotribe, 628

294. Mode of Using the Decapitating Hook, 630

295. Applying the Chain of the Ecraseur for Decapitation, . . 631

296. Decapitation of the Foetus with the Ecraseur, 631

297. Manual Delivery of the Head After Decapitation, . . . 632

298. Delivery of the Child in Cesarean Section, 637

299. Kemoval of the Secundines in Cesarean Section, . . . 638

300. Showing Uterine Incision Closed with Sutures, . . . .640

301. ) Diagrams to Show the Placing of Sutures in the Uterine

302. j Wound After Cesarean Section, 641

303. Pulse in Primigravida, . . 650

304. Pulse During Expulsion, 650

305. Pulse Immediately After Delivery, 651

306. Pulse a Few Hours After Delivery in a Patient who had Suffered

a Profuse but not Dangerous Hemorrhage, . . • 651

307. Pulse Seven Days After Delivery, 652

308. Pulse of Non-pregnant Woman in Health, 652

309. Pulse of Same Woman Under Extreme Nervous Excitement, . 653

310. The Clinical Thermometer, 655

311. Diagram Showing Temperature and Pulse Curves in a Normal

Case, 656

312. Uterus of a Multipara at Term, . 657

313. Inner Surface of Uterus After Delivery, 658

314. Section of Uterine Sinus from the Placental Site Nine Weeks After l»BH

Chapter II. The Articulations And General Characters Of The Pelvis, 7

The Symphysis Pubis — The Sacro-iliac Synchondroses — Mechanical Relations of the Sacrum — The Sacro-coccygeal Joint — The Ligaments of the Pelvis — The Pelvis as a Whole— Dimensions of the Pelvis — Inclination of the Pelvis — Planes of the Pelvis — Axis of the Parturient Canal — The Inclined Planes — Male and Female Pelves.

Chapter III. The Female External Generative Organs, ... 20

The Vulva— The Labia Minori— The Clitoris— The Vestibule— The Vaginal Orifice — The Hymen — The Fossa Navicularis — The Secretory Apparatus — The Bulbi Vestibuli — The Vagina — The Perineum.

Chapter IV. The Female Internal Generative Organs, ... 34

The Uterus — The Uterine Ligaments — The Uterine Cavity — Structure of the Uterus. — Abnormalities of the Uterus.

CHAPTER Y.

THE FEMALE INTERNAL GENERATIVE ORGANS— Continued, . 48 The Fallopian Tubes— The Ovaries — The Graafian Follicles — Vessels and Nerves of the Ovary — The Intra-pelvic Muscles — The Mammary Glands.

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xvi Contents.

PAET II.

PREGNANCY

Chapter I

IMPREGNATION AND DEVELOPMENT OF THE OVUM, . . 57 The Corpus Luteum of Menstruation — The Corpus Luteum of Pregnancy — The Migration of the Ovum — Fecundation — Course of Spermatozoa to Point of Fecundation — Changes in the Ovum After Fecundation — Sources of Nourishment — The Chorion — The Allantois — The Decidua — The Placenta— The Umbilical Cord — The Liquor Amnii.

Chapter II

DEVELOPMENT OF THE EMBRYO AND FCETUS, .... 76 In the First Month — Second Month — Third Month — Fourth Month — Fifth Month — Sixth Month — Seventh Month — Eighth Month — Ninth Month — Circulation of the Blood in the Fcetus — The Cranium — Attitude, Presentation and Position of the Fcetus — Presentations and their Causes — Position.

Chapter III. Changes In The Maternal Organism Wrought By

Uterine Changes — Change in Situation — Inclination of its Longitudinal Axis — Changes of Cervical Position — Changes in the Size and Texture of the Cervix Uteri — Vaginal and Vulvar Changes — Changes in the Mammae — Changes in the Uterine Appendages — Abdominal Changes — Disturbance of Neighboring Organs from Pressure — Changes in the Blood — Miscellaneous Changes — The Permanent Changes.

Chapter IV. The Diagnosis Of Pregnancy, 104

Classification of the Signs — Subjective Symptoms — History of the Case — The Menstrual Flow — Morning Sickness — Unreliability of Subjective Symptoms — Objective Symptoms — Inspection — Palpation — Percussion — Auscultation — Differential Diagnosis— Dia gnosis of Fcetal Death — Proofs of Former Pregnancy and Labor — Diagnosis of Fcetal Presentation and Position by Abdominal Auscultation — Diagnosis of Twin Pregnancy through Auscultation — Diagnosis of Sex from Rapidity of the Fcetal Heart.

