{"1": {"fulltext": "*ll}#-.", "height": "4464", "width": "2456", "jp2-path": "obstetricsmanual00evan_0001.jp2"}, "2": {"fulltext": "Book__E3\\nGpightN\\nCQEaaGur osposm", "height": "3696", "width": "2472", "jp2-path": "obstetricsmanual00evan_0002.jp2"}, "3": {"fulltext": "", "height": "3704", "width": "2456", "jp2-path": "obstetricsmanual00evan_0003.jp2"}, "4": {"fulltext": "", "height": "3672", "width": "2472", "jp2-path": "obstetricsmanual00evan_0004.jp2"}, "5": {"fulltext": "", "height": "3712", "width": "2440", "jp2-path": "obstetricsmanual00evan_0005.jp2"}, "6": {"fulltext": "Lea s Series\\nof Pocket Text-Books.\\nDiseases of the Eye, Ear\\nNose and Throat.\\nByW. ly. Ballknger.M.D ,L,ecturer\\non Rhinology and Laryngology, and\\nA. G.WippERN, M.D., Clinical Instruc-\\ntor in Diseases of the Nose and Throat,\\nCollege of Physicians and Surgeons,\\nChicago.\\nAnatomy.\\nBy Frederick J. Brockway, M.D.,\\nAssistant Demonstrator of Anatomy,\\nCollege of Physicians and Surgeons,\\nNew York.\\nBacteriology and Hygiene.\\nBy W. E. Coaxes, Jr., M.D., Instruc-\\ntor in Bacteriology and Pathology,\\nCollege of Physicians and Surgeons,\\nChicago.\\nDiagnosis.\\nBy C. P. Collins, M. D., Attending\\nPhysician to St. L,uke s Hospital, New\\nYork.\\nPhysiology.\\nBy H. D. Collins, M. D., Assistant\\nDemonstrator of Anatomy, and W. H.\\nRockwell, Jr., A. B M. D., Assistant\\nDemonstrator of Anatomy, College of\\nPhysicians and Surgeons, New York.\\nGynecology.\\nBy Montgomery A. Crockett,\\nA. B., M. D., Adjunct Professor of Ob-\\nstetrics and Clinical Gynecology. Med-\\nical Department, University of Buffalo,\\nNew York.\\nObstetrics.\\nBy David J. Evans, M. D., Demon-\\nstrator of Obstetrics, McGill Univer-\\nsity, Faculty of Medicine, Montreal.\\nSurgery.\\nByBERNB. Gallaudet,M.D., Dem-\\nonstrator of Anatomy, and Clinical\\nLecturer on Surgery, College of Physi-\\ncians and Surgeons, New York.\\nDermatology.\\nBy Joseph Grindon, M. D., Pro-\\nfessor of Dermatology, St Louis and\\nMissouri Medical College, St. Louis.\\nGenito-Urinary and Venereal\\nDiseases.\\nBy Sylvan H. Likes, M.D., Demon-\\nstrator of Pathology and Genito-Uri-\\nnary Surgery at the College of Physi-\\ncians and Surgeons, Baltimore.\\nChemistry and Physics.\\nBy Walton Martin, M. D., Assist-\\nant Demonstrator of Anatomy, and\\nWilliam H. Rockwell, Jr., A. B.,\\nM. D., Assistant Demonstrator of\\nAnatomy, College of Physicians and\\nSurgeons, New York.\\nPractice of Medicine.\\nBy George E. Malsbary, M. D.,\\nAssistant to the Chair of Theory and\\nPractice of Medicine, Medical College\\nof Ohio, Cincinnati.\\nHistology and Pathology.\\nBy John B. Nichols, M. D., Assist-\\nant in Pathology, Medical Depart-\\nment, University of Georgetown, and\\nF. P. Vale, M. D., Demonstrator of\\nNormal Histology, Medical Depart-\\nment, Columbian University, Wash-\\nington, D. C.\\nNervous and Mental Diseases.\\nBy Charles S. Potts, M. D., In-\\nstructor in Electro- Therapeutics and\\nNervous Diseases in the University of\\nPennsylvania, Philadelphia.\\nMateria Medica.\\nBy William Schleif, Ph. G., M.D.\\nInstructor in Pharmacy in the Uni-\\nversity of Pennsylvania, Philadelphia.\\nCloth, $1.50, net.\\nDiseases of Children.\\nBy George M. Tuttle, M.D., At-\\ntending Physician to St. Luke s Hos-\\npital Martha Parsons Hospital for\\nChildren and Bethesda Foundling\\nAsylum, St. Louis, Mo.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0006.jp2"}, "7": {"fulltext": "tea s Series of Pocket Text-^ooks.\\n3ft\\nOBSTETRICS.\\nA MANUAL FOR STUDENTS AND PRACTITIONERS.\\nBY\\nDAYID JAMES EVANS, M.D.,\\nLedum- on Obstetrics and Diseases of Infancy, McOill University, Montreal, Canada;\\nFellow of the Obstetrical Society, London, England.\\nSERIES EDITED BY\\nBERN B. GALLAUDET, M.D.,\\nDemonstrator of Anatomy and Instructor in Surgery, College of Physicians and Surgeons,\\nColumbia University, Xeiv York Visiting Surgeon, Bellevue Hospitcd, New York.\\nILLUSTRATED WITH ONE HUNDRED AND FORTY-NINE\\nENGRAVINGS.\\nLEA BROTHERS CO.,\\nPHILADELPHIA AND NEW YORK.", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0007.jp2"}, "8": {"fulltext": "71414\\n^Libr^i S of Conav^ss\\nI \\\\fct liinu HtCHvED\\nI NOV 6 1900\\nICopynghl entry\\nStCVND COPY.\\nOl-tiv^rfld to\\nEntered according to Act of Congress, in the j ear 1900, by\\nLEA BROTHERS CO.,\\nIn the Office of the Librarian of Congress, at Washington. All rights reserved.\\nWESTCOTT THOMSON,\\nELECTROTYPERS, PHILADA.", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0008.jp2"}, "9": {"fulltext": "PREFACE\\nThe aim of the author in writing this pocket text-book\\nhas been to supply a short, concentrated treatise on the science\\nand art of obstetrics, a work that the student and junior\\npractitioner may find of use in attendance on lectures or in\\nevery-day practice.\\nThe physiology of pregnancy, of labor, and of the puer-\\nperium has been dealt with rather fully, before the considera-\\ntion of their pathology.\\nNormal labor and the more frequent difficulties have been\\ndwelt on at some length, while the rarer conditions and more\\ncomplicated operations have been described more in outline.\\nIn order to condense the work as far as possible the con-\\nsideration of the physiology and pathology of the newborn\\nhas been dispensed with, these subjects being discussed fully\\nin the volume on Pediatrics belonging to this series.\\nTo increase the practical usefulness of the book, a special\\neffort has been made to combine conciseness with clearness,\\nand to keep it within a convenient number of pages.\\nThe standard works on obstetrics have been largely drawn\\nfrom, particularly those of Jewett, Hirst, Playfair, etc.\\nThe author takes this opportunity to acknowledge his\\nindebtedness to Dr. F. Morley Fry for his advice and assist-\\nance in correcting proof, and to Dr. B. B. Gallaudet for his\\npainstaking work in editing the book.\\nMontreal, Canada.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0009.jp2"}, "10": {"fulltext": "", "height": "3712", "width": "2484", "jp2-path": "obstetricsmanual00evan_0010.jp2"}, "11": {"fulltext": "CONTENTS.\\nMENSTRUATION.\\nDefinition; cause; structural changes; onset; character; duration;\\nmenopause 17, 18\\nOvulation Graafian follicle ovum maturation of ovum corpus\\nluteum ovulation and menstruation 18-21\\nPREGNANCY (Normal).\\nEmbryology: Impregnation and conception; semen; fertilization\\nof the ovum development of the decidua reflexa vera\\nlayers of decidua; decidual cells; changes in the ovum de-\\nvelopment of the foetus segmentation blastodermic vesicle\\ncleavage development of the membranes amnion yolk-sac\\nallantois urachus umbilical cord chorion development of\\nthe placenta; structure; villi; capillaries; placenta and mem-\\nbranes at term functions of placenta ovum at different periods\\nof pregnancy; foetal circulation 21-38\\nChanges in Maternal Organism Uterus increase in size\\nchanges in shape and structure relation to pelvis and abdomen\\nalterations in cervix, vagina, and vulva changes in breasts\\nalterations in other than the generative organs linese albicantes 38-44\\nDuration of Pregnancy Date of fruitful coitus rule for deter-\\nmining height of fundus uteri date of quickening 44, 45\\nDiACiNOSTS OF Pregnancy First trimester suppression of men-\\nstruation nausea and vomiting mammary changes vesical\\nirritation nervous disorders softening of cervix violet dis-\\ncoloration of vagina softening and enlargement of body of\\nuterus; second trimester: foetal movement; uterine souffle;\\nfoetal heart-sounds pigmentation ballottement third tri-\\nmester: pressure-symptoms; varices; disturbances of respiration\\nand digestion foetal movements; strise; settling; summary of\\n5", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0011.jp2"}, "12": {"fulltext": "6 CONTENTS.\\nPAGE\\ndiagnosis differential diagnosis of pregnancy diagnosis of\\nparity or nulliparity diagnosis of life or death of child 45-54\\nHygiene and Managemp:nt of Pregnancy Diet exercise\\nclothing bathing care of breasts care of other organs and\\nfunctions examination 54-56\\nOBSTETRIC ANATOMY.\\nAnatomical Elements in Labor 56,57\\nThe Uterus Walls muscle-fibres uterine segments ligaments\\nperitoneum relation of full-term uterus to contiguous structures 57-61\\nThe Pelvi-genital Canal Bony pelvis general description\\njoints mobility of pelvic joints false and true pelvis inlet\\nsuperior strait inferior strait outlet cavity of pelvis lat-\\neral grooves; planes of pelvis pelvic diameters; conjugate;\\ntransverse; oblique; measurements; inclination of the pelvis;\\nsoft parts of the pelvic canal muscles rectum pelvic floor\\nsegments of floor fascia perineum parturient axis other\\naxes 61-76\\nThe Foetus Mature foetus the head vault base sutures\\nfontanelles; obstetric landmarks diameters of foetal head cir-\\ncumferences of planes of foetal head moulding of head im-\\nportance of flexion of head foetal trunk diameters mobility\\nof head and trunk posture of foetus presentations cephalic,\\npelvic, somatic positions vertex, face, breech, shoulder\\ncentre of gravity of foetus foetal movements 76-96\\nMECHANISM AND COURSE OP NORMAL LABOR.\\nGeneral Definitions and Etiology: Eutocia uncomplicated\\nvertex presentations primigravida primipara multipara\\nstages of labor; duration of normal labor causes of the onset\\nof labor forces of labor uterine contractions pains retrac-\\ntion polarity; contraction of abdominal muscles and dia-\\nphragm; gravity 96-102\\nLabor First Stage Premonitory signs and symptoms charac-\\nteristic signs and symptoms of the onset of labor mechanism\\nof the first stage dilatation of cervix hydrostatic pressure of\\nthe bag of waters action of longitudinal fibres of uterus rupt-\\nure of membranes presenting part of foetus as dilator dry\\nlabors; os uteri; initial labor-pains; reflex vomiting; anatomy\\nof soft parts 102-107", "height": "3736", "width": "2472", "jp2-path": "obstetricsmanual00evan_0012.jp2"}, "13": {"fulltext": "CONTENTS. 7\\nPAGE\\nLabor Second Stage Mechanism head movement descent\\nflexion internal rotation extension restitution or external\\nrotation; delivery of the trunk; pains; sufferings of woman;\\nafter the birth of the child moulding of the foetal head\\ncaput succedaneum anatomy 107-116\\nLabor Third Stage: Separation of placenta; separation of\\nmembranes expulsion of placenta and membranes retro-\\nplacental hemorrhage completion of labor blood lost in\\nlabor 116-118\\nMANAGEMENT OF NORMAL LABOR.\\nObstetric Antisepsis: Antiseptic agents; chemical antiseptics;\\nthe obstetrician methods of sterilizing hands the nurse\\nthe patient 119-123\\nPreparations for Labor On the part of the physician\\nobstetric bag and contents; labor-room; linen vulvar pads;\\nbinders labor-bed aneesthetics in labor 124-127\\nManagement of the First Stage: Preliminary conduct of\\nthe physician obstetric examination palpation auscultation\\nvaginal examination succeeding the examination rupture\\nof membranes 128-136\\nManagement of the Second Stage: Position; in rapid cases;\\nansestliesia; perineal stage; laceration of perineum; at\\nmoment of delivery delivery of head delivery of shoulders\\nimmediate care of child; the cord 137-140\\nManagement of the Third Stage To insure firm uterine\\ncontraction lacerations expulsion of placenta Crete s\\nmethod of expression; retraction of uterus; final measures .141, 142\\nTHE PUERPERAL STATE.\\nAnatomy of the Parts immediately after Labor The\\nuterus; vagina; vulva; bladder; peritoneum; abdominal\\nwalls 143-145\\nPhysiology of the Puerperal Period Livolution circula-\\ntory system urinary system skin digestive apparatus\\nlactation; mammary glands; colostrum; milk 145-150\\nManagement of the Puerperium: Lying-in room genitalia;\\ncare of breasts nursing nipples contraindications to suck-\\nling after-pains; visits of the physician; infant s tempera-\\nture 150-154", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0013.jp2"}, "14": {"fulltext": "CONTENTS.\\nPATHOLOGY OF PREGNANCY.\\nPAGE\\nThe Dkcidua Acute and chronic decidual endometritis; atrophy 154-156\\nThe Fcetal Appenda(;es: Oligohydramnios; hydramnios\\namniotic bands; premature rupture of amnion; alterations in\\ncharacter of liquor amnii vesicular mole anomalies of pla-\\ncenta diseases of placenta placental apoplexy placentitis\\ntumors and oedema of placenta abnormal length of cord\\ncoils and knots of cord hernia into cord 156-165\\nThe Fgetus Teratology foetal mortality elephantiasis ana-\\nsarca ichthyosis rachitis syphilis tuberculosis contagious\\ndiseases foetal death 165-169\\nPathology of the Pregnant Woman: Varices; oedema;\\npruritus leucorrhoea vegetations retroversion and prolapse\\nof uterus endocervicitis tumors mammary abscess exces-\\nsive secretion of milk; eczema of the nipples; gingivitis;\\ndental caries parotitis; ptyalism indigestion; constipation;\\ndiarrhoea vomiting pernicious vomiting uterus hemor-\\nrhoids irritability of the bladder haematuria albuminuria\\nkidney of pregnancy acute and chronic nephritis; cough;\\ndyspnoea; pneumonia; phtliisis cardiac disease; heart-mur-\\nmurs enlargement of thyroid gland neuralgia neuroses\\ninfectious diseases 169-188\\nToxemia Eclampsia: Symptoms; definition; frequency; pre-\\nmonitory symptoms the fit etiology pathological anatomy\\ntreatment 188-194\\nAbortion and Premature Labor Definition symptoms\\npathology etiology diagnosis treatment missed abor-\\ntion miscarriage missed labor 194-201\\nEctopic Gestation Definition frequency varieties tubal\\npregnancies terminations tubal abortion etiology path-\\nology symptoms treatment removal of sac technique of\\noperation 202-209\\nPATHOLOGY OP LABOR.\\nDystocia due to Malpositions of the Fgetus: Occipito-\\nposterior cases face presentations brow presentations breech\\npresentations arrest of breech at the brim rapid extraction\\nof trunk delivery of the after-coming head; transverse pres-\\nentations prolapse of the foetal limbs plural births 209-248", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0014.jp2"}, "15": {"fulltext": "CONTENTS. 9\\nPAGE\\nDystocia due to Anomalies of Fostal Development Over-\\ngrowth of foetus premature ossification of skull hydrocepha-\\nlus encephalocele meningocele hydrencephalus tumors of\\ntrunk anencephalus double monsters 248-253\\nDystocia due to Abnormalities of the Fgetal Appendages\\nShort cord prolapse of cord coiling of cord about foetal neck\\nplacenta prievia accidental hemorrhage premature separa-\\ntion of a normally situated placenta retained placenta ad-\\nherent placenta 253-268\\nMaternal Dystocia: Precipitate labor delayed labor; uterine\\ninertia anomalies of the pelvis pelvimetry anomalies of\\nuterine development; atresia and rigidity of cervix impaction\\nof anterior lip of cervix displacements of the uterus pro-\\nlapse abnormal conditions of vagina, vulva, and bladder;\\ntumors of genital canal and neighboring organs rupture of\\nuterus inversion of the uterus 268-312\\nPATHOLOGY OF THE PUERPERAL PERIOD.\\nHemorrhages during the Puerperium: Post-partum hemor-\\nrhage; secondary hemorrhage hsematoma 312-318\\nSubinvolution: Etiology; diagnosis; treatment 318-320\\nAnomalies and Diskases of the Nipples and Breasts\\nSupernumerary nipples inversion of the nipple absence of\\nmammae; hypertrophy of mammae supernumerary mammae;\\ndeficient milk-secretion polygalactia galactorrhoea engorge-\\nment of the breast sore nipples mastitis mammary abscess\\narrest of lactation 320 332\\nIntercurrent Diseases in the Puerperium Miscellaneous\\ndiseases; malaria; puerperal anaemia; hemorrhoids; diseases\\nof the urinary organs neuritis myelitis cerebral hemorihage\\nand embolism; puerperal insanity; sudden death; pulmonary\\nembolism and thrombosis entrance of air into uterine sinuses\\nfever other than septic puerperal septic infection 332-361\\nOBSTETRIC OPERATIONS.\\nEpisiotomy immediate repair of vaginal and perineal lacerations\\nimmediate repair of cervical lacerations induction of abor-\\ntion induction of premature labor forceps operations ver-\\nsions external, bipolar, internal version symphysiotomy\\nCaesarean section Porro operation general rules governing\\nselection of obstetric operations embryotomy 361-417", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0015.jp2"}, "16": {"fulltext": "", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0016.jp2"}, "17": {"fulltext": "OBSTETRICS.\\nMENSTRUATION.\\nMenstruation is a periodic discharge of blood and mucus\\nfrom the uterus and the Fallopian tubes of the woman during\\nthe period of sexual activity i. e., from puberty to the meno-\\npause.\\nThe cause of menstruation is unknown. Many theories have\\nbeen advanced but all that can be said is that nervous influences\\nproceeding from the sympathetic nerve-ganglia in the lower\\nabdomen and pelvis periodically bring about a condition of\\ncongestion of the sexual organs.\\nIt is presumed that the function is analogous to rut in the\\nlower animals, and that from the erect posture of the woman,\\nthe pelvic congestion results in bloody discharge.\\nStructural changes According to Leopold, the intra-uterine\\nmucous membrane becomes thickened and softened almost to\\nliquefaction, but remains practically intact throughout, while\\nit is quite distinct from the j)aler muscular tissue of the uterus.\\nThe uterine glands are swollen and lengthened. In the super-\\nficial portion of the endometrium is an enormously distended\\nnetwork of capillaries. As the venous return is slower than\\nthe arterial supply, there occurs a diapedesis of blood. This\\nblood, along with an excess of mucus from increased activity\\nof the uterine glands, forms the menstrual discharge.\\nThe onset of menstruation, or puberty, varies in different\\ncountries, occurring earlier in southern than in northern cli-\\nmates. Generally in temperate climates it appears about the\\nfourteenth year. It is more likely to come on earlier in city-\\nbred than in country-bred girls.\\nCharacter of the flow: The flow is chiefly composed of\\nblood, but also contains mucus and epithelial detritus.\\nIt has a peculiar odor, which is more marked in brunettes\\n2\u00e2\u0080\u0094 Obst. 17", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0017.jp2"}, "18": {"fulltext": "1 8 MENSTR IJA TION.\\nthan in blondes, and is caused by secretions from the sebaceous\\nglands at the vaginal outlet.\\nThe discharge is dark in color, as a rule does not clot, and is\\nalkaline in reaction.\\nDuration and quantity: Menstruation lasts from three to\\nseven days. As a rule, it occurs every twenty-eight days.\\nThe actual quantity of the discharge is from four to six\\nounces.\\nMenopause Menstruation ceases in the forty-fourth year\\nusually but there are many exceptions. As a rule, a woman\\nmenstruates during a period of about thirty years.\\nThe cessation of menstruation is termed the vnenopause or\\nclimacteric.\\nOvulation By this term we designate the process of forma-\\ntion, development, and discharge of a mature ovum from its\\nGraafian follicle in the ovary.\\nThe Graafian follicle is derived from the germinal epithelium\\non the surface of the ovary. These cells, becoming isolated in\\nthe stroma of the ovary, develop a special containing mem-\\nbrane from the theca folliculi, which becomes divided into two\\nlayers, the tunica fibrosa and the tunica propria. The epi-\\nthelial cells develop and line this membrane, forming the mem-\\nhrana granulosa, and a fluid, the liquor folliculi, distends the\\ncavity.\\nOne of the epithelial cells of the membrana granulosa be-\\ncomes more highly specialized, the ovum, and is surrounded by\\nan aggregation of cells, the discus proligerus (Fig. 1).\\nIt has been calculated that at birth each ovary contains\\n35,000 immature follicles. These do not develop till about the\\ntime of puberty, when one or more rapidly mature and rupt-\\nure. The escape of its contents takes place each month, the\\nprocess being repeated.\\nAs the follicle matures it approaches the surface of the ovary,\\nthe liquor folliculi increases till it points at the surface, rupt-\\nures the tunica propria and washes out the ovum surrounded\\nby its discus proligerus.\\nThe ovum is then swept into the fimbriated extremity of the\\nFallopian tube, through \\\\vhich it passes into the cavity of the\\nuterus.", "height": "3712", "width": "2500", "jp2-path": "obstetricsmanual00evan_0018.jp2"}, "19": {"fulltext": "MENSTRUATION.\\n19\\nThe ovum The immature ovum is a simple epithelial cell\\nwithout a cell-wall, but haviug cell-contents i. e.y the yolk, a\\nnucleus termed the germinal vesicle, and a nucleolus called the\\ngerminal spot (Fig. 2). It early develops two walls, the outer,\\ntermed the vitelline membrane the inner, the cell-membrane.\\nBetween these walls is a clear area, termed the zona pellucida.\\nAs the ovu7n matures previous to its escape from the Graafian\\nfollicle its germinal spot approaches the cell-membrane, where\\nFig. 1.\\nPS KE PS\\nDevelopment of the Graafian follicle KE, germinal epithelium, from which\\nPfliiger s tubes. PS, in ovarian stroma are developed So, ovarian stroma; g,g, small\\nvessels L\\\\ U, primitive ova S, space between membrana granulosa and ovum Lf,\\nliquor folliculi B, discus proligerus Ei, ripe ovum, with germ-vesicle and ger-\\nminal spot (K) Mp, membrana pellucida 3y, muscular sheath of follicle Mg, mem-\\nbrana granulosa. (Wiedersheim.)\\nit seems to disappear, and a portion of the ovum is extruded,\\nknown as the first polar body. After a stage of quiescence\\nthe process is repeated, and a second polar body is extruded.\\nThen appears a new and smaller germinal spot, termed the\\npronucleus.\\nWhen these phenomena have taken place the ovum is mature\\nand the Graafian follicle ruptures.", "height": "3712", "width": "2452", "jp2-path": "obstetricsmanual00evan_0019.jp2"}, "20": {"fulltext": "20\\nMENSTRUATION.\\nThe corpus luteum After the escape of the ovum the rupt-\\nured Graafiau follicle becomes filled with blood, which clots\\naud a fiue capsule develops around it, which gradually becomes\\nthickened and thrown into folds. This formation is termed the\\ncorpus liUcum, from its yellow color. Should pregnancy not\\noccur by the twenty-eighth day it shows on the surface of the\\novary merely as a fibrous lamina in a little pit.\\nBut in pregnancy J from the prolonged congestion, the corpus\\nluteum has a much greater development. Forty days after\\nFig. 2.\\nTriangular bit of ovarian stroma cut from ovary Magnified to show Graafian\\nfollicle and ovule: 1, epithelial covering of ovary; 2, tunica albuginea (fibrous);\\n3, different parts of stroma 4, Graafian follicle (tunica fibrosa) 5, Graafian vesicle\\nor ovisac 6, 6, tunica granulosa 7, liquor folliculi 8, vitelline membrane, or zona\\npellucida; 9, granular vitellus, or yolk; 10, germinal vesicle 11, germinal spot.\\nconception it has a diameter of about two-thirds of an inch\\n(1.5 cm.). At term it is still present, has shrunk to half an\\ninch (1 cm.) in diameter, and is of a distinct lemon-yellow\\ncolor. A month after delivery it is reduced to a small mass\\nof fibrous tissue.\\nOvulation and menstruation Neither ovulation nor menstru-\\nation is dependent on the other.\\nBoth depend on the same cause, a periodic nervous excita-", "height": "3728", "width": "2472", "jp2-path": "obstetricsmanual00evan_0020.jp2"}, "21": {"fulltext": "IMPREGNATION AND CONCEPTION.\\n21\\ntion and congestiou. As a rule, they do occur synchronously;\\nbut Leopold has proved that ovulation has taken place in the\\nintermenstrual period.\\nPregnancy has been known to take place before the onset\\nof menstruation and after the climacteric.\\nPREGNANCY (Normal).\\nEMBRYOLOGY.\\nImpregnation and Conception.\\nThe propagation of the species requires the union of the\\nvital elements of the two sexes.\\nIn the act of copulation the male deposits within the female\\na fluid, the semen, which contains the vitalizing element.\\nThe semen is a white, viscid, dense fluid having a peculiar\\nodor, secreted by the testicles of the male. It consists of water,\\nalbuminous matter, salts of lime and sodium, and contains\\nnumerous peculiar organisms called spermatozoids.\\nThese spermatozoids form the essential fecundating part of\\nthe semen, are about -g-J-g- inch in length, and resemble the tadpole\\nof the frog. Each one is mad^ up of three parts head, middle\\npiece, and tail, and is capable of very rapid vibratory move-\\nment (Fig. 3).\\nAfter emission, if in proper surroundings,\\nthe organisms retain their vitality for a con-\\nsiderable time. Excessively acid or alka-\\nline fluids destroy them.\\nWhile pregnancy has been known to\\nfollow the deposition of semen on the ex-\\nternal genitals of the female, as a rule,\\nthe acid mucus of the lower vagina proves\\nfatal to the spermatozoids.\\nAt the crisis of the sexual act the semen\\nis usually deposited in the upper portion of\\nthe vagina, into which the cervix projects.\\nHence the spermatozoids find their way into\\nthe cavity of the uterus, and ultimately reach the Fallopian\\ntubes. They have been found on the surface of the ovary.\\nFig. 3.\\nSpermatozoids.", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0021.jp2"}, "22": {"fulltext": "22\\nPREGNANCY.\\nAs a rule, the meeting-place of the spermatozoids aod ovum\\nis in the Fallopian tube. Many claim that the normal place\\nof meeting is the upper })oition of the uterine cavity and it\\nis not infrequent that they come in contact on the surface of\\nthe ovary or in the abdominal cavity (ectopic gestation). If\\nthe ovum is discharged at the height of the menstrual conges-\\ntion, it probably does not reach the cavity of the uterus ibr\\nsome days. Hyrtle found the ovum in the uterine extremity\\nof the tube in a girl who had died on the fourth day of men-\\nstruation.\\nPregnancy is more likely to occur after copulation during the\\nfirst eight days succeeding the cessation of menstruation.\\nFertilization of the ovum Of the large number of sper-\\nmatozoids deposited in the vagina, but few probably come into\\nFig. 4.\\n\u00e2\u0080\u009e^-^r/\\nFormation of polar globules in arteria glacialis Sp, nuclear spindle; Pfir, first\\npolar globule Spg, second polar globule; J p, female pronucleus. (After 0. Hert-\\nwig.)\\ncontact with the ovum and of these, but a single spermatozoid\\nactuallv takes part in the fertilization of the ovum.\\nBy friction with the walls of the tube the cells of the discus\\n])roligerus disappear and the zona pellucida becomes surrounded\\nwith an albuminous covering which seems to attract the sper-\\nmatozoid.\\nThe successful spermatozoid, after penetrating the zona pel-", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0022.jp2"}, "23": {"fulltext": "DEVELOPMENT OF THE DECIDUA. 23\\nlucida, comes in contact with a projection of the protoplasm of\\nthe ovum and its tail disappears. The head then penetrates\\nthe cell-contents and disappears, to reappear subsequently as a\\nsmall round body, the male j^i onucleus (Fig. 4). Finally the\\nmale pronucleus and the female pronucleus unite, and concep-\\ntion has occurred. Thus the life-history of the embryo, foetus,\\nand infant begins.\\nDevelopment of the Decidua.\\n\\\\Yhile the above-described processes have been taking place,\\nleading to the fecundation of the ovum, preparations have been\\nin progress for the latter s reception and nourishment within\\nthe uterine cavity.\\nThe mucous membrane lining the body of the uterus becomes\\nmuch increased in thickness, its glands enlarging in ail dimen-\\nsions. The lining membrane of the uterus during pregnancy\\nis termed the decidua.\\nThe ovum when it reaches the uterus thus finds that a soft\\nbed has been prepared for it. It soon settles and becomes\\nadherent, as a result of certain amoeba-like projections (villi)\\nwhich have formed on its surface.\\nThe ovum once fixed, the decidua proceeds to grow up\\naround it, completely imbedding it and thus shutting it off\\nfrom the uterine cavity.\\nSubdivisions of the decidua The decidua lining the uterine\\ncavity is termed the decidua vera that portion on which the\\novum has come to anchor, the site of the future ]}lacenta, is\\ncalled the decidua serotina while that portion which grows\\nup and surrounds the ovum is named the decidua reflexa\\n(Fig. 5).\\nCoalescence of reflexa and vera As the ovum grows and\\ndistends tlie uterus, the decidua reflexa comes in contact with\\nthe decidua vera throughout. As a result of pressure the\\nouter layers of both reflexa and vera then undergo consider-\\nable atrophy. This takes place about the fourth month of\\ngestation.\\nLayers of the decidua: The development of the decidual\\nglands leads to certain changes in the conformation of the\\ndecidua. These glands, dilated and straight toward the sur-", "height": "3688", "width": "2496", "jp2-path": "obstetricsmanual00evan_0023.jp2"}, "24": {"fulltext": "24\\nPREGNANCY.\\nface, become more dilated and tortuous as they pass downward\\nto the muscular uterine wall. As a result, on section the\\ndecidua can be seen to be composed of layers of differing com-\\npactness.\\nThe superficial layer is quite compact. Below this is a\\nlayer which, on section, has a reticulated appearance, the so-\\nFiG. 5.\\nSemi-diagrammatic outline of an anteroposterior section of the gravid uterus\\nand ovum of five weeks n, anterior uterine wall h, posterior uterine wall c, de-\\ncidua vera d. decidua reflexa e, decidua serotina ch, chorion with its villi.\\n(Modified from Allen Thomson.)\\ncalled spongy layer, or ampullary stratum while below this\\nagain, in contact witli the muscle- wall of the uterus, is a com-\\npact layer termed the stratura compadum (Fig. 6).\\nThe spongy layer is of prime importance, for it is through", "height": "3708", "width": "2484", "jp2-path": "obstetricsmanual00evan_0024.jp2"}, "25": {"fulltext": "CHANGES IN OVUM DEVELOPMENT OF FCETUS. 25\\nthis layer that the line of separation runs, when the decidua sero-\\ntina and the decidua vera are cast off with the placenta and\\nmembranes at the conclusion of labor.\\nIn fact, the decidua may be compared to a cake, which is\\ncomposed of two compact layers, between which is a layer of\\njam. If the attempt is made to separate these two layers of\\ncake, the line of separation will run through the jam (which\\nFig. 6.\\nSection through the decidua: a, amnion h, chorion c, decidua d, uterine\\nmuscle e, line of separation in the cellular layer cellular layer g, glandular\\nlayer. (Friedlander.)\\ncorresponds to the spongy layer of the decidua), a considerable\\nportion of which w^ill come away adhering to the top layer of\\nthe cake, while some of it will still be left on the lower layer.\\nDecidual cells Not only do the glands of the decidua\\nhypertrophy, but the interglandular structure as well and in\\nit are developed large epithelioid cells, known as decidual cells.\\nIn microscopic sections of placenta or membranes these cells\\nare characteristic of decidual tissue.\\nChanges in the Ovum; Development of the Foetus.\\nThe impregnated ovum is at first a simple cell.\\nIts wall is the vitelline membrane its contents, the granular\\nvitellus, or yolk, and a nuclem which latter is a complex", "height": "3712", "width": "2368", "jp2-path": "obstetricsmanual00evan_0025.jp2"}, "26": {"fulltext": "26\\nPREGNANCY.\\nstructure formed, as we have seen, of the male and female\\npronuclei, and the remains of the germinal vesicle.\\nTlie next change is known as segmentation First the\\nnucleus divides, then the yolk, thus forming two complete\\ncells within the vitelline membrane. These two cells then\\ndivide into four, these four into eight, and so on, until a great\\nnumber have been formed (Morula stage; Fig. 7).\\nDiagram showing first stages of segmentation in a mammalian ovum.\\nThompson, after E. van Beneden.)\\n(Allen\\nThe first division results in two cells, which differ somewhat\\nboth in size and appearance. This difference is perpetuated,\\nso that as a result of their further division two groups of cells\\ndiffering in size and appearance are formed.\\nThe larger are termed epiblastic cells, and the smaller hypo-\\nblastic cells.\\nThe blastodermic vesicle These two sets of cells then ar-\\nrange themselves in a special manner; the epiblastic cells com-\\npletely surrounding the hypoblastic cells, which collect in a", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0026.jp2"}, "27": {"fulltext": "CHANGES IN OVUM; DEVEL0P3IENT OF FCETUS. 27\\nFig. 8.\\nTwo further stages following segmentation (rabbit s ovum) ep, epiblast\\nhy, hypoblast; ftp, opening in epiblast (blastopore) not yet closed; in B, this open-\\ning has closed.\\nroughly spherical mass (Fig. 8). Between these two layers of\\ncells a little albuminous fluid begins to accumulate, separating\\nthem from one another except at one spot. The fluid rapidly\\nFig. 9.\\nzp, zona pellucida ep, epiblast hy, hypoblast hv, cavity of blastodermic vesicle.", "height": "3700", "width": "2368", "jp2-path": "obstetricsmanual00evan_0027.jp2"}, "28": {"fulltext": "28 PREGNANCY.\\ncollects, and the ovum now forms a distended vesicle, termed\\nthe blastodermic vesicle.\\nAt this stage the epiblastic cells completely line the blasto-\\ndermic vesicle, while the mass of hypoblastic cells having\\nbecome distended by the accumulation of fluid is flattened and\\npressed out over a small area of the epiblastic cell-lining, the\\ncentral portion being thicker than the periphery (Fig. 9).\\nThis thicker part is the commencement of the embryonic area.\\nIt is only this part of the blastodermic vesicle which is con-\\ncerned in the formation of the embryo the remaining portion\\nbeing the non-embryonic part, and concerned only in the for-\\nmation of the amnion and the umbilical vesicle, as we shall see\\nlater.\\nThe primitive epiblastic cells peripheral to the thickened layer\\nof hypoblastic cells now disappear, leaving this portion of the\\nFig. 10.\\nTransection of eighteen-hour chick embryo, showing beginning of medullary\\ngroove and the three layers: a, ectoderm; b, mesoderm; c, entoderm. (Manton\\ncollection.)\\nwall (if one could look, as it were, through the vitelline mem-\\nbrane) somewhat clearer (area pellucida).\\nThe hypoblastic cells now appear as a darker streak in the\\narea pellucida, termed the primitive streak which then devel-\\nops with a groove known as the primitive groove, which is the\\nfirst evidence of the formation of the embryo, indicating, ap-\\nproximately, the position of the future vertebrae.\\nCleavage of the hypoblastic cells If a section be made through\\nthis streak, or groove, at this period (Fig. 10), the hypoblastic\\ncells will be found to have separated into two layers, termed\\nrespectively the ectoderm (permanent epi blast) and the ento-", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0028.jp2"}, "29": {"fulltext": "DEVELOPMENT OF THE MEMBRANES.\\n29\\nderm (permanent hypoblast) while between them another\\nlayer has formed, derived in part from both, termed the mesO\\ndenn (mesoblast).\\nCleavage of the mesoderm In the course of time this meso-\\nderm develops lateral reduplications and divides into two layers,\\nthe parietal and the visceral layers, inclosing spaces. The\\nparietal layer unites with the ectoderm to form the somato-\\npleure and the visceral layer unites with the entoderm to form\\nthe splanchnopleure.\\nThe space included between the two leaves of the cleft meso-\\nderm is the primitive body-cavity, or coelom, which afterward\\nbecomes the pleuroperitoneal cavity.\\nDevelopment of the Membranes.\\nThe amnion The embryo now sinks toward the centre of\\nthe ovum, and as it does so the somatopleure grows up all\\nFig. 11.\\nFig. 12.\\nZP\\nFig. 11.\u00e2\u0080\u0094 7f. head of embryo pp, tail-portion of pleuroperitoneal cavity; amc,\\ntail-portion of primitive amniotic cavity the pr/??i?Y/ce amniotic cavity is the hollow\\nspace inside the double folds that rise over the back of the foetus^ a.t.f., tail-fold of\\namnion ahf. head-fold of amnion *o. somatopleure sp. splanchnopleure fa, false\\namnion hy. hypoblast at, alimentary canal, communicating with cavity of uv, the\\numbilical vesicle ZP, zona pellucida .4, commencing projection of allantois.\\nFig. 12.\u00e2\u0080\u0094 The amniotic folds have united, inclosing amc.t, the true amniotic\\ncavity /a. false amnion, whose cavity nmc, mric.p, is continuous with the pleuroperito-\\nneal cavity: at, alimentary canal, still communicating with uv, the umbilical ves-\\nicle; A, stem of allantois dilating into a vesicle at x hy, hypoblast sp, splanchno-\\npleure, composed of mesoblast and hypoblast, and continuous with splanchnopleure\\nof intestine ZP, zona pellucida.\\naround it, while the splanchnopleure sinks with it. These\\nsomatopleuric folds thus present two surfaces, one looking", "height": "3712", "width": "2372", "jp2-path": "obstetricsmanual00evan_0029.jp2"}, "30": {"fulltext": "30 PREGNANCY.\\ntoward the embryo, the otlier toward the outer surface of the\\novum (Fig. 11).\\nAs those folds meet over the back of the embryo they coa-\\nlesce, and thus form two distinct membranes (Fig! 12). The\\ninner membrane, that next the embryo, forms a complete\\nsac, the amniotic sac% having its origin close to the cephalic and\\ncaudal ends. This membrane is termed the amnion, and its\\ninner surface is derived from the epiblast, and is continuous\\nwith the skin of the embryo, which is also epiblastic.\\nThe outer membrane, which has its outer surface composed\\nof epiblastic cells, then retires toward the outer surface of the\\novum, to form the chorion.\\nPrimitive gut- and yolk-sac While these changes are in\\nprogress in the somatopleure, the splanchnopleure, sinking\\ntoward the centre of the ovum along with tlie embryo, com-\\npletely envelops the yolk. By bending sharply inward at a\\npoint some distance from its origin the splanchnopleure forms\\na second canal, which is thus lined with hypoblast. The upper\\ncanal eventually becomes the alimentary tract while the lower\\nis the yolk-sac (Figs. 11-14). This latter gradually disappears,\\nthough it sometimes persists as a blind sac leading from the\\nileum, known as Meckel s diverticulum.\\nThe allantois A portion of the splanchnopleure forming the\\nwall of the primitive intestine very early buds outward, projects\\ninto the pleuroperitoneal cavity, and approaches the chorion.\\nThis is termed the allantois in its substance the foetal blood-\\nvessels develop (Figs. 11-14). These allantoic bloodvessels\\nline the chorion and dip down into the villi.\\nThe urachus In the course of development, that part of the\\nallantois in connection with the body becomes obliterated. A\\npart forms the urinary bladder, while a portion of it persists\\nas a fibrous cord running from this viscus to the umbilicus,\\ntermed the urachus.\\nThe umbilical cord Both the yolk-sac and the allantois are\\nat one time included in the tube formed by the meeting to-\\ngether of the amnion on the ventral aspect of the embryo,\\ntermed the abdominal stalk, which becomes the umbilical cord.\\nThe chorion is the permanent outer membrane of the ovum,\\nand is formed, as we have seen, from the somatopleuric layer,\\nits outer surface being epiblastic and its inner mesoblastic.", "height": "3732", "width": "2472", "jp2-path": "obstetricsmanual00evan_0030.jp2"}, "31": {"fulltext": "DEVELOPMENT OF THE PLACENTA.\\n31\\nThe whole superficial area of the chorion soon becomes cov-\\nered with little projections, termed rdUi, which dip down into\\nand soon become attached to the decidoa (serotina and reflexa)\\nat all points of contact.\\nEach villus thus has an outer surface of epiblastic tissue,\\nw^hile its core is formed of mesoblast. These villi, as we have\\nseen, receive a vascular equipment from the allantois, though\\nthe more recent view is that the capillaries are simply formed\\nfrom the mesoblastic tissue of the chorion. Subsequently those\\nFig. 13.\\nFici. 14.\\nFig. 13.\u00e2\u0080\u0094 to, true amnion, its cavity, amc.t, beginning to extend with liquor\\namnii fa, false amnion, its cavity, amc, continuous witli pleuroperitoneal cavity\\nso.s, folds of true amnion bulging over abdomen and beginning to form sheath over\\nstems of umbilical vesicle and allantois uv, umbilical vesicle zp, zona pellucida;\\nA, allantois its stem is hollow and continuous with cavity of alimentary canal at\\nX it is dilating into a vesicle lined Avith hypoblast.\\nFig. W.\u00e2\u0080\u0094A, allantois, its cavity now obliterated, it has spread all around, and\\njoined subzonal membrane (composed of false amnion and vitelline membrane)\\nto form chorion uv, remnant of umbilical vesicle; at, alimentary canal; o, dilated\\nroot of allantois within abdomen, to form urinary bladder and urachus w, com-\\nmencing infolding of epiblast to join cavity of alimentary canal, and form mouth\\nand buccal cavity a similar notch at the caudal end of the embryo indicates site of\\nfuture anal opening so.s, folds of true amnion forming sheath of navel string, and\\ninclosing root of allantois and stem of umbilical vesicle. (The other letters have\\nsame reference as in Fig. IB.)\\nvilli in contact with the serotina undergo rapid development\\nand proliferation, forming the chorion frondosum while those\\nin contact with the reflexa, termed chorion Iceve, retrograde and\\nfinally atrophy.\\nDevelopment of the Placenta.\\nStructure The placenta is chiefly composed of foetal tissue,\\nthe chorion frondosum but the superficial layer of decidua", "height": "3708", "width": "2372", "jp2-path": "obstetricsmanual00evan_0031.jp2"}, "32": {"fulltext": "32\\nPREGNANCY.\\nserotina separates with it, and forms its maternal surface.\\nThus the placenta is partly foetal and partly maternal, both in\\norigin and structure.\\nThe villi forming the chorion frondosum are simply tufts of\\nfoetal capillaries covered with two or more layers of embryonal\\nconnective tissue derived from the epiblast, the outermost layer\\nbeing termed the syncitium from its peculiar phagocytic func-\\ntion.\\nThese villi branch in every direction, and, coming into con-\\ntact with the uneven surface of the decidua serotina, often\\nappear on section to have actually dipped down into it but\\nthis is only apparent, and does not really occur (Fig. 15).\\nFig. 15.\\nScheme of placental attachments: Am, amnion; Ch, chorion; V, villi; S,\\ndecidua serotina: D,ic., subchorionic decidua: T\\\\, villi attached to serotina; A,\\nmaternal artery V2, maternal vein. (After Eden.)\\nThe maternal capillaries in the superficial layer of the\\nserotina become enormously distended with blood, thus forming\\nsinuses.\\nThrough the probable phagocytic action of the syncitial\\nmasses on the villi the superficial layer of the serotina and the\\nwalls of the maternal capillaries are in time absorbed, thus\\npermitting the maternal blood to escape into the intervillous\\nspaces.", "height": "3736", "width": "2472", "jp2-path": "obstetricsmanual00evan_0032.jp2"}, "33": {"fulltext": "PLACENTA AND MEMBRANES AT TERM. 33\\nThe foetal villi are then in direct contact with the maternal\\nblood are bathed in it; but there is no actual connection\\nbetween the foetal and maternal circulations, as the walls of\\nthe foetal villi and their coverings are still interposed.\\nThe maternal blood is carried through the decidua by means\\nof spiral twigs derived from the uterine arteries and is carried\\naway by veins having an oblique direction toward the perito-\\nneal layer of the uterus.\\nThis formation of the arteries and veins in the decidua\\nresults in the absolute cutting off of the blood-supply, when\\nuterine retraction and contraction bring about the expulsion\\nof the placenta at birth.\\nPlacenta and Membranes at Term.\\nThe placenta at term e., the end of the period of preg-\\nnancy is a soft, spongy, vascular mass, circular in outline,\\nthickest at its centre, where the umbilical cord is inserted, as a\\nrule. Its surface is six to nine inches in diameter it is from\\none-half to one and one-half inches in thickness and weighs\\nfrom one to one and one-half pounds.\\nThe placenta is fully formed at the third month, though its\\ndimensions increase steadily toward term and bear a propor-\\ntional relationship to the size of the child.\\nThere are two aspects of the placenta to be described first,\\nthe foetal, that side directed toward the foetus secondly, the\\nmaternal., that directed toward the uterus.\\nThe foetal aspect of the placenta is covered with a smooth\\nshining membrane, which is continuous with that covering the\\numbilical cord and lining the amniotic sac, the amnion.\\nBeneath this may be seen the large umbilical vessels running\\ntortuously on the chorion, and dividing into branches, which\\ndip down at right angles into the villi, forming the mass of the\\nplacenta. Deeper dow^n the darker chorion may be seen through\\nthe transparent amnion. The remains of the yolk-sac may occa-\\nsionally be noted, looking like a piece of putty, lying a short\\ndistance from the insertion of the cord.\\nThe maternal aspect of the placenta is of a dark grayish-red\\nhue, and is divided by deep sulci into lobules of irregular out-\\nline, termed cotyledons. Its surface is covered by a grayish,\\n3\u00e2\u0080\u0094 Obst.", "height": "3704", "width": "2372", "jp2-path": "obstetricsmanual00evan_0033.jp2"}, "34": {"fulltext": "34 PREGNANCY.\\nglistening, transparent membrane, which is the maternal por-\\ntion of the placenta, and is composed of the superficial layer\\nof the decidua serotina. Therefore the line of cleavage, when\\nthe placenta separates from the uterine wall, is through the\\nmiddle or spongy layer of the decidua.\\nAround the periphery of the placenta runs a large vein, the\\ncircular sinus or vein, which returns a portion of the maternal\\nblood from the organ.\\nThe site of the placenta in the uterus varies, though it is\\ngenerally on the anterior or on the posterior wall.