Contents. xvii

Chapter V. The Duration Of Pregnancy, . . . 127

The Minimum — The Maximum — Prediction of Date of Confinement — The Date of Quickening — Prediction of Time of Labor from Size of Uterus.

Chapter VI

Conditions of Development — Etiology — Symptoms — Diagnosis — Treatment.

Chapter VII. Extra-uterine Pregnancy, 140

Ovarian Pregnancy — False Ovarian, or Tubu-Ovarian, Pregnancy — Abdominal Pregnancy — Interstitial Pregnancy — Tubal Pregnancy — Pregnancy in a Rudimentary Horn of the Uterus — Rarer Varieties — Symptoms of Extra-uterine Pregnancy — Termination — Diagnosis — Treatment — Cases of Recent Impregnation — Puncture of the Sac — Injections into the Sac — Electricity — Laparotomy — Treatment After Rupture — Cases of Advanced Gestation, the Fcetus Still Living — Operation through the Vagina — Cases of Gestation Prolonged After Death of the Fcetus — Missed Labor — Treatment.

Chapter VIII. Premature Expulsion Of The Ovum, 159

Causes of Abortion — Predisposing — Ovulary — Maternal — Immediate — Symptoms — Incomplete — Expulsion of One Foetus in Twin Pregnancy — Diagnosis — Prognosis — Treatment — Preventive — Promotive — Neglected Cases.

CHAPTER IX. PATHOLOGY OF THE OVUM AND DECIDUvE, 185

Endometritis — Pathology of the Chorion — Causes of Hydatidiform Degeneration — Symptoms and Course — Diagnosis — Prognosis — Treatment — The Placenta^— Size — Situation — Degenerations and Neiv Formations — Syphilis of the Placenta — Apoplexy and Inflammation of the Placenta— Hydramnios — Signs and Symptoms — Diagnosis — Termination — Prognosis — Effect on Labor — Treatment — Deficiency of the Amniotic Fluid — Anomalies of the Amniotic Fluid — Pathology of the Cord — Torsion — Coiling — Cysts — Hernia — Calcareous Deposits — Stenosis of the Vessels — -Anomalous Insertion — Pathology of the Fcetus — Inflammations — Fevers — Syphilis — Hydrocephalus — Pleurisy, etc. — Intra-uterine Amputations — Monstrosities — Death and Retention of the Fcetus — Putrefaction — Mummification — Maceration — Moles.

Chapter X. Diseases And Accidents Of Pregnancy, . . . . 212

The Hygiene of Pregnancy — Derangements of the Digestive System — Ptyalism — Pruritus — Insomnia — Anaemia — Albuminuria — Causes — Symptoms — Effects — Prognosis — Conclusions — Treatment — The Milk Diet — Therapeutics — Chorea — Hysteria — Paralysis — Syncope — Painful Mammj: — Leucorrhoj; a — Odontalgia — Cramps — Traumatic Complications — Constipation — Diarrhcea — Vesical Irritation — Cough — Dyspnoea — Hemorrhoids.

CHAPTER XI. THE DISEASES OF PREGNANCY— Continued, 257

Displacements of the Grayid Uterus — Anteversions and Anteflexions — Retroversions — Retroflexions — Prolapse — Cardiac Diseases — Eruptive Fevers — Variola — Scarlatina — Continued Fevers — Typhoid — Malarial — Pneumonia — Phthisis — Erysipelas — Syphilis — Uterine Rheumatism — Insanity of Pregnancy — Etiology — Diagnosis — Prognosis — Treatment — Eclampsia — Frequency — Etiology — Pathological Anatomy — Prodromata — The Seizure — Diagnosis Occurrence and Mortality — Treatment.

PAET III.

LABOR.

Chapter II

CLINICAL COURSE A*ND PHENOMENA OF LABOR, . . .318 The Stages of Labor — The First Stage — Tt?e Mechanism of Dilatation — Rupture of the Membranes— The Second Stage — Movements of the Pelvic Articulations — The Third Stage — Duration of Labor — The Hour of Labor.