\\nThe functions of the placenta are many. It is at once the\\nlung, the alimentary apparatus, and the kidney of the foetus.\\nIn it the foetal blood parts with its carbonic acid gas and its\\nother waste-products, receiving in return, from the maternal\\nblood, oxygen, and the materials necessary for the nutrition of\\ntlie foetus.\\nThe epithelial layers of the chorionic villi seem to have\\ncertain powers of both selection and resistance; since cer-\\ntain bacilli and drugs pass readily into the foetal circulation,\\nwhile others do not.\\nThe umbilical cord, which unites the foetus with the placenta,\\nis formed about the fourth week of gestation. It averages at\\nterm about twenty inches, varying from four to eighty inches,\\nin length. Its thickness varies from the size of the little\\nfinger to that of the thumb. Its sheath is composed of am-\\nnion it contains tico arteries carrying blood from, and a vein\\ncarrying blood to, the foetus, wdiich are imbedded in a mucoid\\nsubstance known as Wharton^ s jelly. These vessels run in a\\nspiral manner, the twists usually being from right to left.\\nThe amnion and chorion, with the shreddy remains of the\\ndecidua and the placenta, when they are examined after de-\\nlivery, are seen to form a sac, which has been ruptured at one\\nspot, usually at the site of the internal os, to permit the escape\\nof tlie foetus.\\nThe decidua on the membranes is somewhat thicker than\\nthat on the maternal aspect of the placenta, since it consists of\\nthe atr()j)hied reflexa and the superficial layer of the vera. It\\nis reddish in color and very friable.\\nThe chorion can be readily separated from the amnion, each\\nof these forming a distinct membrane as far as the edge of the", "height": "3712", "width": "2508", "jp2-path": "obstetricsmanual00evan_0034.jp2"}, "35": {"fulltext": "THE VUM AT DIFFERENT PERIODS OF PREGNANCY. oO\\nplacenta. The chorion will be noted to be thicker, more\\nopaque, and less tough than the amnion.\\nThe amnion, which is the membrane next to the foetus, is a\\nclear, translucent membrane whose chief characteristic is its\\ntoughness. This toughness permits the sac, when distended\\nwith liquor amnii, to withstand considerable pressure, and\\nenables the bag of membranes to act in an efficient manner as\\na hN drostatic dilator during the first stage of labor.\\nThe liquor amnii, which fills the amniotic sac and in which\\nthe foetus is suspended, is a light-colored turbid fluid of a\\nspecific gravity of about 1010. Its quantity varies from one\\nto two pints in the normal state. Its source is not definitely\\nknown. By many it is believed to exude from the maternal\\nvessels in the uterine walls, but it is probably of foetal origin.\\nIts fiinctio)i is to prevent the foetus being pressed upon, and\\nto allow its free development. Shocks, due to falls or blows on\\nthe part of the mother, are prevented from affecting the foetus.\\nDuring labor, as has been said, it forms the most perfect di-\\nlator of the cervix, and protects the child from the great press-\\nure brought to bear on the uterine contents during the first\\nstage of labor.\\nThe Ovum at Different Periods of Pregnancy.\\nFirst month: At the end of the fourth week the ovum\\nmeasures about 1 inch in diameter, and the straightened-out\\nembryo about J inch. The chorion is covered with villi, and\\nthe amnion does not quite fill the cavity of the chorion, the\\nspace separating them containing a clear fluid.\\nSecond month At the end of this month the ovum is nearly\\n2 inches in diatneter, and the embryo inch long. The\\namnion fills the chorion. The chorion Iseve is atrophying, but\\nthe cord is not yet twisted and contains a loop of intestine at\\nits base.\\nThird month By the twelfth week the ovum is 4 inches\\nin the long diameter, and the foetus, as it is now called, is\\nabout 3J inches (7-9 cm.) in length. The placenta is com-\\npletely formed and the rest of the chorion is quite free from\\nvilli. The cord is twisted and the loop of intestine has been\\nwithdrawn into the abdominal cavity.", "height": "3712", "width": "2360", "jp2-path": "obstetricsmanual00evan_0035.jp2"}, "36": {"fulltext": "36 PREGNANCY.\\nFourth month At the end of the sixteenth week the foetus\\nmeasures about 6 inches (17 cm.) in lengtli. The head is pro-\\nportionally very large. The sex can be distinguished. Lanugo\\nis present.\\nSixth month The average length of the foetus is now about\\n12 inches (28-34 cm.), and it weighs about 23 J ounces (676\\ngm.). The testicles in males are still in the abdominal cavity.\\nSeventh month At the end of this month the foetus meas-\\nures in length 13.75 to 15 inches (35-38 cm.), and weighs 41 J\\nounces (1170 gm.). The whole body is covered with lanugo,\\nexcept the palms of the hands and the soles of the feet. The\\npupillary membrane disappears.\\nEighth month: The foetus now measures 15 to 16 inches (39\\nto 41 cm.) in length and weighs 3 J pounds (1571 gm.) Lanugo\\nis disappearing from the face, and the left testicle is in the\\nscrotum. Ossific centres are present in the lower epiphyses of\\nthe femurs. The child if born is viable.\\nNinth month At the end of this month, the thirty-sixth\\nweek, the foetus averages about 5J pounds in weight. At this\\nperiod, if the infant should be born, Hirst considers that with\\nordinary care it should certainly live.\\nThe consideration of the infant at full term, the fortieth\\nweek, will be taken up under the heading Labor but it is con-\\nvenient at this point to refer to the peculiarities of foetal circu-\\nlation.\\nFoetal Circulation (Fig. 16).\\nThe foetal blood, having been oxygenated in the terminal\\nvilli in the placenta, is returned by various branches to the\\numbilical vein. This is carried along the cord to the foetal\\nbody, which it enters at the umbilicus. It runs thence along\\nthe anterior abdominal wall to the under surface of the liver,\\nwhere it branches, the larger branch emptying into the portal\\nvein, while the smaller, called the ductus venosus, empties\\ndirectly into the ascending vena cava.\\nThus the largest quantity of the arterial blood from the\\nplacenta must pass through the fcetal liver, where it probably\\nundergoes some changes before entering the general circulation.\\nHence is poured into the right auricle of the heart, from the\\nascending vena cava, a stream of blood derived from (1) the", "height": "3728", "width": "2476", "jp2-path": "obstetricsmanual00evan_0036.jp2"}, "37": {"fulltext": "FCETAL CIRCULATION.\\n37\\nFig. 16.\\nhepatic veins (2) the\\nductus venosus and (3)\\nthe lower extremities of\\nthe foetus along the iliac\\nveins.\\nThis mixed stream en-\\nters the right auricle pos-\\nteriorly, is guided across\\nit by a fold of membrane,\\ntermed the Eustachian\\nvalve, through the fora-\\nmen ovale, an opening in\\nthe inter-auricular sep-\\ntum, and thus enters the\\nleft auricle.\\nThe Eustachian valve,\\nby directing the blood-\\ncurrent from the right\\nventricle, thus short-\\ncircuits the stream\\nfrom tlie undeveloped\\nfoetal lungs, which in\\ntheir uuexpanded con-\\ndition could not contain\\nsuch a large quantity of\\nblood.\\nFrom the left auricle\\nthe blood enters the left\\nventricle, passing thence\\nDiagram of the circulatory\\norgans of the human f(ietus at\\nsix months: HA. right auricle;\\nHV. right ventricle: LA, left\\nauricle Ev. Eustachian valve\\nL. liver K. left kidney J. part\\nof small intestine: a. aortic\\narch a its dorsal part a\\nposterior end of abdominal\\naorta ves, superior vena cava\\nrci, inferior vena cava near its\\njunction Avith the right auricle vei posterior part of inferior cava s, subclavian\\nvessels right jugular vein c, common carotid arteries the four dotted arrow-\\nlines indicate the course of the circiilation da, ductus arteriosus: an arrow-line\\nstarting at vci indicates the course of blood-flow from the inferior cava through the\\nforamen ovale hv, hepatic veins rp, vena ports x to vci, the ductus venosus ?n\\numbilical vein ua, umbilical arteries nc, umbilical cord i, i, iliac vessels. (Allen\\nThomson.)", "height": "3712", "width": "2372", "jp2-path": "obstetricsmanual00evan_0037.jp2"}, "38": {"fulltext": "38 PREGNANCY.\\nto the aorta. The greater part of the stream is then directed\\nthrough the carotids to the head, a small quantity only con-\\ntinuing along the aorta.\\nThe venous l)l()od returning from the head is collected in the\\ndescending vena cava, and passing thence into the right auricle\\nanteriorly, it finds its way into tTie right ventricle. It is then\\nforced into the pulmonary artery, whence it passes by another\\nshort circuit, termed the ductus arteriosus, emptying into the\\naorta just beyond where the carotids branch to the head only a\\nsufficient quantity for their nutrition being directed to the lungs.\\nThis venous blood then descends along the aorta, the larger\\nquantity passing thence to the iliac arteries, from the internal\\npair of which two arteries pass directly to the umbilicus, and\\nthence along the cord to the placenta. These arteries within\\nthe body are termed the hypogastric arteries.\\nThus the lower limbs of the foetus receive but a poor supply\\nof what is practically venous blood hence their poor develop-\\nment at birth as compared with the head, which receives a rich\\nsupply of fairly freshly oxygenated blood. With the expan-\\nsion of the lungs at birth the whole course of the circulation\\nchanges to that which persists throughout life.\\nCHANGES IN THE MATERNAL ORGANISM RESULTING\\nFROM PREGNANCY.\\nUterus.\\nThe increase in the size of the uterus takes place chiefly in\\nthe body of that organ.\\nThe cavity of the body increases in length from 11 inches\\n(3.7 cm.) in the unimpregnated state, to 12 inches (00.5 cm.);\\nthe width, from 1 J inches (3.2 cm) to 9 inches (23 cm.) the\\ndepth (anteroposterior), from nothing to between 8 and 9\\ninches (20-23 cm.). The capacity is increased from nothing\\nto about 500 cubic inches (8300 c.cm.).\\nThe weight of the organ increases from 1 ounce (30 gm.) to\\nabout 24 ounces (720 gm.).\\nThese measurements vary with the size of the foetus, the\\nquantity of liquor amnii, and in multiple pregnancy.\\nThis increase in size is a growth, and not a mere distention,\\nI", "height": "3712", "width": "2508", "jp2-path": "obstetricsmanual00evan_0038.jp2"}, "39": {"fulltext": "UTERUS. 39\\nfor in ectopic gestation the uterus is found to go on growing, up\\nto and beyond the fourth month.\\nThe changes in shape are characteristic. In the non-preg-\\nnant condition the uterus is pyriforni, the large end being\\nuppermost and flattened anteroposteriorly.\\nIn the earlier months of pregnancy the lower part seems to\\nincrease in capacity faster than the upper, so that the shape of\\nthe uterus becomes roughly spherical while at the fifth month,\\naccording to Webster, the organ is once more pyriform in\\nshape, but the widest part is lowermost.\\nAt the end of pregnancy the uterus assumes very much the\\nshape of the non-pregnant organ, the roomiest part being again\\nuppermost.\\nThus up to the fifth month the increase in the capacity of\\nthe uterus is chiefly in its lower part and from then till term\\nmainly in its upper portion.\\nMuscle-fibres The marked increase in the bulk of the uterine\\nwall during pregnancy is mainly due to hypertrophy of the\\nmuscle-cells, Helme states that there is no hyperplasia, but\\nthat the existing fibres increase from seven to eleven times in\\nlength and from three to five times in breadth.\\nThe arrangement of these muscle-fibres \\\\w\\\\\\\\\\\\ be discussed\\nlater under the heading of anatomy of labor.\\nThe connective tissue of the uterus increases in proportion\\nto the muscular. There exists a true hyperplasia of the con-\\nnective tissue, which begins in the neighborhood of the blood-\\nvessels.\\nThe arteries of the uterus become markedly increased in\\ncalibre and length. At the placental site there is a spiral\\narrangement of the arterial twigs, as they penetrate the uterine\\ndecidua and empty into the lacunae. The veins become cor-\\nrespondingly increased in size. In fact, the uterus may be\\nregarded as a huge venous plexus during pregnancy, as the\\nblood-supply is so great. The walls of these veins are reduced\\nto the intima, so that after labor the mere contraction of the\\nuterine muscle-fibres is sufficient to obliterate their lumen.\\nThe lymphatics of the uterus become increased both by hy-\\npertrophy and hyperplasia. Beneath the decidua enormous\\nlymph-spaces develop, the tubes or vessels leading from these\\nto the lymphatic plexus beneath the peritoneal layer of the", "height": "3708", "width": "2376", "jp2-path": "obstetricsmanual00evan_0039.jp2"}, "40": {"fulltext": "40 PREGNANCY.\\nuterus reaching the size of goose-quills. This condition of\\nthe uterine lymphatic system explains the remarkably rapid\\nabsorption of the uterus after labor, as well as that of septic\\nmaterial from the uterine cavity.\\nThe nerves of the uterus take part in the general develop-\\nment, the increase being chiefly in the primitive sheath, and\\nnot in the nerve-substance.\\nThe ligaments of the uterus hypertrophy during pregnancy,\\nand their relationships become altered with the elevation of\\nthe fundus in the abdominal cavity.\\nThe connective tissue throughout the pelvis becomes succu-\\nlent and distensible.\\nUterine contractions Throughout pregnancy the uterus is in\\na state of alternate contraction and relaxation. This condition\\nfavors the circulation of the maternal blood in the uterine wall\\nand placental sinuses. These contractions may be noted as soon\\nas the fundus becomes accessible to examination from the ab-\\ndominal surface.\\nRelation to Pelvis and Abdomen.\\nUp to the third month, while the uterus has increased in size\\nand become quite globular in form, its level in the pelvis has\\nundergone no marked change. It has become somewhat more\\nanteflexed, and from its weight has sunk down somewhat into\\nthe pelvis, the cervix being carried backward, so that on mak-\\ning a vaginal examination at this period, the anterior uterine\\nwall can be readily felt and seems to bulge forward.\\nBy the end of the third month the fundus uteri has risen to\\nthe brim of the pelvis, and may be felt on moderately deep\\npressure just above the symphysis pubis.\\nBy the end of the fourth month the fundus is in contact with\\nthe anterior abdominal wall.\\nAt the sixth month it reaches the level of the umbilicus.\\nAt the seventh month it is half-way between the umbilicus\\nand the xiphoid cartilage.\\nAt the ninth month it is up to the level of the lower ribs\\nbut within about two weeks of labor it falls forward somewhat,\\nand seems to be on a slightly lower level, on account of the\\ndescent of the presenting part of the foetus into the brim of the\\npelvis.", "height": "3712", "width": "2504", "jp2-path": "obstetricsmanual00evan_0040.jp2"}, "41": {"fulltext": "CHANGES IN THE BREASTS. 41\\nThe intestines are displaced upward by the uterus as it\\nasceuds, so that on percussion a dull note is obtained over the\\nwhole central part of the abdomen.\\nThere is a certain amount of dextro-rotation of the uterus\\nretained throughout pregnancy, so that the organ leans some-\\nwhat to the right as a rule. This right obliquity of the uterus\\nmay be accounted for by its relation to the sigmoid flexure and\\ndescending colon, the left side of the organ being pushed for-\\nward by these structures.\\nAlterations in the Cervix.\\nThere are two conditions of the cervix during pregnancy\\nwhich are peculiarly characteristic. Both are due to a partial\\nobstruction in the venous return which leads to softening and a\\nmarked blue or violet discoloration.\\nThe softening of the cervix begins, as a rule, about the second\\nmonth. It is first apparent about the tip, but spreads upward\\nas pregnancy advances, so that in the later months the\\nwhole cervix becomes so soft that the finger, if unaccustomed\\nto vaginal examination, may liave difficulty in finding the os\\nuteri. The cervix in pregnancy has been likened in feel to\\nthat of the pouted lips.\\nThe violet discoloration is due simply to the venous engorge-\\nment, and it may be present even in the first few weeks of\\npregnancy. The canal of the cervix remains throughout preg-\\nnancy unaltered in length. Its mucous glands secrete a\\npeculiarly tough mucus, which stops up the canal like a cork\\nthroughout pregnancy (mucous plug).\\nVagina, Vulva, and Breasts.\\nThe vagina and vulva become somewhat hypertrophied\\nduring pregnancy. The color of the mucous membrane\\nbecomes bluish. There is a slightly increased secretion of\\nmucus, and the parts become lax and soft.\\nChanges in the Breasts.\\nWith the onset of pregnancy there is an increased deter-\\nmination of blood to the breasts; and certain alterations pre-\\nparatory to the function of lactation begin.", "height": "3712", "width": "2384", "jp2-path": "obstetricsmanual00evan_0041.jp2"}, "42": {"fulltext": "42\\nPREGNANCY.\\nThese glands attain complete development in the first preg-\\nnancy.\\nTlie lobules enlarge and become distinct from one another.\\nThe epithelium lining the acini becomes active, leading to a\\ncertain amount of desquamation of the upper layers.\\nThese cells undergo fatty degeneration and are set free, con-\\nstituting colostrum-corpuscles.\\nVery early in pregnancy a small quantity of serum may be\\nexpressed from the nipples.\\nThe fat and connective tissue surrounding the lobules hyper-\\ntrophy, and the breasts become enlarged and more prominent.\\nCoincident with these changes there is increased tenderness\\non ])ressure.\\nThe skin becomes stretched and striae develop, having a\\nradial distribution and direction. The veins on the surface\\nbecome more obvious.\\nThe areola becomes darker from deposit of pigment, this\\nbeing more marked in brunettes than in blondes (Fig. 17).\\nFig. 17.\\nBrunette: Wrinkling of primary areola; S. A., well-defined secondary areola.\\n(Dickinson.)\\nThe sebaceous follicles of the areola, ten or twenty in num-\\nber, become more prominent, being of lighter color. These\\nfollicles at the margin of the areola being uncolored, stand out\\nprominently as white spots, forming tlie so-called secondary\\nareola.\\nThe nipples become more prominent as a rule, and are softer", "height": "3712", "width": "2484", "jp2-path": "obstetricsmanual00evan_0042.jp2"}, "43": {"fulltext": "ALTERATIONS IN OTHER THAN GENERATIVE ORGANS 43\\nthan in the non-pregnant state. In the later months of preg-\\nnancy dried cakes of secretion may be fonnd encmsted on their\\nsurface.\\nAlterations in Other than the Generative Organs.\\nNervous system There is present during pregnancy a condi-\\ntion of exalted nerve-tension. Hence there is an increased\\ntendency to nerv^ous instability. The woman is more prone to\\nhysterical attacks. There are often present perversions of taste,\\nsmell, etc. also neuralgia, especially of the face and teeth.\\nMental affections are apt to develop during this period.\\nThis condition of increased nerve-tension causes about two-\\nthirds of all pregnant women to suffer from vomiting at some\\ntime or another of their pregnancy.\\nThis so-called vomiting of pregnancy begins, in a large ma-\\njority of cases, early in the second month it usually persists\\nduring the second and third months, but may last throughout\\npregnancy. It may be looked upon as one of the symptoms of\\nthe pregnant condition.\\nIt usually occurs on first rising in the morning, and may be\\nmild or sufficiently severe to endanger the woman s life.\\nThe essential exciting cause of the vomiting probably origin-\\nates in the physiological uterine contractions occurring through-\\nout pregnancy (see Pernicious Vomiting).\\nCirculatory system The total quantity of blood is increased.\\nThe quality is also changed, there being an increase in fibrin\\nand white corpuscles; while the red corpuscles and albumin\\nare diminished.\\nThe heart, probably as a result of the changes in blood\\nquality, undergoes some dilatation but as the quantity of the\\nblood is increased there is a perfectly compensatory hypertrophy\\nwhich is more marked on the left side. Both spleen and thyroid\\ngland increase in size.\\nRespiratory system As the range of movement of the dia-\\nphragm becomes interfered with by the uterus the thorax\\nwidens to a slight extent. Owing to increased oxidation-proc-\\nesses, the work of the lungs is augmented.\\nThere is but little change in the alimentary system. The\\ndigestive processes are somewhat more active, and, as a rule,\\nthe appetite is increased. Digestive disturbance is common.", "height": "3712", "width": "2364", "jp2-path": "obstetricsmanual00evan_0043.jp2"}, "44": {"fulltext": "44 PREGNANCY.\\nUrinary system The urine is increased in quantity and is\\nmore watery, the specific gravity being about 1014. The\\nquantity of urea excreted is normal.\\nCutaneous system The functions of the skin are increased\\nduring pregnancy.\\nPigmentat ion is increased. There is, as a rule, a marked\\ndeposit of pigment over the linea alba, so much so as to con-\\nstitute one of the signs of pregnancy it may reach from the\\npubes to the ensiform cartilage. The skin around the eyes is\\ndarkened, and frequently irregular spots of pigment appear on\\nthe surface of the body, chiefly in the face.\\nLineae albicantes Certain skin-cracks are to be noticed,\\nchiefly as a result of over-stretching. They are termed strice,\\nlinece albicantes, linece matenice, or linece gravidarum^ and appear\\nusually on the skin of the abdomen and breasts. They run\\nusually in the lines of tension, and are due to yielding of the\\ncorium in stretching, the epidermis being continuous over them\\nwithout any change in structure. They vary in length up to\\ntwo or more inches, and when recent are red in color. Later\\non, as a result of scar-formation, they become white, and form\\nstrong presumptive evidence when present of previous preg-\\nnancy.\\nDURATION; DIAGNOSIS; HYGIENE AND MANAGE-\\nMENT OF PREGNANCY.\\nDuration of Pregnancy.\\nAs a rule, it is impossible to predict exactly the date when\\nlabor will take place.\\nIf the date of fruitful coitus can be fixed, then labor will\\nmost likely set in two hundred and seventy-one days later,\\naccording to Ahlfeld.\\nThe common rule is that labor will occur on the day of the\\ntenth menstrual period i. e., two hundred and eighty days\\nafter the first day of the last menstruation. Allowance must\\nalways be made for the short month February.\\nAs a rule, one seldom predicts the exact day of labor, and the\\nvariation of a week or two is far from common.\\nWhen pregnancy occurs during a period of amenorrhcea, as", "height": "3712", "width": "2560", "jp2-path": "obstetricsmanual00evan_0044.jp2"}, "45": {"fulltext": "FIBST TRIMESTER\u00e2\u0080\u0094 SUBJECTIVE SYMPTOMS.\\n45\\nlactation; or if the date of the last menstruatiou cannot be\\nascertained, then the probable date of labor may be fixed by\\nnoting the height of the fundus\\nThe following table has been given by Satngiu and Galabin\\nWeeks\\n16\\nInches\\n4\\nCm.\\n10\\n20\\n24\\n28\\n32\\n34\\n36\\n38\\n5.4\\n6.6\\n7.8\\n8.7\\n9\\n9.3\\n9.6\\n13.5\\n16.5\\n19.5\\n22\\n23\\n23.5\\n24\\n40\\n10\\n25.5\\nThis nietiiod can only be employed in cases where the head\\npresents at the brim of the pelvis. The measurement is made\\nby placing one tip of a pair of calipers on the symphysis pubis\\nand the other on the fundus uteri.\\nThe date of quickening i. e., the first occasion on which the\\nmother feels the movements of the foetus is of some value in\\nestimating the duration of pregnancy. Quickening occurs in\\nthe twentieth week as a rule in primiparse and in the twenty-\\nfirst or twenty-second week in multiparse.\\nDiagnosis of Pregnancy.\\nThe recognition of pregnancy is not always an easy matter,\\nespecially in the earlier months of gestation.\\nCareful, systematic, and, if necessary, repeated examination\\ncannot fail to permit a certain diagnosis being made.\\nFailure in diagnosis is nearly ahvays the result of careless\\nand unsystematic examination.\\nFor convenience of study the nine calendar months of preg-\\nnancy may be divided into trimesters and a classification of\\nthe symptoms and signs as to these three periods be made.\\nFirst Trimester Subjective Symptoms.\\nThe suppression of menstruation constitutes, as a rule, the\\nfirst evidence of pregnancy. This function is usually sus-\\npended throughout gestation but this is not invariable. Some\\nwomen menstruate at least once, and occasionally several times\\nafter the occurrence of pregnancy. The value of this sign as\\nevidence is less in w^omen who are very irregular in menstru-\\nating.\\nCauses: Suppression may result from exposure to cold;", "height": "3712", "width": "2368", "jp2-path": "obstetricsmanual00evan_0045.jp2"}, "46": {"fulltext": "46 PREGNANCY.\\nfrom the preseuce of debilitating disease, as tuberculosis,\\nanaemia, etc. over-anxiety or marked fear of pregnancy may\\nproduce this result, as may also sudden mental shock change\\nof climate or surroundings occasionally act in the same way.\\nThese exceptions should be held in mind but suppression of\\nmenstruation in a healthy woman of regular habit usually\\nmeans pregnancy.\\nNausea and vomiting, occurring in the morning especially,\\nform one of the most common symptoms of pregnancy.\\nThe sensation usually conies on when the woman first as-\\nsumes the erect position in the morning, hence the term morn-\\ning sickness commonly applied to it.\\nThese symptoms, as a rule, appear in the fourth or fifth week\\nbut may occur even earlier. They cease, as a rule, about the\\nfourth month but may persist throughout pregnancy. The\\ncausation has already been referred to.\\nThe mammary changes begin as early as the second month,\\nthe congestion of the parts causing a sensation of fulness, with\\ntingling and tenderness. Increase of pigmentation about the\\nareolae and the presence of serum in the lacteal ducts become\\napparent during the third month.\\nVesical irritation is often complained of very early in preg-\\nnancy. As a result of the increase in the normal anteversion\\nof the uterus, the bladder is pressed upon and its functions in-\\nterfered with this usually persists till the fourth month.\\nFrequently digestive disturbances arise early in pregnancy,\\nhaving a reflex origin. The appetite becomes capricious, and\\nacidity is common.\\nNervous disorders, which are purely functional, are not infre-\\nquent. Ptyalism is not uncommon, and may persist throughout\\ngestation. Neuralgias, cardiac disturbances, mental perturba-\\ntion and irritability frequently manifest themselves very early\\nand are often very persistent.\\nFirst Trimester Objective Signs.\\nThese are confined chiefly to the uterus and the breasts.\\nTiie softening of the cervix uteri begins in the first month\\nof pregnancy. The whole cervix, beginning first at the external\\nOS, gradually softens as a result of the physiological uterine", "height": "3732", "width": "2512", "jp2-path": "obstetricsmanual00evan_0046.jp2"}, "47": {"fulltext": "FIBST TRIMESTER\u00e2\u0080\u0094 OBJECTIVE SIGNS.\\n47\\ncoDgestion. This change is most marked in the primipara,\\nbut is also present in the multipara. The cervix becomes\\nplugged with mucus as a result of the increase in the activity\\nof the cervical mucous membrane.\\nA violet discoloration of the mucous membrane of the\\ncervix, vagina, and vulva may be noted on inspection of these\\nparts, beginning as early as the fifth week in many cases.\\nThis discoloration, being due to a certain degree of venous\\nstasis, becomes more marked as pregnancy advances it shades\\nfrom a pale violet tinge to a dusky bluish hue.\\nThe softening and enlargement of the body of the uterus\\nconsequent upon pregnancy may be readily made out by care-\\nful combined examination. Hegai ^s sign (see below) of early\\npregnancy depends upon the presence of these changes, and\\nmay be obtained as early as the eighth week. As a result of\\nthe presence of the ovum in the upper segment of the uterus,\\nall the diameters of the latter become increased, while the\\nempty lower segment simply becomes softened and perhaps\\nrather thinned out.\\nOn bimanual examination the bulky, partly softened cervix\\ncan be felt just above this is a very soft compressible area and\\nFig. 18.\\nresilient\\nPujiiiQ\\ncontracnon\\nChanges in the pregnant uterus of the sixth week on the left when relaxed, ou the\\nright when contracting. (Dickinson.)\\nabove this again the boggy rounded fundus uteri may be dis-\\ntinguished (Fig. 18). The sensation conveyed to the exam-", "height": "3712", "width": "2364", "jp2-path": "obstetricsmanual00evan_0047.jp2"}, "48": {"fulltext": "48\\nPREGNANCY.\\niner s finger is that the cervix is joined to tlie body of the\\nuterus by two longitudinal bands (Hegar^s sign). This is\\nbest obtained by placing the thumb of the right hand in the\\nanterior vaginal fornix and introducing the forefinger of the\\nsame hand into the rectum, then the left hand placed over the\\npul)is presses the uterus downward so that the cervix and\\nFig. 19.\\nA.\\nBimanual examination for compressibility of the isthmus at the sixth week.\\n(Dickinson.)\\nlower part of the body may be grasped between the thumb\\nand forefinger of the right hand or as shown in Fig. 19.\\nIn the third month the body of the uterus is felt to be en-\\nlarged and rounded as well as softened while the whole organ,\\nwhich pretty well fills the pelvic cavity, is in a position of\\nmarked anteversion as a rule.\\nSecond Trimester.\\nIn this period the subjective symptoms are (1) continued\\nabsence of menses; (2) the passing away of the troublesome\\nnausea and vesical irritation (3) the sensation of quicken-\\ning\\nJ\\n-i, e.y fcetal movement.", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0048.jp2"}, "49": {"fulltext": "SECOND TRIMESTER. 49\\nThe objective signs are (1) enlargement of the abdomen\\n(2) progressive changes in the mammae; (3) progressive\\nchanges in the uterns (4) the feeling of uterine contractions\\nand of the foet(d movements by the examiner (5) auscultation\\nof foetal heart-sounds (6) hallottement.\\nIn the fourth month the fundus becomes easily accessible\\nfrom the anterior abdominal wall hence at this period for the\\nfirst time may be felt the irregular intermittent uterine contrac-\\ntions which continue throughout pregnancy. These contrac-\\ntions take place at intervals of from ten to twenty minutes, and\\nlead to marked hardening of the whole uterine tumor.\\nFoetal movements, or quickening, are usually first noticed\\nby the mother about the twentieth week. As pregnancy ad-\\nvances these movements become more marked and constant,\\nand may be best obtained by the physician by suddenly placing\\nhis cold hand on the mother s abdomen over the uterus.\\nOn auscultation a loud bruit may be heard over some portion\\nof the uterus as early as the fourth month. This sound has\\nbeen termed the uterine souffle. It is synchronous with the\\nmaternal pulse, and is very uncertain in its duration and place.\\nIt is heard not only during pregnancy, but it is occasionally\\nassciated with the presence of interstitial fibroids and with ova-\\nrian tumors.\\nThe foetal heart-sounds may be heard as early as the twen-\\ntieth week by skilled examiners. They are heard best while\\nthe patient is in the dorsal position with the abdominal wall\\nrelaxed, and with the bell of the stethoscope resting lightly in\\ncontact with it. If pressure be made on the bell, or even if it\\nbe held in place by the hand, the sounds cannot be heard so\\nwell.\\nThe rate of pulsation varies from 120 to 150 per minute,\\nbeing slower in males than in females. The sounds are\\ndouble, the first being somewhat clearer than the second. The\\nsounds of the foetal heart have been very aptly compared to\\nthose of a watch ticking under a pillow. The foetal heart-\\nsounds bear no relation to, and are quite distinct from, the\\nmaternal pulsations.\\nBy the sixth month, the fundus having reached the level of\\nthe umbilicus, which has become flattened out, the abdomen has\\nbecome quite prominent.\\n4\u00e2\u0080\u0094 Obst.", "height": "3708", "width": "2360", "jp2-path": "obstetricsmanual00evan_0049.jp2"}, "50": {"fulltext": "50\\nPEEG NANCY.\\nAt this time also a brownish pigmentation may be noted ex-\\ntending from the pubes up to and beyond the umbilicus.\\nBallottement, one of the most valuable signs of pregnancy,\\nbecomes available late in the fourth month. It is a passive\\nmovement of the fcetus obtained by its sudden displacement\\nfrom below by the examiner (Fig. 20). While placing the\\nFig. 20.\\n.-o\u00c2\u00abJajl[ii \u00e2\u0080\u009e,_\\nInternal ballottement, semi-recumbent posture, at sixth month. (Dickinson.)\\nforefinger of the right hand in the anterior vaginal fornix,\\none may by a brisk impulse displace the foetus upward, which,\\nas it resumes its original position, conveys a gentle tap to the\\nfinger-tip held in the vagina. Ballottement can only be simu-\\nlated by a small cystic ovarian tumor having a long pedicle.\\nThird Trimester.\\nThe subjective symptoms in this period are: (1) continued\\nabsence of menstruation (2) foetal movements (3) pressure-\\nsymptoms.", "height": "3736", "width": "2484", "jp2-path": "obstetricsmanual00evan_0050.jp2"}, "51": {"fulltext": "SUMMARY OF DIAGNOSIS. 51\\nThe objective signs are (1) continued enlargement of the\\nabdomen; (2) continued mammary and uterine changes; (3)\\ndevelopment of striae on abdomen and breasts.\\nOwing to the great enlargement of the uterus pressure- symp-\\ntoms become very marked in many cases, ^arlces of the lower\\nlimbs and vulva, often accompanied by oedema, become more\\nor less marked. Constipation from pressure on the rectum,\\nand vesical Irritation from displacement of the bladder upward,\\nare common.\\nDisturbances of digestion and of respiration are common, both\\nresulting from the great abdominal distention.\\nThe movements of the fcstus can be plainly seen through the\\nabdominal wall.\\nThe skin on the abdomen frequently shows linear markings,\\nwhich appear as red radiating striae, chiefly on the lower quad-\\nrants.\\nThe umbilicus becomes prominent, and there is an increase in\\nthe deposit of pigment in the middle line.\\nSettling Within two weeks of labor the presenting part\\nof the foetus partially enters the brim of the pelvis, becoming\\nmore accessible to the examining finger. The cervix also be-\\ncomes somewhat thinned out and feels shortened. At this time\\nthe prominence of the abdomen becomes less marked.\\nTo these changes occurring in the last two weeks prepara-\\ntory to labor the term settling has been applied.\\nThe mammary changes continue to become more marked, and\\ncolostrum can be expressed from the nipj)les.\\nSummary of Diagnosis.\\nThe presumptive evidences of pregnancy are: (1) menstrual\\nsuppression (2) morning sickness (3) irritable bladder (4)\\nmental and emotional phenomena.\\nThe probable evidences are (1) mammary changes (2)\\nabdominal chauges (e. g.^ size, shape, markings) (3) uterine\\nchanges (size, shape, color, and consistency of cervix) (4)\\nuterine contractions and bruit.\\nThe only positive signs are festal: (1) foetal heart-sounds;\\n(2) foetal movements (3) ballottement.", "height": "3704", "width": "2352", "jp2-path": "obstetricsmanual00evan_0051.jp2"}, "52": {"fulltext": "52 PREGNANCY.\\nDifferential Diagnosis of Pregnancy.\\nThe physician is not infrequently called upon to make an\\nexamination where the patient either feigns, desires, or, more\\ncommonly, conceals the condition of pregnancy. The diffi-\\nculties of diagnosis are much greater before the fourth month\\nof gestation but careful systematic examination will scarcely\\nfail to establish a certainty in the majority of cases. Care\\nmust be taken not to express an opinion until a reasonable cer-\\ntainty of the condition present is obtained.\\nFirst Trimester.\\nIn this period the following conditions may resemble preg-\\nnancy amenorrhoea subinvolution metritis uterine fibroid\\nretained menses malignant disease tumors in the neighbor-\\nhood of the uterus, as ovarian growths; salpingitis and ectopic\\ngestation.\\nSimple amenorrhoea accompanied by symptoms of gastric\\nirritation may very closely resemble pregnancy but a careful\\nbimanual examination will demonstrate the absence of uterine\\nchanges.\\nIn subinvolution the uterus does not increase in size, and it\\nis not globular while its texture is harder than that of the\\norgan in pregnancy.\\nIn metritis the uterus, while enlarged, is sensitive to the\\ntouch, and is hard and dense. Its shape is that of the unim-\\npregnated organ simply increased in size.\\nAn interstitial fibroid of the uterus may be distinguished by\\nits denseness and by the irregular contour. Menstruation, in-\\nstead of being absent, is, as a rule, increased.\\nRetained menses may cause an enlargement of the uterus\\nbut in such cases the fact that menstruation has never been\\nestablished, and a history of abdominal pains occurring at\\nmonthly intervals, will indicate the nature of the case.\\nIn malignant disease of the uterus the menstruation is, as a\\nrule, increased, and intermenstrual hemorrhages occur.\\nIn ovarian tumors the uterus is not affected and menstrua-\\ntion })er8ists as a rule. The tumor is usually situated to one\\nside of the uterus and causes some displacement of that organ.", "height": "3708", "width": "2484", "jp2-path": "obstetricsmanual00evan_0052.jp2"}, "53": {"fulltext": "DTAGNOSTS OF PARITY OR NULLIPARITY. 53\\nEctopic gestation may simulate uterine pregnancy but care-\\nful examination will reveal the prer^ence of a tumor outside\\nthe uterus.\\nIn the Later Months of Pregnancy\\nthe following conditions may lead to an error of diagnosis\\nobesity, ascites, tympanites, phantom tumor, and large ovarian\\nor fibroid tumors.\\nIn obese women with irregular menstruation it is not infre-\\nquently difficult to establish a diagnosis of pregnancy but the\\nabsence of mammary changes and auscultatory signs will clear\\nup the case.\\nIn ascites a diagnosis may be made by placing the })atient in\\nthe dorsal decubitus and percussing the abdomen. Both flanks\\nwill give a dull note, while the middle area of the abdomen\\nwill be clear. Fluctuation may be obtained and on changing\\nthe position of the patient the area of dulness will alter.\\nIn tympanites, the whole abdomen, while enlarged, gives a\\nclear note on percussion. The bimanual examination in both\\nthe above conditions will reveal the unimpregnated condition\\nof the uterus.\\nPhantom tumors, which are occasionally met with in hysteri-\\ncal women, can be recognized on applying the usual tests of\\nauscultation, percussion, etc.\\nPseudocyesis, or spurious pregnancy, is a very interesting\\ncondition met with usually in women about the time of the\\nmenopause. The woman imagines herself to be pregnant, and\\ndevelops many of the characteristic symptoms of that condi-\\ntion. Enlargement of the abdomen, fulness and tenderness of\\nthe breasts, may mislead the careless examiner; but in both\\nthe above classes of cases the administration of an anaesthetic, to\\npermit of a thorough examination, will clear up the diagnosis.\\nOvarian and fibroid tumors, if large, may cause distention of\\nthe abdomen but in these cases the absence of all signs of a\\nfoetus will suffice to distinguish the conditions from pregnancy.\\nDiagnosis of Parity or Nulliparity.\\nCertain mechanical effects are produced on the abdominal\\nwall and birth-canal of a woman who has previously borne a", "height": "3708", "width": "2352", "jp2-path": "obstetricsmanual00evan_0053.jp2"}, "54": {"fulltext": "54 PREGNANCY.\\nfull-term child, ^vhicll time fails quite to eradicate. On these\\ndepends the diagnosis of parity or nulli])arity.\\nIf the ovum has been discharged before it was sufficiently\\nlarge to produce these changes, then it is practically impossible\\nto be certain as to parity.\\nThese signs consist of changes in the breasts, perineum,\\nvagina, and cervix, as well as laxity and striie of the abdom-\\ninal wall.\\nIn the parous woman the breasts are apt to be well developed\\nand somewhat pendulous, the nipples being large and promi-\\nnent. Occasionally stride may be noticed.\\nThe abdominal wall is lax and yielding, the skin being\\nmarked with white striae.\\nThe perineum may show marks of laceration and be some-\\nwhat lax the four(;hette being absent.\\nThe vagina is capacious and lax, the walls being somewhat\\nsmooth. The remains of the hymen may be noticed as forming\\nnumerous small caruncles (carunculse myrtiformes).\\nThe cervix is short and broad very often it is lacerated,\\ngenerally on the left side.\\nDiagnosis of Life or Death of Child.\\nIt is not always easy to decide that the child is dead. The\\nwoman may suspect this to be the case because of certain vague\\nsensations of coldness about the pubes, and because of a feeling\\nof weight or dragging. She may cease to feel the movements\\nof the foetus.\\nThe matter can only be settled if after repeated examination\\nthe physician fails to hear the foetal heart or feel foetal move-\\nments. If at the same time the uterus ceases to grow, and the\\nbreasts become flabby, it may be inferred that the child has\\nperished.\\nHygiene and Management of Pregnancy.\\nWhile the condition of the pregnant woman is a purely\\nphysiological one, it must be borne in mind that the border-\\nline between health and disease may be very easily passed.\\nHence it is the duty of the physician to give every woman\\nengaging his services for her confinement such hygienic instruc-\\ntion as she may require. In fact, a certain degree of pro-", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0054.jp2"}, "55": {"fulltext": "HYGIENE AND MANAGEMENT OF PREGNANCY. 55\\nfessional attention should be given to all women throughout\\nthe whole period of pregnancy.\\nDiet: The diet during pregnancy should be plain. Simple,\\neasily digestible, and highly nutritious food should be taken at\\nregular intervals. Overeating, especially in the later months,\\nshould be guarded against. Meat should be eaten but once\\ndaily, and fruit, both cooked and fresh, shoidd form a prin-\\ncipal part of all meals.\\nExercise All violent exercise should be avoided. Walks\\nin the open air and simple gymnastics within doors should be\\nindulged in daily. All lifting and straining should be avoided.\\nBicycling may be permitted in moderation, but not over rough\\nroads. The same applies also to carriage-driving.\\nClothing should be worn in such a manner as to avoid undue\\npressure upon either chest or abdomen. The corset, if wo];ii\\nat all, should be a short one and should be very loose. AVomen\\nwith lax abdominal walls should wear an abdominal support\\nso arranged that the pressure is exerted upward.\\nBathing should be indulged in daily, especially since the\\nfunction of the skin is increased during pregnancy. If the\\nwoman is in the habit of taking cold baths daily, they may be\\ncontinued, but the initial shock may be avoided by having the\\nbath warm at first, and then adding cold water to it. In the\\nlater months at least two warm baths per week should be taken.\\nVery hot and very cold baths should be avoided.\\nThe care of the breasts Attention should be given the breasts\\npreparatory to nursing. As these organs enlarge, the clothing\\nmust be arranged so as to avoid undue pressure upon them.\\nThe nipples, if retracted, should be drawn out and gently\\nmanipulated for a few minutes daily. In the last few weeks\\ndaily inunctions of the nipples with fresh cocoa-butter or white\\nvaseline may be recommended as a prophylactic against fissures\\nduring nursing. The use of astringent lotions, such as tea,\\nbrandy, etc., commonly employed, should be proscribed.\\nShould vaginal discharge be present, daily injections of boric-\\nacid solution at the temperature of the body may be employed,\\nthe fountain-syringe only being used.\\nSexual intercourse nmst be restricted, and should not be-\\nindulged in at the menstrual dates, especially by women who\\nhave previously aborted.", "height": "3704", "width": "2352", "jp2-path": "obstetricsmanual00evan_0055.jp2"}, "56": {"fulltext": "56 OBSTETRIC ANATOMY.\\nDigestive irregularities should be controlled. The regular\\naction of the bowel must be maintained. Woman seems to be\\na naturally constipated organism, and is especially so during\\npregnancy. All violent purgatives should be avoided the best\\nlaxatives are aloin and cascara sagrada. The mineral waters\\nprove very useful, such as salines, etc.\\nThe urinary excretion requires careful attention throughout\\npregnancy. Chemical and microscopical examination of the\\nurine should be made every month at first; and in the later\\nmonths every week. The total amount voided in the twenty-\\nfour hours should be noted.\\nThe nervous condition of the pregnant woman should always\\nbe noted. All undue excitement should be avoided, and any\\ndepression of spirits combated. Plenty of sleep at least\\neight hours each night should be obtained. Daily naps should\\nbe encouraged.\\nThe use of drugs should be avoided as much as possible dur-\\ning pregnancy. Large doses of quinine and calomel should\\nnot be administered. The all too common habit of taking\\ndrugs of the coal-tar series by women, to relieve headache, etc.,\\nshould be especially discouraged during pregnancy, on account\\nof their deleterious action on the heart. Many of the cases of\\nsevere cardiac failure following labor may be set down to this\\npernicious habit.\\nThe physician should make a careful general examination of\\nevery pregnant woman under his care about the eighth month\\nof the pregnancy. A careful external and, if thought neces-\\nsary, an internal examination should be made. The pelvis\\nshould be measured and the attitude of the foetus noted. The\\nbreasts and nipples should also be examined. Inquiry should\\nalso be made as regards the presence or absence of vaginal\\ndischarge. If present, its character should be noted and a\\nbacteriological examination made.\\nOBSTETRIC ANATOMY.\\nFor detailed anatomy of the female pelvic structures the\\nstudent is referred to special works or to obstetric systems,\\nsuch as Jewett s Practice of Obstetrics.\\nThe chief anatomical elements concerned in labor are three", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0056.jp2"}, "57": {"fulltext": "THE UTERUS. 57\\nin number, namely: (1) the uterus; (2) the pelvi-genital\\ncanal (3) the foetus.\\nIn the act of parturition the mutual reaction of these ele-\\nments is concerned.\\nThe uterus may be couceived of as a nuiscular sac opening\\ninto a curved tube, the upper part of which is bony, therefore\\nrigid and the lower part yielding, being formed of muscle\\nand other soft structures. This curved tube is the pelvi-\\ngenital canal, which includes the distensible vagina, the upper\\npart being intrapelvic, while the lower, in the pelvic floor, is\\nsubpelvic.\\nThe fcetus is the passenger, and consists of two ovoids, the\\ntrunk and the head the former plastic, the latter more or less\\nrigid, and therefore the more important as regards its relations\\nto the birth-canal.\\nThe Uterus.\\nAt term the uterus is an ovate viscns; it is less part of the\\nbirth-canal than it is the engine by which the passenger the\\nfoetus is expelled.\\nThe cavity of the uterus at term has been stated as measur-\\ning 12 inches in length, 9 inches in breadth, and 8 inches in\\ndepth.\\nThe walls of the uterus vary in thickness from one-fourth\\nto one-fiftli of an inch the posterior being thicker than the\\nanterior.\\nThe muscle-fibres of tlie uterus may be distinguished at\\nterm as forming rongldy three layers an outer, a middle, and\\nan inner layer\\nIn the outer layer there are two sets of fibres (1) longitudi-\\nnal and (2) transverse (Fig. 21).\\nThe longitudinal fibres, posteriorly from the junction of the\\nbody with the cervix, pass in the form of a broad band verti-\\ncally upward over the fundus and down the middle line ante-\\nriorly to the cervix the marginal fibres toward the fundus\\nbranching off to interlace with those of the round and broad\\nligaments.\\nThe transverse fibres arranged at right angles to these pass\\nacross the uterus from side to side at the fundus passing from\\none cornu to the other. These fibres interlace in great part at", "height": "3708", "width": "2344", "jp2-path": "obstetricsmanual00evan_0057.jp2"}, "58": {"fulltext": "58\\nOBSTETRIC ANATOMY.\\nthe sides of tlie uterus, but some of them are prolonged along\\nthe broad and the round ligaments as well as along the tubes.\\nFk;. 21\\nExternal muscular layer of the posterior wall of the uterus.\\nIn the middle layer the fibres have no definite direction on\\naccount of the numerous bloodvessels traversing them. They\\nFig. 22.\\nMiddle muscular layer at the fundus a, a, superficial layer dissected back\\nb, branches belonging to the inner layer t, t, tubes.\\npass in every direction longitudinal, transverse, and oblique\\ntwisting and curving about the vessels. Frequently they are", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0058.jp2"}, "59": {"fulltext": "THE UTERUS.\\n59\\narranged in the form of a figure-of-eiglit, forming rings about\\nthe vessels, thus constituting living ligatures (Fig. 22). This\\nlayer is probably the thickest, and is most marked in the upper\\nsegment of the uterus.\\nIn the inner layer some fibres are arranged in a series of con-\\ncentric rings about the oritices of the tubes (Fig. 23). Other\\nfibres pass directly across from\\none cornu to the other trans-\\nversely while others pass\\ndownward longitudinally to\\nthe cervix, in the middle line\\nof the anterior and posterior\\nwalls.\\nUterine segments These\\nlayers are not all distinct, but\\nshade imperceptibly into one\\nanother. In the Hpj:)er part of\\nthe uterus the arrangement in\\nlayers is fairly distinct but\\nin the lower part the fibres are\\nmore loosely arranged, passing\\nchieflv in a lono-itudinal direc-\\ntion.\\nHence the uterus may be\\ndivided into two portions, the upper of which has a firmer\\nmuscular arrangement than the lower.\\nThese portions are termed respectively the upper and the\\nhirer uterine segrnent\\nThe line of separation between the segments lies nearly at\\nthe level of the uterovesical fold of the peritoneum, and is\\ntermed the retraction-ring, or BancWs ring.\\nThe upper segment plays an active role in labor, while the\\nlower has but a passive role. The lower segment along with\\nthe cervix must undergo dilatation preparatory to the expulsion\\nof the f(Tetus.\\nThe upper segment includes roughly the upper two-thirds\\nof the entire body of the uterus; while the lower segment and\\nthe cervix, which are nearly of equal lengths, forui the remain-\\ning one-third.\\nThe round and the broad ligaments, which have become\\nInternal surface of the uterus as\\nshown after incision in the median\\nline of the anterior wall. (Parvin.)", "height": "3708", "width": "2356", "jp2-path": "obstetricsmanual00evan_0059.jp2"}, "60": {"fulltext": "60 OBSTETRIC ANATOMY.\\nliypertrophied during j)rogiiaiKy, serve as guys to steady the\\nuterus during its contractions, so that its h)ng axis corresponds\\nto that of the pelvic inlet.\\nThe peritoneum covering the uterus is firmly attached to this\\norgan as far down as the retraction-ring; below this its attach-\\nment is loose and it may easily be stripped off. Thus the site\\nof the retraction-ring, or BandFs ring, is at the lower border\\nof firm peritoneal attachment.\\nThe peritoneum at term has in front of and behind the uterus\\nthe same relations as in the non-pregnant condition but at the\\nsides it has been so lifted up by the enlarged uterus that it does\\nnot descend into the pelvis. The broad ligaments have become\\nso elevated that their bases are only at the pelvic brim, extend-\\ning on either side from the iliopectineal eminence to the sacro-\\niliac joint. Thus there exists on either side of the uterus at\\nterm a large triangular area uncovered by peritoneum. Owing\\nto the drawing up of the uterosacral ligaments the pouch of\\nDouglas becomes much deeper than in the non-pregnant con-\\ndition.\\nThe Relation of the Full-term Uterus to Contiguous Structures.\\nThe intestines do not descend behind the uterus at all, and\\nin front only as low as the umbilicus. A portion of the rectum\\nlies behind the uterus, and occasionally a loop of the sigmoid\\nflexure of the colon.\\nThe urinary bladder lies wholly within the pelvis before the\\nonset of labor, its highest point being below the symphysis\\npubis, except when distended.\\nThe cellular tissue about the uterus exists as a thin layer\\nbehind but in front there is a broad band between the cervix\\nand the bladder. At the sides of the uterus it is enormously\\nincreased as compared with the non-pregnant condition. At\\nthe bases of the broad ligaments (defined above) there exists\\nonly cellular tissue (no peritoneum) between the uterus and\\nthe pelvic; wall this deposit extends upward and backward\\nbetween the layers of the broad ligament into the iliac fossae.\\nThe ureters enter the pelvis just in front of each sacro-iliac\\njoint and pass downward, forward, and inward to the neck of\\nthe bladder in such a way that they are not in the least liable\\nto pressure between the uterus and the bony pelvis.", "height": "3732", "width": "2480", "jp2-path": "obstetricsmanual00evan_0060.jp2"}, "61": {"fulltext": "BONY PELVIS. 61\\nThe shape and position of the uterus as well as the direction\\nof the axis of its cavity change as the organ passes from its\\nrelaxed state to one of active contraction. These will there-\\nfore be discussed later.\\nThe Pelvi-genital Canal.\\nBony Pelvis.\\nDefinition The pelvis is the bony basin, or canal, which\\nforms the most important part of the birth-canal (Fig. 24).\\nFtg. 24\\nThe female pelvis. (Jevvett.)\\nThe term is derived from the Latin pelvis, a bowl. The pelvic\\ncanal is irregularly funnel-shaped, flattened from before back-\\nward, the larger end looking upward and forward, the smaller\\ndownward and baclvward, when the woman is in the erect\\nposition. It contains in the non-pregnant state the essen-\\ntial organs of generation, and in labor the child is expelled\\nthrough it.", "height": "3712", "width": "2352", "jp2-path": "obstetricsmanual00evan_0061.jp2"}, "62": {"fulltext": "62 OBSTETRIC ANATOMY.\\nAu intimate knowledge of the pelvis as related to the\\nmechanism of labor is essential to complete understanding of\\nthe problems of the art of obstetrics.\\nGeneral description The pelvis is composed of the sacrum,\\nthe coccyx, and the two ossa innominata. Each of these\\nbones is made up of separate parts which become united by\\nthe twentieth year of life. The articulations of the pelvis,\\nw hich are of considerable obstetrical importance, are the sacro-\\niliac joints, the sacrococcygeal joint, and the symphysis pubis.\\nThe sacro-iliac joints The opposed surfaces of each bone\\nforming these joints are covered with tliin plates of cartilage.\\nThese become separated by spaces containing a small quantity\\nof glairy fluid, but no synovial membrane can be demonstrated.\\nEach of these joints has anterior and posterior ligaments and\\nintercartilaginous bands of these, the posterior are by far the\\nmost important. Each of these posterior ligaments is formed\\nof three fasciculi the two superior run nearly horizontally\\nfrom bone to bone; while the inferior passes obliquely down-\\nward and inward from the posterior superior spine of the ilium\\nto the third and fourth sacral vertebrae.\\nThe sacrococcygeal joint has an interosseous fibrocartilage\\nwhich permits recession of the coccyx. Its ligaments are of\\nno importance.\\nThe symphysis pubis The slightly convex surface of each\\npubic bone is covered with a thin plate of cartilage sufficient\\nonly to fill out any irregularities in the bones forming the joint.\\nThe opposed surfaces are held together by an intervening mass\\nof fibrocartilage, which constitutes the interpubic disk. A\\nsmall cavity is frequently present in the centre of this disk,\\nthe result of absorption of the fibrocartilage it is non-syn-\\novial in character.\\nThe ligaments of this joint are four in number anterior,\\nposterior, superior, and inferior of these, the most powerful is\\nthe inferior, often termed the ligamentum arcuatum. It is a\\nstrong fibrous bimdle passing across from one descending\\npubic ramus to the other, blending at the median line with the\\ninterpubic disk.\\nBesides the ligaments which are associated with the pelvic\\njoints, we have the sacrosciatic ligaments, which play a very\\nimportant part in the mechanism of labor.", "height": "3712", "width": "2568", "jp2-path": "obstetricsmanual00evan_0062.jp2"}, "63": {"fulltext": "BONY PELVIS. 63\\nThe greater sacrosciatic ligament arises from the posterior\\ninferior spine of the ilium and from the side of the sacrum\\nand coccyx. It narrows and thickens in its middle part, be-\\ncoming broad again at its anterior attachment to the inner sur-\\nface of the ischial tuberosity.\\nThe lesser sacrosciatic ligament takes its origin from the\\nside of the sacrum and coccyx, and, passing in front of the\\ngreater, is inserted into the spine of the ischium.\\nMobility of the pelvic joints Toward the end of gestation\\nthere obtains a certain degree of swelling or oedema of all the\\ninterarticular structures of the pelvic articulations, which per-\\nmits of some slight expansion of the pelvis during labor, under\\nthe wedge-like advance of the foetal head. The sacrum per-\\nmits of a slight rotation on its transverse axis. There is also\\na hinge-like motion of the coccyx on the sacrum which permits\\nan enlargement of the anteroposterior diameter of the pelvic\\noutlet.\\nThe pelvis presents two divisions, the false and the t7nie pel-\\nvis, the dividing-line being at the plane of the brim i. e., the\\nplane cutting the upper end of the sacrum, the top of the sym-\\nphysis pubis, and the iliopectineal line on either side.\\nThe false pelvis has but little obstetric interest; it simply\\nforms with the vertebral column and the abdominal walls a\\nfunnel-shaped approach to the true pelvis, and is included in\\nthe abdominal cavity.\\nThe true pelvis constitutes that portion of the pelvis lying\\nbelow the iliopectineal lines. It is a deep basin-shaped cavity, the\\nposterior wall, formed by the sacrum and coccyx, being sharply\\ncurved with an anterior concavity. The anterior loall is formed\\nby the symphysis pubis and is short and straight. The lateral\\nwalls, which are formed by the lower portions of the ilia, the\\nrami and tuberosities of the ischia, the sacro-iliac ligaments,\\nand parts of the descending rami of the pubes, are irregular in\\noutline, sloping inward, so that the transverse diameter of the\\npelvis is less at their lower than at their upper extremities.\\nThe true pelvis may be divided into three portions: 1, the\\ninlet, or superior strait 2, the outlet, or inferior strait 3, the\\nexcavation, or cavity.\\n(1) The inlet, or superior strait, of the pelvis, sometimes termed\\nthe hinm, is usually described as being heart-shaped, though in", "height": "3704", "width": "2348", "jp2-path": "obstetricsmanual00evan_0063.jp2"}, "64": {"fulltext": "64 OBSTETRIC ANATOMY.\\nthe fresh state it is more nearly circular. Its boundaries are\\ndefined by the top of the sacrum behind, the iliopectineal lines\\non either side and the top of the symphysis pubis in front.\\n(2) The outlet, or inferior strait (Fig. 25), is bounded by the\\nsubpubic ligament, the descending rami of the jmbes, the rami,\\ntuberosities, and spines of tlie ischia, the sacrosciatic ligaments,\\nand the coccyx. Its outline is roughly triangular in shape,\\nbut when distended by the advancing head in labor, it becomes\\novate, owing to the distensibility of the sacrosciatic ligaments\\nand the yielding character of the coccyx and sacro-iliac joints.\\nFig. 25.\\nOutlet of pelvis. (Lelsehman.)\\n(3) The excavation, or cavity of the pelvis, is bounded by\\nthe superior and inferior straits, and comprises all that i)ortion\\nof the pelvis between them.\\nPosteriorly^ the cavity is bounded by the sacrum and coccyx\\nanteriorly, by the pubic bones and their rami laterally, by the\\nlower portions of the ilia, the bodies, tuberosities, spines, and\\nrami of the ischia, and by the sacrosciatic ligaments.\\nThe posterior wall is concave from above downward its\\ndepth, following the sacral curve, is 11.5 to 12.5 cm. (4J to 5\\ninches).\\nThe anterior ivall is concave from side to side its depth at\\nthe symphysis is 4 cm. (If inches).\\nThe lateral wall is about 9 cm. (3^ inches) in depth.", "height": "3712", "width": "2476", "jp2-path": "obstetricsmanual00evan_0064.jp2"}, "65": {"fulltext": "BONY PELVIS. 65\\nFor description each must be divided into three portions,\\nwhich may be mapped out in Fig. 26.\\nThe first jmrtion is triangular in shape, its base being aline\\ndrawn from the iliopectiueal eminence to the top of the sacro-\\niliac joint, its lateral boundaries meeting at the iliac spines.\\nThis portion is bony throughout, and is smooth and curved.\\nThe second portion lies forward and somewhat below the\\nfirst, and has but little bone in its composition, being chiefly\\nmade up of the membranous tissues of the foramen ovale cov-\\nered by the obturator muscle.\\nThese structures are at term somewhat softened and more\\nelastic than in the non-pregnant condition. When the pre-\\nFiG. 26.\\nSide view of pelvis.\\nsenting part in labor, in advancing, impinges on these structures\\ntheir recession converts this portion of the lateral wall into\\nmore or less of a groove, with bony edges and elastic floor\\nthis groove deepens as it descends, and its direction tends toward\\nthe lower border of the symphysis. The ischiopubic ramus\\nforming the lower part of this portion, is curved laterally out-\\nward and lends itself to the continuation of this groove.\\nThe third portion is made up mainly of the pyriformis\\nmuscle and the elastic sacrosciatic ligaments its borders are\\nbony, being composed posteriorly of the lateral borders of the\\n5\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2352", "jp2-path": "obstetricsmanual00evan_0065.jp2"}, "66": {"fulltext": "6^\\nOBSTETRIC ANATOMY.\\nsacniin and coccyx, and anteriorly by the posterior edge of the\\nilium. During descent of the head these ligaments and muscles\\nare put on the stretch, and this portion is thus converted into\\na K)ng, s|)iral gi oove, which deepens as it descends and turns\\nforward.\\nThe second and third portions of tlie lateral walls are termed\\nrespectively the anterior and the posterior lateral grooves of the\\n])elvis.\\nThe question of the role they play, if any, in the mechanism\\nof labor will be discussed later.\\nObstetric planes of the pelvis The pelvic canal varies in size\\nand shape at ditiereut parts of its course; these variations are\\nFig. 27.\\nObstetric diameters of the pelvic brim A A conjugate diameter; T T transverse\\ndiameter L O, left oblique diameter R O, right oblique diameter. (Jewett.)\\nbest understood by means of a series of transverse planes\\nthrough the pelvic cavity at diiferent levels. Three of these\\nare of special importance obstetrically the plane of the brim,\\nthe plane of the outlet, and middle plane of the cavity.\\nPlane of the brim The anatomical brim of the pelvis is at\\nthe level of the true pelvis, Avhile the ohdetrlcal plane of the\\nbrim is situated at the level of least expansion of the upper", "height": "3736", "width": "2476", "jp2-path": "obstetricsmanual00evan_0066.jp2"}, "67": {"fulltext": "BONY PELVIS.\\n67\\npart of the pelvic canal. This lies at the level of the summit\\nof the sacral promontory, the iliopectineal line, and the posterior\\nsurface of the symphysis pubis, at a point 1 cm. of an inch)\\nbelow its upper margin (Fig. 27).\\nPlane of the outlet At the outlet also the anatomical and\\nobstetrical planes differ. The obstetrical plane of the outlet\\nis defined by the tip of the sacrum, the lower border of the\\nischial spines, and the lower border of the symphysis pubis at\\na point just above the lower margin (Fig. 28).\\nFig. 28.\\nObstetric diameters of the pelvic outlet S. P., sacropubic diameter; Bi. I., bis-\\nIschial diameter; Bi. S., bisischiatic diameter, (Jewett.)\\nPlane of the cavity The middle plane of the pelvic cavity\\nlies at the level of the upper end of the third piece of the\\nsacrum, the middle of the symphysis pubis, and the centre of\\nthe acetabular cavities (Fig. 29).\\nInternal pelvic diameters The dimensions of each plane are\\nmeasured in four directions the anteroposterior, the transverse,\\nand the two oblique.\\nAt the plane of the brim The anteroposterior diameter of\\nthe brim is the least distance between the sacral promontory\\nand the symphysis pubis. It is measured from the middle of", "height": "3704", "width": "2368", "jp2-path": "obstetricsmanual00evan_0067.jp2"}, "68": {"fulltext": "68\\nOBSTETRIC ANATOMY.\\nthe sacral promontory to the posterior surface of the symphy-\\nsis, at a point 1 cm. inch) below its upper margin. It is\\nDiagram showing axes and planes of pelvis A B C D, axis of entire parturient\\ncanal X, anus as distended at acme of expulsion E F, plane of brim K L, mid-\\nplane of cavity M N, plane of outlet P, axis of brim Q R, axis of mid-plane\\nS T, axis of outlet H. horizon E N, diagonal conjugate diameter.\\ntermed the conjugatey or true conjugate and measures 11 cm.\\n(4| inches) (Fig. 27).", "height": "3712", "width": "2520", "jp2-path": "obstetricsmanual00evan_0068.jp2"}, "69": {"fulltext": "BONY PELVIS.\\nFig. 30.\\n69\\nPlanes of the pelvis with horizon A B, horizon C D, vertical line A B 1, angle\\nof inclination of pelvis to horizon, equal to 60\u00c2\u00b0 B I C, angle of inclination of pelvis\\nto spinal column, equaHo 150\u00c2\u00b0; C I J, angle of inclination of sacrum to spinal col-\\numn, equal to 130\u00c2\u00b0 E F, axis of pelvic inlet L M, mid-plane in the middle line;\\nN, lowest point of mid-plane of ischium. (Play fair.)\\nThe inlet, or superior strait.\\nA P, anteroposterior diameter, 4.3 to 4.5 inches, or II-IIV2 centimetres.\\nTS, transverse, 5.3 or IS^^\\nR 0, right oblique, 4.7 to 4.9 or 12-123^\\nX 0, left oblique, 4.7 to 4.9 or 12-123^\\nThe circumference of the inlet is 15.8 inches, or 40 centimetres.", "height": "3708", "width": "2344", "jp2-path": "obstetricsmanual00evan_0069.jp2"}, "70": {"fulltext": "70 OBSTETRIC ANATOMY.\\nThe frdnsverse diameter (Fig. 31) is the greatest distance\\nbetween the iliopectineal lines, and measures 13.5 cm. (5 J\\ninches).\\nThe oblique diaineters (Fig. 31) are measiu ed one from the\\nright and the other from the left sacro-iliac joint where it inter-\\nsects the iliopectineal line, to the opposite iliopectineal emi-\\nnence. The right oblique springs from the right, and the left\\noblique from the left, sacro-iliac joint. They each measure\\nabout 12.5 cm. (5 inches).\\nAt the plane of the cavity: The anteroposterior diameter is\\nthe distance from the upper margin of the third piece of the\\nsacrum to a point midway on the posterior surface of the sym-\\nphysis (Fig. 30), and is 12.5 cm. (5 inches).\\nThe transverse diameter is the greatest diameter of the pelvis\\nat this plane, and measures 12 cm. (4| inches).\\nThe oblique diameters of this plane are valueless from an\\nobstetrical point of view.\\nAt the plane of the outlet The anterojjosterior diameter is a\\nline drawn from the tip of the sacrum to a point just above the\\nlower border of the symphysis pubis (Figs. 28 and 29). It\\nmeasures 11.5 cm. (4|- inches).\\nThe transverse diameter at this plane may be measured in\\ntwo places (Fig. 28). The greatest transverse diameter is the\\nbisischial line, which is measured from a point on the inner\\nsurface of one ischial tuberosity at the middle of its posterior\\nborder, to the same point on the opposite side. This measures\\n11.5 cm. (4J inches).\\nThe least transverse diameter is the distance between the\\nischial spines, the bisischiatic diameter, which measures 10.5\\ncm. (4| inches).\\nThe oblique diameters at this plane are of no importance.\\nIt will be noted by comparing the dimensions at the differ-\\nent planes, that the transverse diameter of the pelvic canal\\ngrows progressively smaller from the brim to the outlet the\\ndifference between these being 2.5 cm. (1 inch); and also\\nthat the anteroposterior diameter of the pelvic canal is 0.5\\nlonger at the outlet than at the brim.\\nMeasurements The internal diameters of the bony pelvis\\nas stated in the following table are sufficiently accurate for all\\npractical purposes, and should be memorized:", "height": "3728", "width": "2524", "jp2-path": "obstetricsmanual00evan_0070.jp2"}, "71": {"fulltext": "THE SOFT PARTS OF THE PELVIC CANAL. 71\\nAnteroposterior. Oblique. Transverse.\\nBrim, 10 cm. (4 inches). 11.5 cm. (4.^ inclie\u00c2\u00ab). 12.5 cm. (5 inches).\\nCavity, 11.5 (4^ 11.5 (4^ 11.5 (4J\\nOutlet, 12.5 (5 11.5 (4J 10.0 (4\\nInclination of the pelvis The inclination (Fig. 30) of the\\nplane of the pelvic brim to the horizon, with the woman in the\\nerect position, may be stated as fifty-five degrees. The inclina-\\ntion of the pelvis, of course, differs with changes of posture.\\nIn the erect position the symphysis i)ubis is nearly 9 cm. (3 J\\ninches) below the level of the promontory and the coccyx is\\n2 cm. (f inch) above the level of the lower border of the\\nsymphysis pubis, the pubococcygeal line making an angle of\\nten degrees with the horizon.\\nThe Soft Parts of the Pelvic Canal.\\nThe lower segment of the uterus and the cervix form a part\\nof the birth-canal while the upper segment is the chief source\\nof the propelling power. This portion of the soft parts has\\nalready been described.\\nThe soft parts which line the bony pelvis and those which\\ncontribute to the formation of the pelvio floor are of great ob-\\nstetric importance. The former diminish somewhat the diame-\\nters of the bony ca\\\\ ity the latter form the knver portion of\\nthe birth-canal.\\nThe psoas and iliacus muscles, which lie at the brim, dimin-\\nish the transverse diameter of this portion of the pelvis a\\nquarter of an inch on either side, thus bringing this diameter\\ndown to about the size of the oblique diameter.\\nThe external iliac vessels run along the inner borders of\\nthese muscles, and the main trunk of the lumbar plexus fol-\\nlows the course of the psoas, the crural nerve running between\\nthe psoas and iliacus muscles.\\nThe obturator internus, which is but a thin muscle-sheet,\\ncovers portions of the anterior and lateral walls and a part of\\nthe small sciatic notch. Thus it practically covers the anterior\\ninclined groove of the pelvis, and is by many thought to make\\nthe groove of but little value obstetrically.\\nThe pyriformis, which is a thin fan-shaped muscle, lies a\\nlittle over the edge of the sacrum and completely fills the great", "height": "3712", "width": "2352", "jp2-path": "obstetricsmanual00evan_0071.jp2"}, "72": {"fulltext": "72 OnSTKTRlC ANATOMY.\\nsciatic notch, thus eoutributiiig to the formation of the floor\\nof the so-called posterior pelvic groove.\\nThe anterior wall of the pelvis is not covered by muscle,\\nbut during pregnancy the bladder lies in relation with it.\\nDuring labor the greater part of this viscus is drawn up above\\nthe inlet but its base may, in tedious labors, be subjected to\\nprolonged pressure between the head and the pubes, thus\\ndamaging it to such an extent that sloughiug may occur and\\nvesicovaginal fistula result.\\nThe rectum lies in front of the left sacro-iliac joint. It runs\\nforward and inward, descending in the median line down the\\nanterior surface of the sacrum and coccyx. When distended\\nit may encroach on the pelvic space to a very considerable\\nextent. Its presence in this portion of the pelvis is supposed\\nto account for the greater frequency with which the long\\ndiameter of the foetal head occupies the right oblique diameter\\nat the onset of labor.\\nThe pelvic floor comprises the soft structures which close the\\noutlet of the bony pelvis. Its function is to support the\\npelvic viscera. Its upper limit is the peritoneum, its lower,\\nthe skin it is perforated by the rectum, vagina, and urethra.\\nHart has divided the pelvic floor into two segments, as\\nfollows: the posterior vaginal wall and the soft structures\\nbehind it constitute the sacral segment; the anterior vaginal\\nwall and the soft structures in front of it compose the pubic\\nsegment.\\nIn labor the pubic segment is drawn upward and the sacral\\nsegment is pushed downward and distended as the foetus\\ndescends. The resiliency of the sacral segment holds the foetal\\nmass in close relation with the ischiopubic rami during the\\nlatter part of labor, and assists in its final expulsion.\\nThe pelvic floor when stretched by the foetus measures,\\nfrom the tip of the sacrum to the anterior border of the\\npubic segment, about 5 inches (12.75 cm.). It is mainly com-\\nposed of muscles and fasciae.\\nThe muscles forming the pelvic floor are the levator ani, the\\nsphincter ani, the transverse muscles of the perineum, and the\\nsphincter vaginae.\\nThe levator ani muscle, which is the most important, takes\\nits origin from the posterior layer of the triangular ligament,", "height": "3728", "width": "2568", "jp2-path": "obstetricsmanual00evan_0072.jp2"}, "73": {"fulltext": "THE SOFT PARTS OF THE PELVIC CANAL.\\n73\\nfrom the spine of tlie iscliiiim, and from the whole lengtli of\\nthe white line (Fig. 32).\\nThose fibres which arise from the pubes pass backward to\\nbe inserted into tlie last two pieces of the coccyx, and on\\nFig. 32.\\nDrawing from a photograph of a dissection made at the Long Island College\\nHospital 1, symphysis 2, coccyx 3, anus 4, superficial fibres from the pubic\\norigin of the levator ani 5, deeper fibres from the pubic origin 6, fibres from the\\nwhite line 7, fibres from the spine of the ischium 8, gluteus maximus muscle.\\n(Browning.)\\ntheir way send fibres to the urethra, vagina, and the internal\\nsphincter ani, and a few to unite with those of the opposite", "height": "3712", "width": "2468", "jp2-path": "obstetricsmanual00evan_0073.jp2"}, "74": {"fulltext": "74\\nOBSTETRIC ANATOMY.\\nside behind the anus. That part arising from the white\\nline and the rest of the line of origin which forms the greater\\nbulk of the muscle, runs backward, downward, and inward\\nto the side of the coccyx and lower end of the sacrum. The\\nmuscle thus forms a diaphragm with the concavity upward.\\n1\\nFig. 33.\\nCoronal section of the pelvis: ilium; P, ischium; C, acetabulum D, psoas\\nmagnus muscle E, obturator internus F, levator ani G, sphincter ani externus\\na, transversalis fascia h, iliac fascia c, obturator fascia d, white line e, recto-\\nvesical fascia Alcock s canal. (Browning.)\\nThe other muscles entering into the formation of the pelvic\\nfloor form a second layer thinner than that formed by the\\nlevator ani. They all meet at the central point of the peri-\\nneum.\\nThe fascia forming the pelvic floor is probably a more", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0074.jp2"}, "75": {"fulltext": "THE SOFT PARTS OF THE PELVIC CANAL.\\n75\\nimportant element obstetrically than tlie muscle layer. It\\nmav be described in two portions, a parietal and a visceral\\nlayer (Fig. 33).\\nTile parietal layer, which is the less important, covers the\\nmuscles, padding the sides of the pelvis in front it forms the\\nj)osterior layer of the triangular ligament, and is perforated by\\nthe urethra and vagina at the back it helps to cover the\\nsciatic notches.\\nThe visceral layer is continuous Avith the fascia covering the\\nsides of the pelvis. From its line of origin at the white line\\nthe visceral layer passes downward and inward to the middle\\nline, where its fibres fuse with the connective tissue at the base\\nof the bladder, the vagina, and the rectum, thus slinging these\\nstructures in the pelvis. On its lower surface is the levator\\nani muscle.\\nThe perineum may be defined as that })ortion of the body\\nlying between the anus and the orifice of the vagina. It is\\nformed by the perineal body (Fig. 34), which is the aggrega-\\nFiG. 34.\\nThe external genital?, as seen in mesial section: a, anus; h, perineal body; c,\\nina d, urethra; e, labium minus; clitoris; g, fossa navicularis, in front of\\nvas:\\nwhich is the hymen\\n(Henle.)\\ntion of the tissues lying between the rectum and vagina below\\ntheir point of contact. On section the perineal body is tri-\\nangular in outline and pyramidal in form. Its skin surface\\n(base) from the anterior part of the anus to the posterior part\\nof the vaginal orifice measures about 2.5 cm. (1 inch).", "height": "3712", "width": "2476", "jp2-path": "obstetricsmanual00evan_0075.jp2"}, "76": {"fulltext": "76\\nOBSTETRIC ANATOMY.\\nThe parturient axis The\\nvie canal is a line which\\nAxis of the birth-canal r, anus; a b,\\nplane of outlet of completed canal; e,\\nperpendicular to plane or axis of ex-\\npulsion.\\nmathematical axis of the pel-\\npierces each pelvic plane per-\\npendicularly at its central\\npoint. This axis is a curved\\nline with its concavity for-\\nward, and represents very\\nclosely the course the foetal\\nhead follows in its descent\\nthrough the pelvis in normal\\nlabor (Fig. 35).\\nThe axis of the brim if pro-\\nlonged would strike the tip\\nof the coccyx below, above\\nit would touch a point on\\nthe abdomen near the umbil-\\nicus.\\nThe axis of the bony outlet,\\nif prolonged upward, would\\npass immediately in front of\\nthe sacral promontory. The\\naxis of the plane of the vulvo-\\nvaginal inng at the moment\\nwhen the head is expelled, is\\na line directed upward almost\\nparallel with the lower part\\nof the abdominal wall of the\\nmother (Fig. 29).\\nHirst points out that the\\ndirection of the pelvic canal\\ndepends entirely on the curve\\nof the sacrum, and that this\\ndiffers in every pelvis.\\nThe Foetus.\\nThe third anatomical element concerned in labor is the body\\nto be expelled. This consists of the whole ovum, viz., pla-\\ncenta, membranes, and foetus. The anatomy of the placenta\\nand membranes has already been described, therefore this\\nsection will be concerned with the foetus only.", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0076.jp2"}, "77": {"fulltext": "THE FCETUS. 77\\nThe mature foetus At term the foetus measures usually\\nbetween 46 and 51cm. (18-20 inches) in length, lis iveight\\naverages from 3150 to 3290 grammes (7-7^- pounds), males\\nbeing somewhat heavier than females. Not rarely the weight\\nmay reach as high as 5400 grammes (12 pounds), the phe-\\nnomenal W cight of 9000 grammes (20 pounds) has been\\nrecorded.\\nThe head bears a much larger proportion to the trunk than\\nin the adult. Its diameters are greater than those of any part\\nof the trunk, and are more incompressible. It therefore offers\\nthe principal resistance to the passage of the child through\\nthe pelvis. In the mechanism of labor it is with the head\\nthat obstetric problems are mainly concerned.\\nThe whole body of the foetus before and during labor forms\\na roughly ovoid mass. So long as the long diameter of the\\nfoetal ovoid coincides as nearly as possible with the axis of\\nthe parturient canal the mechanism is a normal one. This is\\nthe case whichever extremity, head or breech, the foetus\\npresents.\\nThe head Obstetrically, the foetal head presents tw^o divi-\\nsions (1) the cranial vault; (2) the cranial base and face.\\nThe vault, which is compressible, is composed of thin, raem-\\nbrano-cartilaginous plates, which are in themselves flexible\\nand are, with the exception of the frontal bone, united to the\\nbase and to each other by membrane only.\\nThe base is formed of bones which are solid and firmly\\nankylosed. It is therefore incompressible, thus affording\\nprotection during birth to the ganglia at the base of the\\nbrain.\\nThe attachment between the base and the vault of the\\ncranium is along a line drawn through the junction of the\\norbital and squamous parts of the frontal bone, continued\\nbackward by the squamous suture and downward by the\\nhinge-like junction of the tabular part of the occipital bone\\nto the basilar and condylar portion.\\nThe bones forming the cranial vault are the two parietal,\\nthe frontal, and the squamous portions of the occipital\\nand of the two temporal bones. These are united only by\\nthe unossified external periosteum and by the dura mater.\\nThe plasticity of the vault is due to the cartilaginous char-", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0077.jp2"}, "78": {"fulltext": "78\\nOBSTETRIC ANATOMY.\\nactor of the bones and to the existence of the membranous\\ninterspaces.\\nThe sutures of the vault are the membranous intervals\\nbetween two adjacent bones. The most important are the\\nsagittal, running between the two parietals; the frontal,\\nbetween the two portions of the frontal bone the coronal,\\nbetween the frontal and parietals and the lamhdoidal, between\\nthe parietals and the occipital bone (Figs. 36 and 37).\\nFig. 37.\\nAnterior and posterior fontanelles, sagittal, lambdoidal, coronal, and frontal\\nsutures.\\nThe fontanelles are the larger spaces formed by the widen-\\ning out of the sutures between the angles of three or four\\nadjacent bones.\\nThe largest is the anterior fontanelle, or bregma, situated at\\nthe junction of the sagittal, the coronal, and the frontal sut-\\nures. It is kite-shaped, or quadrangular, with its most acute\\nangle forward. Its average diameter is about one inch, but\\nits size varies in different heads. Four lines of sutures run\\ninto it.\\nThe posterior, or small, fontanelle is formed at the junction\\nof the sagittal and lambdoidal sutures, and is merely felt as a\\nsmall triangular depression. There are three lines of sutures\\nrunning into it.\\nTetiiporal fontanelles At the junction of the temporal with", "height": "3728", "width": "2472", "jp2-path": "obstetricsmanual00evan_0078.jp2"}, "79": {"fulltext": "TEE FCETUS.\\nFig. 38.\\n79\\nThe diameters of the fcetal head: O F, occipitofrontal; O B, suboccipito-\\nbregmatic; B T, cervicobregmatic. The maximum diameter, occipitomental, is\\nindicated by the long dotted arrow. Measurements are centimetres. (l arabeut\\nand Yarnier.)\\ndiameters of the flexed head: P P, Biparietal diameter, 9^4 cm. (After\\nFarabeuf and Yarnier.)", "height": "3708", "width": "2452", "jp2-path": "obstetricsmanual00evan_0079.jp2"}, "80": {"fulltext": "80 OBSTETRIC ANATOMY.\\nthe parietal and occipital bones, on either side of the head,\\nthere exists a small quadrilateral fontanelle.\\nFalse fontanelles are occasionally observed either in the\\nbody of the bone or in the course of a suture. These are\\ndue to some defect in ossification. A quadrilateral false fon-\\nFiG. 40.\\nVertex. Left occipito-anterior position. (Ribemont-Dessaignes and Lepage.)\\ntanelle is not infrequently to be felt in the line of the sagit-\\ntal uture a short distance from the usual small fontanelle.\\nObstetric landmarks: Certain landmarks about the foetal\\nhead are of considerable obstetrical importance.\\nThe vertex is that portion of the head between the anterior", "height": "3728", "width": "2472", "jp2-path": "obstetricsmanual00evan_0080.jp2"}, "81": {"fulltext": "THE FCETUS. 81\\nand posterior fontanelles, and extending laterally to the parie-\\ntal eminences.\\nThe occijjut is that portion of the head behind the posterior\\nfontanelle.\\nThe sinciput is that portion of the head in front of the\\nbregma.\\nFig. 41.\\nVertex. Right occipito-anterior position. (Ribemont-Dessaignes and Lepage.)\\nThe glabella is the space over the root of the nose and\\nbetween the supra-orbital ridges.\\nFive protuheranceH are presented by the cranial bones\\nThe occipital protuberance situated in the middle of the\\nsquamous portion of the occi})ital bone about 2.5 cm. (1 inch)\\nbehind the po.sterior fontanelle. The parietal protuberance\\nis the boss or eminence in the centre of each parietal bone.\\n6\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0081.jp2"}, "82": {"fulltext": "82 OBSTETRIC ANATOMY.\\nThe frontal protuberance is the eminence in the centre of\\neach frontal bone.\\nDiameters of the foetal head Occipitofrontal, extending\\nfrom the glabella to the tip of the occipital protnberance\\n11.5 cm. (41 inches) posterior end, Fig. 88, too high.\\nFig. 42.\\nVertex. Right occipito-posterior position. (Ribemont-Dessaignes and Lepage.)\\nOccipitomental y extending from the ti]) of the occipital pro-\\ntuberance to the centre of the chin. Measures 14 cm. (5^\\ninches). The posterior end. Fig. 38, is too high.\\nSuhoccipitobreginatic, extending from the junction of the\\nneck and occiput to the centre of the bregma. Measures 9.5\\ncm. (3J inches).\\nSuboccij)itofrontal, extending from the junction of the neck", "height": "3712", "width": "2504", "jp2-path": "obstetricsmanual00evan_0082.jp2"}, "83": {"fulltext": "THE FCETUS. 83\\nand occiput to the summit of the brow. Measures 11 cm.\\n(4| inches).\\nBiparietal, measures through the centre of the parietal\\neminences. Measures 9.5 cm. (3|- inches).\\nFrontomental, extending from the summit of the brow to\\nthe centre of the lower border of the chin. Measures 9 cm.\\n(34 inches).\\nFig. 43.\\nVertex. Left occipito-posterior position. (Ribemont-Dessaignes and Lepage.)\\nCervlcobreginatic, extending from the junction of the neck\\nand chin to the centre of the bregma. Measures 9.5 cm. (3J\\ninches).\\nThe above diameters (Figs. 38 and 39) are all of them\\nmore or less compressible.\\nThe remainder are incompressible.\\nBimastoidj measured through the mastoid processes, 7 cm.\\n(2f inches).", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0083.jp2"}, "84": {"fulltext": "84\\nOBSTETRIC ANATOMY.\\nBimalary measured through the malar eminences, 7 cm. (2f\\ninches).\\nBitemporal, measured through the lower extremities of the\\ncoronal suture, 8 cm. (3 J inches).\\nThe following table is sufficiently accurate for all practical\\npurposes and should be memorized\\nFig. 44.\\nFace. Left mento-anterior position. (Farabeuf and Varnier.)\\nDiameters of the Foetal Head (Jeicett).\\nBiparietal, 9 cm. (J^ inches\\nSuboccipitobregmatic,\\n9 cm. (31\\na\\nFrontomental,\\n9 cm. (31\\nu\\nOccipitofrontal,\\n11.5 cm. (41\\ni(\\nOccipitomental,\\n14 cm. (51\\n(i", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0084.jp2"}, "85": {"fulltext": "THE FCETUS. 85\\nIn the following table the circumferences of the most im-\\nportant planes of the foetal head are given\\nCircumferences of the Planes of the Fcetal Head.\\nSuboccipitobregmatic, 33 cm. (13 inches).\\nSuboccipitofrontal, 35 cm. (]3|\\nOccipitofrontal, 34.5 cm. (13J\\nFig. 45.\\nFace. Right mento-anterior position. (Farabeuf and Varuier.)\\nImportance of flexion of foetal head When the head is com-\\npletely flexed, as it is in normal labor, its smallest plane\\n(measured by its circumference) comes into relation with the\\ndifferent pelvic planes successively as the head descends. This", "height": "3608", "width": "2456", "jp2-path": "obstetricsmanual00evan_0085.jp2"}, "86": {"fulltext": "86\\nOBSTETRIC ANATOMY.\\nsmallest plane, as will be noticed in the above tal)le, is the suh~\\noccipitobregmatic. The importance of the maintenance of\\ncomplete iflexion of the fcrtal head until almost the moment\\nof its delivery will thus be easily comprehended.\\nFig. 46.\\n1\\n^ht mento-posterior position. (Farabeuf and Varnier.)\\nMoulding of the foetal head During labor the head under-\\ngoes more or less compression which results in its alteration\\nin shape.\\nMoulding results from the overlapping of the cranial bones,\\n\\\\vhich takes place in a definite way in all cases. The parietal", "height": "3708", "width": "2576", "jp2-path": "obstetricsmanual00evan_0086.jp2"}, "87": {"fulltext": "THE FCETUS.\\n.87\\nboues override the occipital and frontal bones and of the\\nparietals the one most pressed upon, generally the one in rela-\\ntion to the promontory, always slips under the other. The\\nFig. 47\\nFace. Left mento-posterior position. (Farabeuf and Varnier.)\\ntwo halves of the frontal bone follow the same rule as the\\nparietal bones.\\nThe whole volume of the head is reduced by compression,\\nthe greater portion of the cerebrospinal fluid and of the con-\\ntents of the cerebral bloodvessels being forced out of the\\ncranial cavity during labor.", "height": "3692", "width": "2408", "jp2-path": "obstetricsmanual00evan_0087.jp2"}, "88": {"fulltext": "88\\nOBSTETRIC ANATOMY.\\nThe foetal tnmk The diameters of importance in the trunk\\nare few, as the whole body is very incompressible. The h ls-\\nacromial is the longest and measures 12 cm. (4| inches), and is\\nreducible to the extent of 2 to 3 cm.\\nThe hitrochanteric measures about 10 cm. (4 inches).\\nThe dorsosternal measures 9 cm. (3^ inches).\\nBreech Left saero-anterior position. (Farabeuf and Varnier.)\\nThe length of the foetal ovoid, that is, from the vertex to the\\nbreech, may be given as 24-24,5 cm. (9^ to 10 inches).\\nMobility of the foetal head and trunk The movements of\\nflexion, extension, and rotation of the/cc/a/ head are of great\\nimportance in the mechanism of labor. Flexion is limited by\\nthe pressure of the chin upon the chest.", "height": "3704", "width": "2608", "jp2-path": "obstetricsmanual00evan_0088.jp2"}, "89": {"fulltext": "THE FCETUS.\\n89\\nExtension is limited by compression of the occiput against\\nthe back. Rotation is safe through an arc of 90 degrees\\non each side^ till the chin points over the shoulder.\\nThe trunh permits of a certain amount of rotation which is\\nlimited by the rotation of the vertebral bodies. A certam\\nFig. 49.\\nBreech. Right sacro-anterior position. (Farabeuf and Varnier.)\\ndegree of lateral flexion is also possible as well as ordinary\\nflexion and ex .ension.\\nThe posture of the foetus is the relation which the trunk,\\nhead, and limbs of the child have to one another, independently\\nof the relations of any part of the foetus to any part of the\\nmother.\\nThe normal posture of the foetus during pregnancy and", "height": "3700", "width": "2508", "jp2-path": "obstetricsmanual00evan_0089.jp2"}, "90": {"fulltext": "90\\nOBSTETR TC A NA TOM 1\\nparturition is one of flexion, the head being flexed on the\\ntrunk, tlie tliighs on the abdomen, and the legs on the thighs,\\nthe arms behig folded on the chest.\\nThe relation of the uterine and foetal axes During the latter\\npart of pregnancy and in parturition the long axis of the foetal\\novoid may correspond to the long axis of the uterus (longi-\\ntudinal) or may be at right angles to it (transverse).\\nBreech. Right sacro-posterior position. (Farabeuf and Varnier.)\\nNormally the long axes correspond any deviation from this\\nrelationship leads to serious complications in labor.\\nCommonly, obstetricians apply the term presentation to\\ndenote the relation of the long axis of the foetal ovoid to the\\nuterine axis. In our opinion the use of this term to denote", "height": "3728", "width": "2576", "jp2-path": "obstetricsmanual00evan_0090.jp2"}, "91": {"fulltext": "THE FCETUS.\\n91\\nthis relationship is a misnomer. The term jjresentation should\\nonly be used to denote the part of the foetus which presents at\\nthe pelvic brim and is accessible to the examining iinger.\\nPresentations: Under the definition just given there are\\nthree forms of fcetal presentation the ceplialicy thejpe/t ic, and\\nFig. 51.\\nBreech. Left sacro-posterior position. (Farabeuf and Varnier.)