Chapter III. The Management Of Normal Labor, 337

Preliminary Arrangements — Armamentarium — How to Approach the Patient — The Examination — Has Labor Begun ? — False Labor Pains — Patient's Bed and Dress — Position op the

Contents. xix

Woman — First Stage — Bearing Down — Treatment of the Membranes — The Second Stage — Bearing Efforts — The Use of Anesthetics — Indications for Interference — The Prevention of Laceration — Frequency of Laceration — Extent of Rupture — Treatment of the Cord — Early and Late Ligation — The Third Stage — Delivery of the Placenta by Expression — The Mixed Method — Manual Compression of the Uterus — Immediate Repair of Lacerations — Post-partum Care of the Woman — The Binder — General Therapeutics of Labor.

CHAPTER IY.

USE OF ANESTHETICS IN MIDWIFERY PRACTICE, . . .383 Obstetrical Anesthesia — Surgical Anesthesia — Rules for Administering Anesthetics.

Chapter V. The Various Positions Of The Fcetus, . ... . .390

The Theory of Classification — The Basis of Classification — The Relative Frequency of Positions — Points of Coincidence Between the Various Positions.

Chapter VI. Vertex Presentations, 401

Relative Frequency of Vertex Presentations — Mechanism of Labor in the First Position — Expulsion of the Trunk — Mechanism of the Second Position — Mechanism of Occipito-posterior Positions — Caput Succedaneum — Configurations of the Head in Vertex Presentation — Diagnosis of Positions, etc.

Chapter VII. Face Presentations, .417

Relative Frequency of Positions — Form of Cranium in Face Presentation — Prognosis — The Second Position-^Third and Fourth Positions — Conversion of Face into Vertex Presentation — Management when the Face does not Enter the Brim — Persistent Mento-posterior Positions — Brow Presentation.

Chapter VIII. Pelvic Presentations, 427

Frequency — Prognosis — Causes of Infantile Mortality — Etiology of Pelvic Presentation — Mechanism of Breech Presentation in First and Second Positions — Mechanism of Breech ■ Presentation in the Third and Fourth Positions — Footling Presentation — Configuration of the Head in Pelvic Delivery — Management of Pelvic Presentations — Expulsion of the Trunk — Extraction of the Head.

^mm xx Contents.

Chapter IX. Transverse Presentation 442

Frequency — Causes — Diagnosis — Prognosis — Treatment — Complex Presentations.

Chapter X. Precipitate Labor, . . . . .454

WEAK LABOR 455

Causes — Symptoms — Treatment — The Forceps in Inert Labor — Treatment of Third Stage Complicated by Inertia.

CHAPTER XL

PARTURIENT ANOMALIES REFERABLE TO THE MATERNAL

SOFT PARTS, 463

Rigidity op the Cervix — Symptoms — Treatment — Uterine Tetanoid Constriction — Diagnosis — Treatment — Atresia op the External Uterine Orifice — Complete Obliteration of the Cervical Canal — Tumefaction and Incarceration of the Anterior Lip — Carcinoma of the Cervix — Thrombus of the Vagina and Vulva — Cystocele — Rectocele — Vesical Calculus — Diffuse Swelling — Unyielding Hymen — Uterine Polypi — Ovarian Tumors — Rigidity of the Perineum.

Chapter XII. Parturient Anomalies Referable To The Maternal

OSSEOUS STRUCTURES, 478

Deformities of the Pelvis — Large Pelvis — Symmetrically-contracted Pelvis — Flattened Pelvis — Flattened, Generally Contracted Pelvis — Irregular Rachitic and Malacosteon Pelvis — Oblique Oval Pelvis — Flattening of the Pelvis — Exaggerated Curve of the Sacrum — Funnel-shaped Pelvis — Infantile Pelvis — Deformities from Spinal Curvature — The Anchylotic, Transversely-contracted Pelvis — Spondylolisthetic Pelvis — Osteosarcoma and Exostosis — Other Osseous Tumors and Projections — The Chief Causes of Pelvic Deformities — Diagnosis — Influence of Pelvic Contraction on the Uterus During Pregnancy — Influence of Pelvic Contraction on Fatal Presentation — Influence of Pelvic Contraction on Labor-pains — Influence of Pelvic Contraction on the First Stage of Labor— Effect of Pressure on the Soft Pelvic Tissues— Effect of Pressure on the Child's Head — Prognosis — Treatment — Induction of Abortion in Extreme Deformity — Induction of Premature Labor in Deformed Pelvis — When is Interference During Labor Advisable? — Traction Force Applied After Version, with Results — The Forceps and Version Compared — Cases in which a Full-term Living Child Cannot be Born, but Delivery through the Natural Passages is Advisable — Cases wherein Extraction Through the Natural Passages Appears to be Impossible.