\\nthe somatic. There occur distinct varieties of each of these\\nforms, as will be noted in the following table\\nTable of Foetal Presentations.\\nFrequency.\\n97 per cent.\u00e2\u0080\u0094 vertex, (h) face, (c) brow.\\n1.6 per cent. breech, leg, (c) foot.\\nCephalic J\\nPelvic,\\nSomatic,\\n0.5 per cent. (a) shoulder, (6) elbow, (c) hand.", "height": "3712", "width": "2492", "jp2-path": "obstetricsmanual00evan_0091.jp2"}, "92": {"fulltext": "92\\nOBSTETRIC ANATOMY.\\nThe latter form of [)resentation is often termed transverse or\\ncrossed birth.\\nPosition: The pelvic brim is divided by the conjugate and\\ntransverse diameters into Jour quadrants. Position may be\\ndefined as the relationship of the presenting part of the foetus\\nto the quadrants of the pelvic brim. Thus for each presenta-\\nFiG. 52.\\nI\\nShoulder. Left scapulo-anterior position. (Farabeuf and Varnier.)\\ntion there are four positions. They are named according to\\nthe ])articular quadrant confronted by the presenting part.\\nIn vertex, face, and breech presentations the long diameter\\nof the presenting part engages in one of the oblique diameters\\nof the pelvic inlet.\\nIn vertex presentations vhen the occiput confronts the left", "height": "3712", "width": "2616", "jp2-path": "obstetricsmanual00evan_0094.jp2"}, "93": {"fulltext": "THE FCETUS. 93\\nanterior quadrant of the pelvic brim, the position is left\\noccipito-anterior, and so on.\\nFace i^resentations are named similarly according to the\\ndirection of the chin, left mento-anterior, etc.\\nBreech presentations are named according to the position of\\nthe sacrum, left sacro-anterior, etc.\\nShoulder. Right scapulo-anterior position. (Farabeuf and Varnier.)\\nShoulder presentations are named according to the direction\\nof the scapula, left scapulo-anterior, etc.\\nThe positions are sometimes spoken of as first, second, third,\\nor fourth, the left anterior being the first and the others fol-\\nlowing in order from left to right around the pelvic brim.\\nThis method is apt to mislead, as various authorities differ as\\nto which is the first position in certain presentations, and con-", "height": "3704", "width": "2488", "jp2-path": "obstetricsmanual00evan_0095.jp2"}, "94": {"fulltext": "94 OBSTETRIC ANATOMY.\\nfusion results. It is better to designate each position in full\\nor by the initial letters (Figs. 40-55).\\nFig. 54.\\nShoulder. Right scapulo-postcrior position. (Farabeuf aud Varnier.)\\nVertex positions\\nLeft occipito-anterior, L. O. A.\\nRight occipito-anterior, Iv. O. A.\\nRight occipitoposterior, R. O. P.\\nLeft occipitoposterior, L. O. P.\\nFace positions\\nLeft nicnto-anterior, L. M. A.\\nRight men to-anterior, R. M. A.\\nRight mentoposterior, R. ]\\\\I. P.\\nLeft mentoposterior, L. M. P.", "height": "3732", "width": "2572", "jp2-path": "obstetricsmanual00evan_0096.jp2"}, "95": {"fulltext": "THE FCETUS.\\n95\\nBreech positions\\nLeft sacro-anterior, L. S. A.\\nRight sacro-anterior, R, 8. A.\\nEight sacroposterior, R. 8. P.\\nLeft sacroposterior, L. S. P.\\nSomatic or shoulder presentations\\nLeft scapulo-anterior, L. Sc. A.\\nRight scapulo- anterior, R. Sc. A.\\nRight scapuloposterior, R. Sc. P.\\nLeft scapuloposterior, L. Sc. P.\\nShoulder. Left seapulo-posterior position. (Farabeuf and Varnier.)\\nFace presentations are sometimes named according to the\\npelvic quadrant confronted by the brow, as left fronto-anterior,\\nL. F. A., etc.", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0097.jp2"}, "96": {"fulltext": "96 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nThat some form of cephalic presentation occurs in 97 per\\ncent, of all cases is not quite satisfactorily accounted for.\\nThere are three conditions each of which has some influence\\nin bringing about this result. These are: 1, the position of\\nthe centre of gravity of the foetus 2, the relative shapes of\\nthe uterus and of the foetus 3, the movements of the foetus\\n1. Matthews Duncan long ago found that the centre of\\ngravity of the foetus lay somewhere about the shoulders, and\\nnearer the right than the left, owing to the presence of the\\nliver on the right side. Thus if a foetus is immersed in a\\nsaline fluid of the same specific gravity as its own, it sinks\\ninto a position with the back of its right shoulder looking\\ndownward, this, therefore, becoming the lowest part of the\\nbody.\\n2. The relative shapes of the uterus and of the foetus The\\nfundus is at term the most roomy part of the uterus hence\\nat term the more bulky breech finds greater accommodation in\\nthe upper segment, Avhile the head readily adapts itself to the\\nsmaller lower segment.\\nThe foetal movements The movements of the legs of the\\nfoetus are probably more powerful than those of the arms.\\nHence if the child lie with the feet downward these will\\nwhen in a state of motion come into contact with the resist-\\ning pelvic brim, which will result in lateral displacement of\\nthe child s body. The shape of the uterus will then tend to\\nconvert this attitude again into a longitudinal one. The\\naction of the specific gravity of the foetus will tend to bring\\nthe cephalic pole downward, and when once this position lias\\nbeen obtained its alteration is not likely to occur provided no\\nabnormal conditions are present.\\nTHE MECHANISM AND COURSE OF NORMAL\\nLABOR.\\nDefinition The term eutocia, indicating normal labor, is\\napplied to labors which terminate without artificial aid and\\nwithout injury to the mother or child.\\nUnder this definition, in this work, only iincomplicated\\nvertex preseniatioiis will be classed as normal.\\nAt this point it may be mentioned that a woman pregnant\\nI", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0098.jp2"}, "97": {"fulltext": "THE CAUSES OF THE ONSET OF LABOR. 97\\nfor the first time is termed a primigrmrida one in labor or in\\nthe puerperium for the first time, a primij^ara.\\nIf a woman has had several children or miscarriages pre-\\nviously she is termed a multipara. When it is desired to in-\\ndicate the exact number of the labor she is spoken of as a\\ni para, ii para, iii para, and so on.\\nStages of labor While there is frequently a premonitory\\nstage before labor actually sets in, it is customary to divide\\nlabor itself into three distinct stages\\nThe first stage, or stage of dilatation, ends with the full\\ndilatation of the os uteri, with which the rupture of the\\nmembranes is usually coincident.\\nThe second stage, or stage of expulsion, ends with the\\ncomplete birth of the child.\\nThe thM stage, or placental stage, ends with complete\\nexpulsion of the placenta and membranes and retraction of\\nthe uterus.\\nThe duration of normal labor The average duration of\\nnormal labor in primipara3 may be stated as eighteen hours\\nwhile in multiparse it is from eight to ten hours.\\nThe average duration of the first stage in primiparse is\\nabout twelve hours in multiparse from six to eight hours.\\nThe second stage in primiparse lasts about four to six\\nhours; and in multiparse from one to two hours.\\nThe thir^d stage, which is but rarely terminated spontane-\\nously, lasts from a few minutes to two hours.\\nThe Causes of the Onset of Labor.\\nNo entirely satisfactory theory has been advanced to ac-\\ncount for the onset of labor, which usually occurs on the two\\nhundred and eightieth day after the beginning of the last\\nmenstrual period.\\nIt is known that three motor centres exist which preside\\nover uterine contractions a centre in the medulla the cervi-\\ncal ganglia and the ganglia in the anterior vaginal wall and\\nthe uterine walls.\\nLabor is not the result of the operation of one, but rather\\nof a number of concurrent causes. These act by increasing\\nthe painless rhythmic contractions of tlie uterus present\\nthroughout the whole period of pregnancy.\\n7_0bst.", "height": "3712", "width": "2452", "jp2-path": "obstetricsmanual00evan_0099.jp2"}, "98": {"fulltext": "98 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nThe following are among the most probable causes\\n1. Loosening attachment of the ovum, thus converting it\\ninto a foreign body\\n2. Excess of carbon dioxide in the blood\\n3. Distention of the uterus by the ovum\\n4. iNIental impressions.\\n1. Loosening attachment of the ovum: It has been observed\\nthat toward the end of pregnancy the trabeculse in the spongy\\nlayer of the decidua vera decrease in size, causing this layer,\\nas it were, to shrivel up, and thus easy separation of the ovum\\nis permitted. Also slight hemorrhages, which occur as the\\nresult of violent uterine contractions, tend to aid in detaching\\nthe ovum from the uterine walls. The ovum thus becomes a\\nforeign body and excites the uterus to further action.\\n2. Excess of carbon dioxide in the blood: As the foetus\\ndevelops it demands more nourishment, and there is at the\\nsame time an increase in its tissue-waste, which includes\\ncarbon dioxide. This gas has been proved by Brown-Sequard\\nto excite uterine action by stimulating the nerve-centres men-\\ntioned above.\\nCertain changes are supposed to take place in the placenta\\nleading to an increase in the quantity of carbon dioxide.\\nWhen the venous blood has accumulated a sufficient quantity\\nof this gas, uterine contractions are stimulated to such an\\nextent that labor is established.\\n3. Distention of the uterus: All hollow viscera wdien dis-\\ntended to a certain limit contract and expel their contents.\\nWitness the distention of the bladder, the rectum, and the\\noverloaded stomach of the infant.\\n4. Mental impressions The emotions play a large part fre-\\nquently in inducing uterine contractions. Great grief, joy, or\\nsevere fright experienced toward the end of pregnancy fre-\\nquently precipitate labor.\\nThe Forces of Labor.\\nThe expcllent forces of labor are\\n1. Contractions of the uterus and of the vaginal and pel-\\nvic muscles\\n2. Contractions of the abdominal muscles and diaphragm\\n3. Gravity.\\nI", "height": "3732", "width": "2492", "jp2-path": "obstetricsmanual00evan_0100.jp2"}, "99": {"fulltext": "CONTRACTIONS OF THE UTERUS, ETC. 99\\n1. Contractions of the Uterus and of the Vaginal and Pelvic\\nMuscles.\\nUterine Contractions.\\nThese are by far the most important factor in bringing\\nabout the expulsion of the ovum.\\nThe contractions are involuntary, occurring independently\\nof the woman s will though they undoubtedly are weakened\\nor even inhibited by various agents. Emotion, such as the\\ndread of pain, or nervousness caused by the entrance of the\\nphysician or a stranger, may inhibit them. A loaded rectum\\nor a full bladder may reflexly inhibit uterine contractions.\\nThey are peristaltic, the wave of the contraction being from\\nthe fundus to the cervix, and lasting from one-third to two-\\nthirds the length of the labor pain.\\nThey are intermittent. The contraction begins gradually,\\nrapidly reaches an acme, and then slowly passes off. This\\nmay be demonstrated clinically by keeping the hand on the\\nwoman s abdominal wall throughout a contraction the uterus\\nwill be felt to harden gradually then, remaining in this con-\\ndition for a short interval, to relax and become soft again.\\nTheir duration averages about one minute. In the earliest\\nstage of labor they occupy but a few seconds but in the ex-\\npulsive stage they last longer and are stronger. The con-\\ntractions are rhythmical in their intermissions. There is a\\ncertain regularity in their appearance and disappearance. The\\ngreater their frequency the longer their duration. At the\\nbeginning of labor the interval is long, say a quarter of an\\nhour toward the end the interval between the pains may be\\nbut a few seconds, so that the contractions seem to be almost\\ncontinuous.\\nThe contractions are painful, hence the term pains\\nusually applied to them. This pain is due to the forcible\\nstretching of the cervix and its attachments, and of the vagina\\nand vulva consecutively also in part to the fact that the\\nuterus is contracting against resistance. A parallel to this\\nlatter occurs in the intestine when an obstruction exists. The\\npain is usually referred to the sacral region, especially in the\\nearlier stages later, when the sacral nerves are pressed upon\\nby the advance of the foetus, the pain is felt down the limbs.\\nL.cfC.", "height": "3712", "width": "2452", "jp2-path": "obstetricsmanual00evan_0101.jp2"}, "100": {"fulltext": "100 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nThe individual muscle-fibres of the uterus during contraction\\nbecome shorter and thicker than they are during relaxation.\\nRetraction is a process peculiar probably to all involuntary\\nmuscle-fibres but is most marked in those of the uterus.\\nRetraction enables a muscle-fibre which has shortened dur-\\ning contraction to relax without returning to its original\\nlength. The fibres after contraction do not quite return to\\ntheir original length, but remain persistently somewhat shorter\\nand thicker.\\nRetraction is due in part also to a rearrangement of the\\nfibres. These are assumed at the beginning of labor to be\\nnearly end to end in the course of retraction they come to\\nlie almost side to side. Retraction is practically limited during\\nlabor to the muscle-fibres forming the upper uterine segment.\\nThis portion of the uterine wall as the ovum is pushed down\\nbecomes gradually thicker thus its propulsive force during\\ncontraction augments^ and it is enabled to remain constantly\\nin contact with the upper end of the ovum until its expulsion\\nfrom this segment.\\nThe lower uterine segment, not possessing the power of retrac-\\ntion, becomes progressively thinner and dilates as the ovum is\\nforced down through it. Retraction thus enables the uterus\\nto preserve the expulsive results of contraction.\\nPolarity is a useful term to express the fact that throughout\\nlabor the expelling part of the uterus the upper segment is\\nin a state of opposite function to the sphincter part the\\nlower segment and cervix.\\nDuring pregnancy the muscle forming the body of the\\nuterus is practically at rest, while the cervix, especially the\\ninternal os, is in a state of tonic contraction, it is active.\\nDuring labor this relation is inverted, the body contracts\\nwhile the cervix is relaxed. This relation is taken advantage\\nof when it is necessary to induce labor for any cause that is,\\nto set up active contractions in the muscle forming the body\\nof the uterus. This is usually accomplished by dilating the\\ncervix either manually or by instruments, which brings about\\nthe desired result.\\nEffect of uterine contractions: In changing the shape and\\nposition of the uterus: During a contraction the longitudinal\\nand anteroposterior diameters of the uterus are increased.", "height": "3712", "width": "2484", "jp2-path": "obstetricsmanual00evan_0102.jp2"}, "101": {"fulltext": "CONTRACTION OF THE ABDOMINAL MUSCLES, ETC 101\\nwhile its transverse diameter is decreased, the whole organ\\nassuming a roughly cylindrical form (see also pp. 38 and 39).\\nThe fundus is held against the abdominal wall and becomes\\nmore prominent this brings the long axis of the uterus into\\nline with that of the inlet of the pelvis.\\n0)1 the circulation in the uterus and placenta During con-\\ntraction the uterine sinuses are slowly obliterated and emptied,\\nrefilling as it passes off; but the foetal portion of the placenta\\nis not affected. Thus throughout the whole of pregnancy the\\ncirculation of blood in the uterus is assisted by the regular\\nrhythmical uterine contractions.\\nOn thefwtal heart: The foetal heart is slowed because the\\npressure on the placental site raises the general foetal blood-\\npressure.\\nOn the maternal pulse The maternal pulse-rate increases\\nten to twenty beats, thus contrasting with the foetal pulse-\\nrate.\\nVaginal and Pelvic 3Iuscles.\\nThese muscles play but a very unimportant part in bring-\\ning about the expulsion of the ovum. They act only in the\\nlater stages.\\n2. Contraction of the Abdominal Muscles and Diaphragm.\\nThe muscles entering into the formation of the abdominal\\nwalls, along with the diaphragm, when simultaneously in a\\nstate of contraction, increase the intra-abdominal pressure and\\nthus render very important aid to the uterus. These muscles\\ntaken altogether form, as it Avere, a second layer of muscular\\ntissue external to the uterus.\\nTheir mode of action is as follows A deep inspiration is\\ntaken, thus flattening out and depressing the diaphragm,\\nwhich is then fixed by the closure of the glottis then the\\nmuscles in the abdominal walls contract. The descent of the\\ndiaphragm pushes the fundus forward this is resisted by\\nthe contraction of the muscles of the abdominal wall, so that\\nthe resultant of the combined pressure of these muscles is in\\nthe direction of the long axis of the uterus that is, down-\\nward in the axis of the pelv^ic brim.", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0103.jp2"}, "102": {"fulltext": "102 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nThe action of these muscles is not exerted until the second\\nor expulsive stage, and is at first entirely voluntary. In the\\nlater stages of the expulsive period their action is entirely\\ninvoluntary.\\nAt first they act only during the acme of a i)ain, when the\\nwoman voluntarily bears down but later, when the pain\\nlasts longer, the woman is compelled to open the glottis to\\nrespire, thus relaxing the pressure but immediately another\\nbreath is taken, they act again, so that there are often several\\nabdominal contractions to one pain.\\n3. Gravity.\\nThe weight of the child and of the waters contained in\\nthe membranes exerts but a small influence in aiding ex-\\npulsion, except perhaps during the first stage of labor, when\\nthe woman is more or less in the erect or semirecumbent\\nposition.\\nLABOR\u00e2\u0080\u0094 FIRST STAGE.\\nPremonitory Signs and Symptoms of Labor.\\nThe events which indicate the approach of labor are varia-\\nble in their duration and may be so slight as quite to escape\\nobservation.\\nThe change of position of the uterus which takes place\\nduring the last weeks of pregnancy has been referred to\\nalready.\\nIrregular pains, usually felt low down in the abdomen in\\nfront, are frequently complained of by patients for some days\\nbefore the onset of true labor. They are sometimes severe,\\nand may cause much suffering to sensitive women. These\\nfalse pains, as they are termed, may be distinguished\\nfrom true pains by their irregularity and by their site true\\nlabor-pains being felt chiefly in the sacral region. These\\nfalse pains have absolutely no effect on the cervix, and no in-\\ncrease in the vaginal secretion accompanies them.\\nFrequency of micturition and, less often, of defecation, may\\nbe troublesome during the last few days, and are probably\\ncaused by increase in the nervous excitability of the pelvic\\nstructures usually present at this time.\\nI", "height": "3712", "width": "2492", "jp2-path": "obstetricsmanual00evan_0104.jp2"}, "103": {"fulltext": "MECHANISM OF THE FIRST STAGE. 103\\nCharacteristic Signs and Symptoms of the Onset of Labor.\\nRegular uterine contractions The interval between these is\\nlong at first, bnt shortens steadily as the labor progresses.\\nThe pains at this period are always referred to the sacral\\nregion.\\nAppearance of the show This is the term commonly\\napplied to the mucus tinged w^ith blood which escapes from\\nthe cervix and vagina at this time. The mucus comes\\nchiefly from the cervix, and the blood from the separated\\nsurfaces of the membranes and the uterine walls just above\\nthe internal os.\\nSoftening and shortening of the cervix These changes can\\nonly be noticed by making a vaginal examination. The\\nsoftening of the cervix is due to infiltration Avith serous exu-\\ndate resulting from the interference with the return circula-\\ntion caused by the uterine contractions. The shortening of\\nthe cervix results from the yielding of the internal os, which\\nis undoubtedly a physiological relaxation analogous to that\\nwhich takes place in sphincter muscles.\\nMechanism of the First Stage.\\nThe uterine contractions during this stage are occupied en-\\ntirely with dilating the cervix, there being little or no expulsion\\nof the ovum, this being limited to the slight advance of the\\nbag of membranes through the internal os.\\nDilatation of the cervix results from: (1) the yielding of\\nthe internal os, w^iich is a physiological relaxation (2) the\\nhydrostatic pressure of the bag of waters and (3) the action\\nof the long muscular fibres in the outer muscle-layer of the\\nuterus.\\n1. The first of these has already been discussed.\\n2. The hydrostatic pressure of the bag of waters The first\\nresult of uterine contraction is an increase in the geneixd intra-\\nuterine fluid pressure. When the waters are abundant and\\nthe membranes intact the effect of this pressure is nil so far\\nas the foetus is concerned, as the law^ of fluid pressure is that\\nit is equal and opposite in all directions.\\nThe direction of the force of the uterine contraction is\\ncentripetal; this is opposed centrifugally by the bag of waters.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0105.jp2"}, "104": {"fulltext": "104 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nThe force of the contraction is centripetal, while the force\\nexerted by the bag of waters in opposition is centrifugal.\\nThese two forces would then equalize one another if: (1)\\nthe uterine wall were of equal thickness throughout, and\\ntherefore of ecpial strength throughout and if (2) the uterine\\nwall were in a state of e(][ual contraction throughout at the\\nsame moment of time.\\nBoth these conditions fail in that first, the uterine wall is\\nnot of equal thickness throughout, the lower segment being\\nthinner and having a solution in its continuity (the yielding\\ninternal os), it is weaker and therefore must expand secondly,\\nthe uterine wall is not in a state of equal contraction through-\\nout at the same moment of time, in that the contraction is\\nvermicular, beginning at the fundus and spreading downward\\nto the cervix, so that when the fundus is in a state of con-\\ntraction the cervix is relaxed. This may be demonstrated\\nclinically by keeping the finger-tip on the lowest point of the\\nbag of waters, when at the onset of a pain this will be felt to\\nbecome tense some seconds before the woman complains of\\nthe pain which causes the increase of pressure.\\nFor these reasons the force of the centrifugal pressure of\\nthe waters is exerted most markedly on the lower uterine\\nsegment and cervix hence dilatation of these parts takes place\\nas a result of the increase in the general intra-uterine fluid\\npressure.\\n^.s dilatation proceeds the membranes, having become\\nloosened from their attachment to the uterine walls, insinuate\\nthemselves into the opening. Since the fluid within the mem-\\nbranes transmits the force of the uterine contraction equally in\\nall directions, the bag of waters is distended laterally as well\\nas downward, thus exerting an expansive action directly on the\\nwalls of the cervix, and finally on the margins of the external\\nOS. As the cervix and external os dilate this lateral pressure\\nof the bag of waters increases proportionately.\\n3. The action of the longitudinal muscle-fibres of the uterus\\nThe contents of the uterus being practically incompressible,\\nthe pull of the longitudinal fibres will result in drawing the\\nlower uterine segment and cervix, whose structure is thinner\\nthan that of the upper segment, up over the contained body.\\nIn this action the oblique fibres assist to a considerable extent.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0106.jp2"}, "105": {"fulltext": "MECHASJSM OF THE FIRST STAGE. 105\\nThe wave of contraction probably passes through the longi-\\ntudinal fibres more rapidly than through the circular fibres,\\nhence the former will tend to draw the cervix up over the\\npresenting part while the lower segment is relaxed.\\nWhen the cervix and external os have become well dilated\\nthe membranes usually rupture. This, as a rule, occurs during\\na pain, and is announced by a gush of Avaters from the vagina.\\nThe quantity escaping will depend on how rapidly the pre-\\nsenting part of the foetus descends and occludes the lower\\nuterine segment.\\nThe rupture of the membranes may occur at or before the\\nonset of labor or may not take place till the end of the\\nexpulsive stage but it is very rare that a full-term child is\\nborn with the membranes unruptured though it has hap-\\npened that in precipitate labors the whole ovum has come\\naway entire.\\nOn the rupture of the bag of waters, the presenting part of\\nthe foetus takes its place as a dilator. The fluid still retained\\nin utero then transmits the effective intra-uterine pressure to\\nthat portion of the foetus in contact with the margins of the os.\\nIn dry labors e., in cases where the membranes rupture\\nprematurely, thus permitting the escape of the waters before\\ndilatation has progressed to any extent the first stage of labor\\nbecomes tedious, for the reason that no part of the foetus can\\nact as a dilator so satisfactorily as the hydrostatic pressure\\nexerted by the bag of waters. In these cases the long fibres\\nof the uterus practically draw the cervix up over the wedge-\\nlike presenting part of the foetus, whatever that part may be.\\nThese longitudinal fibres when in a state of contraction\\nproduce a downward traction of the fundus upon the foetus\\ntending to force it downward this force is transmitted to the\\npresenting part, in vertex or in breech cases, by the vertebral\\ncolumn of the child.\\nThis downward traction of the fundus exerted by the longi-\\ntudinal fibres when in a state of contraction, does not cause a\\ndrawing down, or descent, of the fundus uteri, because the\\ncircular fibres by their more powerful action tend, as it were,\\nto straighten out the somewhat bowed foetus with the result\\nthat the position of the fundus in relation to the abdominal", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0107.jp2"}, "106": {"fulltext": "106 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nAvail throughout labor does not vary but the whole resultant\\nof the forces exerted by the contractions of these two sets of\\nfibres is transmitted down the vertebral column of the foetus to\\nthe presenting part, which is thus forced to advance, while\\nat the same time the cervix is dilated and drawn up over it.\\nOs uteri during first stage of labor On making a vaginal\\nexamination very early in labor, in a primipara, that portion\\nof the cervix not yet taken up may be felt as a soft appendage\\nto the spherical surface of the distended lower pole of the\\nuterus. Possibly the external os may be sufficiently soft and\\ndilated to permit the insertion of the finger-tip. Under the\\nsame circumstances in a multipara the os may be quite patent\\nlong before the cervix is taken up, so that the finger may\\neasily be inserted into the uterus. Under these circumstances\\nthe only way to be certain of the extent of cervix still remain-\\ning to be taken up is to insert the finger till the membranes\\ncan be felt, then, while withdrawing it making firm pressure\\non the posterior wall, note the length of cervix before the mar-\\ngin of the external os is reached.\\nLater, when the cervix is completely taken up, during a\\npain the sharp edges of the external os can be distinguished,\\nand the smooth surface of the membranes can be felt stretch-\\ning across the aperture.\\nIn primipara the edge of the external os is at first thin and\\nsharp later it becomes more cedematous. In multipara it\\nmay be thick, and as a result of laceration in a previous\\nlabor the external os may have a very irregular shape.\\nThe degree of dilatation may be described by stating that\\nthe OS will admit one, two, or three fingers or it may be com-\\npared with the size of a ten-cent piece, quarter, etc.\\nClinical Phenomena of the First Stage.\\nThe initial labor-pains come on, as a rule, in the earlier part\\nof the night and they differ but little from the false pains,\\nexcept that they occur more regularly and gradually increase\\nin strength and frequency.\\nThe pains are sharp and nagging, many patients finding\\nthem more difficult to bear than those of the expulsive stage.\\nMany prefer to walk restlessly about, bending over a chair", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0108.jp2"}, "107": {"fulltext": "MECHAMSM OF THE SECOND STAGE. 107\\nor the foot of the bed during the acme of the pain. Usually\\na plaintive cry or moan is uttered with each pain, and the\\npatient s face becomes congested owing to involuntary fixation\\nof the respiratory muscles.\\nReflex vomiting is of frequent occurrence as dilatation pro-\\ngresses.\\nThe patient is compelled frequently to evacuate the bladder\\nand rectum on account of the increased nervous irritability of\\nthe organs.\\nThe pulse and respiration are not markedly affected, as a\\nrule, in tliis stage, though in cases where it is prolonged the\\nrate of both may be considerably accelerated and the tem^^\\nperature may rise to 100\u00c2\u00b0 F., or even higher.\\nAnatomy of the Soft Parts at the End of the First Stage.\\nThe external os is, as a rule, dilated so as to admit three\\nfingers. The cervix is completely taken up. The whole lower\\nsegment of the uterus is thinned out somewhat from stretch-\\ning while the upper segment is slightly thicker than before\\nthe onset of labor.\\nThe bladder, as a rule, is drawn upward with the cervix, the\\nupper end being displaced forward over the pubes. The\\nupper end of the vagina is somewhat distended.\\nLABOR\u00e2\u0080\u0094 SECOND STAGE.\\nMechanism of the Second Stage.\\nDuring this stage the foetus is expelled from the maternal\\npassages.\\nVertex presentations being considered in this work as nor-\\nmal, and the left occipito-anterior position being by far the\\nmost common, the corresponding mechanism will be fully\\ndescribed at this point while the mechanism of the other\\npositions will be described only in so far as they differ from it.\\nThe mechanism of this stage is concerned chiefly with the\\nmovements which the foetal head and trunk undergo in their\\npassage through the birth-canal.", "height": "3700", "width": "2472", "jp2-path": "obstetricsmanual00evan_0109.jp2"}, "108": {"fulltext": "108 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nTlio most important part of the meclianism is that relating\\nto the ItcdcJ, on account of its size and the incompressibility\\nof its diameters as compared with the trunk.\\nThe Head Movements.\\nThese are descent flexion internal rotation extension\\nand finally, after expulsion, restitution or external rotation.\\nDescent Descent of the head begins, as already mentioned,\\nwith the rupture of the membranes, or as soon as it comes into\\ncomplete contact with the lower uterine segment, or os. It is\\ncaused by the uterine contractions reinforced by the action of\\nthe abdominal muscles and diaphragm, and persists through-\\nout this stage, resulting in the other movements about to be\\ndescribed.\\nFlexion The position of the head is naturally one of par-\\ntial flexion, as it lies in the lower uterine segment at the onset\\nof the second stage. As the head descends this flexion in-\\ncreases as the result of various causes:\\n(a) At the beginning of this stage the intra-uterine fluid\\npressure acts on the whole base of the skull, and flexion re-\\nsults from the different angles at which the anterior and pos-\\nterior slopes of the vertex meet the resistance of the lower\\nuterine walls. The friction offered by the wall to the anterior\\nend of the head is greater and this end is more impeded in its\\ndescent, hence flexion is assisted. This is reinforced by the\\naction of the circular fibres of the cervix compressing the\\nhead. The force exerted by these fibres not being equal and\\n()p})osite, flexion of the head is favored.\\nWhen the waters drain away sufficiently to permit the\\nfundus to come into direct contact with the foetus, then a\\nmore powerful force is exerted to produce flexion of the\\nhead. The propulsive force of the uterine action trans-\\nmitted down the vertebral column of the foetus acts on the\\nhead along a line running nearer the occipital than the sin-\\ncipital pole.\\nThe head is so attached to the trunk that its sincipital is\\nlonger than its occipital pole it corresponds to a lever with\\nunequal arms, the occipito-atlantoid articulation being the", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0110.jp2"}, "109": {"fulltext": "MECHANISM OF THE SECOND STAGE.\\n1U9\\npivotal point, and the sincipital the long arm of the lever.\\nHence the sincipital pole is more acted on by the resistance\\noffered to descent, while the occipital pole receives the\\nmaxmnm pressure from above (Fig. 56.)\\nThus is flexion produced\\nand maintained. Fig. 56.\\nThe advantage of flexion is\\nthat it brings the smallest, or\\nsuboccipito-bregmatic, circum-\\nference of the head into rela-\\ntion Avith the girdle of resist-\\nance offered by the pelvis and\\nsoft parts. It also results in\\nthe occiput reaching the pelvic\\nfloor in advance of any other\\npart of the head, a point of\\nvery considerable importance,\\nas will be seen later.\\nWhen flexion is complete the\\nposterior fontanelle is brought\\nwdthin easy reach of the ex-\\namining finger. At this time\\nif the sagittal suture be felt, it\\nseems to lie nearer to the pos-\\nterior than to the anterior\\nw^all of the pelvis, and the\\nhead seems to occupy a some-\\nw^hat oblique position in the\\npelvis as regards the plane of\\nthe brim, the anterior or right\\nparietal bone seeming to be at\\na lower level than is the left\\nparietal bone. This led Naegele\\nto infer that the head usually\\nentered the pelvis with the sagittal suture nearer to the prom-\\nontory than to the pubes. This is not a real but an appar-\\nent obliquity, and is due to the pelvic inclination. The head\\nnormally enters the pelvis Avith its horizontal plane in com-\\nplete coincidence with the plane of the brim. This condition\\nis known as syncUtism. The absence of the proper relation of\\nIllustrating the different lengths of\\nthe frontal arm, F B, and the occipital\\narm, B O, of the lever presented by the\\nfoetal head. (Jewett.)", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0111.jp2"}, "110": {"fulltext": "no THE MECHANISM AND COURSE OF NORMAL LABOR.\\nthese planes is known as ast/nclitism, a condition which\\nusually occurs when any deformity of the pelvis is present.\\nInternal rotation The long diameter of the foetal head\\noccupies the right oblique diameter of the brim when the\\nposition is L. O. A., but it must emerge at the outlet with its\\nlong diameter directed anteroposteriorly, because this diameter\\nof the outlet is the greater. The movement by which the\\nFig. 57.\\nBeginning extension of head. (Farabeuf and Varnier.)\\noblique position at the brim is converted into an anteropos-\\nterior position at the outlet is termed rotation.\\nWithout good flexion of the foetal head rotation cannot\\noccur. As a result of flexion the occipital pole of the foetal\\nhead occupies a lower plane in the pelvis than does the sin-\\ncipital pole. When the occiput is directed forward the sin-\\nciput must move in a contrary direction that is, backward.\\nWhen the head descends in the L. O. A. position, the occiput\\nmust of necessity enter the upper part of the anterior groove\\non the left side of the pelvis. It will follow this groove in\\nits descent, and will thus come into contact with the pelvic\\nI", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0112.jp2"}, "111": {"fulltext": "MECHANISM OF THE SECOND STAGE.\\nIll\\nfloor well forward of the transverse line of the pelvis. As a\\nresult of this slightly forward direction of the occipital pole\\nthe sincipital pole will descend along the sacro-iliac groove on\\nthe right side of the pelvis. When the pelvic floor is reached\\nthe line of least resistance is downward and forward, hence\\nwhichever part of the foetal head (in this case the occiput)\\ncomes into relationship with the pelvic floor first, follows this\\nand is directed to the under border of the symphysis\\ninie\\npubis. In R. O. P. and L. O. P. positions the occiput de-\\nFiG. 58.\\nMaximum distention of pelvic floor. Equator of head about to pass.\\nand Varnier.)\\n(Farabeuf\\nscends along one or other, as the case may be, of i\\\\\\\\Q posterior\\ngrooves of the pelvis, and impinges on the pelvic floor behind\\nthe transverse line of the pelvic outlet. Potation thus is\\nlonger, being through three-eighths of a circle instead of one-\\neighth, as in anterior positions.\\nThus the main factor in causing rotation of the head is the\\nresistance offered by the pelvic floor. By the time the peri-\\nneum is well distended rotation is completed and a portion of", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0113.jp2"}, "112": {"fulltext": "112 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nthe liairy scalp over the occiput is in view between the dis-\\ntended hibia.\\nExtension At the moment when the next movement, exten-\\nsion, begins, the sagittal suture is directed anteroposteriorly\\nand the sinciput lies in the hollow of the sacrum. Descent\\ngoes on in this position until the occiput clears the lower\\nborder of the subpubic ligament, and the neck is pressed\\nfirmly against the back of the symphysis.\\nThe base of the occiput then pivots on the lower edge of\\nthe symphysis, and at each pain the head extends, stretching\\nFig. 59.\\nOcciput rides up in front of symphysis. Pelvic floor retracts. (Farabeuf and\\nVariiier.)\\nthe perineum and vulvar ring as it does so. Gradually the\\nvertex, brow, and face successively glide from under the peri-\\nneum, which retracts over the chin and the head is born\\n(Figs. 57-59).\\nRestitution or external rotation Directly after the head is\\nborn it resumes its usual relation to the shoulders, namely,\\nwith its occipitomentjd diameter at a right -angle to the bis-\\nacromial.\\nThe shoulders enter the brim in the opposite oblique to", "height": "3712", "width": "2496", "jp2-path": "obstetricsmanual00evan_0114.jp2"}, "113": {"fulltext": "CLINICAL PHENOMENA OF THE SECOND STAGE. 113\\nthe head thus in L. O. A. position they enter in tlie left\\noblique diameter, and as they descend the right shoulder\\ncomes to the front. Hence the head when it escapes from\\nthe vulva turns so that the occiput points to the left side of\\nthe mother, which is the same position it occupied at the\\nbrim. This movement of the head is termed restitution, and\\nis of interest, as it indicates usually its primary position\\n(Fig. 60).\\nFig. 60.\\nFoetal head after restitution. Shows also caput succedaneum. (Ribemont-\\nDessaignes and Lepage.)\\nDelivery of the Trunk.\\nThe anterior shoulder is, as a rule, arrested at the lower\\nborder of the symphysis, so that the posterior passes over the\\nperineum and appears at the vulva first. After the posterior\\nshoulder escapes the anterior descends and is delivered. The\\nhips emerge with the bisiliac diameter in the anteroposterior\\nposition.\\nClinical Phenomena of the Second Stage.\\nAt the conclusion of the first stage the pains not infre-\\nquently cease for a time, and the more or less exhausted\\n8\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2452", "jp2-path": "obstetricsmanual00evan_0115.jp2"}, "114": {"fulltext": "114 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nwoman has a few moments of rest and possibly of sleep.\\nEspecially is this the case if chloral has been administered.\\nThe pains are more severe during the second stage and\\nlast longer but the patient becomes more hopeful as a rule,\\nfor she realizes that with each pain definite progress is being\\nmade. When the pelvic floor is reached the perineum\\nbegins to distend from the pressure of the head, and the\\nsphincter ani relaxes, so that not infrequently a quantity of\\nfascal matter or mucus escapes from the anus.\\nAt this time the contractions of the abdominal muscles are\\ninvoluntary, and the patient is forced to strain down with\\neach pain, holding her breath as she does so. As a rule, the\\nwoman grasps any support near by firmly with her hands\\nand braces her feet, to assist her expulsive efforts.\\nIn the intervals between the pains she rests quietly and\\nmay fall asleep.\\nAVhen the vulvar ring is being distended the sufferings of\\nthe woman may become so intense as to result in a condition\\nbordering on delirium. At this period the head advances\\nrapidly with each pain, coming plainly into view as it does\\nso. In the intervals it recedes, thus permitting the circula-\\ntion of blood in the perineum to be resumed.\\nIf this recession does not take place, oedema of the parts\\nrapidly comes on, and may be very marked in some cases.\\nUsually there is a pause when the head is born.\\nAccompanying the delivery of the body there is a gush of\\nwaters and blood.\\nAfter the birth of the child the woman soon quiets down,\\nno matter how noisy she may have been the freedom from\\npain affording her great satisfaction and a keen sense of rest.\\nHer temperature at this time may be slightly elevated\\nespecially if the labor has been difficult. The pulse-rate\\nrapidly subsides and in a few moments resumes its normal\\nfrequency.\\nMoulding of the Foetal Head.\\nThe child s head, even in normal labor, undergoes considerable\\nalteration in shape as it is forced through the maternal passages.\\nThe manner in which the bones overlap has been already\\nreferred to.", "height": "3704", "width": "2512", "jp2-path": "obstetricsmanual00evan_0116.jp2"}, "115": {"fulltext": "ANATOMY OF THE SECOND STAGE. 115\\nThe degree of moulding depends on the relative size of the\\nhead and the pelvis, and also upon the extent of ossification\\npresent.\\nThe moulding of the head is essential to the mechanism of\\nthe expulsive stage in that it leads to adaptation of the head\\nto the pelvis; and also because its elongation favors rotation\\nby increasing the dip of the leading pole, so that it is more\\neasily directed forward.\\nElongation In L. O. A. and L. O. P. positions the elonga-\\ntion of the head is along a line joining the chin to the posterior\\nupper angle of the right parietal bone.\\nIn E,. O. A. and R. O. P. positions the elongation of the\\nhead is along a line joining the chin to the posterior upper\\nangle of the left parietal bone.\\nThis deformity is accentuated by the caput succedaneum.\\nCaput Succedaneum.\\nDefinition The caput succedaneum is an oederaatous swell-\\ning which is developed on the presenting part in the course of\\nbirth, usually after rupture of the membranes. The vessels\\nof the presenting part become engorged during the pains, and\\nserous exudation takes place into that portion of the foetal\\nsurface which escapes the pressure of the girdle of resistance.\\nIts size varies with the degree of force producing it hence\\nit is large in difficult and prolonged labors. Its size is an\\nindication of the degree of obstruction encountered by the\\nfoetus in its passage through the pelvis.\\nIts location indicates the position in which the head has\\ndescended. In anterior positions it is situated on the posterior,\\nand in the posterior positions on the anterior aspect of the\\nsummit of the head. In left positions it is on the right and\\nin right positions it is on the left of the median line.\\nThe exact position of the caput may be modified if the\\nhead has been subjected to prolonged pressure at the outlet or\\nat the vulva.\\nAnatomy of the Second Stage.\\nWhen the head is in the distended perineum the shoulders\\nlie just within the dilated cervix.", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0117.jp2"}, "116": {"fulltext": "116 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nThe uterus has retracted on that part of the foetus remain-\\ning inside it. The differentiation between its upper and lower\\nsegments has become marked and if the labor is a difficult\\none, the retraction-ring may be felt running obliquely across\\nthe uterus a short distance above the pubes. The higher this\\nring is felt the more serious is the obstruction which has been\\nencountered by the foetus.\\nThe bladder is now wholly above the pubes and the urethra\\nis greatly elongated hence catheterization is difficult and\\nurination impossible, the pressure of the head increasing the\\ndifficulty.\\nThe structures in the sacral segment of the pelvic floor have\\nbeen pushed downward and backward the contents of the\\nrectum are forced out by the pressure of the head and the\\nanus has become widely distended, permitting the anterior\\nwall of the rectum to come into view. The edges of the vulva\\nare forced apart and they may be oedematous.\\nLABOR\u00e2\u0080\u0094 THIRD STAGE.\\nThis stage of labor is occupied with the detachment and\\nexpulsion of the placenta and the membranes.\\nMechanism of the Third Stage.\\nSeparation of the Placenta.\\nThe placenta is separated by retraction and contraction of\\nthe uterus.\\nMany theories have been advanced to explain the method\\nof placental separation and the following description is but\\na summary of those most generally accepted.\\nAs a residt of retraction of the uterus after expulsion of\\nthe child the placenta is compressed to about one-half its\\noriginal size before detachment occurs.\\nThe method of its detachment d(!pends on its site.\\nIf the site be confined to the Avail and does not encroach\\non the fundus, the separation probably begins at the margins\\nand advances toward the centre. If the ])lacental attachment\\nis to any extent fundal, the placenta, as the result of uterine", "height": "3728", "width": "2496", "jp2-path": "obstetricsmanual00evan_0118.jp2"}, "117": {"fulltext": "MECHANISM OF THE THIRD STAGE. 117\\nretraction, becomes bent over at an angle, and detachment\\nwill begin at its lower margin and detrusion will occur. That\\nis, the placenta will slip down sideways as detachment goes\\non, being detached ]\\\\y the expulsive force of the uterine con-\\ntractions.\\nAs separation advances uterine vessels are torn across and\\nsome hemorrhage takes place.\\nIn some cases this retroplacental hemorrhage plays an im-\\nportant role in placental detachment and in all cases it renders\\neasier the shrinkage of the placental site away from the\\nplacenta.\\nSeparation of the Membranes.\\nAs a result of the protrusion of the bag of membranes\\nthrough the os, in the first stage of labor, some separation of\\nthe membranes from the walls of the lower uterine segment\\ntakes place.\\nAffcer rupture of the membranes and escape of the waters\\nthe non-elastic membranes become thrown into folds and\\nAvrinkles, and as a result become partially detached in some\\nplaces. The placenta, in the process of expulsion, strips the\\nmembranes completely off the uterine walls as it descends.\\nIt is important that the amnion and the chorion remain\\nfirmly united failure of these structures to adhere to one\\nanother results in portions of the chorion being left behind\\nin the uterus, a condition it is desirable to avoid.\\nIn cases where too early rupture of the membranes occurs,\\nthere is no bag of waters, hence the membranes adhere to\\nthe uterine wall too closely, and no detachment of these can\\noccur until the placenta in its expulsion strips them off.\\nExpulsion of the Placenta and Membranes.\\nAs the result of uterine contractions, the placenta is ex-\\npelled.\\nIt usually presents at the vulva by some spot on its foetal\\naspect about two inches from its lower margin. The presenta-\\ntion of the foetal aspect is caused by the retroplacental hemor-\\nrhage leading to an inversion of the ])lacenta, which has to strip\\nfrom the uterine wall a portion of the membranes between its", "height": "3712", "width": "2444", "jp2-path": "obstetricsmanual00evan_0119.jp2"}, "118": {"fulltext": "118 THE MECHANISM AND COURSE OF NORMAL LABOR.\\nFig. 61.\\nlower margin and the os hence this part is delayed to a certain\\nextent (Fig. Gl). The higher in the uterus the placenta is situ-\\nated the more membrane has to\\nbe stripped off between its lower\\nmargin and the os, and the greater\\nis the degree of inversion, or\\nfolding over of the placenta.\\nThe placenta never presents by\\nits margin at the vulva unless its\\nlower edge was originally situated\\nclose to the internal os.\\nThe membranes are dragged out\\nby the descent of the placenta\\nhence they are usually inverted\\nand the amnion appears outer-\\nmost.\\nThe whole mass of placenta\\nand membranes is accompanied\\nby a variable amount of clots\\nand fluid blood, these coming\\nfrom the placental site.\\nAfter expulsion of the after-\\nbirth the uterus is found re-\\ntracted and contracted to about\\nthe size of the foetal head. Its\\nsize varies with the amount of retraction and with the size\\nof the child.\\nThe position of the fundus immediately after labor is about\\nhalf-way between the pubes and umbilicus. Later, when the\\n])aralyzed lower segment has regained its tone by retraction,\\nthe fundus rises to a position about the level of the um-\\nbilicus.\\nLabor is now completed, and the puerperal period begins.\\nInversion of the ovum and expul-\\nsion of the placenta as an inverted\\numbrella. (Schultze.)\\nBlood lost in labor: The average amount of blood lost\\nin labor is about six to ten ounces. The total quantity\\nvaries considerably. Women who menstruate profusely\\nhabitually lose more than those whose menstruation is usually\\nscanty.", "height": "3712", "width": "2496", "jp2-path": "obstetricsmanual00evan_0120.jp2"}, "119": {"fulltext": "OBSTETRIC ANTISEPSIS. 119\\nTHE MANAGEMENT OF NORMAL LABOR.\\nIn the management of a case of labor it is the duty of the\\nphysician to assist the woman in the processes of labor when\\nrequired, in order that she may be spared unnecessary suffer-\\ning and discomfort and also to protect her from any infec-\\ntion which might be imported from without.\\nIt has already been mentioned that it is desirable in every\\ncase to make a preliminary examination of the patient about\\nfour weeks before the expected confinement. Besides the ordi-\\nnary obstetric examination, the general condition of the patient\\nshould be noted at this time. Any irregularities should be\\ncorrected, and everything should be arranged so that at the\\ndate of the expected labor the patient s strength and vitality\\nshall be the best possible.\\nOBSTETRIC ANTISEPSIS.\\nIn 1847 Ignatius P. Semmelweis, having been deeply im-\\npressed by the heavy mortality in the A^ienna Maternity, first\\napplied the antiseptic method to the management of labor. By\\nsimply compelling students attending all cases of labor to\\ncleanse the hands thoroughly in chlorine-water, he reduced\\nthe mortality in the maternity clinic from 12 per cent, to\\nunder 2 per cent, in less than a year.\\nSince that date the mortality from puerperal sepsis in all\\nmaternity hospitals has been reduced to considerably under 1\\nper cent.\\nThat the application of the antiseptic method to the man-\\nagement of private labor cases has not been as widespread is\\nevidenced by the fact that the mortality-returns, both in Brit-\\nain and America, show there has been but little decrease in\\nthe number of deaths due to puerperal sepsis in recent\\nyears.\\nThe great numbers of women who throng the gynecologic\\nclinics in all parts of the country, suffering from disease dat-\\ning from a previous confinement, are witnesses to the fact\\nthat the application of the antiseptic method to the conduct\\nof labor is still far from being as general as it should be.", "height": "3700", "width": "2472", "jp2-path": "obstetricsmanual00evan_0121.jp2"}, "120": {"fulltext": "120 THE MANAGEMENT OF NORMAL LABOR.\\nAntiseptic Agents.\\nSoap and hot water are probably the most valuable agents.\\nMany who practise obstetrics neglect these, while making\\nuse of some antiseptic chug in solution, which blinds them to\\nthe fact that asepsis is more important than antisepsis.\\nThe plentiful use of soap and hot water accompanied by\\nmuscle and common sense would greatly reduce not only\\nmortality, but also morbidity in obstetric work, even if anti-\\nseptics had never been heard of.\\nThe use of these agents should always precede the employ-\\nment of antiseptics.\\nHeat, either dry or moist, is the most general and available\\ngermicide.\\nAll utensils employed about a puerperal woman should be\\nat least scalded thoroughly with hot water, and where possi-\\nble should be boiled.\\nAll dressings or material which it is intended to use as\\nvulvar pads should be boiled or steamed before labor, and\\nkept carefully wrapped up until used.\\nAll instruments should be boiled for at least five minutes\\nin a 1 per cent, soda solution, after which they may be placed\\nin sterilized water.\\nAll water used in the labor-room should be boiled, and\\nthen kept covered until wanted.\\nIn fact, cleanliness in all that pertains to the woman, not\\nonly during labor, but for two weeks subsequently, is abso-\\nlutely necessary if it is desired to have fever-free obstetric\\ncases.\\nIn all details the method followed should be as simple as\\npossible.\\nChemical Antiseptics.\\nThe most useful chemical germicides are mercuric chloride\\ncarholic acid; and formalin.\\nCreolin, lysol, and permanganate of potassium are also\\nvery commonly employed in obstetric practice.\\nIt should be remembered that soap decomposes mercuric\\nchloride and permanganate of potassium, rendering them inert\\nthat carbolic acid and permanganate of potassium are incom-", "height": "3700", "width": "2472", "jp2-path": "obstetricsmanual00evan_0122.jp2"}, "121": {"fulltext": "THE OBSTETRICIAN. 121\\npatible that mercuric chloride is decomposed in the pres-\\nence of albumin, forming therewith an inert albuminate of\\nmercury.\\nTherefore when the latter is used in a solution for douching,\\nit should be combined with tartaric, acetic, or hydrochloric\\nacid in the proportion of five parts of the acid to one of\\nthe mercurial.\\nConvenience and accuracy are secured by using tablets\\ncontaining raercuriG chloride combined with the proper pro-\\nportion of the acid. Sublimate solutions are used in strengths\\nof from 1 5000 to 1 500.\\nFormalin solutions are now replacing sublimate solutions\\nfor douching purposes, as they are free from the objections\\nconnected with the use of the latter. Formalin solutions\\nvary in strength from 1 2000 to 1 500 as ordinarily used.\\nThe strength of the usual commercial formalin is 40 per cent,\\nof the gaseous compound formaldehyde in water.\\nIn the application of the antiseptic method to the conduct\\nof labor not only are the obstetrician and the 7iurse con-\\ncerned, but also the patient.\\nThe Obstetrician.\\nThe obstetrician should always be careful to keep his hands\\nnot only clean, but also in good condition. He should avoid\\nas far as possible any work which w^ill render his hands rough\\nand hard. Care should be taken to keep the skin intact, for\\ncuts, scratches, and chapping all render the making of the\\nhands surgically clean an impossibility. Should there be\\nany of these conditions present, it is the duty of the obstet-\\nrician to v.ear aseptic rubber gloves when conducting a case\\nof labor. Care should be taken not to handle septic material;\\nif compelled to do so, the hands should be sterilized repeatedly\\nsubsequently.\\nThe nails should receive particular attention. They should\\nbe cut short and well filed, so that ragged edges may not be\\nleft to scratch or injure in the slightest degree the maternal\\nsoft parts.\\nThere are two methods of sterilizing the hands, both of\\nwhich are probably equally efficacious. These may be desig-", "height": "3708", "width": "2448", "jp2-path": "obstetricsmanual00evan_0123.jp2"}, "122": {"fulltext": "122 THE MANAGEMENT OF NORMAL LABOR\\nnated respectively (1) the sublimate method; (2) the perman-\\nganate method.\\nThe Sublimate Method.\\n(a) The hands and forearms are scrubbed thoroughly for\\nfive minutes with a nail-brush, using water as hot as can be\\nborne and a good soap either an ethereal or alcoholic solu-\\ntion of green soap being the best for this purpose. Special\\nattention must be paid to the nails and subungual spaces.\\n(b) After thorough rinsing in plain sterilized water, the\\nnails should be cleansed with a nail-cleaner or sterilized mani-\\ncure-stick.\\n(c) Then the hands and forearms are laved with pure alcohol,\\nto dehydrate the skin, for at least one minute.\\n(f/) The next step is to immerse the parts in a hot 1 2000\\nsolution of mercuric chloride for from three to five minutes.\\nThe Permanganate Method.\\nThe hands and forearms are scrubbed and cleaned as in\\nsteps a and b of the preceding method.\\n(c) They are then immersed for five minutes in a hot satu-\\nrated solution of potassium permanganate, vigorous friction\\nbeing applied by means of a sterilized swab, till the skin is\\nstained a rich mahogany-brown.\\n(d) Then they are bathed in a hot saturated solution of\\noxalic acid till the brown stain has been completely removed.\\nThis may be followed by rinsing in plain sterilized warm\\nwater or a 1 1000 sublimate solution.\\nIt is much to be desired that the obstetrician should follow\\nthe operating surgeon s example not only in the preparation\\nof his hands, but in wearing a freshly laundried, or, better,\\nsterilized, long coat-gown of linen or duck, when attending a\\ncase of labor.\\nThe Nurse.\\nThe nurse should be no less particular in her attention to\\ndetail, in the application of the antiseptic method to the con-\\nduct of labor.", "height": "3712", "width": "2504", "jp2-path": "obstetricsmanual00evan_0124.jp2"}, "123": {"fulltext": "THE PATIENT. 123\\nThe nurse should make an entire change of clothing, after\\ntaking a bath, before assuming charge of a patient in labor.\\nHer clothing should be absolutely clean, and she should wear\\nwash-dresses.\\nIf she has recently been exposed to sepsis, it is her duty to\\ninform the physician of the fact before taking charge of a\\ncase of labor.\\nBefore attending to the vulva of the patient the nurse\\nshould sterilize her hands thoroughly, and the process should\\nbe repeated each time she has occasion to cleanse the parts.\\nThe Patient.\\nThe aseptic preparation of the patient should begin weeks\\nbefore the expected date of labor. She should be informed\\nof the importance of ^ivmi personal cleanliness. Any diseased\\nconditions of the rectum, vulva, or bladder should receive\\ntreatment.\\nAt the onset of labor the patient should take a warm bath\\nand then put on clean linen. The lower bowel should be\\nemptied by an enema.\\nThe nurse should then thoroughly scrub the lower part of\\nthe abdomen and thighs with green soap and hot water,\\nmaking use of a soft hand-brush, or a jute swab, for this pur-\\npose.\\nThe vulvar hair should be clipped if it be too long.\\nThen these parts should be washed with a warm solution\\n(1 500) of formalin or of (1 2000) mercuric chloride.\\nAfter the parts have been dried Avith an aseptic towel a\\nsterile vulvar pad should be applied. The pad should be worn\\nduring the first and second stages of labor.\\nThe normal vaginal secretion of a pregnant woman has been\\nproved to be germicidal therefore in normal cases no ante-\\npartum vaginal injections should be permitted. Not only is\\nvaginal irrigation useless, but it may cause actual harm in im-\\npairing the secretive activity of the vaginal walls, thus inter-\\nfering with nature s protection against sepsis.", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0125.jp2"}, "124": {"fulltext": "124 THE MANAGEMENT OF NORMAL LABOR.\\nPREPARATIONS FOR LABOR.\\nOn the Part of the Physician.\\nThe physician should give the patient a list of those things\\nhe wishes her to provide and have ready for the labor.\\nThe patient, if a priraipara, should be warned of certain\\nconditions which may arise at the onset of labor, such as prem-\\nature rupture of membranes, hemorrhage, etc., and instructed\\nto send for the physician early.\\nThe call to a case of labor should always receive the phy-\\nsician s immediate attention, such a summons taking prece-\\ndence over everything.\\nHe should go provided with such instruments and drugs as\\nare likely to be needed in the conduct of ordinary labor and\\nin the more important obstetric emergencies. These can all\\nbe carried in a hand-bag.\\nThe obstetric bag should contain the following\\nA pair of obstetric forceps.\\nTwo pair of haemostatic forceps.\\nOne needle-forceps for suturing.\\nNeedles, curved and straight, of various sizes.\\nA pair of scissors.\\nA Sims speculum.\\nA pair of long uterine dressing-forceps.\\nA double tenaculum.\\nA pelvimeter, and a measuring-tape.\\nA hypodermic case, well equipped.\\nA gravity syringe for douching, etc.\\nA long uterine douche nozzle, either of glass or metal.\\nTwo soft-rubber catheters, Nos. 8 to 12.\\nCatgut, silk, and silkworm-gut for suturing.\\nTwo nail-brushes.\\nA small package of sterile iodoform gauze.\\nA two-ounce bottle of chloroform.\\nA quarter-pound tin of ether.\\nA two-ounce bottle of syrup of chloral.\\nAntiseptic tablets or solutions.\\nAn apparatus for the subcutaneous injection of sterile salt\\nsolution should also be carried. This may consist of a fair-", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0126.jp2"}, "125": {"fulltext": "ON THE PART OF THE PATIENT 125\\nsized exploring-needle, attached to a piece of soft-rubber\\ntubing one yard in length, and a four-ounce glass or alu-\\nminum funnel.\\nMany physicians carry also a freshly laundried linen coat\\nand duck apron, as well as a pair of rubber gloves. These\\nlatter may be sterilized and wrapped up in a package, not to\\nbe opened till required.\\nOn the Part of the Patient.\\nThe labor-room: Where practicable, a large, high, well-\\nventilated room should be selected for the lying-in chamber.\\nIt should not be exposed to contamination from defective\\nplumbing.\\nThe room selected should be thoroughly cleaned a few days\\nbefore the expected labor if possible, and all unnecessary\\nhangings and furniture removed, especially those likely to\\ncollect dust. It is well to have two or three small tahles\\navailable for holding basins, instruments, etc.\\nAll linen and other things provided for the labor should be\\nkept under cover in this room, so as to be immediately avail-\\nable as required.\\nOne dozen towels and a half-dozen freshly laundried sheets\\nshould be ready.\\nTwo rubber sheets, or sheets of some impervious material, to\\nreach across the bed, about four feet wide, should be provided.\\nThe patient should also make or obtain a labor-pad, about\\nthree feet square and about three inches thick, made of\\ncheese-cloth and filled with surgical cotton or other ab-\\nsorbent material.\\nAlso two dozen vulvar pads made of the same material\\nshould be provided. These should be two inches thick, four\\ninches wide, and ten inches long, and have tail-pieces attached\\nto either end to fasten them to the binder. Two or three\\nlinen or cotton binders should be ready each should be a\\nyard and a half long and half a yard wide.\\nThe labor-pad, vulvar dressings, and binders, as well as\\nhalf a dozen towels, should be wrapped in four separate par-\\ncels, steamed for half an hour, and then put away and not\\nopened till required for use.", "height": "3704", "width": "2456", "jp2-path": "obstetricsmanual00evan_0127.jp2"}, "126": {"fulltext": "126 THE MANAGEMENT OF NORMAL LABOR.\\nThe following should also be provided a bed-pan, a bottle\\nof antiseptic tablets for solution, a fountain-syringe, four\\nounces of tincture of green soap, a half-pound package of\\nabsorbent cotton, and a one-ounce bottle of vaseline, as well\\nas a skein of bobbin.\\nOn the Part of the Nurse.\\nThe nurse^s first duty is to prepare the patient for labor,\\nas has already been described.\\nThe labor-bed should then be made ready. This should\\nby preference be a single bed, with a stiff spring and a fairly\\nhard hair-mattress. Over this a rubber sheet should be\\nspread and then covered by an ordinary sheet, which should\\nbe securely pinned at each corner under the mattress. In\\nthe middle third of the bed another rubber sheet is then laid,\\ncovered over by a folded draw-sheet, both being securely\\npinned under the mattress at each side of the bed. On this\\nthe labor-pad is placed when it is required. The bed should\\nbe accessible from both sides.\\nThe nurse should see that everything likely to be needed in\\nthe course of labor has been provided and is at hand for\\nimmediate use.\\nThe nurse should see that plenty of hot water is at hand,\\nand make ready two jugs of sterile water, covering the tops\\nand placing them where the water will rapidly cool.\\nA pair of scissors and the necessary ligatures for the cord\\nare to be sterilized and placed within reach.\\nA small bowl containing a solution of boric acid, and a few\\nsmall cotton sAvabs, should be ready for washing out the child s\\neyes and mouth.\\nWrappings to receive the child should also be prepared, and\\nin winter kept warm till wanted for use.\\nUse of Anaesthetics in Labor.\\nObstetric anaesthesia differs from surgical anaesthesia in that\\nin the former the object is to blunt and not wholly to abolish\\nthe sensibilities.", "height": "3712", "width": "2492", "jp2-path": "obstetricsmanual00evan_0128.jp2"}, "127": {"fulltext": "USE OF AN^JSTHETICS IN LABOR. 127\\nThe prolonged and too free use of ansesthetios during labor\\nis capable of harm but at the same time it is the duty of the\\nphysician to relieve the patient of needless suffering and to\\nspare her unnecessary exhaustion.\\nThe rule should be to use an anaesthetic when the pains are\\nnot well borne without it. The degree of pain which some\\nwomen can endure is wonderful^ while in other cases the\\nlimit of endurance is soon reached.\\nAnaesthetics are usually indicated toward the end of the\\nsecond stage of labor. At the acme of expulsion surgical\\nanaesthesia should be induced, as a rule.\\nChloroform or ether may be employed. Chloroform is\\ngenerally preferred, as the necessary quantity is less bulky,\\nand it is pleasanter to take. When partial anaesthesia is all\\nthat is desired chloroform is the more satisfactory but in\\ncases requiring surgical anaesthesia for any length of time ether\\nis undoubtedly the safer and the better.\\nChloroform is said to weaken, and ether rather to stimu-\\nlate, uterine contractions. Ether should not be employed\\nwhen bronchitis is present, or when the patient is the sub-\\nject of atheroma.\\nIn eclampsia and tetanic contraction of the uterus chloro-\\nform is to be preferred.\\nAdministration In cases requiring only partial anmsthesia,\\nthe administration can be entrusted to the nurse, acting under\\nthe physician\\\\s direction. A mask or folded towel is held\\nover the patient s face, and at the approach of each pain the\\nnurse is instructed to sprinkle a few drops upon it. It is\\nwell in all cases to smear the patient s face with a light coat-\\ning of vaseline, as the anaesthetic may occasionally fall on\\nskin and cause considerable irritation subsequently should\\nthis precaution be overlooked.\\nCare should also be taken to remove any false teeth before\\ncommencing the administration of the anaesthetic.\\nWhen .surgical aricesthe.sia is required for any length of\\ntime its administration should never be left to the nurse, but\\na physician should be called for this purpose.", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0129.jp2"}, "128": {"fulltext": "128 THE MANAGEMENT OE NORMAL LABOR.\\nMANAGEMENT OF THE FIRST STAGE OF LABOR.\\nPreliminary Conduct of the Physician.\\nThe physician is usually the one person to whom the woman\\nin labor looks for help and encouragement in her hour of trial.\\nHis duty is to win the absolute conficlence of the patient,\\nand to inspire her with hopefulness and courage throughout\\nthe labor.\\nHis bearing should be quiet and confident, and his manner,\\nwhile firm, should be sympathetic and gentle.\\nThe effectiveness of a woman s labor depends very consider-\\nably on the preservation of her self-control and the absence of\\nstrongly inliibiting emotions. The physician cannot afford to\\nlose the intelligent assistance of his patient. Nor is he justi-\\nfied in adding fear or despair to the suiferings. Thus, what-\\never he may tell her relatives, he should, after his examination,\\ngive his patient the impression that all is satisfactory.\\nThe physician is sent for at this time because the patient\\nbelieves herself to be in labor. In this she may be mistaken.\\nOn entering the lying-in -room the physician should not pro-\\nceed at once to examine the patient but should try to set his\\npatient at ease and permit her to become accustomed to liis\\npresence.\\nIn a quiet, conversational manner, information as to the\\ntime of onset, the frequency, and the duration of the pains\\nshould be obtained.\\nThe condition of the patient s general health since the last\\nvisit of the physician should be learned, etc.\\n^yhile thus engaged the physician may watch for himself any\\nsymptoms of labor which may be manifest, and at the same\\ntime he should observe his patient carefully for any obvious\\nsign of disease as shown in her face or bearing, and seek to\\nestimate for himself the character and type of woman with\\nwhom he has to deal.\\nShould it be evident that labor has commenced the nurse\\nmay then be instructed to prepare the patient, if this has not\\nbeen done already.\\nIn any case the patient should have the bladder and bowel\\nevacuated before any physical examination is made.\\nI", "height": "3712", "width": "2500", "jp2-path": "obstetricsmanual00evan_0130.jp2"}, "129": {"fulltext": "MAyAGEJIEXT OF THE FIRST STAGE OF LABOR. 129\\nObstetric Examination.\\nExternal Examination.\\nPreparation The patient should be placed in the dorsal\\nposition close to the edge of the bed with her limbs extended\\nand her head on a low pillow. The clothing should be\\narranged so as to expose the abdomen from the ensiform car-\\ntilage to the pubes. The physician, having washed his hands\\nin hot water, may then take a position alongside the patient,\\neither sitting or standing as may be more convenient.\\nInspection The prominence and contour of the abdomen\\nshould first be observed. The condition of the umbilicus,\\nwhether depressed or prominent, the presence or absence of\\nstriae, pigmentation, or scars, and the condition of the flanks\\nshould all be noted. Evidence of uterine contraction and of\\nfoetal movements should be looked for.\\nPercussion The abdomen should then be percussed. In\\nnormal cases the dulness should be limited to central regions\\nof the abdomen extending from a short distance above the\\nnavel to the pubes, wdiile the flanks and epigastric regions\\nshould give a clear note.\\nPalpation,\\nBefore proceeding to the actual palpation the character and\\ntemperature of the skin should receive attention. Then the\\ndegree of panniculus adiposus, and the presence or absence of\\noedema in the hypogastric region, should be noted. The shape\\nof the uterus and the height of the fundus should then be\\nmade out.\\nThe upper borders of the pelvis should then be examined by\\nplacing the tips of the fingers of each hand on either iliac\\ncrest, with the thumb-points resting on the anterior superior\\niliac spines. The relationship of the spines as regards the\\ncrests should be observed, and a rough estimate of the width\\nof this part of the pelvis made.\\nThe upper border of the pubes should then be located, for\\nbeginners are very apt to mistake the pubes for the head when\\nendeavoring to explore the pelvic excavation from above.\\n9\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0131.jp2"}, "130": {"fulltext": "130 THE MANAGEMENT OF NORMAL LABOR.\\nThe next point is to explore the excavation of the pelvis in\\norder to ascertain whether it is full or enipty^ and^ if full, the\\ncharacteristics of that part of the foetus occupying it. In\\norder to do this the hands should be placed over the lateral\\naspects of the lower abdomen w^th their palmar surfaces\\nalmost facing each other, the finger-tips being directed toward\\nthe patient s feet and resting about an inch and a half above\\nPoupart s ligaments.\\nThe patient is then directed to breathe deeply, and with each\\nexpiration the finger-tips are pressed downward and backward\\ninto the pelvis, care being taken to avoid the pubes. In sen-\\nsitive patients the pressure exerted may cause pain in such\\ncases this manoeuvre can be carried out by a series of ballotte-\\nment-like movements, and the information desired thus ob-\\ntained with the minimum of discomfort to the patient.\\nIf the excavation be occupied, the finger-tips are quickly\\narrested in their descent. The only part of the foetus which\\nsinks into the pelvis before or very early in labor is the\\nhead. This may be recognized by its hardness and by its\\nglobular outline, which can be readily defined. The breech,\\non the other hand, is soft and bulky, and its outline very\\ndifficult to define.\\nShould the head of the ftetus occupy the pelvis in the nor-\\nmal condition of flexion (Fig. 62), it will be noted that one\\nhand is arrested above the brim, while the other sinks to a\\nlower level before meeting wdth resistance.\\nThe part of the head which is thus most accessible is the\\nbrow. This condition is most marked in occipitoposterior\\npositions of the head. Hence if this fact be noted the posi-\\ntion of the foetus is pretty well indicated.\\nIf the head be located at the brim and the excavation\\nof the pelvis not be accessible, it should be noted whether it\\nis engaged that is, fast in the brim or Avhether it is\\nmovable. If the head be found to be freely movable, an\\nattempt should be made to engage it by pressing it down-\\nAvard and backward in the axis of the pelvic inlet, and thus\\nto estimate the relative proportions of these ])arts.\\nThe upper pole of the uterus is pal[)ated by grasping the\\nfundus firmly between both hands, having the finger-tips di-\\nrected toward the head of the mother. By thus steadying the", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0132.jp2"}, "131": {"fulltext": "MANAGEMENT OF THE FIRST STAGE OF LABOR. 131\\nfundus between the hands, by flexing the fingers the upper\\nfoetal pole can be palpated for the distinguishing marks of the\\nhead or the breech. AVhen the head is at the fundus it can\\nbe readily felt and is very susceptible to ballottement. The\\nFig. 62.\\nPalpation with head in pelvic cavity fingers toward the occiput enter deeper than\\nthose toward forehead.\\nbreech is not so movable, is much more bulky, and is more\\ndifficult than the head to define.\\nThe foetal back and limbs must then be located.\\nThe back oifers a broad resisting surface, which is somewhat\\nconvex from end to end. In certain positions it is not possible\\nto feel the back, but in this case the lateral plane of the foetus\\ncan be felt it is narrower than the back, not convex, and the", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0133.jp2"}, "132": {"fulltext": "132 THE MANAGEMENT OF NORMAL LABOR.\\nshoulder can generally be located without difficulty. By\\nmaking firm pressure downward on the fundus with one hand,\\nthe back, if directed to the front, can be more readily palpated\\nwith the other. This pressure in the long axis of the foetus\\nincreases the convexity of the dorsal plane and renders it more\\naccessible.\\nThe limbs are felt as small nodules, knees, heels, elbows,\\netc., which slip about freely under the touch.\\nIf the small parts are numerous and found near the middle\\nline of the abdomen, a posterior position of the foetus is indi-\\ncated. Finding of the small parts in one section of the abdo-\\nmen confirms the location of the dorsum in the opposite region\\nthus small parts to the right indicate a left, and small parts to\\nthe left indicate a right position of the foetus.\\nAuscultation,\\nAuscultation is best practised with the binaural stethoscope.\\nIt is a mistake to press the bell of the instrument firmly on\\nthe abdominal wall it should be allowed to rest lightly upon\\nthe skin, being steadied by the slightest touch of one finger\\non the cross-bar.\\nThe first object is to locate the point at which the foetal\\nheart is heard with maximum intensity.\\nThe foetal heart-sounds are transmitted most loudly through\\nthe back, generally about tlie lower angle of the left foetal\\nscapula.\\nIn (interior vertex presentations the heart-sounds are heard\\nbest at a point midway between the umbilicus and the anterior\\nsuperior spine of the side to which the foetal back is directed\\nwhile in posterior vertex presentations their point of maximum\\nintensity is in the corresponding flank.\\nFig. 63 illustrates the points of maximum intensity of the\\nfoetal heart-sounds in the various positions and presentations.\\nThe sounds produced by the foetal heart have been com-\\npared to the muffled ticking of a watch under a pillow, the\\nrate being about 120-160 per minute.\\nIt should be remembered that in dorsoposterior positions, in\\nhydramnios, and in certain other conditions the heart-sounds\\nmav not be audible.", "height": "3728", "width": "2592", "jp2-path": "obstetricsmanual00evan_0134.jp2"}, "133": {"fulltext": "MANAGEMENT OF THE FIRST STAGE OF LABOR. 133\\nThe loud rhytluiiic swishing-sound occurriDg synchronously\\nwith the maternal heart-beat, occasionally heard low down on\\none or other side of the uterus, is termed the uterine bruit.\\nThis sound is caused by the rushing of blood through the\\nFig. 63.\\nIllustrating the points of maximum intensity of foetal heart-sounds in vertex and\\nbreech presentations.\\nenlarged uterine vessels, and is generally to be heard loudest\\nin the neighborhood of the placenta.\\nKarely a high-pitched hissing or blowing sound, which is\\nsynchronous with the pulsations of the foetal heart, may be\\nheard. This is termed the funic souffle, and is caused by the\\nblood rushing through the vessels of the cord. It is, as a\\nrule, only heard when the cord is twined around the body of\\nthe foetus.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0135.jp2"}, "134": {"fulltext": "134 THE MANAGEMENT OF NORMAL LABOR.\\nVaginal Examination.\\nThe physician having completed the external examination\\nof the patient, shonld then ascertain the condition of the\\nvulva, the vagina, the cervix, and the bag of waters.\\nWhile making the vaginal examination he should note the\\nposition of the presenting part, and should make a rough esti-\\nmate of the capacity of the pelvis.\\nPreparations The patient is placed on her left side, with\\nher hips brought Avell to the edge of the bed and her lower\\nlimbs flexed. The clothing should be so arranged as not to\\ninterfere with the access of the examining hand, and a sheet\\nis then draped over the patient. While this is being attended\\nto, the physician should cleanse and sterilize his hands, ac-\\ncording to the directions already given.\\nThe Examination.\\nEverything being in readiness, the physician seats himself\\nfacing the patient s genitalia. The nurse is then directed to\\nlift the sheet covering the patient, so as to expose the but-\\ntocks.\\nWith his left hand the physician then gently cleanses the\\nvulva with a pledget of absorbent cotton wet with an anti-\\nseptic solution.\\nHaving moistened his right hand in the same solution, he\\nthen separates the lips of the vulva by means of the thumb\\nand middle finger of this hand, holding the examining fore-\\nfinger well flexed into the palm so that it will not come into\\naccidental contact with any part of the patient.\\nHaving thus exposed the orifice of the vagina, he then ex-\\ntends his forefinger, passing it gently in in the direction of\\nthe hollow of the sacrum.\\nHaving already noted the condition of the vulva and\\nvaginal discharge, he now examines the perineum and the\\nposterior vaginal wall. The finger is then passed upward\\nfollowing the curve of the sacrum, Avhich should be noted,\\nuntil it reaches the posterior vaginal fornix.\\nThe posterior lip of the cervix will now be felt, and is to\\nbe traced down till the margin of the external os is reached.", "height": "3728", "width": "2592", "jp2-path": "obstetricsmanual00evan_0136.jp2"}, "135": {"fulltext": "MANAGEMENT OF THE FIRST STAGE OF LABOR. 135\\nThe finger is then swept round the external os, note being\\ntaken of its condition and of the degree of dilatation present.\\nThe bag of waters is then felt if present if not, the\\nfinger is inserted within the os until the presenting part of\\nthe foetus is reached. This is then explored for landmarks\\nand its position in the pelvis ascertained.\\nOn withdrawing the finger the anterior lip of the cervix\\nshould be followed and the anterior vaginal wall as wtII as\\nthe posterior surface of the pubes should be explored.\\nFig. 64.\\nManual method of measuring the diagonal conjugate.\\nThe capacity of the pelvis should then be ascertained by\\nsweeping the finger about in various directions. If possible,\\nan attempt may be made to reach the promontory of the\\nsacrum if this can readily be touched, there is some degree\\nof pelvic contraction present.\\nThe diagonal conjugate should therefore be measured.\\nFor this purpose the finger should be withdrawn and the\\nwhole hand again immersed in an antiseptic solution. The\\nfirst and second fingers are then inserted into the vagina, and\\nthe tip of the second finger placed in contact with the most", "height": "3692", "width": "2484", "jp2-path": "obstetricsmanual00evan_0137.jp2"}, "136": {"fulltext": "136 THE MANAGEMENT OF NORMAL LABOR.\\nprominent i)oint of the promontory tlie naclial edge of the\\nhand is then raised until it rests against the subpubic liga-\\nment (Fig. 64). This point of contact is then marked by a\\nfinger-nail of the other hand. On withdrawing the hands\\nthe distance between the two points of contact is then meas-\\nured and the true conjugate estimated (see Pelvimetry).\\nSucceeding the Examination.\\nHaving now gathered all his facts the physician is enabled\\nto make a diagnosis. It is unwise to venture a diagnosis till\\nall the facts are in hand.\\nPredictions as to the probable duration of the labor should\\nbe avoided but at the same time the patient should be given\\nall the encouragement and assurance possible.\\nIf the presentation be favorable and the part well engaged\\nin the pelvic brim, the patient may be allowed the liberty of\\nher room, and indeed should be encouraged to move about.\\nThe attendance of the physician during the first stage of\\nlabor is not required, in the absence of any complication.\\nThe nurse should be instructed to give the patient small\\nquantities of liquid nourishment at short intervals. It is\\nwell to leave a couple of 15-grain doses of chloral to be ad-\\nministered to the patient, with an interval of twenty minutes\\nbetween each, should her suffering become acute. The nurse\\nshould also be instructed to keep the patient in bed, and to\\nsummon the physician when the membranes rupture or on\\nthe occurrence of bearing-down pains.\\nAfter an interval of two to four hours, should the mem-\\nbranes not have ruptured, a second vaginal examination may\\nbe made to ascertain what progress has been attained.\\nShould it be found that the tenseness of the bag of waters\\nremains the same during the pains as in the intervals, or\\nshould the os be dilated so as easily to admit three fingers,\\nthen the membranes may be ruptured.\\nThis is accomplished by a scratching movement of the fore-\\nfinger, accompanied by pressure. Should this fail, a sterilized\\nprobe or straightened-out hairpin may be employed for this\\n])urpose, the greatest care being exercised not to injure the\\nmaternal tissues nor the skin of the presenting part of the\\nfoetus.", "height": "3704", "width": "2568", "jp2-path": "obstetricsmanual00evan_0138.jp2"}, "137": {"fulltext": "MANAGEMENT OF THE SECOND STAGE OF LABOR. 137\\nMANAGEMENT OF THE SECOND STAGE OF LABOR.\\nDuring the second stage of labor the patient should be kept\\nin bed. Her ordinary night-clothing should be turned up\\nand pinned at the shoulder, so as to prevent its being soiled.\\nPosition: The patient may assume any posture during this\\nstage in which she can secure the greatest amount of comfort,\\nprovided there is no reason why she should be constantly kept\\nin one position.\\nShe should be encouraged to bring all her expulsive efforts\\ninto operation, and to this end her feet may be braced against\\nsome object, and she may be allowed to assist herself by either\\npulling upon the hands of a bystander or on a sheet-sling\\nfastened to the foot of the bed.\\nIn rapid cases these measures should be avoided, and the\\npatient instructed not to bear down, but to relax her muscles\\nby short, panting breathing or by crying out aloud during the\\nacme of the uterine contractions. In this way too rapid dis-\\ntention and rupture of the perineum may be avoided. The\\nphysician should be in constant attendance during this stage.\\nThere is but little occasion to make a vaginal examination\\nwhen the second stage of labor is established. Should it be\\nfound that advance does not occur in spite of apparently good\\nuterine action, then a vaginal examination should be made to\\nestablish if possible the cause of delay but frequent examina-\\ntions should be avoided.\\nDuring the second stage an anaesthetic may be employed k)\\ncontrol and limit the expulsive efforts of the patient should\\nthis be desired, as well as to relieve her suffering. Not infre-\\nquently it is necessary to employ it in the first stage for the\\nlatter object. It should only be administered during the\\npains, according to the directions already given.\\nWhen the anus begins to distend with each pain, the head\\nhas reached the pelvic floor and rotation is under way.\\nPerineal stage It is now the duty of the physician to\\nwatch the effect of each contraction of the uterus in advancing\\nthe head.\\nAs the perineum begins to distend with each pain, not in-\\nfrequently a small quantity of faecal matter is expelled from\\nthe anus. This must be washed away, from before backward,", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0139.jp2"}, "138": {"fulltext": "138 THE MANAGEMENT OF NORMAL LABOR.\\nso as to prevent infection, with pledgets of absorbent cotton\\nsoaked in an antiseptic solution.\\nLaceration of the perineum occurs in about 35 per cent, of\\npri mi parse, and in about half that number of multiparse.\\nPrevention of this accident depends on the distensibility of\\nthe pelvic floor and the smallness of the engaging circumfer-\\nence of the fcetal head. Slow delivery of the foetal head, by\\ngradual stretching of the perineum, minimizes the possibility\\nof rupture. Half the injuries occurring to the pelvic floor in\\ngeneral obstetric practice are preventable by skilful manage-\\nment of the perineal stage of labor.\\nThe patient should at this time be placed on her left side,\\nwith her hips close to the edge of the bed. Her legs should\\nbe flexed and a folded pillow placed between her knees.\\nThe physician should sit close to the edge of the bed, facing\\nits foot. Near at hand on a chair or low table should be a\\nbasin containing an antiseptic solution, in which he may dip\\nhis hands from time to time, as well as ligatures for the cord,\\nscissors, swabs, etc., which he will require as the case pro-\\nceeds.\\nThe rate of the descent of the head is moderated by con-\\ntrolling the expulsive eflbrts of the patient and by direct press-\\nure upon the perineum. Should there be evidence of oedema\\nof this region, hot fomentations may be applied, care being\\ntaken first to anoint the parts with carbolized vaseline, so as\\nto prevent burning.\\nAs the moment of delivery of the head approaches the\\nphysician should slip his left hand over the patient s abdo-\\nmen and between her thighs, so as to place his fingers on the\\nocciput as it emerges below the pubic arch (Fig. 65). By\\nexerting pressure with this hand too early extension of the\\nhead can be prevented, and any of the soft structures of the\\npubic segment of the pelvic floor, which may be caught in\\nfront of the occiput, can be pushed back in the intervals\\nbetween the pains and held out of the road, so as to permit\\nits early escape under the arch of the i)ubes.\\nThe fingers of the right hand are held on the lower side of\\nthe vulva, and the thumb on the upper, while the palm covers\\nthe perineum.\\nAs the occiput escapes under the pubic arch pressure is", "height": "3712", "width": "2604", "jp2-path": "obstetricsmanual00evan_0140.jp2"}, "139": {"fulltext": "MANAGEMENT OF THE SECOND STAGE OF LABOR. 139\\nmade with the fingers and thumb of the right hand, so as to\\npush the head forward, and at the same moment the left hand\\nfirmly grasps it in order to moderate the rapidity of its escape\\nthen the right hand is free to prevent the perineum slipping\\ntoo rapidly over the face.\\nAs the head escapes from the vulva it is well to have the nurse\\nextend the limbs of the patient somewhat, which movement\\nresults in a certain degree of relaxation of the perineum.\\nFig. 65.\\nProtection of pelvic floor and delay of fcetal head. (Davis.)\\nWith the hands placed as directed above to control the de-\\nlivery of the head, this extension of the limbs interferes in no\\nway with the physician s work.\\nDuring the moment of delivery the anaesthetic should be\\npushed so as to induce surgical anaesthesia, in order to prevent\\nany unexpected movement of the mother and also to spare her\\nagonizing pain.\\nHaving delivered the head, the physician may now quickly\\ncleanse his hands in the antise})tic solution before proceeding to", "height": "3712", "width": "2452", "jp2-path": "obstetricsmanual00evan_0141.jp2"}, "140": {"fulltext": "140 THE MANAGEMENT OF NORMAL LABOR.\\nexamine tlie neck of the child to see if it be encircled by the\\ncord.\\nShould this be the case, he may draw down the cord and loosen\\nthe loop sutliciently either to pass it over the child s head or\\nto deliver the slioulders through it if this be impossible, it\\nmust be tied, cut, and the child rapidly delivered.\\nNo effort for a couple of minutes should be made to deliver\\nthe shoulders after the head has been born, except when the\\nlabor has been long and difficult. Should they not advance,\\nthen the anterior shoulder should be reached if possible by\\npassing two fingers over the dorsal surface till the arm is\\nreached, when it is delivered by flexing the fingers, so that it\\nmoves over the chest.\\nThe physician should then place his left hand over the\\nfundus of the uterus, making firm pressure upon it, while at\\nthe same time with his right he pushes the head and body of\\nthe child forward toward the pubes as it escapes from the\\nvulva.\\nImmediate care of the child The nurse should then take\\ncharge of the fundus, while the physician attends to clearing\\nthe mucus from the child s mouth and to wiping its eyes.\\nEfforts should then be made to establish re^^piration, should\\nthe child not cry, by slapping it briskly or by sprinkling it\\nwith cold water. When once it cries lustily it should be laid\\non its side, while the mother is being turned over into the\\ndorsal position.\\nThe cord may now be tied an inch from the navel. A short\\ndistance beyond this a second ligature is placed, and the cord\\nslipped between the middle and third fingers of the left hand,\\nwhich is placed with its dorsum resting on the child s abdo-\\nmen. The ligatured part of the cord thus lies in the palm\\nof the hand, so that in cutting it there is not the slightest\\ndanger of the child s being injured by the points of the\\nscissors.\\nThe foetal end of the cord should then be washed and\\nexamined to see that it has been firmly tied, when it may be\\nwrapped in a dry piece of sterile gauze.\\nThe child is then wrapped up warmly and put in a safe\\nplace till it can be washed.", "height": "3712", "width": "2592", "jp2-path": "obstetricsmanual00evan_0142.jp2"}, "141": {"fulltext": "MANAGEMENT OF THE THIRD STAGE OF LABOR. 141\\nMANAGEMENT OF THE THIRD STAGE OF LABOR.\\nIn order to insure firm and continuous uterine contraction,\\neither the nurse or the physician should take charge of the\\nfundus from the moment the head is delivered till the binder\\nhas been applied. Should the uterus become relaxed a few\\ncircular movements of the hand over the fundus will stimu-\\nlate contraction and prevent hemorrhage.\\nA sterilized bed-pan or soup plate may now be placed under\\nthe buttocks so as to catch any blood that may escape from the\\nvagina and also to receive the after-birth.\\nLacerations While waiting for the placenta to be delivered\\nmany physicians place the nurse in charge of the fundus while\\nthey utilize this time to examine the vulva and perineum for\\nthe presence of lacerations.\\nShould the lacerations not be extensive^ they may be im-\\nmediately sutured according to the directions given in the\\nTreatment of Lacerations. The sutures should not be tied\\nuntil the placenta has been expelled but their ends may be\\ncaught in a pair of artery-forceps meanwhile. The advan-\\ntage of passing the sutures at this time is that the patient is\\nstill partially under the influence of the anaesthetic, and the\\noperation causes no pain.\\nShould the placenta not have been expelled in half an hour\\nafter the birth of the child, preparations should be made to\\ndeliver it by Crede s method of expression.\\nThe patient s limbs are drawn up till her feet rest on the\\nbed as close as possible to the buttocks, her knees being widely\\nseparated. The sheet covering her is then arranged so as to\\nexpose only the vulva. The physician should then sterilize\\nhis hands, for in cases where the placenta is found firmly\\nattached to the uterine wall, in whole or in part, it is\\ndesirable that the hand be ready for immediate entrance into\\nthe uterus.\\nWith his left hand placed upon the fundus so that the\\nfingers are behind and the thumb in front of it, and the thumb\\nand forefinger of the right hand grasping the cord just within\\nthe vulva, the physician, after kneading the uterus to secure\\ngood, firm contraction, makes strong, steady pressure down-\\nward in the axis of the pelvic inlet, at the same time squeez-", "height": "3712", "width": "2452", "jp2-path": "obstetricsmanual00evan_0143.jp2"}, "142": {"fulltext": "142 THE MANAGEMENT OF NORMAL LABOR.\\ning the organ firmly. When the placenta is felt to detach itself,\\ngentle traction may be made upon the cord so as to guide it\\nout of the vagina.\\nShould the first attem])t fail, it is repeated with each succes-\\nsive contraction until the after-birth is expelled.\\nShould the membranes be caught, they may be grasped by\\nthe fingers of the right hand and gentle traction made upward\\ntoward the pubes and parallel with the vulva, in order to\\nseparate them.\\nThe nurse is now given charge of the fundus while the\\nphysician carefully examines the placenta and membranes in a\\ngood light in order to assure himself that no fragment has\\nbeen left behind. Having satisfied himself on this point, he\\nmay now take charge of the fundus while the nurse pro-\\nceeds to wash the vulva and remove all soiled linen from the\\nbed.\\nRetraction of the uterus Should the fundus not retract\\nfirmly after delivery of the placenta, a drachm dose of the\\nfluid extract of ergot should be administered to the patient.\\nIn all cases the fundus should be gently kneaded for half an\\nhour after the delivery of the placenta. When retraction is\\ncomplete the abdominal binder may be put on, a fresh pad\\napplied to the vulva, and the patient made comfortable.\\nThe physician, before proceeding to wash up and collect his\\ninstruments, etc., should carefully examine the infant for the\\npossible existence of developmental anomalies, and to ascer-\\ntain that no injuries have been received in the course of de-\\nlivery.\\nFor further directions as to the care of the newborn the\\nreader is referred to the compend of this Series on Children s\\nDiseases.\\nFinal measures Before leaving the patient the physician\\nshould assure himself as to the condition of the fundus, the\\nlochia, and the pulse. The nurse should be given full instruc-\\ntions with reference to the care of the mother and the child.\\nIt is w^ell to leave the nurse one or two half-drachm doses of\\nergot to be administered should the fundus show any tendency\\nto relax she may also be left a prescription for relieving the\\nafter-pains should they prevent the patient resting.", "height": "3712", "width": "2596", "jp2-path": "obstetricsmanual00evan_0144.jp2"}, "143": {"fulltext": "THE PUERPERAL STATE\u00e2\u0080\u0094 THE UTERUS. 143\\nTHE PUERPERAL STATE.\\nThe puerperal period, or puerperium, begins at the termination\\nof labor and concludes when involution and regeneration of\\nthe genital organs are completed.\\nThis period varies in individual cases, but averages about\\nsix weeks.\\nThe physiological phenomena of the puerperium are the\\ninvolution of the uterus and vagina disintegration of the\\ndecidua and the regeneration of the endometrium retrograde\\nchanges in the uterine ligaments, pelvic peritoneum, cellular\\ntissue, lymphatics, bloodvessels, and nerves alterations in the\\nblood and circulatory system changes in body-weight, tem-\\nperature, and skin, as well as in the urinary and alimentary\\nsystems and finally the establishment of lactation.\\nThe two opposed processes of decay and regeneration occur\\nsimultaneously with great rapidity in the puerperium. These\\nprocesses, which involve whole systems and organs, take place\\nin the natural healthy woman without affecting her subjective\\ncondition.\\nThe puerperal state, though it is physiological, borders so\\nclosely on the pathological that conditions of disease may very\\nreadily arise.\\nHence during this period the woman is so beset with diffi-\\nculties and dangers that accidents and complications are\\nlikely to occur unless she is guarded and cared for with\\nknowledge and skill.\\nAnatomy of the Parts Immediately After Labor.\\nThe Uterus.\\nPosition: This organ lies in an anteverted and anteflexed\\nstate with its fundus in contact with the anterior abdominal\\nwall. Its shape is usually an irregular ovoid.\\nThe upper uterine segment is thick- walled (IJ inches, 3 to 4\\ncm.), and is pale pink in color on section.\\nThe lower uterine segment is separated from the upper by a\\nwell-marked line. Its walls being much thinner, are thrown\\ninto folds by the weight of the upper segment.", "height": "3700", "width": "2460", "jp2-path": "obstetricsmanual00evan_0145.jp2"}, "144": {"fulltext": "144 THE PUERPERAL STATE.\\nThe cervix can roughly be made out, its walls being\\nrather thicker than the lower segment. The li23S are usually\\neverted, resting on the posterior vaginal wall, and are flattened\\nby the weight of the uterus.\\nThe lower segment and cervix are much congested, and\\nthus contrast with the bloodless body of the uterus.\\nThe placental site, which measures roughly 4 by 3 inches,\\nhas a ragged surface, and is somewhat elevated. It shows the\\nopenings of the sinuses filled with clots. The area of the at-\\ntachment of the membranes is paler in color and smoother than\\nthe placental site. Shreds of decidua are scattered over the\\nsurface.\\nThe cavity of the uterus measures 6 to 6^ inches (15 to 16\\ncm.) in length.\\nThe Vagina.\\nIt retains its usual shape, but is much distended. Its walls\\nare thickened and their surface smooth and oedematous they\\nalso present more or less evidence of contusion or abrasion.\\nThe Vulva.\\nThe vaginal orifice is stretched and torn to a variable degree.\\nAll the external parts are frequently somewhat bruised and\\nlacerated, and may also present more or less oedema.\\nThe pelvic floor is greatly relaxed and not infrequently torn,\\nthe edges of the wound in this case gaping somewhat.\\nThe Bladder.\\nThis lies in its usual position, and is once more a pelvic\\norgan.\\nThe Peritoneum and Broad Ligaments.\\nThe peritoneum over the body of the uterus is smooth but\\nat the mdes and at Douglas s pouch it is thrown into folds. The\\nbroad Ugmnents lie folded and to a certain extent compressed\\nbetween the body of the uterus and the pelvic walls. This\\ncompression of the broad ligaments must retard the circula-\\ntion in the vessels contained in them, and so lessen the en-\\ngorgement of the uterus.", "height": "3700", "width": "2620", "jp2-path": "obstetricsmanual00evan_0146.jp2"}, "145": {"fulltext": "INVOLUTION. 145\\nThe abdominal walls are relaxed and the skin usually\\nthrown into folds and wrinkles.\\nPhysiology of the Puerperal Period\\nInvolution.\\nThe uterus Immediately after the expulsion of the placenta\\nthe fundus of the uterus may be felt about half-way between\\nthe umbilicus and the pubes but in a short time, from one to\\nsix hours, it will be found to occupy a position at or slightly\\nabove the umbilicus. The dilatation of the lower uterine seg-\\nment and cervix necessary to permit the passage of the child\\nresults in more or less complete loss of tone, so that the weight\\nof the upper segment compresses them but as tone is re-\\ngained they become capable of supporting the superimposed\\nweight and the fundus becomes elevated slightly.\\nFrom this time the uterus diminishes rapidly in size, so that\\nthe fundus gradually sinks, and at the tenth day may be found\\nat the level of the pelvic brim.\\nInvolution of the uterus proceeds most rapidly between the\\nthird and the twelfth day of the puerperal period. The uterus\\nnever quite returns to its virginal condition, its cavity in the\\nparous woman being about half an inch longer than in the\\nvirgin.\\nChanges in the muscle-cells The firm contraction and\\nretraction of the uterus, after labor, cut off its blood-supply\\nto a very considerable extent, and thus being deprived of\\nnourishment the muscle-cells rapidly undergo fatty degenera-\\ntion. At the same time a portion of the cell-contents is con-\\nverted into a peptone, which is absorbed into the blood and\\ndischarged through the kidneys.\\nIt is doubtful if any cells are destroyed in toto for\\nSanger s observations prove that reduction of the uterus after\\nlabor is effected by a diminution in size of the individual cells\\nand not by their destruction.\\nChanges in the uterine vessels and nerves The bloodvessels,\\nlymphatics, and nerves have all participated in the general\\ngrowth during pregnancy. These all take on retrograde\\nchanges. The bloodvessels, which are closed by thrombi, are\\n10\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0147.jp2"}, "146": {"fulltext": "146 THE PUERPERAL STATE.\\ncompressed, thus bringing their walls in apposition. Partly\\nby organization of the clots and partly by excessive growth\\nof connective tissue in the walls, the vessels become ob-\\nliterated.\\nUterine mucosa The ovum when it is cast off carries with\\nit chiefly the upper layer of the decidua, which remains\\nattached to the chorion, and leaves behind on the uterine wall\\nthe lower cellular layer and the glandular portion.\\nDiminished blood-supply from uterine retraction soon\\nresults in loss of vitality in the lower portion of the\\ndecidua, fatty degeneration and disintegration of the cells\\nrapidly ensue, and they are cast off in the lochial discharge.\\nThis process soon lays bare the glandular layer from which\\nthe new mucous membrane originates. The epithelial cells of\\nthe glandular layer as well as the interglandular connective\\ntissue rapidly proliferate and form the new mucous membrane.\\nThis process takes about eight weeks to complete.\\nLochia The term lochia is applied to the discharge which\\ncomes from the vagina of the puerperal woman.\\nIt is composed of blood, degenerated epithelial cells, debris\\nof clots, mucus, and quantities of harmless micro-organisms.\\nIt begins after the placenta has been delivered, and lasts from\\nten to fourteen days.\\nIts character changes as the puerperium advances. At first\\nit mainly consists of pure blood mixed with cervical mucus\\nand small clots the lochia rubra. In two or three days it\\nbecomes paler and consists of serum and mucus the lochia\\nserosa. About the sixth day it becomes thicker and is choco-\\nlate colored but as the blood disappears and leucocytes become\\nmore abundant, it is white, having the appearance of thin pus,\\nwhich it practically is the lochia alba.\\nFrequently when the patient first assumes the erect posture\\nthe lochia again becomes tinged more or less with blood.\\nIts quantity was formerly greatly overestimated by Gassner,\\nwho gave it as about fifty ounces. Recently Giles, from care-\\nful measurement in a large number of cases, estimated the\\ntotal quantity as being only ten and a half ounces.\\nIts odor is peculiar. The lochia rubra has the odor of fresh\\nblood but later the mucus from the vulvar glands gives it a\\npeculiar and somewhat penetrating odor. Practically the odor", "height": "3712", "width": "2604", "jp2-path": "obstetricsmanual00evan_0148.jp2"}, "147": {"fulltext": "CHANGES IN THE UEINARY SYSTEM. 147\\nmay be defined as an acid odorwlien the discharge is normal.\\nAmmoniacal or alkaline odor always suggests that putrefactive\\ngerms have gained access to the vagina.\\nVulva and vagina In primiparse the hymen and fourchette\\nare invariably torn the remains of the former persist around\\nthe vaginal orifice in the form of small irregularly shaped\\nelevations which are termed carunctdoe myrtiformes.\\nMore extensive tears of the vulva and perineum, if not\\nsutured, heal by granulation and cicatrization, occasionally\\nleaving extensive scars.\\nThe vagina rapidly becomes smaller and narrower its walls\\nfrom being smooth, gradually become rugated though the\\nrugse are never so marked as in the nullipara. As the hyper-\\nsemia of the parts passes off, the vulva and vagina assume\\nmore their previous color and proportions.\\nInvolution also takes place in the uterine ligaments, ovaries\\nand tubes, abdominal walls, and pelvic joints, all gradually\\nreturning more or less to their condition as before the occur-\\nrence of pregnancy.\\nChanges in the Circulatory System.\\nPulse The pulse-rate shortly after labor falls to about 60,\\nor even lower. The cause of this lies in the reduction of the\\ngeneral blood-pressure due to changes in the constitution of\\nthe blood and also to the decreased intra-abdominal pressure.\\nThe blood, probably as the result of hemorrhage during and\\nafter the third stage of labor, becomes deficient in red blood-\\ncorpuscles and haemoglobin.\\nThe heart, which has become slightly hypertrophied during\\npregnancy, quickly resumes its former condition.\\nChanges in the Urinary System.\\nThe urine is not markedly increased in quantity. Peptone\\nand acetone are said to be normally present in the urine of\\npuerperal women. The occurrence of sugar is not unusual,\\nespecially when there is distention of the breasts. Albumin\\nmay be present for a few days, but its persistence is always of\\ngrave import.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0149.jp2"}, "148": {"fulltext": "148 THE PUERPERAL STATE.\\nThe bladder not infrequently becomes overdistended in\\npuerperal women and micturition impossible. The causes\\nof this condition are twofold First, the bladder is now\\nsubjected to less pressure than it was, because the greatly\\ndistended uterus has been emptied, in consequence of which\\nthe intra-abdominal pressure is greatly decreased and the\\nabdominal walls flaccid hence the bladder has more room\\nto distend and less resistance is offered to it. Second, small\\nfissures about the vulva smart severely when the urine trickles\\nover them, hence the woman is led almost unconsciously to\\nretain her urine as long as possible.\\nThe Skin.\\nDuring the puerperium the sweat-glands become unusually\\nactive. The skin is more moist and not infrequently during\\nsleep profuse perspiration takes place. This is probably one\\nof the factors by which the hydrsemia of pregnancy is cor-\\nrected.\\nThe Digestive Apparatus.\\nThe power of digestion of solid food is for a time enfeebled.\\nThirst is usually present, and is easily accounted for by the\\ngreat drain of water from the body by perspiration, the lochia,\\nthe milk, and the urinary secretion.\\nThe bowels are apt to be sluggish, constipation being usu-\\nally present, probably caused by the decrease in intra-abdom-\\ninal pressure, the lax condition of the abdominal wall, and\\nthe great drain of water from the system referred to above.\\nLoss in weight takes place rapidly, as elimination exceeds\\ningestion during the puerperium. This loss is very marked\\nin most cases, and has been estimated at from one-twelfth to\\none-eighth the body-weight in the first seven days. This\\ndiminution should cease by the tenth day.\\nLactation.\\nBy lactation is meant the suckling of the infant. It usu-\\nally commences on the third day and lasts for about a year", "height": "3712", "width": "2600", "jp2-path": "obstetricsmanual00evan_0150.jp2"}, "149": {"fulltext": "LACTATION. 149\\nthough after the seventh or eighth month there is a falling\\noff in the quality of milk secreted.\\nThe mammary glands are two large racemose glandular\\norgans situated on the upper portion of the chest, anterior\\nto the muscular structures of the thoracic walls. They\\noccupy the space bounded above by the third rib, and below\\nby the sixth rib on the inner side by the edge of the\\nsternum, and on the outer by the anterior axillary line.\\nThey are epiblastic in origin and belong essentially to the\\nskin as do the sweat and sebaceous glands.\\nThey are globular, and vary in size in different women.\\nAt the summit of each breast is a small conical elevation\\nknown as the nipple, which is surrounded by an area of pig-\\nmented skin, termed the areola, in which there is a number of\\nlarge sebaceous glands the glands of Montgomery.\\nInternally each mammary gland is composed of from\\nfifteen to twenty-four lobes, united by a certain amount of\\nconnective tissue and fat. Each lobe is divided into lobules,\\nand these are further subdivided into a large number of\\nacini or vesicles, in which the milk is secreted.\\nThe vesicles empty their contents into small ducts these\\nexcretory ducts from contiguous lobules unite to form a\\nsingle large lactiferous canal.\\nOf these latter there are fifteen or more in each breast,\\neach conveying the milk from a separate lobe to the nipple.\\nThe epithelium lining these canals is continuous with that of\\nthe integument.\\nColostrum Until the establishment of lactation the breasts\\ncontain only colostrum, which is a yellowish fluid resemb-\\nling milk, but differing from it chemically, in that it contains\\nmore sugar, fat, and salts. It has a laxative effect on the\\nchild, due to the excess of fats and salts it contains. Micro-\\nscopically it can be recognized by the large, so-called colos-\\ntrum-cells, which are simply large epithelial cells studded\\nwith fat-globules.\\nMilk is the secretion of the mammary glands. It is a\\nyellowish-white fluid of an alkaline reaction having a specific\\ngravity of 1024 to 1034.\\nGood human milk has approximately the following chemi-\\ncal composition", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0151.jp2"}, "150": {"fulltext": "150 THE PUERPERAL STATE.\\nPer cent\\nFat,\\n4.00\\nSugar,\\n7.00\\nProteid (casein),\\n1.50\\nSalts,\\n0.20\\nWater,\\n87.30\\nThe fats, sugar, and proteids are produced from the cells\\nlining the acini of the glands; the plasma and salts are de-\\nrived from the blood.\\nThe CLuality of the milk is altered by varied conditions of\\nthe mother mental and physical disturbances may so change\\nthe milk as to render it unwholesome.\\nThe quantity of milk secreted varies in different women and\\nat different times. At first about 200 c.c. is secreted daily,\\nbut after the tenth day the amount increases to from one-half\\nto two litres.\\nThe secretion of milk usually begins about forty-eight\\nhours after labor. The breasts distend, become engorged with\\nblood, and are painful or tender when touched.\\nAVhen the breast is full it is hard and nodular to the feel,\\nand milk may be expressed from the nipple on the slightest\\npressure.\\nThe establishment of lactation may be painful, and may\\ngive rise to considerable emotional disturbance on the part\\nof the patient, causing a slight elevation of temperature; this\\nis, however, rare except in primiparse. There is no such\\nthing as the so-called milk fever if fever occur at this\\ntime, it is a traumatic fever, and the result of infection only.\\nThe Management of the Puerperium.\\nThe lying-in-room should be in the quietest part of the house\\nif possible. It should be well ventilated, and the light should\\nbe so arranged as to cause no inconvenience to the patient.\\nIt should be kept thoroughly clean and well dusted. The\\ntem])erature of the room should be maintained at between 65\u00c2\u00b0\\nand 70\u00c2\u00b0 F. Soiled linen should l)e taken from the room as\\nsoon as possible after being removed from the patient. The\\npatient s linen and draw-sheet should be changed daily.\\nI", "height": "3712", "width": "2612", "jp2-path": "obstetricsmanual00evan_0152.jp2"}, "151": {"fulltext": "CARE OF BREASTS, NURSING, ETC. 151\\nFriends and relatives should not be permitted to use the\\nroom as a general meeting-place.\\nThe care of tlie genitalia The vulvar dressings should he\\nchanged at least every three hours during the first twenty-\\nfour; after this as often as soiled, or three or four times\\ndaily.\\nAVhen the pad is removed the external genitals should be\\ncleansed of lochia by means of swabs dipped in a saturated\\nsolution of boric acid and squeezed dry, before a fresh dress-\\ning is applied.\\nAfter the bed-pan has been used the lips of the vulva should\\nbe gently separated and a stream of warm boric-acid solution\\npoured over them from a douch bag or small jug. The parts\\nshould then be carefully dried with a sterile towel or bits of\\ngauze and a fresh dressing applied.\\nAll manipulations should be carried out with the strictest\\naseptic precautions.\\nCare of Breasts, Nursing, Etc.\\nThe child should be put to the breast for a few moments\\nevery six hours until the secretion of milk is established.\\nThis may be supplemented by an occasional ounce of sweet-\\nened water should the infant prove restless.\\nWhen lactation is established the child should be suckled\\nevery two hours from 6 a. m. to 10 p. m. Usually it is\\nnecessary to give one nursing during the night for the first six\\nweeks. The importance of regularity in nursing should be\\nimpressed upon the mother, for without regularity it is scarcely\\npossible for mother or child to do well. Overfrequent and\\nirregular nursing deranges the infant s digestion and impairs\\nthe quality of the milk.\\nThe nipples should be cleansed with a saturated boric-\\nacid solution, both before and after suckling.\\nIn drying the nipples only absorbent cotton or soft gauze\\nshould be employed, and care should be taken not to rub\\nthem.\\nShould they become tender any antiseptic emollient may be\\napplied. The following makes a very satisfactory ointment\\nfor this purpose", "height": "3700", "width": "2480", "jp2-path": "obstetricsmanual00evan_0153.jp2"}, "152": {"fulltext": "152 THE PUERPERAL STATE.\\nI^. Acid, boric, 3J\\nBismiitli. snbnit.,\\nOl. ricini, da 5ss. M.\\nFt. ling.\\nSig. To be applied after nursing, and covered with a small\\nsquare of white waxed paper.\\nIt may be necessary to use a well-fitting glass nipple-shield\\nfor a short time, should the act of suckling give rise to irrita-\\ntion of the nipples.\\nNot infrequently, usually in women with large, pendulous\\nbreasts, considerable discomfort, even amounting to pain, is\\nsuffered when the glands become distended with milk. In\\nthese cases a snugly fitting breast-binder will afford great ease\\nand comfort. Either the Murphy or the Y binder may be\\nemployed.\\nContraindications to suckling While suckling benefits the\\nmother by promoting involution through reflex nervous ac-\\ntion, and while there is certainly no food so suitable for the\\ninfant as mother s milk, there are still certain conditions\\nwhich may render it unwise for the patient to nurse her child.\\nA feeble state of health, tuberculosis, and persistent albu-\\nminuria all contraindicate suckling. The same applies to\\ncases in which syphilis has been contracted late in pregnancy,\\nfor it is possible the child may have escaped infection.\\nInversion of the nipples, or severe and painful fissures,\\nmastitis, or defective secretion, all act as contraindications of\\nsuckling.\\nNourishment: As the process of digestion is usually im-\\npaired during the first days of the puerperium, the diet at this\\nperiod should consist chiefly of fluids. Milk, clear soup,\\ngruel, cocoa, week tea, toast, stale bread, and soft-boiled eggs\\nmay be permitted. After the third day a gradual return to\\nthe usual diet may be made. Malt liquors and wines may be\\npermitted in small quantities if patients are accustomed to\\ntheir use.\\nRest Everything about the patient should be so disposed\\nthat she may obtain absolute mental and physical rest. It is\\nnot necessary, provided uterine retraction be firm, for the\\npatient to remain constantly on her back she may gently turn", "height": "3708", "width": "2596", "jp2-path": "obstetricsmanual00evan_0154.jp2"}, "153": {"fulltext": "CARE OF BREASTS, NURSING, ETC. 153\\nover to one or other side should she so desire. After the\\nfirst day she may be allowed to rise almost to the sitting\\nposture for a short time, should there be occasion, the use of\\nthe catheter thus being rendered unnecessary. All move-\\nments should be slow and deliberate, sudden changes of posi-\\ntion being always avoided.\\nAfter-pains: In primipara? after-pains due to uterine con-\\ntractions are seldom severe enough to demand relief. In\\nmultiparse, on the other hand, they may be so troublesome as\\nto preclude all possibility of rest or sleep. Morphine gives\\nrelief, but should be used with care. Doses of J-J gr. may\\nbe repeated as often as required. When it is undesirable to\\nuse this drug, antifebrin or phenacetin in gr. v doses, com-\\nbined with caifeine cit., gr. ij, m^y be given.\\nShould the uterus remain lax and soft, involution may be\\npromoted by friction of the fundus ten minutes two or three\\ntimes daily, and a pill containing ergot., gr. ij quin. sulph.,\\ngr. ij strych. sulph., gr. may be given twice or thrice in\\nthe twenty-four hours. After the fifth day a hot vaginal\\ndouche, night and morning, may prove of value in this condi-\\ntion.\\nVisits of the physician The first visit after labor should be\\nmade within twelve hours, and afterward one or two visits\\ndaily, as the case may require. While the patient may be\\nallowed out of bed when once the uterus has become a\\npelvic organ, still she should continue under the physician s\\nobservation until fully convalescent.\\nThe nurse in charge of the case should record, morning and\\nevening, the temperature, pulse, and respiration, as well as\\nevacuations of the bowels and bladder, and the condition of\\nthe lochia.\\nAt each visit the physician should note the record of the\\npulse, temperature, respiration, etc. He should also exam-\\nine the condition of the uterus, the bladder (bearing in\\nmind the danger of distention of the latter), the breasts and\\nnipples, the skin, the digestive apparatus, and the lochia.\\nThe bowel having been pretty well cleared at the onset of\\nlabor, it is seldom that a purgative is required till the third\\nday. It is usual to give a dose of castor oil or other laxative\\nso as to operate on the morning of the third day after this a", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0155.jp2"}, "154": {"fulltext": "154 PATHOLOGY OF PREGNANCY.\\ndaily movement should be obtained, and a mild laxative\\nshould be regularly administered if required.\\nThe infant s temperature should be taken twice daily until\\ntwo days after the separation of the cord, which usually takes\\nplace in from five to ten days.\\nIt should be a routine practice to make a bimanual examina-\\ntion of the pelvic organs in the third or fourth week of the\\npuerperium, with the object of determining the presence or\\nabsence of injuries of the vagina and cervix, the degree of\\nuterine involution, and the existence of displacement of the\\nuterus or other abnormal conditions.\\nPATHOLOGY OF PREGNANCY.\\nTHE DECIDUA.\\nThe decidual mucous membrane of the pregnant uterus may\\nbe the seat of disease, owing to the enormous hypertrophy of\\nthe mucous membrane incident to pregnancy. These diseased\\nconditions often manifest themselves in exaggerated forms as\\ncompared with the non-pregnant state. In consequence of\\nthe relation of the decidua to the ovum, diseased conditions\\nof this membrane may have more serious consequences than\\nin the non-gravid state. Most decidual diseases have their\\norigin in either acute or chronic endometritis.\\nAcute Decidual Endometritis.\\nEtiology This is a very rare condition. It may result\\nfrom trauma, in consequence of attempts to procure abortion\\nor from certain infectious diseases. AYhen due to trauma the\\ninflammation is frequently of a septic nature, and is charac-\\nterized by the presence of an offensive purulent discharge.\\nDeciduitis accompanying the develoj)ment of infectious dis-\\neases during pregnancy usually results in abortion. This\\nresult is probably due to the hypertrophied mucosa, because\\nof its vascularity, becoming the seat of an intense inflamma-\\ntion and participating in the eruption which usually affects\\nthe mucosa of the body in exanthemata.\\nThe treatment in these cases consists in controlling hemor-", "height": "3712", "width": "2576", "jp2-path": "obstetricsmanual00evan_0158.jp2"}, "155": {"fulltext": "CHRONIC DECIDUAL ENDOMETRITIS. 155\\nrhage, favoring abortion, and attending to complications as\\nthey arise.\\nChronic Decidual Endometritis.\\nOccurrence Chronic inflammation of the decidua is very\\ncommon and is the cause of a vast majority of early abor-\\ntions. Usually the inflammation of the endometrium ante-\\ndates the pregnancy.\\nTwo forms are commonly observed, a chronic diffuse endo-\\nmetritis, or polypoid degeneration and a catarrhal endometritis,\\nor hydrorrhoea gravidarum.\\nIn diffuse endometritis there is more or less hyperplasia of\\nthe connective tissue, resulting in great thickening of the\\ndecidua.\\nShould the disease advance with great rapidity an abortion\\nwill usually result, either from hemorrhages into the mucous\\nmembrane, thus separating it from the uterine wall or from\\nthe death of the embryo owing to crowding of the ovum by\\nthe rapidly thickening decidua. In the latter case the em-\\nbryo may be absorbed, and the decidua afterward cast off as\\nan empty sac with greatly thickened walls, forming what is\\nknown as 3. fleshy mole.\\nIf the inflammation of the decidua be of a more chronic\\ncharacter, the pregnancy may proceed to term. In this case\\nthe parturition is likely to be prolonged by reason of the un-\\ndue adhesion of the membranes or great difficulty may be\\nencountered in the third stage from adhesion of the placenta\\nto the uterine wall.\\nIn the catarrhal form of chronic deciduitis there is present\\nnot only a proliferation of the cellular elements of the decidua,\\nbut also increased secretion hydrorrhoea gravidarum. In\\nthis form there takes place, every few days, a discharge from\\nthe uterus of a greater or less quantity of a clear viscid\\nliquid having a yellowish tinge and containing albumin.\\nHydrorrhoea occurs more frequently in multiparse than in\\nprimipanie. The discharges may begin early in the pregnancy,\\nbut usually occur toward the end.\\nThe treatment consists of keeping the patient as quiet as\\npossible. An anodyne may be administered should uterine\\ncontractions accompany the escape of fluid. Vaginal douches", "height": "3692", "width": "2472", "jp2-path": "obstetricsmanual00evan_0159.jp2"}, "156": {"fulltext": "156\\nare likely to do more harm than good, and should not be em-\\nployed.\\nAtrophy of the decidua: Very often the decidiia may fail\\nto develop as it should during pregnancy, tending to prolapse\\nof the ovum, and ultimately to abortion.\\nTHE FCETAL APPENDAGES.\\nThe Amnion.\\nThe amnion, like serous membranes, is liable to be the site\\nof changes of secretion and of the formation of plastic exu-\\ndates and bands of adhesion.\\nOligohydramnios, or Deficiency of the Amniotic Fluid.\\nThe cause of this condition is imknown it is usually\\nassociated with deformities of the foetus.\\nThe quantity of fluid may be so much below normal as\\nseriously to interfere with the growth of the foetus and thus\\nto cause its premature expulsion.\\nThe condition cannot be recognized before labor begins.\\nLabor is apt to be tedious, owing to the absence of the fluid\\nwedge of the bag of waters.\\nHydramnios, or Dropsy of the Amnion.\\nDefinition The conventional limit of the quantity of liquor\\namnii is given as from two to four pints. Should this be ex-\\nceeded tlie condition of hydramnios exists.\\nOccurrence In frequency it is a comparatively rare con-\\ndition, if the term be restricted to cases in which the quantity\\nof fluid is sufficiently in excess to cause symptoms. It has\\nbeen stated to occur in about 1 in every 150 to 200 cases; it\\noccurs more frequently in multigravidse and in twin preg-\\nnancies.\\nEtiology Until tlie origin of the liquor amnii has been\\nsatisfactorily explained tlie etiology of this condition must\\nremain a purely hypothetical problem. It may be due to", "height": "3708", "width": "2580", "jp2-path": "obstetricsmanual00evan_0160.jp2"}, "157": {"fulltext": "HYDRA My lOS, OR DROPSY OF THE AMNION. 157\\noversecretiou or to deficient absorption of the liquor amnii.\\nSome authorities hold that this fluid is derived from the\\nblood-current of the mother through the chorion and the\\namnion by transudation. Others consider it is produced\\nsolely by the foetus, either as an excretion from the kidney\\nand skin or by a process peculiar to the amnion.\\nSymptoms: As a rule, hydramnios does not develop before\\nthe fifth or sixth month of gestation, though it may occur as\\nearly as the tenth week. Usually the first sign to attract the\\npatient s attention is the undue enlargement of the abdomen,\\nwhich is usually out of proportion to the period of pregnancy.\\nThus at the sixtli month the uterus may reach the diaphragm.\\nThis great distention gives rise to oedema of the lower limbs,\\npalpitation of the heart, and dyspnoea. Locomotion becomes\\ndifficult, the functions of the liver or kidney may be inter-\\nfered with, and icterus or albuminuria develop sleep may\\nalso be interfered with, and the patient becomes worn and\\nhaggard.\\nOn palpation the uterus is tense, and tlie foetus, if felt, Avill\\nbe found preternaturally mobile while on auscultation the\\nheart-sounds may be feeble or inaudible.\\nDiagnosis The condition is to be differentiated from twin\\npregnancy, ascites, and ovarian cysts, as follows\\nIn twin pregnancy the enlargement of the abdomen begins\\nearlier and not abruptly at about the sixth month the preter-\\nnatural mobility of the foetus is not present. Two foetal heart-\\nsounds in different parts of the abdomen may be heard. It\\nmay be possible to palpate two foetal heads and bodies.\\nIn ascites the symptoms of pregnancy are absent, but it is\\nquite possible that both conditions may be present in the same\\ncase. On percussion a dull note is obtained in the flanks,\\nwhile the central portions of the abdomen are tympanitic. In\\nhydramnios the dulness is in the central region of the abdomen\\nwhile the flanks are tympanitic. In ascites change in the\\npatient s position alters the location of the tympanitic areas.\\nIn ascites organic disease of the heart, liver, or kidneys will\\nbe found to exist.\\nOvarian cyst is to be distinguished by the history and phys-\\nical signs the growth is more gradual and longer in develop-\\nment. Menstruation is generally present. The fluid wave is", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0161.jp2"}, "158": {"fulltext": "158 PATHOLOGY OF PREGNANCY.\\nmore pronounced. No foetal parts can be palpated. A\\nbimanual examination will permit the uterus to be differen-\\ntiated from the tumor. The enlargement of the abdomen is\\nnot, as a rule, as symmetrical as in hydramnios.\\nPrognosis For the mother this is usually favorable, but\\nprobably one-fourth of the children are born dead or non-\\nviable. The risk to the mother is increased by the tendency\\nto malposition of the chihi, by overdistention of the uterus\\nleading to changes in its structure which render hemorrhages\\nduring and subsequent to labor more frequent, and by the\\nincreased liability to collapse following the sudden escape of\\nfluid.\\nTreatment The abdomen may be supported by a properly\\nfitting abdominal binder; the patient should be kept at rest\\nas much as possible. When the distention becomes extensive\\nand serious symptoms develop then the membranes should be\\nruptured. When this is done the liquor amnii should be\\nallowed to escape slowly and precautions should be taken to\\navoid syncope. Strychnine (gr. y^-) and fl. ext. of ergot (3j)\\nshould be administered after the placenta has been delivered, to\\ninsure good uterine contraction and to avoid the risks of post-\\npartum hemorrhage.\\nOther Affections of the Amnion.\\nAmniotic bands Early in embryonal life should there not\\nbe sufficient liquor amnii present to separate the amnion\\nfrom the early formed skin of the embryo, adhesions may\\nform between the skin and the amnion. As the amniotic\\ncavity becomes distended the adhesive material becomes\\nstretched, finally forming bands of greater or less length\\nand thickness. No satisfactory theory has been advanced to\\nexplain the pathology of this condition. Braun regards the\\nadhesions as resulting from folds of amnion, inflammation of\\nthe amnion being impossible, as it contains no bloodvessels.\\nThe bands thus formed result in producing grave deform-\\nities in the fetus, such as eventration, anencephalus, amputa-\\ntion of the limbs, etc. The foetal cord may be artificially\\nshortened, or even completely severed by such amniotic\\nbands.", "height": "3712", "width": "2584", "jp2-path": "obstetricsmanual00evan_0162.jp2"}, "159": {"fulltext": "HYDATIDIFORM DEGENERATION OF CHORION. 159\\nPremature rupture of the amnion Several cases have been\\nreported where later on in pregnancy the amnion has under-\\ngone rupture and yet the integrity of the ovum has been pre-\\nserved by the chorion. The amnion in these cases is usually\\nfound rolled upon itself and forming a sort of cuif about the\\nplacental end of the cord.\\nAlterations in the character of the liquor amnii The liquor\\namnii is a clear limpid fluid in the earlier months of gesta-\\ntion later on it becomes thicker and contains small whitish\\nflakes derived from the vernix caseosa. In cases of death of\\nthe foetus with maceration, the fluid becomes much thickened,\\nof a dirty brownish or greenish color, and occasionally emits a\\nfoetid odor.\\nThe Chorion.\\nHydatidiform Degeneration of the Chorion, or Vesicular Mole.\\nOccurrence This is the only disease of this membrane\\nwhich is in any degree common.\\nIt is characterized by hypertrophy of the chorionic villi,\\nand by their conversion into cysts varying in size from that\\nof a millet seed to a hen s ^gg. These cysts are connected to\\neach other and to the base of the chorion by pedicles of\\nvarious lengths and are filled with a fluid much resembling\\nthe liquor amnii (Fig. 66).\\nPathology The degeneration of the chorion usually begins\\nnot later than the tenth week as a rule the whole membrane\\nis involved and the foetus perishes; in fact it is seldom to be\\nfound when the mole is expelled. The epithelium lining the\\nchorionic villi is the part first affected, it undergoes a marked\\nproliferation which distends each villus and thus the grape-\\nlike bodies are produced. Occasionally when the disease\\ncomes on late it may be limited to the placenta. In excep-\\ntional instances the growth may encroach on the uterine wall\\nand even penetrate the peritoneal covering.\\nEtiology Nothing definite is known as to the cause of the\\ndisease. It occurs most frequently between the ages of twenty-\\nfive and forty years.\\nVesicular mole symptoms Three symptoms are available\\nfor the diagnosis of this condition", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0163.jp2"}, "160": {"fulltext": "160\\nPATHOLOGY OF PREGNANCY.\\n(a) There usually occurs a more or less profuse serosan-\\nf/uineous discharge from the uterus resembling red currant-\\njuice. This discharge may be continuous or intermittent.\\nFig. 66.\\nX\\nVesicular mole. (Modified from Ribemoi;t-Des saigncs and Lepage.)\\n(h) A .mdden and rapid int reaHe in the size of the abdomen,\\nin which the uterine enlargement does not correspond to the\\nsup])o.sed period of gestation.\\n(c) The expulsion of cysts from the vagina. This is the only\\npathognomonic symptom and is comparatively rare. The", "height": "3712", "width": "2652", "jp2-path": "obstetricsmanual00evan_0164.jp2"}, "161": {"fulltext": "ANOMALIES OF THE PLACENTA. 161\\nuterus usually presents a doughy feel and foetal movements\\nand ballottement are absent. The condition may be confounded\\nwith placenta praevia and hydramnios.\\nPrognosis This is rarely grave for the mother, but is gen-\\nerally fatal for the child. The dangers which threaten the\\nmother are hemorrhage and septic infection.\\nVesicular mole treatment The uterus should be emptied\\nas soon as a diagnosis is established. The patient should be\\nanaesthetized, the os dilated, and the growth slowly removed,\\nthe hand only being used for this purpose. Should it be im-\\npossible completely to clear the uterus in this way, then the\\nblunt curette may be employed but it must be borne in mind\\nthat the uterine wall may be so thinned out in areas as to be\\nvery easily penetrated. This should be followed by a hot\\nuterine douche and, if uterine retraction fails, the cavity of\\nthe uterus may be packed with iodoform or plain sterilized\\ngauze.\\nAnomalies of the Placenta.\\nOf position, size, shape, and weight Normally the position\\nof the placenta is near the fundus uteri, but it may occupy\\nany position on the uterine walls (see Placenta Prcevia).\\nIn size it may vary considerably. In conditions of chronic\\ninflammation of the endometrium the placenta may be ab-\\nnormally thick and enlarged in all directions. Atrophy of\\nthe decidua or interstitial overgrowth followed by retraction\\nmay cause the placenta to be abnormally small. In this case\\nthe foetus will be found ill developed.\\nThe following varieties as to shape may be encountered\\nPlacenta membranacea The villi may persist over the\\nentire surface of the chorion and may all develop equally.\\nCrescentic, or horseshoe placenta This is a very rare form.\\nBattledore placenta In this form the cord is inserted at\\nthe margin of the placenta. Occasionally an accentuation of\\nthis form is seen, in which the vessels from the cord branch\\nout before reaching the placenta this is termed a velamentous\\ninsertion of the cord.\\nPlacentae succenturiatse Tliere may occasionally be found\\ntwo or more distinct masses of placental tissue produced by\\nthe growth of isolated patches of chorionic villi. The vessels\\n11\u00e2\u0080\u0094 Obst.", "height": "3696", "width": "2472", "jp2-path": "obstetricsmanual00evan_0165.jp2"}, "162": {"fulltext": "162 PATHOLOGY OF PREGNANCY.\\nof each patch course along the membranes to unite with those\\ngoing to the cord. In multiple pregnancies each child may\\nhave its own placenta.\\nDiseases of the Placenta.\\nCalcareous degeneration of the placenta Deposits of lime\\nsalts in the placenta are not uncommon. These deposits only\\noccur as fine sand-like particles, or as scales. They usually\\noccur at the edges, though they may be found in the substance\\nof the cotyledons and consist of amorphous phosphates\\nand carbonates of lime and magnesia. They cannot be said\\nto have any pathological significance.\\nWhite infarctions Yellowish or grayish masses of degener-\\nated placental tissue are to be found in nearly every placenta.\\nAVhen small and few in number they have no pathological\\nsignificance but if extensive, foetal death may result.\\nFatty degeneration of the placenta may occur as the result\\nof some local obstruction of blood supply to the parts affected.\\nSmall areas are commonly observed close to the margin of the\\nplacenta. If extensive degeneration occurs the function of\\nthe placenta may be interfered with and the foetus perish.\\nPlacental Apoplexy.\\nDefinition This is an effusion of blood either within or be-\\nhind the ])lacenta. If it takes place before the third month\\nthe eflPused blood may force its way between the loose attach-\\nments of the decidua and chorion and thus result in abortion,\\na very common occurrence.\\nJoncquemin described three well-marked forms of placental\\napoplexy as follows\\n{a) Tlie effusion takes place directly into one or more\\nplacental cotyledons forming here and there small soft clots.\\n(6) The effusion leads to destruction of portions of placenta\\nforming irregular cavities which are surrounded by infiltrated\\nand reddened areas.\\n(c) The effusion may occupy a number of clearly defined\\nirregular cavities of varying sizes, from millet seed to a\\npigeon s Qgg, which are not surrounded by areas of infiltra-", "height": "3712", "width": "2584", "jp2-path": "obstetricsmanual00evan_0166.jp2"}, "163": {"fulltext": "PLACENTITIS. 163\\ntion. In time these apoplectic areas lose their color, become\\ndenser, and form yellowish-white masses.\\nCauses Placental apoplexy is determined by diseased\\nstates of either the maternal or the foetal structures entering\\ninto the formation of the placenta. Most commonly the\\ncause is maternal in origin, as nephritis and albuminuria,\\nwhich produce increased arterial tension and venous con-\\ngestion. Traumatism, as a blow or kick upon the abdomen,\\nmay produce it.\\nRarely the cause lies in diseased conditions of the fcetal\\nvilli leading to rupture when the umbilical vessels are dis-\\neased, rupture of one or more of their branches may result\\nin exsanguination of the foetus and its death.\\nThe results of placental apoplexy depend on the stage of\\ngestation at which the hemorrhage occurs, the number of\\nclots formed, and the extent of placental tissue involved.\\nAfter the third month placental apoplexy but rarely results\\nin abortion or premature labor. If the effusion is large and\\nthe placenta situated low down, the blood may dissect its\\nway down to the os and escape, constituting accidental hemor-\\nrhage. Large efiPusions may result in destroying so much of\\nthe placenta that the nourishment of the foetus is impaired\\nto such an extent that it is born feeble and puny.\\nPlacental apoplexy symptoms Slight hemorrhage gives\\nrise to no symptoms large hemorrhages give rise to pain\\nand tenesmus. If these symptoms are produced, then death\\nof the foetus will probably follow.\\nTreatment consists in absolute rest and sedatives, such as\\nmorphine (gr. administered every six hours.\\nPlacentitis.\\nThis term is applied to an inflammation of the substance\\nof the placenta. The condition is rare.\\nPathological changes Some authorities contend that by\\nreason of the anatomical structure of the placenta a true in-\\nflammation cannot occur. But it is certain that a marked\\nhyperplasia of the connective-tissue cells entering into the\\nformation of the placenta does sometimes occur. This fibrous\\nchange may originate in the decidua serotina, the placental", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0167.jp2"}, "164": {"fulltext": "164 PATHOLOGY OF PREGNANCY.\\nvilli or the intervillous spaces. When the clecidua serotina\\nis affected the result is firm attachment of the placenta to the\\nuterine wall, the so-called adherent i^lacentd.\\nIn the other two forms the placenta will be found to con-\\ntain a number of firm fibrous masses. Occasionally the cen-\\ntral portions of these masses may undergo a cheesy degenera-\\ntion which appears very like pus.\\nTumors of the Placenta.\\nRarely either cystic or solid tumors of the placenta are met\\nwith.\\nSyphilis of the Placenta.\\nThe syphilitic placenta is characterized by its thickness\\nand density, while its general color is paler than normal.\\nScattered over its surface and through its substance are\\ncherry-like nodules. There are present marked fibroid de-\\ngeneration and great hypertrophy of the villi.\\nThe seat and extent of the lesions vary with the manner\\nand time of the foetal infection. It is only by a microi^coplcal\\nexamination that a placenta can safely be pronounced syph-\\nilitic.\\n(Edema of the Placenta.\\nA serous infiltration of the placenta is often observed with\\na dead and macerated foetus. Interference with the foetal\\nor placental circulation may also produce this condition.\\nAnomalies of the Umbilical Cord.\\nLength The cord may be found abnormally long, measuring\\nas much as seventy inches, or abnormally short, measuring\\nonly two to four inches. Anomalies of insertion of the cord\\nhave already been mentioned.\\nCoils The cord, if it be of unusual length, may be found\\nencircling the limbs or neck of the child. It is most fre-\\nquently coiled about the neck in extreme cases as many as\\nsix or eight coils may be present. In such cases asphyxia is\\ncommon.\\nI", "height": "3704", "width": "2604", "jp2-path": "obstetricsmanual00evan_0168.jp2"}, "165": {"fulltext": "IDIOPATHIC DISEASES, 165\\nKnots When the liquor amnii is excessive and the cord\\nunusually long it may be found to have one or two knots,\\nformed by the passage of the foetus through its loops.\\nRarely this results in the death of the foetus.\\nHernia into the cord A congenital protrusion of some of\\nthe abdominal viscera into the sheath of the umbilical cord is\\noccasionally met with. It is due to imperfect development\\nof the abdominal wall at the seat of the hernia.\\nTHE FCETUS.\\nAnomalies and Monstrosities,\\nTeratology, wliich is the science pertaining to foetal malfor-\\nmations and monstrosities, forms a special branch of pathology,\\nreference to which must be had elsewhere.\\nSuch malformations of the foetus as interfere with the\\nmechanism of labor will be discussed under the headino^ of\\ndystocia of foetal causation.\\nDISEASES OF THE FCETUS.\\nIt is probable that foetal mortality exceeds that of any\\nother period of life. It is impossible to say exactly what is\\nthe foetal death-rate, as actual statistics are wanting but that\\nit must be very high the frequency of abortion proves.\\nAVhitehead has stated that the ratio of abortions to pregnan-\\ncies is 1 to 7 while Priestly, from a study of the miscar-\\nriage-rate in the well-to-do classes, considered the ratio of\\nabortions to pregnancies as about 1 in 4J.\\nBut a few of the more important pathological conditions\\naffecting the foetus can be referred to in a limited work of\\nthis kind.\\nIdiopathic Diseases.\\nThose originating, so far as at present known, in the foetus\\nitself:\\nCongenital cystic elephantiasis This disease is characterized\\nby a great overgrowth of the subcutaneous connective tissue\\nall over the body. At intervals in the hypertrophied tissue", "height": "3712", "width": "2448", "jp2-path": "obstetricsmanual00evan_0169.jp2"}, "166": {"fulltext": "166 PATHOLOGY OF PREGNANCY.\\ncysts are present, which vary greatly in size. As malforma-\\ntions of a grave character are usually associated with this\\ndisease, the subjects of it are usually born prematurely and\\nscarcely ever survive the birth.\\nAnasarca General anasarca of the foetus is occasionally\\nseen. The condition is usually associated with collections of\\nfluid in the pleural and abdominal cavities. The subjects of\\nthis disease are usually born prematurely and seldom survive.\\nIchthyosis This disease is observed in two forms, the\\ngrave and the mild.\\nThe grave form is characterized by the existence over the\\nwhole surface of the body of horny epidermic plates, separated\\nfrom each other by fissures and furrows, and associated with\\ndeformities of the face and extremities which lead to death\\nof the infant soon after birth.\\nThe mild form is characterized by the presence of a col-\\nlodion-like substance over the whole body of the foetus which\\nlater, by a process of desquamation, forms into flakes. It is\\nusually associated with ectropion and eclabium. It does not,\\nas a rule, prove fatal, but may persist more or less throughout\\nlife, or may terminate by complete cure.\\nWith regard to the etiology but little can be said beyond\\nasserting that heredity is probably the most powerful factor.\\nTreatment: Warm baths and inunctions with weak anti-\\nseptic ointments promote separation of the scales. Perfect\\ncleanliness is necessary to prevent infection of the fissures\\nexisting in the skin.\\nRachitis That this disease occasionally occurs during in-\\ntra-uterine life is believed by many. Children have been\\nborn whose bones were still soft and easily distortable while\\nin others, in whom the disease had probably pursued a longer\\ncourse, the bones were thick and hard, and set in the de-\\nformed shapes they had acquired in utero. The presence of\\nthe disease in the foetus has been held to account for those\\nrare cases of spontaneous fracture in utero, in which there\\nhas been no history of external violence.", "height": "3704", "width": "2596", "jp2-path": "obstetricsmanual00evan_0170.jp2"}, "167": {"fulltext": "FCETAL SYPHILIS. 167\\nTransmitted Diseases.\\nThose due to diseases in the parents\\nFoetal Syphilis.\\nThis is probably the most important if not the most com-\\nmon disease of intra-uterine life. Page has reported that\\n83 per cent, of premature and stillbirths have their cause in\\nsyphilis of one or both parents.\\nInfection The ovule may be diseased before impregnation,\\nwhere the woman is a syphilitic. Infection may occur along\\nwith impregnation where the male is a syphilitic. The foetus\\nmay become infected at any, period of intra-uterine life,\\nshould the mother contract syphilis Avhile pregnant. When\\nthe infection is directly paternal in origin, the syphilitic\\npoison may be conveyed from the foetus to the mother, and\\nshe may thus develop secondary symptoms of the disease\\nwithout a primary lesion. It is undoubted that many women\\ngive birth to syphilitic offspring without themselves at any\\ntime manifesting symptoms of the disease. The likelihood\\nof development of the disease in the foetus is undoubtedly\\naifected by the period of time since the acquisition of syphilis\\nby either parent, though as yet no limit of safety has been\\ndiscovered. The author has met with a case where the dis-\\nease had remained latent in the father for twelve years. The\\nmother at no time gave evidence of syphilitic infection, yet\\nthe only child developed well-marked symptoms a few weeks\\nafter birth. Hutchinson has reported cases in which women\\nwere infected near term and gave birth to syphilitic infants.\\nManifestations of fcBtal syphilis The disease produces a\\ngreat variety of manifestations, the lesions depending upon\\nthe tissues attacked. Thus there are bullous eruptions of the\\nskin inflammations of mucous and serous membranes\\nabnormal development of connective tissue in the liver,\\nkidneys, lungs, spleen, etc and a characteristic osteitis and\\nosteochondritis. In some cases the infants are born appar-\\nently healthy and only manifest symptoms of the disease\\nwithin a few weeks of birth.\\nDiagnosis Should the foetus be born dead the diagnosis can", "height": "3712", "width": "2452", "jp2-path": "obstetricsmanual00evan_0171.jp2"}, "168": {"fulltext": "168 PATHOLOGY OF PREGNANCY.\\nbe made with certainty by a few perfectly reliable and easily\\ndetected signs.\\nThe most certain sign of foetal syphilis is to be found in the\\ncondition of the dividing line between the diaphysis and epiph-\\nysis of the long bones this line instead of being sharp\\nand regular as it is in the healthy infant, will be found to be\\njagged, broad, and of a yellow color, due to an osteochondri-\\ntis. This is known as Wagner^s sign and is determined by\\nmaking an incision over the trochanter as though for excision\\nof the head of the femur the end of the bone is then turned\\nout after cutting its ligaments, and a median section of the\\nepiphysis and diaphysis is made with a strong cartilage knife.\\nThe liver and spleen of a syphilitic infant are always\\nenlarged as a result of connective-tissue overgrowth. For a\\nmore detailed diagnosis of syphilis in the infant the reader\\nis referred to other works.\\nThe treatment of foetal syphilis consists in submitting the\\nmother to a thorough course of antisyphilitic treatment\\nthroughout pregnancy. If a history of syphilis in either\\nparent be obtained, whether occurring before or subsequent to\\nconception, the woman should receive throughout the preg-\\nnancy antisyphilitic treatment as a prophylactic measure.\\nOther Infectious Diseases.\\nA large number of cases have been collected by various\\nobservers which prove the possibility of contagious diseases\\nbeing transmitted from the mother to the foetus in utero.\\nRare cases are recorded where children have been born with\\nunmistakable evidences of variola, scarlatina, measles, ery-\\nsipelas, malaria, and typhoid.\\nAVith regard to tuberculosis Hirst states that there is a\\nremote possibility of the passage of the tubercle bacilli from\\nmother to foetus; but that it must be regarded as a very\\nexceptional occurrence.\\nFoetal Death.\\nThe death of the foetus in utero may be due to many causes.\\nAmong these may be mentioned syphilis, acute infectious dis-", "height": "3712", "width": "2604", "jp2-path": "obstetricsmanual00evan_0172.jp2"}, "169": {"fulltext": "THE VULVA AND VAGINA. 169\\neases, icterus gravidarum, malnutrition, etc. It is also caused\\nby twisting or knotting of the cord, diseased conditions of\\nthe placenta, or by trauma.\\nSequelae If death occur before the second month the\\nproduct of conception may be entirely absorbed. In the later\\nmonths of pregnancy the foetus may undergo maceration,\\nmummification or calcification. Should putrefaction of the\\ndead foetus occur, the mother may be involyed in sepsis. The\\ndead foetus is usually cast out of the uterus in a short time,\\nthough it may be retained for years.\\nPATHOLOGY OF THE PREGNANT WOMAN.\\nThe Vulva and Vagina.\\nAbnormal conditions of the vulva or yagina during preg-\\nnancy are generally due either to increased blood-supply or\\nto infection.\\nVarices Obstruction to the yenous return offered by the\\nenlarging uterus frequently results in yaricosed conditions\\nabout the yulva or yagina; these varices may be ruptured\\nby straining or by a blow or kick; severe hemorrhage may\\noccur and has proved fatal.\\nTreatment consists in protection by means of a snugly\\nfitting T-bandage, and rest in bed with the hips elevated.\\n(Edema may occur in normal pregnancy simply from pres-\\nsure of the uterus. It may result from renal insufficiency or\\nfrom labial abscess.\\nPruritus of the yulya in varying degrees is not uncommon\\nduring pregnancy. It may be caused by irritating discharges\\nor may be a neurosis.\\nTreatment: Cleanliness and tepid injections of such solu-\\ntions as the following borax, 3j to Oj acid, carbolic, 1 200\\nor zinci acetat., oSS to Oj an ointment composed of chloral\\nhydrate, camphor, aa 5ss, ung. aq. rosse, sij, may give relief.\\nIn severe cases it may be necessary to apply solutions of\\ncocaine, 4 grains to the ounce, in order to obtain any relief.\\nVaginal leucorrhoea may be very troublesome during preg-\\nnancy. In all cases where the discharge is profuse it should\\nbe examined for gonococci. Simple leucorrhoea usually yields", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0173.jp2"}, "170": {"fulltext": "170 PATHOLOGY OF PREGNANCY.\\nto mild antiseptic astringent douches which shoidd be given\\nwith great care, e.g., Condy s fluid, .^j to Oj.\\nShould gonococcl be found in the vaginal discharge the\\ntreatment should be energetic bichloride (1 2000) or perman-\\nganate of potassium (sj to Oj) douches should be given twice\\ndaily, and an occasional application to the walls of the vagina\\nand urethra of a solution of silver nitrate (gr. x-xx to 5j) will\\nprobably give good results.\\nVegetations of the vulva sometimes reach excessive size dur-\\ning pregnancy. The treatment consists in washing with liquor\\nsodse chlorinatse, afterward dusting with calomel, and keeping\\nthem perfectly dry.\\nThe Uterus.\\nThis organ may in pregnancy be displaced forward, back-\\nward, to either side, or downward.\\nRetroversion of the Gravid Uterus.\\nCausation The displacement is of frequent occurrence and\\nmay have existed before the onset of pregnancy or it may\\noccur as the result of a fall or sudden jar.\\nAnatomical results As long as the uterus is less than four\\ninches in length it may lie across the axis of the pelvis. As\\nits bulk and length increases, it becomes too large for the pel-\\nvis. If upward movement be prevented by the projecting\\npromontory incarceration occurs, and pressure symptoms\\nl)egin to develop. Incarceration usually occurs about the end\\nof the third or the beginning of the fourth month. The dis-\\ntended fundus will on examination be found to occupy the\\nhollow of the sacrum causing a bulging downward of the pos-\\nterior vaginal wall, while the cervix is pressed upward and\\nforward against the pubes, thus displacing the anterior vag-\\ninal wall and urethra. The bladder is thus displaced upward.\\nThe uterus may regain its normal position by growing upward\\nin the direction of least resistance or it may remain incar-\\ncerated and give rise to serious trouble.\\nSymptoms The earliest and most distinctive symptom is\\ndysuria, accompanied by sensations of weight and bearing-", "height": "3712", "width": "2604", "jp2-path": "obstetricsmanual00evan_0174.jp2"}, "171": {"fulltext": "TREATMENT OF RETROVERSION. 171\\ndown pains. If the condition be overlooked or neglected the\\nbladder symptoms become rapidly more marked. Retention\\nof urine from pressure on the urethra brings about overdis-\\ntention of the bladder, and a more or less severe cystitis\\nresults.\\nWhile the urinary symptoms are the most characteristic,\\nthe condition also gives rise to rectal tenesmus and obstinate\\nconstipation. OEdema of the vulva and of the uterine walls\\nmay develop from interference with the pelvic circulation.\\nThe abdomen becomes distended and vomiting may occur.\\nDiagnosis Where the retroversion is suspected the bladder\\nmust first be catheterized before making a vaginal examina-\\ntion. The condition will then be readily ascertained.\\nThe history of retention of urine and dribbling in a woman\\nwho has been pregnant for three or four months, the round\\ndoughy-feeling mass occupying the vagina, and the position\\nof the cervix make the diagnosis conclusive.\\nThe condition may be simulated by ectopic gestation, sub-\\ninvolution of the uterus, intraperitoneal hsematocele, uterine\\nfibroid, and ovarian cyst but careful examination, if neces-\\nsary, under an anaesthetic, will clear up the diagnosis.\\nTreatment of Retroversion.\\nIn mild cases the bladder having been catheterized and the\\npatient placed in the knee-chest position, the uterus can be\\nreplaced by pressure upward on the fundus in the direction\\nof one or the other sacro-iliac joints, so as to avoid the\\n])romontory, two fingers being placed in the posterior vaginal\\nfornix for this purpose. If necessary the cervix may at the\\nsame time be drawn down with a tenaculum. If the attempt\\nsucceeds, as it usually does, a large tampon should be placed\\nin the posterior vaginal fornix to retain the uterus in position.\\nThis may be replaced later by a large-sized pessary. If the\\nattempt fails, the patient should be placed under ether and a\\nsecond effort made to replace the uterus.\\nIn severe incarcerated cases there is occasionally great dif-\\nficulty in emptying the bladder. If, after drawing down the\\ncervix with a tenaculum, the catheter fails to pass, then the\\nbladder must be aspirated by suprapubic puncture. If all", "height": "3708", "width": "2456", "jp2-path": "obstetricsmanual00evan_0175.jp2"}, "172": {"fulltext": "172 PATHOLOGY OF PREGNANCY.\\nattempts at reduction fail, then abortion must be induced. If\\nthe cervix cannot be reached for this purpose then the uterine\\nwall must be punctured through the vaginal vault and the\\nliquor amnii drained away. This may make it possible to\\ndraw down the cervix, which should then be dilated and the\\nuterus emptied. Vaginal hysterectomy may be necessary in\\nrare cases where suppuration or gangrene of the uterine wall\\nhas occurred.\\nProlapse of the Gravid Uterus.\\nCausation This condition may occur in the early months\\nof pregnancy as the result of accident or from violent strain-\\ning when the vaginal walls and outlet are greatly relaxed.\\nTreatment consists in the replacement of the prolapsed\\norgan and the adjustment of a perfectly fitting pessary to\\nretain it.\\nEndocervicitis Tumors.\\nEndocervicitis This condition is frequently found during\\npregnancy. It may be the origin of a leucorrhoea and is fre-\\nquently associated with hyperemesis.\\nIt is best treated with applications of fairly strong solutions\\nof silver nitrate (gr. xx to 5j) through a cylindrical speculum.\\nThe speculum is pushed up against the cervix and the solu-\\ntion then poured in and allowed to remain in contact for at\\nleast five minutes.\\nUterine fibroids and cancer usually complicate labor more\\nthan pregnancy, and will therefore be dealt with under that\\nhead.\\nDiseases of the Breasts.\\nMammary abscess may occur during pregnancy (see Diseases\\nof Puerperal Period).\\nExcessive secretion Occasionally during the latter part of\\npregnancy the breasts secrete excessively, causing a serous\\nflow which gives rise to considerable inconvenience. Appli-*\\ncations of belladonna may afford relief.\\nEczema of the nipples may require treatment, though the\\ncondition is very obstinate.", "height": "3708", "width": "2604", "jp2-path": "obstetricsmanual00evan_0176.jp2"}, "173": {"fulltext": "PTYALISM, OB SALIVATION. 173\\nDISEASES OF THE ALIMENTARY CANAL.\\nGingivitis is an unpleasant though somewhat infrequent\\naffection of the pregnant woman. This and other conditions\\nabout to be mentioned are due, not so mucli to uncleanliness,\\nas to an alteration in the secretions of the buccal cavity con-\\nsequent upon pregnancy. The gums become spongy and soft,\\nred or violet in color at the margins, and occasionally ulcera-\\ntion occurs. Pain on eating, foul breath, and bleeding are\\nsymptoms of this condition.\\nTreatment: Sometimes gingivitis is very obstinate and in\\nspite of treatment persists through pregnancy and even lacta-\\ntion. Astringents, locally, and alkaline tonics give the best\\nresults. Special attention in the Avay of cleanliness as regards\\nthe mouth and teeth should be observed throughout preg-\\nnancy.\\nDental caries: There is a common saying among women,\\nfor every child a tooth, so frequent is caries of the teeth\\nduring pregnancy. All dental cavities should be cleaned\\nout and filled temporarily, as prolonged and ])ainful dental\\noperations are to be avoided during pregnancy. Syrup of\\nthe lactophosphate of lime in doses of 3J t. i. d. has been\\nrecommended.\\nParotitis, either unilateral or bilateral, is an infrequent com-\\nplication of pregnancy.\\nPtyalism, or Salivation.\\nOccurrence This is a not infrequent complication of preg-\\nnancy. It is generally associated with extreme nausea and\\nvomiting in highly neurotic women. It may persist through-\\nout pregnancy, beginning as early as the second month\\nsome cases lose as much as a quart of saliva a day. Ptyalin,\\nand sodium salts are diminished or may be absent from the\\nsaliva. Frequently these patients complain of pain on swal-\\nlowing; and the submaxillary and sublingual glands become\\nswollen and tender.\\nTreatment is most unsatisfactory in most cases. Copious\\nrinsing of the mouth with weak solutions of potassium chlor-\\nate, ash bark, cinchona, etc., may be employed. In the ex-", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0177.jp2"}, "174": {"fulltext": "174 PATHOLOGY OF PREGNANCY.\\nperience of the author, local measures afford but little if any\\nrelief. The (X)n(lition is a neurosis and must be treated as\\nsuch. Therefore chloral and sodium bromide in large doses\\nmay be tried atropine in doses of gr. j^q- t. i. d. may give re-\\nlief. What rarely fails to give temporary relief is morphine\\n(gr. with atropine (gr. y^-Q^), tliese administered together\\ngive better results than either alone. The latter must not\\nbe given as routine treatment, but only occasionally to permit\\nrest and sleep, while the patient should always be kept in\\nignorance of what she is given in order to guard against the\\nformation of the morphine habit. Antipyrin (gr. v, t. i. d.)\\nand small doses of cocaine hydrochlorate (gr. i, t. i. d.) have\\nproved useful in the hands of some physicians.\\nIndigestion; Constipation; Diarrhoea.\\nIndigestion Gastric indigestion is very common in the\\nearliest months of pregnancy. If careful feeding and the\\nordinary remedies fail to give relief, chloral, bromides, and\\nother nerve sedatives should be resorted to. Intestinal in-\\ndigestion may give rise to severe abdominal pains and may\\nsimulate appendicitis or even extra-uterine foetation. Pil,\\naloes et asafoetid^ and careful dieting, as a rule, give good\\nresults.\\nConstipation is very frequent in most women at all times.\\nCare should be taken to regulate the bowels by careful diet-\\ning and ordering plenty of fluids. Where this condition is\\nchronic the tablet triturate of aloin, belladonna, cascara, and\\nstrychnine will be found satisfactory; active purgation is to\\nbe avoided.\\nDiarrhoea as a complication of pregnancy is rare if persist-\\nent in spite of ordinary astringent treatment, nerve sedatives\\nwill probably give relief.\\nVomiting.\\nVomiting is one of the commonest disorders of the digestive\\ntract occurring in pregnancy.\\nIt is met with in two forms A simple, vomiting, which is\\nphysiological and pernicious vomiting, which is pathological.", "height": "3712", "width": "2636", "jp2-path": "obstetricsmanual00evan_0178.jp2"}, "175": {"fulltext": "PERNICIOUS VOMITING OF PREGNANCY. 175\\nSimple vomiting of pregnancy lias been already referred to.\\nIt is usually present during the earlier months and ceases at\\nthe end of the fifth month. AVhile causing distress and dis-\\ncomfort it does not seriously impair the nutrition of preg-\\nnant women.\\nPernicious Vomiting of Pregnancy.\\nThis, on the other hand, is a very serious condition, which\\nmay, if it resist treatment, p^ace the woman s life in jeopardy.\\nSymptoms This uncontrollable form of vomiting rarely\\nbegins abruptly, the vomiting, Avhich is at first mild, becoming\\ngradually more severe and almost constant. Ultimately ab-\\nsolutely nothing can be retained, and the patient rapidly loses\\nstrength. At first the vomited matter consists of thick mucus,\\nparticles of food, and bile later only blood- stained mucus is\\nejected, and the retching becomes more severe, e])igastric pain\\ndevelops, and there is great aversion to food. Ptyalism and\\ndiarrhoea are not infrequent at this stage. The patient rapidly\\nloses strength, becomes mentally depressed, and suffers more\\nor less constant pain.\\nIf the condition is not relieved the temperature rises and\\nthe patient develops symptoms of auto-intoxication. The\\ntemperature may range from 101\u00c2\u00b0 to 103\u00c2\u00b0 F. and the pulse\\nfrom 120 to 140; the extremities become cold and the skin\\nmoist and clammy the mouth becomes dry and the patient\\ncomplains of intense thirst; sordes appear on the teeth, the\\ntongue becomes coated with a heavy brown fur, and the\\nbreath is extremely offensive. The urine becomes scanty,\\nhigh colored and offensive, its specific gravity is high, and\\nit contains albumin and casts.\\nEmaciation advances rapidly and the patient s condition\\nsoon becomes serious in the extreme. Cerebral symptoms,\\nhallucinations, delirium, and finally coma develop shortly\\nbefore death closes the scene.\\nThe duration of the malady is two or three months, but\\nits course is subject to intermissions the cause of which is\\nhard to explain. The symptoms may disappear for several\\ndays and the patient give evidence of improvement, when\\nsuddenly they recur, only too often with increased severity.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0179.jp2"}, "176": {"fulltext": "176 PATHOLOGY OF PREGNANCY.\\nThe etiology of pernicious vomiting is very obscure. So\\nmany factors may contribute to the production of this con-\\ndition that just what is the cause in any definite case can\\nrarely be stated. Giles has pointed out that probably three\\nfactors enter into the causation of the physiological vomiting\\nof pregnancy, namely (1) exalted nerve tension; (2) periph-\\neral nervous irritation arising from the enlarging uterus and\\n(3) an easy outlet for this exalted tension, namely, the vagus.\\nBy the exaggeration of any one or two of these factors\\npernicious vomiting may be produced. Bearing these three\\nfactors in mind, the predisposing causes of pernicious vomit-\\ning may be grouped as follows\\n(a) Primiparity. In primiparse the distention of the womb\\nis accomplished with increased difficulty on account of the\\ngreater tonicity of the uterine muscular fibres.\\n(6) Preexisting disease of the uterus, as metritis or endo-\\nmetritis, or displacements of the organ.\\n(c) Disease of other pelvic structures, either preexisting or\\ncoexisting, as salpingitis, ovaritis, etc.\\n{(1) Pathological states of the alimentary canal, as gastric\\nulcer, dyspepsia, gastritis, etc.\\n(e) Too frequent sexual intercourse.\\nMental or physical shocks.\\n(j7) Toxic conditions of the blood, uraemia, saprsemia, etc.\\nRecently I have advanced the view that probably the essen-\\ntial exciting cause of the nausea and vomiting of pregnancy\\nis the physiological uterine contractions. It is well known\\nthat the uterus is subject to rhythmical contractions through-\\nout the whole period of pregnancy. The purpose of these\\ncontractions is probably the acceleration of the circulation of\\nblood through the uterine sinuses. The enormous dilatation\\nof the veins of the uterus which occurs as the result of preg-\\nnancy brings about a retardation of the blood flow through\\nthem. As the result of contraction of the uterine muscular\\nfibres these sinuses become emptied of blood and thus the\\nuterus may be said to supplement the action of the heart, to\\nwhich it may be compared, as its nervous supply is very simi-\\nlar in arrangement. The nerve supply of the uterus is chiefly\\nderived from the ovarian and hypogastric plexuses of the", "height": "3712", "width": "2628", "jp2-path": "obstetricsmanual00evan_0180.jp2"}, "177": {"fulltext": "PERNICIOUS VOMITING OF PREGNANCY. 177\\nsympathetic system, which to a limited extent have an inde-\\npendent action while in the medulla there exists a centre\\npresiding over uterine contraction. The development of the\\nembryo and its envelopes, as well as the hyperplasia of the\\nuterus and its lining, are accompanied by tremendous chemi-\\ncal changes. It is certainly from the venous sinuses at the\\nplacental site that the embryo derives its chief nourishment\\nand into which its effete material is emptied. The ordinary\\ncirculation of the blood through the sinuses to a certain extent\\nprovides for change in the supply, but owing to the retardation\\nof the blood-current from dilatation of these sinuses there\\nmust be a certain residuum, which, as it becomes surcharged\\nwdth effete material, probably acts as an irritant and stimu-\\nlates the uterus to contraction, and thus to a certain degree\\nthe organ may be said to empty itself.\\nIt is these contractions, so brought about, which probably\\nprecipitate the paroxysms of nausea and vomiting. The\\nnausea is seldom constant, but is usually rhythmical in its\\noccurrence. As has already been stated it is usually most\\nsevere in the morning when after a long fast the patient as-\\nsumes the erect position. It is probable that the occurrence\\nof the retching at this time is due to the engorgement of the\\npelvic circulation consequent on the change of posture. This\\nengorgement leads to excessive uterine contraction, and thus\\nthe peripheral irritation is increased. It is commonly noticed\\nthat if the patient partakes of food before rising nausea and\\nvomiting are not so likely to ensue. This is due no doubt to\\nthe engorgement of the pelvic veins being reduced by the\\ndetermination of blood to the stomach from the presence of\\nthe food in that viscus.\\nThe causes mentioned in the foregoing table as predisposing\\nto pernicious vomiting probably act by increasing the tendency\\nto contraction on the part of the uterus (too frequent inter-\\ncourse nervous shocks and toxic conditions) or by render-\\ning them more difficult and therefore increasing the irritation\\nthey cause (primiparity metritis, and disease of neighboring\\nstructures).\\nThe prognosis should be guarded in all cases, as the mortality\\nranges from 30 to 60 per cent, in the pernicious form.\\n12\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0181.jp2"}, "178": {"fulltext": "178 PATHOLOGY OF PREGNANCY.\\nPernicious Vomiting Treatment.\\nDietetic and hygienic The diet should be light and easily\\ndigestible before rising in the morning the patient should\\ntake a glass of iced milk or some hot clear coifee or weak\\ntea. In some cases a glass of sherry and a dry biscuit answer\\nthe purpose very well.\\nIt is a good plan to order small quantities of plain food at\\ntwo-hour intervals during the day, instead of allowing the\\npatient three regular meals. If the nausea be troublesome\\nthe patient should be kept reclining as much as possible,\\nwhen the weather permits, out in the open air. Close, warm\\nrooms and tight clothing should be avoided, and attention\\nshould be given to the condition of the bowels. When vom-\\niting occurs only in the morning such measures will enable\\nthe patient to pass the day in comparative comfort.\\nWhen vomiting takes place several times a day, some simple\\nsedative mixture should be ordered, such as the following\\nI^. Sod. brom., gr. xv\\nAq. camphorse, ^ss. M.\\nSig. t. i. d.\\nEffervescent bromocaffeine in drachm doses three or four times\\ndaily often renders good service. Iodine or carbolic acid in\\nminim doses, well diluted, may be tried.\\nPatients who do not yield to the above treatment should be\\nconfined to bed. A thorough examination should be made to\\nascertain if any of the pathological conditions above enumer-\\nated as predisposing to hyperemesis gravidarum are present,\\nand if so appropriate treatment should be inaugurated.\\nWhere nothing can be discovered to account for the con-\\ndition beyond pregnancy, the stomach should be given a\\nrest and rectal alimentation resorted to. Predigested milk\\nand eggs, nutrient broths, and beef peptonoids may be ad-\\nministered per rectum every six hours.\\nThe rectum should be washed out at least twice daily, and\\nimmediately afterward a pint of normal saline solution should\\nbe introduced by means of a catheter attached to the nozzle\\nof the syringe, high up into the bowel, in order to relieve the", "height": "3712", "width": "2652", "jp2-path": "obstetricsmanual00evan_0182.jp2"}, "179": {"fulltext": "ICTERUS. 179\\ntroublesome thirst which is usually present in these cases.\\nThe nutrient enemata should be given very slowly, and should\\nnever consist of more than five or six ounces. Twice daily\\nan enema containing chloral hydrate, (gr. xx) and sod. brom.\\n(gr. xl) in 6 ounces of milk should be given. Cold packs to\\nthe spine or the application of a spray of ether in the region\\nof the fourth or fifth dorsal vertebra may prove of benefit.\\nXearly every drug in the pharmacopoeia has been recom-\\nmended as a specific in this condition. The following have\\nbeen employed with success by many antipyrin, gr. v, t. i. d.\\ntrional, gr. xv, b. i. d. cocain, gr. hourly till five doses have\\nbeen taken ac. hydrocyanic, dil., TTLiij in carbonated w^ater\\naft^r food and vin. ipecac, in half-minim doses every hour\\nfor several doses. The application of 4 per cent, solution of\\ncocaine to the cervix has been recommended very highly. The\\napplication of solutions of nitrate of silver, gr. xx-xl to the\\nounce, after the manner recommended in the treatment of\\nendocervicitis, has many advocates.\\nCopeman first recommended digital dilatation of the cervix\\nin the treatment of this condition. Cervical dilatation is more\\nconveniently done by means of instruments, either Hegar s or\\nGoodell s but care must be taken not to rupture the mem-\\nbranes. This treatment is uncertain, and is therefore not to be\\nrecommended.\\nIn rare cases it is necessary to induce abortion in order to\\nsave the patient s life. It is a difficult question to decide just\\nwhen one is justified in terminating the pregnancy. If rectal\\nalimentation fails after a fair trial and the patient is absohitely\\nunable to retain anything on the stomach if the pulse rises\\nto 120 and prostration becomes marked, then the sooner the\\nuterus is emptied the better.\\nThis procedure should never be adopted Avithout the sup-\\nport of a competent consultant.\\nIcterus.\\nJaundice is occasionally met with in pregnancy. It may\\nresult from gastro-intestinal catarrh, from phosphorus-poison-\\ning, or from obstruction of the bile-duct due to the pressure\\nof an overdistended uterus. The development of gall-stones", "height": "3708", "width": "2460", "jp2-path": "obstetricsmanual00evan_0183.jp2"}, "180": {"fulltext": "180 PATHOLOGY OF PREGNANCY.\\nin pregnancy is of somewhat frequent occurrence. A severe\\nform, icterus gravis gravidarum^ is of very rare occurrence. It\\nis nearly always fatal, and is due to an acute degeneration of\\nthe whole hepatic structure. Acute degeneration of the liver\\nand icterus are not infrequent in eclamptic cases.\\nIcterus endangers to a high degree the life of the foetus, by\\nbringing on abortion or by the injurious action of the bile\\nsalts. Not infrequently the liquor amnii and fcetus are stained\\nby the coloring-matter of the bile.\\nTreatment In mild cases, warm alkaline baths and calomel\\nassociated with mild purgative waters are indicated. In very\\nsevere cases the induction of abortion should be considered,\\nespecially if the foetus is viable.\\nHemorrhoids.\\nThe pelvic congestion of pregnancy and the pressure of the\\ngravid uterus predispose to this troublesome affection.\\nTreatment can only be palliative. Laxatives, rest in bed,\\nand the frequent assumption of the knee- chest posture will\\nafford relief. Locally, ung. gallse cum opio, or hot sugar of\\nlead lotions, may be serviceable. Suppositories containing\\nopium (gr. and ext. hamamelidis (gr.j) may be employed\\nif the pain is severe.\\nDISEASES OF THE URINARY SYSTEM.\\nThe Bladder.\\nIrritability of the bladder is a frequent functional disorder\\nof pregnancy. It is generally relieved by the administration\\nof alkaline sedative mixtures.\\nHsematuria may occur during pregnancy, and is generally\\nassociated with vesical hemorrhoids. If severe, the bladder\\nshould be washed out daily with a weak solution of silver\\nnitrate (gr. ss-j to .Ij).\\nScanty, high-colored urine having a high specific gravity,\\nresults from indiscretion in diet, and is associated with inactiv-\\nity of the skin and bowels this condition of the urine should\\nalways receive attention. A non-nitrogenous diet, laxatives,\\nand copious draughts of water should be ordered.", "height": "3712", "width": "2644", "jp2-path": "obstetricsmanual00evan_0184.jp2"}, "181": {"fulltext": "THE KIDNEYS. 181\\nAlbuminuria is found in from 5 to 6 per cent, of pregnant\\nwomen, and is usually associated with kidney-changes due to\\npregnancy, or nephritis.\\nThe Kidneys.\\nKidney of pregnancy: There exists undoubtedly a chronic\\nform of renal disease which is dependent on pregnancy, and\\nwhich, as a rule, does not give rise to serious disturbance of the\\npatient s general health. It is usually associated with albu-\\nminuria and subsides rapidly after parturition. It is impor-\\ntant, as it predisposes to the development of the condition of\\neclampsia, in so far as it interferes with the proper function of\\nthese important excretory organs.\\nFrequency As already stated, albuminuria is present in from\\n5 to 6 per cent, of all cases of pregnancy but it is probable\\nthat a far larger proportion of cases have some degree of renal\\ninsufficiency, though albumin may not be present in the\\nurine.\\nPathology The kidneys are usually anaemic, and present\\nevidences of fatty infiltration of the epithelial cells w^ithout\\ninflammatory changes.\\nSymptoms The condition is not infrequently met with in\\nprimiparse. The symptoms usually manifest themselves in\\nthe latter half of the pregnancy, and are generally mild.\\nHeadache, pallor, weakness, and slight shortness of breath\\nare usually the only subjective manifestations. The urine is\\nlessened in quantity, is clear, and its specific gravity is re-\\nduced it contains from a quarter to one-half its bulk of\\nalbumin, and a few granular casts the albumin is mainly\\nparaglobulin. The urea daily excreted is generally below\\nthe average of health generally the lower the index of urea\\nthe more marked are the patient s symptoms. Delivery is\\nfollowed by diuresis, which is most marked from the third to\\nthe fifth day.\\nEtiology The cause of the condition is probably a diminu-\\ntion of the blood-supply due to increased intra-abdominal\\ntension and to irritation from the excess of effete substances\\ncontained in the maternal blood.\\nTreatment is as that for true nephritis.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0185.jp2"}, "182": {"fulltext": "182\\nPATHOLOGY OF PREGNANCY.\\nAcute and Chronic Nepliritis.\\nThese diseases are more prone to occur during pregnancy\\non account of the extra amount of work devolving upon the\\nkidneys at this period.\\nThe symptoms are the same as in cases not complicated by\\npregnancy.\\nDifferential diagnosis It is not always easy to differentiate\\nbetween the kidney of pregnancy and chronic nephritis but\\nthe following differential signs may prove of aid\\nHistory.\\nKidney of Pregnancy.\\nChronic Nephritis.\\nKidneys normal before\\nExisted before preg-\\npregnancy.\\nnancy.\\nQuantity of urine.\\nAbout normal or slightly\\nlessened.\\nIncreased.\\nSpecific gravity.\\nLow.\\nLow.\\nCasts.\\nFew and only with severe\\nNumerous and appear\\nsymptoms.\\nearly in pregnancy.\\nKetinitis.\\nAbsent.\\nVery often present.\\nGrave symptoms.\\nGenerally appear in later\\nMay be pronounced\\nmonths of pregnancy.\\nin early months.\\nCeases with parturition.\\nPersists after parturi-\\ntion.\\nPrognosis The possibility of complications renders the\\nprognosis for the mother doubtful, while as regards the child\\nit is decidedly grave on account of the tendency to the forma-\\ntion of placental infarctions. Premature interruption of the\\npregnancy is also of frequent occurrence.\\nTreatment As it is important to know the condition of the\\nkidneys in pregnancy, frequent examinations of the urine\\nshould be made. Should evidences of renal insufficiency\\npresent themselves, the patient should at once be placed upon\\na dietetic and hygienic regimen. Meat should be excluded,\\nand the diet consist of milk and farinaceous foods large\\ndraughts of water, preferably Poland or lithia water, should\\nbe systematically taken. The patient should be guarded\\nagainst fatigue and exposure to cold or dampness. A saline\\nlaxative should be administered two or three times a week.", "height": "3712", "width": "2636", "jp2-path": "obstetricsmanual00evan_0186.jp2"}, "183": {"fulltext": "DISEASES OF THE RESPIRATORY SYSTEM. 183\\nShould the quantity of the urine excreted not increase, and\\noedema appear, the patient should then be placed on an ex-\\nclusively milk diet and be put to bed a diuretic mixture\\nshould be ordered, such as Basham s mist, ferri et ammon.\\nacetatis, U. S. P., in 3ss doses after meals.\\nIf under tliis treatment the symptoms grow gradually\\nworse, then the termination of pregnancy is necessary. When\\nalbuminuric retinitis develops, abortion must at once be in-\\nduced if the patient s life is to be saved, hence the importance\\nof an ophthalmoscopic examination in all cases in which ob-\\nscurity of vision is a symptom.\\nDISEASES OF THE EESPIRATORY SYSTEM.\\nCough, with or without evidence of bronchial catarrh, is a\\nvery common and occasionally troublesome affection during\\npregnancy. The reflex cough of pregnancy may be very\\npersistent, and when the paroxysms are severe and continuous\\nmay lead to abortion. In its treatment antispasmodics and\\nsedatives are indicated rather than expectorants. Bromide\\nof sodium and tr. belladonnse in combination give good results,\\nas do also drachm doses of the linctus codeia.\\nDyspnoea occasionally occurs as a reflex, and may cause the\\npatient considerable distress. It is more frequent in the\\nlater months of pregnancy, when it is generally due to over-\\ndistention of the abdomen and mechanical pressure of the\\nuterus upon the diaphragm. In the former class of cases\\nsedatives are indicated while in the latter relief may be ob-\\ntained by avoiding tight clothing, and having the patient\\nsleep with the head and shoulders elevated.\\nPneumonia is a disease much to be dreaded when complicated\\nby pregnancy. The symptoms are always aggravated and the\\nmortality for both mother and foetus is high.\\nPhthisis pulmonalis Pregnancy has a most unfavorable in-\\nfluence on this disease. Rarely, patients suffering from phth-\\nisis seem to improve during pregnancy but the disease only\\nadvances the more rapidly after delivery has occurred.", "height": "3700", "width": "2456", "jp2-path": "obstetricsmanual00evan_0187.jp2"}, "184": {"fulltext": "184 PATHOLOGY OF PREGNANCY.\\nWomen already affected and predisposed to tuberculosis\\nshould be strongly advised against maternity.\\nDISEASES OF THE CIRCULATORY SYSTEM.\\nCardiac diseases in pregnancy are not rare the danger of\\nthe heart lesions is increased by pregnancy abortion is apt\\nto occur from the formation of infarctions in the placenta\\nnot infrequently the child is born badly nourished.\\nThe GompUcations to be dreaded are failure of compensation\\ndue to fatty degeneration and pulmonary congestion. If\\ncompensation is good, no untoAvard symptoms are likely to\\ndevelop, beyond oedema and albuminuria, the latter being\\ndue to renal congestion. Hirst states that with proper treat-\\nment he has no fear of heart disease in pregnancy.\\nTreatment: All women suffering from cardiac disease\\nshould be kept under constant observation throughout gesta-\\ntion. The urine should be frequently examined. Should\\nsymptoms of failure of compensation arise, digitalis and\\nstrophanthus should be exhibited, combined with strychnine\\nthe bowels should be kept open, and rest and moderate ex-\\nercise ordered.\\nHirst states that pregnancy should not be allowed to con-\\ntinue longer than the thirty-sixth week ia a woman who ex-\\nhibits any symptoms of imperfect compensation. Cardiac\\ndiseases do not contraindicate the employment of anaesthetics\\nduring labor. These benefit by preventing the injurious effects\\nof straining and by quieting the action of the heart during\\nparturition.\\nFunctional heart-murmurs in pregnancy In the later months\\nof pregnancy soft, blowing murmurs can occasionally be heard,\\nboth over the mitral and aortic areas these are usually sys-\\ntolic in rhythm, but may also be diastolic. They may be\\nexplained by the hydrsemic state of the blood in pregnancy,\\nand may in part be due to a certain amount of displacement\\nof the organ resulting from overdistention of the abdomen.\\nThey disappear completely shortly after labor.\\nThe bloodvessels Varicose conditions of the veins of the", "height": "3712", "width": "2616", "jp2-path": "obstetricsmanual00evan_0190.jp2"}, "185": {"fulltext": "NEUROSES. 185\\npelvis, abdominal walls, and lower limbs are frequent during\\npregnancy. They result in part from changes in the vessels\\nthemselves, and in part from the mechanical obstruction to\\nthe circulation offered by the increasing bulk of the uterus.\\nTreatment consists of elastic support where this is possible,\\nand in the avoidance of constipation.\\nEnlargement of the thyroid gland The fact that there exists\\na peculiar relationship between the thyroid gland and the\\nuterus and general circulation is well known. Usually a\\nsympathetic growth of this gland occurs at the same time as\\nenlargement of the uterus hence the fulness of the neck so\\noften noticed in pregnant women. Thus in simple and in\\nexophthalmic goitre pregnancy exerts a very unfavorable\\ninfluence. The growtli of the gland may progress to such a\\ndegree as to cause pressure upon the trachea resulting in dysp-\\nnoea, and even threatening maternal death from asphyxia. In\\nrare cases tracheotomy has been resorted to in order to save\\nthe patient^s life.\\nDISEASES OF THE NERVOUS SYSTEM.\\nNeuralgia in various portions of the body is a frequent af-\\nfection of the pregnant woman. The most common situations\\nare the head, hands, face, teeth, and breasts. Pelvic neuralgia\\nis usually due to pressure of the growing uterus upon the\\npelvic nerves occasionally neuralgia occurs in the uterus.\\nIn the treatment of these troublesome neuralgias, tonics con-\\ntaining iron, quinine, and arsenic are particularly valuable.\\nAttention should always be paid to the matter of diet, sleep,\\nand the state of the emunctories in these cases. Any of the\\ncoal-tar derivatives, combined with the citrate of caffeine to\\nprevent depression, usually promptly relieve the severe pain.\\nAll sources of local irritation should be sought for and re-\\nmoved.\\nNeuroses.\\nChorea Mild grades of chorea cannot be said to be uncom-\\nmon in pregnancy. Chorea is more common in primiparse.", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0191.jp2"}, "186": {"fulltext": "186 PATHOLOGY OF PREGNANCY.\\nRheumatism, chlorosis, heredity, and the previous occurrence\\nof the disease in childhood are considered as predisposing\\ncauses. It usually appears early in pregnancy and is apt to\\npersist throughout its course. As a rule, in the milder cases\\nit does not manifest itself during sleep. In the grave form\\nit may result in the patient s death, after causing premature\\nexpulsion of the ovum.\\nThe treatment is the same as when not complicated by preg-\\nnancy.\\nEpilepsy is a rare complication of pregnancy. It does not,\\nas a rule, exert an unfavorable influence upon the course of\\ngestation, and it can usually be controlled by the free admin-\\nistration of potassium iodide.\\nHysteria is frequent during pregnancy.\\nVomiting and coughing occur as neuroses during pregnancy,\\nand have already been referred to.\\nPsychical disturbances Not uncommonly a complete change\\nin the disposition and mental character of the woman may\\noccur during pregnancy.\\nInsomnia may be troublesome toward the close of pregnancy.\\nA warm bath on retiring, a glass of milk, or a cup of warm\\nbroth, taken at the same hour, may be sufficient to induce\\nsleep; sulphonal or trional in 10- to 15-grain doses may be\\nresorted to if required.\\nInsanity is of but rare occurrence during gestation, being\\nmuch more likely to develop during the puerperal period.\\nMelancholia and mania are the more usual forms, the former\\nbeing more frequent.\\nThe prognosis in the maniacal form is more grave than in\\nthe melancholic. Insanity may recur in successive preg-\\nnancies. It may be stated that gravidity exerts usually an\\nunfavorable influence upon insanity.\\nThe treatment can only be expectant and symptomatic in-\\nduction of labor, when marked symptoms have developed, only\\ntends to aggravate the condition.\\nTemporary delirium may occur during labor, and is far from\\ncommon. A woman rendered delirious from acute suffering\\nin labor may do serious injury to her child, for which she\\ncannot be held responsible.", "height": "3728", "width": "2588", "jp2-path": "obstetricsmanual00evan_0192.jp2"}, "187": {"fulltext": "INFECTIOUS DISEASES. 187\\nDISEASES OF THE CUTANEOUS SYSTEM.\\nHerpes gestationis is a peculiar neurotic skin aiFection usu-\\nally met ^vith in early pregnancy. It generally persists\\nthroughout gestation in spite of treatment. The eruption is\\nmultiform, exhibiting erythema vesicles and bullae. Its treat-\\nment consists in the administration of nerve sedatives and the\\nregulation of the diet and mode of life of the patient.\\nImpetigo herpetiformis is rare. It usually occurs toward the\\nclose of pregnancy. It generally locates itself in the folds\\nof the body around the groins, the umbilicus and axillae, and\\nunder the mammae. It occurs as small pustules forming\\ncrusts it tends to spread rapidly and may cover the whole\\nbody. It is generally accompanied by marked symptoms of\\nsystemic disturbance, high fever, chills, vomiting, and severe\\nprostration. Hirst states that of twelve cases ten terminated\\nfatally. The disease did not terminate gestation prior to the\\nmaternal death.\\nThe treatment is symptomatic, with the application of sooth-\\ning remedies locally.\\nPruritus is usually a local aifection limited to the vulva\\nbut it may occur as a general affection. It may cause intense\\nsuffering to the patient, and cases have been reported in which\\nit was necessary to induce labor in order to relieve the patient.\\nTreatment consists in alkaline baths (5 ounces of bicarbonate\\nof sodium to the bath), and frictions with sedative lotions, as\\nthe camphor or chloroform liniment. Usually this treatment\\nmust be combined with the internal administration of chloral\\nand bromide.\\nExaggerated pigmentation Dark spots of pigmentation may\\nappear on the breasts, thighs, and abdomen, and occasionally\\non the face. The condition is not amenable to treatment, and\\nusually disappears shortly after labor.\\nInfectious Diseases.\\nCertain of the infectious diseases are more prone to attack\\nthe pregnant woman than are others.\\nVariola is probably the most virulent of the infectious dis-\\neases attacking the pregnant woman. It generally results\\nspeedily in both foetal and maternal death.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0193.jp2"}, "188": {"fulltext": "188 PATHOLOGY OF PREGNANCY.\\nScarlatina is apt to be exceedingly virulent, but it is more\\nprone to attack the puerperal woman.\\nMeasles in the pregnant woman usually assumes a severe\\ntype and generally leads to abortion. The patient exhibits a\\nmarked tendency to develop pneumonia as a complication.\\nTyphoid fever does not, as a rule, tend to assume an unusually\\nsevere type when it attacks the pregnant woman. The pro-\\nlonged elevation of temperature tends to bring about abortion.\\nTOXAEMIA\u00e2\u0080\u0094 ECLAMPSIA.\\nDefinition Eclampsia is a disorder of pregnancy character-\\nized by epileptiform convulsions, and depending upon the\\nretention within the body of toxins. The term is derived\\nfrom the Greek ixXa/Kft^, a shining forth. The convulsive\\nseizures may occur during pregnancy, labor, or the puerperal\\nperiod, though they are most frequently associated with labor.\\nFrequency It occurs about once in 300 cases of pregnancy.\\nIt is more frequently met with in primiparse, especially in\\nthose illegitimately pregnant and in those over thirty years\\nof age. In multigravidse it is more commonly associated with\\nmultiple pregnancy, and with exposure to dampness and cold\\nin women of the poorer classes who are underfed and over-\\nworked. Women who are deficient in action of the skin, kid-\\nneys, and bowels are good subjects for eclampsia should they\\nbecome pregnant.\\nEclampsia\u00e2\u0080\u0094 Symptoms.\\nPremonitory symptoms usually manifest themselves some\\ntime before the eclamptic convulsion. These are a condi-\\ntion of irritability and heaviness frontal headache dis-\\nordered vision and diminished secretion of urine. Occa-\\nsionally fedema of the face and limbs is present and not\\ninfrequently more or less severe epigastric pain. The general\\nvascular tension is usually markedly increased. Rarely\\neclampsia occurs without any premonitory symptoms.\\nThe urine is diminished in quantity to from one-half to one-\\nthird the average in health. The specific gravity is very high,\\nfrom 1030 to 1045 in rare cases it may be lower than nor-\\nmal, 1010 and the quantity of urine undiminished.\\nI", "height": "3712", "width": "2600", "jp2-path": "obstetricsmanual00evan_0194.jp2"}, "189": {"fulltext": "ECLAMPSIA. 189\\nAlbumin is, as a rule, present in the urine in very large\\nquantities, though it may in rare cases be absent. The albu-\\nminous precipitate is composed of serum-albumin and para-\\nglobulin. The presence of large quantities of serum-albumin\\nin the urine indicates very extensive damage to the renal cells,\\nin which case the prognosis is rendered more serious.\\nTo distinguish the relative amounts of the two kinds of\\nalbumin, the urine must first be saturated with magnesium\\nsulphate to precipitate the paraglobulin. After filtering, the\\nfiltrate may be tested for serum-albumin by the nitric-acid or\\nheat test. The precipitate obtained from the filtrate may\\nthen be compared with that thrown down by heat or nitric\\nacid in a specimen which has not been saturated wdth magne-\\nsium sulphate, and the difference noted.\\nUrea is, as a rule, largely diminished, not only in quantity,\\nbut also in percentage.\\nCasts may or may not be found in the urine.\\nLeucin and tyrosin, if sought for, will usually be found in\\nthe urine of eclamptics.\\nThe eclamptic fit usually begins with a fixed expression of\\nthe eyes, the head being turned to one side the eyelids twitch\\nrapidly, the pupils contract, and the eyeballs roll. The spasm\\nof the muscles then spreads rapidly, the mouth is drawn to\\none side, the jaws clench, often causing severe injury to the\\ntongue, which may be caught between the teeth the head is\\nrolled rapidly from side to side and then drawn back as the\\nmuscles of the trunk and limbs become affected the whole\\nbody is thrown into a condition of tonic spasm. As respira-\\ntion is interfered with the face becomes livid and bloody froth\\nissues from the mouth.\\nThis condition is rapidly succeeded by a series of clonic\\nspasms in which all the muscles are thrown into violent con-\\ntractions, causing quick jerking movements of the limbs and\\nhead. In severe cases the woman may be thrown into a posi-\\ntion of opisthotonos.\\nConsciousness is lost during the attack and the patient\\nusually remains in a condition of coma, breathing stertorously,\\nfor some time after.\\nThe duration of the fit is seldom longer than a minute,\\nwhile the coma lasts a variable time, from a few minutes to", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0195.jp2"}, "190": {"fulltext": "190 PATHOLOGY OF PREGNANCY.\\nseveral hours. The paroxysms are repeated at varying inter-\\nvals, in which the patient may regain consciousness. In some\\ncases the patient remains in a condition of coma, with or with-\\nout restlessness. Sometimes restlessness precedes another\\nparoxysm. As many as 160 fits have been counted in one\\ncase.\\nCourse and Terminations.\\nEclampsia ends in recovery or death in from thirty-six to\\nforty-eight hours.\\nDeath may occur from oedema of the brain, of the lungs or\\nof the larynx, asphyxia, exhaustion, or heart-failure. An\\noverwhelming accumulation of the toxins in the system may\\ncause the coma to grow deeper and deeper, with or without\\nthe cessation of fits. Not infrequently the temperature\\nsteadily rises, and the patient dies with hyperpyrexia.\\nRecovery takes place in about two-thirds of all cases under\\nproper treatment. The fits cease, the secretion of the urine\\nincreases, and the coma fades gradually, though mental con-\\nfusion often persists for some time. The bowels and skin\\nbecome active. In some cases a condition of puerperal in-\\nsanity may complicate the recovery but when it occurs it\\nis generally mild and passes off in a few days.\\nEtiology.\\nWhile we do not know the cause of eclampsia, the present\\nview most generally accepted is that it is the result of a\\ntoxaBmia, originating in the bodies of the mother and of the\\nfoetus. The urine of a healthy individual is highly charged\\nwith toxic materials. Bouchard has isolated from the urine\\ntwo substances which produce convulsions, and one which\\nproduces coma. The urine of the albuminuric patient has\\nbeen proved to be much less toxic than in the normal state\\nwhile the urine of the eclamptic is scarcely toxic at all.\\nIn the eclamptic there is a diminution of the urinary\\nsecretion combined with this is an absence of toxicity of the\\nurine and an arrest of elimination of the toxins. Coinciding\\nwith the disappearance of the toxicity of the urine there are an\\narrest of elimination of and an accumulation of toxins in the", "height": "3712", "width": "2592", "jp2-path": "obstetricsmanual00evan_0196.jp2"}, "191": {"fulltext": "PATHOLOGICAL ANATOMY OF ECLAMPSLL 191\\nblood. That the toxins are retained in the blood has been\\nproved by an examination of the blood-serum of eclamptics.\\nIt has been found that in these cases the toxicity of the blood-\\nserum is in inverse proportion to the toxicity of the urine.\\nAs to the formation of these toxins but little is known. It\\nis supposed by some that they originate chiefly from the pres-\\nence of the foetus in the uterus but the most generally\\naccepted view is that they originate from the decomposition\\nof food within the bowel. The liver probably plays an im-\\nportant part in the destruction of the toxins, while the kid-\\nneys and skin are charged with their elimination.\\nIt is a well-known fact that the pregnant woman rarely ex-\\ncretes a normal amount of urea. Urea is the most powerful\\ndiuretic known, and it is probable that its function is to\\nstimulate the kidneys to the elimination of the toxins.\\nHence when the urea is diminished the kidneys are deprived\\nof their stimulus to the excretion of these poisons.\\nThe effect of the efforts of the liver and the kidneys to\\nbreak up and eliminate the toxins is to bring about certain\\nchanges in their structure which explain the presence of\\nalbumin, as well as of leucin and ty rosin, in the urine.\\nPathological Anatomy of Eclampsia.\\nThe kidneys In most cases in which necropsies have permit-\\nted the examination of the kidneys, these organs presented\\nmacroscopic evidences of either acute or chronic nephritis.\\nIn some cases the kidneys have appeared perfectly healthy.\\nBut in all cases in which the kidneys have been microscopically\\nexamined, certain changes in the structure have been found\\nwhich are not those of inflammation, but rather of degenera-\\ntion, and very similar to those changes associated with blood-\\npoisoning.\\nThis degeneration seems to be of a colloid nature, and is\\nusually most marked in the epithelial cells of the tubules of\\nthe cortex. To the naked eye, kidneys whicli have under-\\ngone this degeneration have very much the appearance of\\nparenchymatous nephritis, and it is only h\\\\ means of the\\nmicroscope that the true character of the change present can\\nbe made out.", "height": "3708", "width": "2484", "jp2-path": "obstetricsmanual00evan_0197.jp2"}, "192": {"fulltext": "192 PATHOLOGY OF PREGNANCY.\\nThus in eclampsia the lesion present in the kidneys is not\\nnephritis, but an acute degeneration due to toxins in the blood.\\nThe liver Hemorrhages into the substance of the liver are\\nthe most marked change to be noted in these cases. They\\noccur as dark-red stains or blotches, and may be very ex-\\ntensive or so slight as only to be revealed by the microscope.\\nBetween the sites of the hemorrhages the liver-cells show\\neither fatty degeneration or actual necrosis. These changes\\ncan only result from severe contamination of the blood.\\nThe spleen presents, as a rule, very much the same changes\\nas those found in the liver.\\nThe lungs and brain usually show certain changes, which\\nprobably result chiefly from the convulsions.\\nDiagnosis.\\nEclampsia has to be distinguished from convulsions due to\\nepilepsy, hysteria, and organic brain disease. The distinction\\nmay be made by an examination of the urine.\\nPrognosis of Eclampsia.\\nMaternal mortality is about 30 per cent., while the foetal\\nmortality is about 50 per cent. The earlier in pregnancy the\\neclamptic condition occurs the worse is the prognosis.\\nPrognosis is favorable- when\\nThe attacks are infrequent and mild\\nThe patient regains consciousness between the attacks\\nThe skin, bowels, and kidneys can be stimulated to func-\\ntionate freely.\\nPrognosis is unfavorable when\\nThe attacks become progressively more severe in spite of\\ntreatment\\nThe urine is completely suppressed, and purgation cannot\\nbe induced.\\nTreatment.\\nThe prophylactic treatment of eclampsia consists in the\\nfrequent examination of the urine, with special regard to the\\nquantity secreted, the percentage of urea and of albumin,\\nand the presence and character of sediment.", "height": "3712", "width": "2604", "jp2-path": "obstetricsmanual00evan_0198.jp2"}, "193": {"fulltext": "TREATMENT OF ECLAMPSIA. 193\\nThe bowels and shin should be kept active by the internal\\nand external use of Avater, and mild laxatives should be\\nemployed regularly if required.\\nThe patient should be ordered a readily oxidized and non-\\nconstipating diet, and outdoor exercise in moderation, and\\ndirected to avoid exposure to cold and dampness.\\nMedical treatment Should the urea present in the urine\\nfall to 1.5 per cent., then treatment should be inaugurated, as\\nthis indicates renal inadequacy.\\nThe nitrogenous diet should be reduced by placing the\\npatient on a diet of milk, fish, and white meats. Elimination\\nof the toxins by stimulating the action of the bowels, skin,\\nand kidneys is the object of treatment. This object can be\\nobtained by the regular use of a pill of aloes and colocynth,\\ngr. V. at bedtime, warm baths two or three times a week, and\\nthe free use of drinking-water. The occasional employment\\nof a dose consisting of calomel and soda, da gr. x, will be\\nfound to stimulate the action of the liver.\\nWhen this treatment fails to improve matters, the patient\\nshould be put to bed, and the diet limited to milk as far as\\npossible. The eliminative treatment already suggested may be\\nreinforced by the daily lavage of the colon with at least two\\ngallons of normal salt solution at a temperature of 100\u00c2\u00b0 F.\\nThe pill of aloes and colocynth may be replaced by Epsom\\nor Rochelle salts in these more serious cases.\\nThe kidneys being already overtaxed, the employment of\\nstimulating diuretics should be avoided.\\nDuring the eclamptic attack the following scheme of treat-\\nment offers the best chance of success in the author s opinion\\nDuring the convulsion administer chloroform, and also when-\\never for any reason the patient is to be disturbed, should it be\\nfound that such disturbance tends to precipitate a convulsion.\\nThen inject hypodermically ext. veratr. viridis (tllxv) and\\ngive an enema containing chloral hydrate (3J in four ounces\\nof water), and place two drops of croton oil on the back of the\\ntongue. Have the patient s clothing entirely removed, and\\nenvelop her body in blankets wrung out of hot water, covering\\nthese with several dry ones. Then inject into the colon by\\nmeans of a large-sized catheter attached to a fountain-syringe\\nseveral quarts of warm saline solution. Where possible a\\n13\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0199.jp2"}, "194": {"fulltext": "194 PATHOLOGY OF PREGNANCY.\\npint or more of sterile saline solution should also be injected\\nunder the breasts, using a large exploratory needle for this\\npurpose.\\nShould the convulsions recur and the patient be a full-\\nblooded, strong woman, a pint or more of blood may be\\ndrawn by opening one or more of the large veins of the arm.\\nThe veratrum, in TlXv doses, may be injected at short intervals\\ntill the pulse is reduced to 70 per minute. The chloral enema\\nshould be repeated every four hours, provided the condition\\nof the pulse is satisfactory. As soon as the patient can swallow,\\ndessertspoonful doses of a concentrated solution of Epsom\\nsalt may be administered every fifteen minutes till the bowels\\nare acting freely. The hot packs should be renewed suf-\\nficiently often to keep up free diaphoresis.\\nThe obstetrical treatment When should pregnancy be ter-\\nminated in those cases in which eclampsia is threatened\\nWhen, in spite of active treatment, the patient s condition\\ngets steadily worse, or where improvement is only transient\\nand relapses occur, the only safe course is to terminate the\\npregnancy.\\nAYhea eclampsia occurs during parturition interference\\nwith the progress of labor should be avoided until the os\\nis fairly well dilated. Accouchement force is to be con-\\ndemned, except in very rare instances. The convulsions must\\nfirst be combated, and as a rule labor comes on spontaneously.\\nIt may be terminated by forceps in order to prevent its undue\\nprolongation, as soon as the os is moderately dilated, the\\npatient always being deeply anaesthetized for this purpose.\\nThe after-treatment consists in keeping up free action of\\nthe emunctories. Daily doses of Epsom salt should be given.\\nThe patient should be encouraged to drink large quantities of\\ncream of tartar water, 3J to the pint. The diet should be\\nlimited to milk until the kidney condition has improved.\\nHeart tonics may be required, and none is better than strych-\\nnine in full doses.\\nABORTION AND PREMATURE LABOR.\\nDefinition Abortion is the term used to denote the expul-\\nsion of the ovum up to the end of the third month of preg-", "height": "3712", "width": "2612", "jp2-path": "obstetricsmanual00evan_0200.jp2"}, "195": {"fulltext": "SY3IPT0MS OF ABOBTTON. 195\\nnancy. Premature labor signifies the birth of a viable foetus\\nwhile the term miscarriage is usually applied to the expulsion\\nof the ovum between the fourth and sixth months of preg-\\nnancy.\\nFrequency It is impossible to estimate correctly the fre-\\nquency of abortion but it is probable that the proportion of\\nabortions is about one in every three or four pregnancies.\\nSymptoms.\\nThe cardinal symptoms of abortion are, pain, hemor^rhage,\\nand the expulsion of the ovum. The pain is due to uterine\\ncontractions and the hemorrhage results from the separation\\nof the ovum from its uterine attachments.\\nIn some cases the hemorrhage is the first symptom, the pain\\nfollowing after the ovum has been converted into a foreign\\nbody by the blood having caused a separation of the mem-\\nbranes from the decidua.\\nIn other cases the pains precede the hemorrhage in this\\ninstance the abortion is more prolonged, as a result of the\\nslow^ separation of the membranes. It is in this class of cases\\nthat preventive treatment is more likely to be successful.\\nAbortion may take place suddenly or it may last over\\nseveral days.\\nAbortion occurring at or before the eighth week partakes\\nof the character of a painful and rather profuse menstruation.\\nSuch it is often supposed to be by the patient. In some cases\\nthe uterine colic may be so severe as to cause vomiting or ner-\\nvous chills the ovum usually passes unnoticed with blood-\\nclots. On bimanual examination the uterus Avill be found\\nenlarged and the os more or less patulous. When the abor-\\ntion is not complete fragments of the ovum may be felt within\\nthe cervix.\\nAt the third month, which is the most common period for\\nabortion, the process generally occurs in two stages first, the\\nexpulsion of the foetus and second, the expulsion of the\\nnewly formed placenta and membranes. The process is more\\nprolonged and more painful than in the earlier months. In\\nsome cases, especially when the foetus has been dead for some\\ntime, the placenta and membranes may soon follow its expul-", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0201.jp2"}, "196": {"fulltext": "196 PATHOLOGY OF PREGNANCY.\\nsioii. Should the placenta remain adherent, the cervix may\\nclose again, though the pains and hemorrhage may continue.\\nAs the placenta is softer and more attached to the uterus than\\nit is later, it is more apt to come away piecemeal hence por-\\ntions may be retained for days, weeks, or even months, and\\ngive rise to a varied train of symptoms.\\nAbortion after the fourth month gives rise to the clinical\\nphenomena of a miniature labor.\\nPathology of Abortion.\\nAs the result of uterine contractions, or from degeneration\\nof the vessels, blood is effused from the ruptured vessels into\\nthe decidua vera, and forces its way between the decidua and\\nchorion, stripping oiF the ovum, which is then expelled entire.\\nIf the ovum be floated in water, it presents very much the\\nappearance of a chestnut-burr.\\nOccasionally the decidua is cast off entire along with the\\novum, which it completely envelops.\\nOccasionally also blood is extravasated into the membranes,\\nat intervals. This coagulates in strata, and leads to the for-\\nmation of what is known as a blood-mole.\\nIn some cases the abortion may not be completed for some\\ntime, and the coloring-matter of the eifused blood may be\\nabsorbed, while the strata undergo partial organization and a\\nfleshy mole results. This may form a connection with the\\nuterine wall, and be retained indefinitely^\\nIn those cases in which portions of placenta are retained\\nthese masses may form polypi, remaining in the uterus for\\nweeks or months, causing a fetid discharge and an elevation\\nof temperature.\\nEtiology.\\nThe causes of abortion may be divided into those of paternal,\\nof maternal, or of fcetal origin.\\nPaternal Syphilis is probably the most common paternal\\ninfluence in causing abortion. Other causes which may be\\nmentioned under this heading are alcoholism, debility, tuber-\\nculosis, lead-poisoning, advanced age, and excessive venery.\\nMaternal: General: Similar causes to those mentioned in\\nthe father act in the mother.", "height": "3712", "width": "2616", "jp2-path": "obstetricsmanual00evan_0202.jp2"}, "197": {"fulltext": "DIAGNOSIS OF ABORTION. 197\\nAcute and chronic diseases cause abortion by excess of tem-\\nperature, or by blood-changes, or by producing alterations in\\nthe placenta. Traumatism and severe emotional disturbances\\nmay produce abortion. Certain drugs, as quinine, savin, ergot,\\nand a host of others, are said to cause abortion but it is\\ndoubtful if this is the case when the uterus is in a normal\\ncondition.\\nLocal Displacements of the uterus, pelvic inflammations\\nor adhesions, cervical lacerations, endometritis, metritis, fibro-\\nmyomata, and abnormal development of the uterus may be\\nmentioned as conditions which predispose to abortion.\\nThere are women who abort constantly in whom no reason-\\nable cause can be found to this condition the term habitual\\nabortion is applied.\\nFcetal Sypliilis, which acts by producing changes in the\\novum or in the placenta, leading to the death of the foetus, is\\nprobably the most common foetal cause of abortion.\\nDegeneration of the chorion, hydramnios, and vicious inser-\\ntion of the placenta frequently result in abortion.\\nDiagnosis.\\nIn cases of suspected abortion it is necessary to determine\\nthe existence of pregnancy. The abortion may be threatened;\\ninevitable or wholly, or partially accomplished.\\nThreatened abortion If the patient has been exposed to\\nthe possibility of impregnation and the menses have been sup-\\npressed if a hemorrhage from the uterus occur, associated\\nAvith more or less pain then it is probable that an abortion is\\nthreatened.\\nDysmenorrhoea may be mistaken for impending abortion\\nbut in this case the .cervix is closed and firm to the feel.\\nHemorrhage, associated with the presence of a soft polypoid\\ntumor in the uterus, may simulate the condition of threat-\\nened abortion very closely but a careful local examination\\nwill generally establish the nature of the condition present.\\nInevitable abortion AYhen the membranes have ruptured, or\\nthe foetus is dead, or when any foetal part is engaged in the cer-\\nvix, the abortion may be said to be inevitable. Cases have\\noccurred in which large portions of decidua have escaped from", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0203.jp2"}, "198": {"fulltext": "198 PATHOLOGY OF PREGNANCY.\\nthe uterus, associated with considerable hemorrhage, and yet\\nhave afterward gone on to full term. Again the os may\\nopen sufficiently to admit the finger, yet close again, and the\\npregnancy continue. It is, therefore, sometimes a difficult\\nmatter to say that an abortion is inevitable.\\nComplete, or partial, abortion It is important always to de-\\ntermine whether a part of, or the whole uterine contents have\\nbeen expelled. To make a diagnosis, everything discharged\\nfrom the uterus must be carefully examined when any doubt\\nremains a digital exploration of the uterine cavity must be\\nmade when anything is retained, the cervix usually remains\\npatulous so that the finger can be inserted without much dif-\\nficulty.\\nIn cases of complete abortion in the first two months of\\npregnancy there is functionally no lochial discharge. Should\\nthe hemorrhage continue it is probable that portions of the\\ndecidua have been retained.\\nIn incomplete abortions at the third month, or later, the\\nlochial discharge remains free and bloody, instead of gradually\\nsubsiding, as it should when the uterus has been emptied and\\nis involuting properly.\\nPrognosis.\\nThe prognosis of abortion depends upon the treatment.\\nIf the uterus has been carefully emptied under aseptic pre-\\ncautions, then the mortality from abortion should be nil.\\nRetained masses of decidua or of placenta are followed by\\ndecomposition of these substances in utero, and acute or\\nchronic septic infection is the result.\\nHemorrhage very rarely leads to a fatal result in cases of\\nabortion.\\nWhen neglected, abortion may be the starting-point of vari-\\nous uterine diseases, as subinvolution, metritis, etc., which\\nmay lead to invalidism.\\nTreatment of Abortion.\\nProphylactic When any of the conditions are present which\\nmay tend to premature expulsion of the ovum, all precautions", "height": "3712", "width": "2656", "jp2-path": "obstetricsmanual00evan_0204.jp2"}, "199": {"fulltext": "TREATMENT OF ABORTION. 199\\nmust be taken to prevent such an accident. Appropriate\\nsystemic treatment should be undertaken when indicated, and\\nat the same time the patient should be instructed to observe\\nspecial precautions, such as the avoidance of overexertion\\nby lifting or reaching, particularly at the menstrual periods.\\nI he use of strong purgatives should be avoided. At each\\nmenstrual epoch the patient should remain in bed for several\\ndays. Abnormal uterine conditions, such as displacements,\\nmetritis, and lacerations of cervix, should receive appropriate\\ntreatment. Sexual intercourse should be avoided, especially\\nat or about the menstrual epochs.\\nThreatened abortion The main principle of treatment is to\\nsecure for the patient absolute rest, mental and physical.\\nThis is obtained by putting her to bed, in a cool, darkened\\nroom, where she can be kept in absolute quietness and by\\nthe free use of opium, bromide, and chloral.\\nOpium is best administered by the rectum. A suppository\\ncontaining opium, gr. ss, should be gently inserted every eight\\nhours, or at least sufficiently often to keep the patient well\\nunder the influence of the drug. At the same time a m.ixture\\ncontaining sodium bromide, gr. xxx, and chloral hydrate, gr.\\nXV, may be given three times daily. Many prefer the fluid\\nextract of viburnum prunifolium in drachm doses, t. i. d.,\\ninstead of the bromide and chloral mixture.\\nInevitable abortion Two methods of treatment are avail-\\nable, the expectant and the active\\nThe expectant treatment Should the bleeding be severe\\nbefore the os is dilated, it must be controlled by means of a\\nvaginal tampon of sterile or iodoform gauze. To apply va-\\nginal tamponage properly the patient should be placed in the\\nleft semiprone position, with the hips resting on a rubber\\nsheet or Kelly pad at the edge of the bed. The vulva and\\nvagina should then be washed Avith spirits of green soap and\\nhot water, and then swabbed with a 1 500 formalin solution.\\nIf the vulvar hair is long, it should be clipped. The only\\ninstruments required are a Sims speculum, a pair of uterine\\nforceps, and a pair of scissors, which may be sterilized while\\nthe patient is being prepared.\\nThe speculum is then inserted and the perineum retracted\\nso as to expose the cervix to view. A strip of gauze (sterile", "height": "3704", "width": "2460", "jp2-path": "obstetricsmanual00evan_0205.jp2"}, "200": {"fulltext": "200 PATHOLOGY OF PREGNANCY,\\nor iodoform), about two inches wide and a yard long, is then\\nseized above by means of the uterine forceps and packed\\nfirmly around the cervix. As the gauze is being inserted the\\nspecuhim is gradually withdrawn. A sufficient quantity of\\ngauze should be introduced to distend the vagina. The\\npatient is then made comfortable, and should remain in bed.\\nTo facilitate the emptying of the uterus, the fluid extract of\\nergot may be administered in half-drachm doses three times\\ndaily. If the uterine contractions are painful, an opiate may\\nbe combined with the ergot. The vaginal tampon should be\\nremoved in twenty-four hours, and replaced by a fresh one if\\nnecessary. A close watch should be kept over the patient s\\ntemperature. Often when the first tampon is removed the\\novum comes with it, or the cervix will be found softened and\\nthe OS sufficiently dilated to permit the introduction of the\\nfinger, with which the ovum may be extracted. If the ovum\\nrupture and a part be retained in the uterus, the woman\\nmust be kept in bed, the ergot continued, and the vagina\\ndaily douched with a solution of formalin, 1 500. In many\\ncases this treatment will be sufficient but in spite of every\\nprecaution the discharges may become foul and the tenipera-\\nture rise, in which case the uterine cavity must be thoroughly\\ncuretted.\\nActive treatment This is the treatment to be recommended,\\nin preference to the expectant plan, in the large proportion of\\ncases. The vaginal tampon may be employed, as recommended\\nabove. If at the end of twenty-four hours the os is not\\npatulous, the patient should be anaesthetized, and the cervix\\ndilated with Hegar s or Barnes s dilators, and the uterus\\nemptied, as recommended below.\\nAs soon as the os is sufficiently dilated to permit the intro-\\nduction of the forefinger the ovum should be sW^ept out and\\nthe decidua or placenta removed by scraping. The forefinger\\nof the right hand is the best instrument for tl s purpose. It\\ncan be made to reach all parts of the uterus, with the assist-\\nance of the left hand pressing on the fundus through the\\nabdominal wall. When the secundines cannot all be removed\\nin this manner the interior of the uterus may be gently\\nscraped with a blunt curette. In all cases, after emptying the\\nuterus its cavity should be thoroughly douched with plain", "height": "3712", "width": "2632", "jp2-path": "obstetricsmanual00evan_0206.jp2"}, "201": {"fulltext": "MISSED LABOR. 201\\nsterilized water or formalin solution, used hot. For this pur-\\npose the Fritsch-Bozeman uterine catheter is by far the best\\ninstrument. The Emmet curette forceps will be found to be\\na very valuable adjuvant to the curette in removing shreds\\nfrom the uterine cavity.\\nAfter-treatment of abortion: The woman should be kept in\\nbed for at least a week or ten days, the temperature should be\\nwatched, and, if necessary, appropriate treatment to prevent\\nthe onset of lactation should be applied.\\nMissed Abortion.\\nIt occasionally happens that the foetus perishes, symptoms\\nof impending abortion develop only to disappear, and the\\novum is retained in the uterus for weeks, or even months. To\\nthis condition the term missed abortion is applied. No\\ntreatment is indicated, provided the condition does not affect\\nthe general health of the patient, for sooner or later contrac-\\ntions will occur and the uterus empty itself of its contents.\\nPremature Labor and Miscarriage.\\nThe phenomena of premature labor are very much the\\nsame as of labor at term, with the exception that the placenta\\nis more frequently adherent to the uterine wall. When such\\nis the case the uterus must be entered and the placenta\\nstripped off and removed, after which a hot uterine douche\\nshould be given.\\nMissed Labor.\\nIn this condition, which is very rare, the woman may\\nexhibit a few ineffectual signs of labor at term these disap-\\npear, and the product of conception is retained in utero for\\nmonths, or even years. The foetus in these cases always\\nperishes, and either macerates or mummifies. The soft parts\\nof the foetus may be absorbed, and the bones may be dis-\\ncharged at intervals for a long time afterward, or they may\\nfind their way through the uterus into the bladder or rectum.\\nIt is a good general rule to induce labor in all cases in which\\nthe patient is known to have gone two weeks beyond the nor-\\nmal period of pregnancy.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0207.jp2"}, "202": {"fulltext": "202 PATHOLOGY OF PREGNANCY.\\nECTOPIC GESTATION.\\nDefinition When the impregnated ovum becomes attached,\\nand develops outside the uterine cavity, the pregnancy is\\ntermed ectopic, or extra-uterine.\\nFrequency Ectopic gestation occurs probably about once\\nin 500 cases of pregnancy.\\nVarieties There are three primary forms of ectopic gesta-\\ntion: (1) tubal (2) ovarian; and (3) abdominal.\\nMany authorities classify the various terminations of these\\nprimary forms of ectopic gestation as secondary forms, each\\nbeing designated according to the location of the displaced\\novum. The term secondary as thus employed simply\\nmeans subsequent to rupture or displacement.\\nWhile primary ovarian and abdominal pregnancies do\\noccur, they are undoubtedly extremely rare, and are difficult\\nof absolute demonstration as a general rule, ectopic gestations\\nare tubal.\\nTubal pregnancies are classified according to the site of the\\nattachment of the ovum, as\\n(1) Interstitial when the ovum develops in that portion of\\nthe tube which passes through the wall of the uterus, or in a\\ndiverticulum of this portion of the tube.\\n(2) True tubal, or ampullar, when the ovum develops in\\nthe free portion of the tube.\\n(3) Infundibidar when the ovum develops in the infundib-\\nulum of the tube, and prevents the closure of the abdominal\\nostium. Cases of this variety are also termed tubo-ovarian.\\nTerminations of Ectopic Gestation.\\nInterstitial pregnancies usually terminate about the third\\nmonth by rupture into the peritoneal sac. The patient gen-\\nerally succumbs to hemorrhage and shock. Rupture into the\\nuterine cavity, with expulsion of the foetus through the cervix,\\nis possible, as is also rupture into the base of the broad liga-\\nments.\\nTrue tubal pregnancies terminate by rupture either (a) up-\\nward into the abdominal cavity, or (b) downward between\\nthe layers of the broad ligament. When the rupture occurs", "height": "3712", "width": "2620", "jp2-path": "obstetricsmanual00evan_0208.jp2"}, "203": {"fulltext": "TERMINATIONS OF ECTOPIC GESTATION. 203\\ninto the abdominal cavity the hemorrhage is usually severe,\\nand may be fatal in from sixteen hours to three or four days.\\nWhen rupture occurs early and the hemorrhage is not severe,\\nthe foetus may be absorbed, as the embryonic sac usually\\nruptures at the same time as the tube.\\nWhen the rupture occurs downward, between the layers of\\nthe broad ligament, the ovum may perish and all trace of it\\ndisappear, while the blood effused may be retained, forming a\\npelvic hsematocele. The ovum may develop for a time, and\\nthen burst into the peritoneal cavity, or continue to full term\\nby stripping the peritoneum from the pelvic wall as it en-\\nlarges. In either case the ovum develops for a time and\\nthen perishes, and is either absorbed or macerated, when it\\nmay ulcerate through into the bowel, bladder, or vagina, and\\nescape.\\nIn still other cases the gestation-sac may undergo putrefac-\\ntion from access of bacteria from the bowel, and be converted\\ninto a broad-ligament abscess, which may rupture into the\\nperitoneal cavity, or into the bladder, rectum, or vagina. In\\nother cases the foetus after death may be converted into a\\nlithopaedion or may be mummified, and thus remain for\\nyears.\\nInfundibular pregnancies may either rupture into the perito-\\nneal cavity or develop to full term.\\nOvarian pregnancies may terminate by rupture of the sac\\nand profuse hemorrhage or arrest of development may\\noccur at an early period and the sac remain a cystic tumor.\\nAdvance to full term is possible, but not probable.\\nAbdominal pregnancies may advance to full term or the\\nsac may rupture early, and the foetus be either absorbed or\\nmummify.\\nTubal abortion This term is applied to a certain rare con-\\ndition in which blood is effused into the ovum, destroying it\\nand its attachments to the tube-walls. The ovum may re-\\nmain as a tubal mole, forming a solid tumor of the tube or it\\nmay escape with the blood from the fimbriated extremity of\\nthe tube into the abdominal cavity.", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0209.jp2"}, "204": {"fulltext": "204 PATHOLOGY OF PREGNANCY.\\nEtiology of Ectopic Gestation.\\nAs has been stated, the ovum usually becomes impreg-\\nnated while still in the Fallopian tube. If the tube is in\\na normal condition, the impregnated ovum is moved along\\nit until it finds its resting-place in the uterine cavity. It is\\ntherefore probable that the most important factor in producing\\nectopic gestation is some abnormal condition of the tubes.\\nSuch abnormal conditions may arise either from inflam-\\nmation of the tissues of the tubes or from parametritic\\nexudations, which lead to their constriction or destruction.\\nMalformations of the tubes are not infrequent, such as di-\\nverticula, accessory tubal canals, etc., and have been noticed\\nin connection with ectopic gestation.\\nAny diseased condition of the mucous membrane of the\\ntubes, or any condition which interferes with their normal\\nperistaltic action, may be said to favor the development of\\nectopic gestation.\\nThe condition is generally encountered in women who\\npresent a history of a protracted period of sterility.\\nPathology of Ectopic Gestation.\\nThe uterus With the establishment of pregnancy the\\nuterus begins to enlarge the enlargement continues through-\\nout the pregnancy, though at a much slower rate than is the\\ncase in intra-uterine gestation. As a rule, this organ begins\\nto involute when the foetus perishes. A decidua forms in\\nall cases of ectopic gestation, which is quite similar to the\\ndecidua vera of normal pregnancy. It is cast off either\\ncomplete or in shreds, at the time of the primary tubal\\nrupture, whether the ovum perishes or not. The shredding\\nof the decidua is invariably accompanied with metrorrhagia.\\nThe decidua varies in thickness from one-eighth to one-fourth\\nof an inch it is shaggy on its uterine side, while its inner\\nsurface is quite smooth and shows no trace of either the\\ndecidua serotina or reflexa.\\nChanges in the tube and ovum As the tube enlarges its\\nrelation to surrounding parts becomes greatly modified. The\\nfirst change in the tube is a turgescence, due to increase in\\nsize of the vessels, the result of the stimulus of pregnancy.", "height": "3712", "width": "2632", "jp2-path": "obstetricsmanual00evan_0210.jp2"}, "205": {"fulltext": "SYMPTOMS OF ECTOPIC GESTATION. 205\\nThe muscle-fibres of the tube s walls then increase in size,\\nbut later atrophy as the result of minute ruptures due to small\\nhemorrhages into their substance. Then folloAvs free develop-\\nment of connective tissue, which replaces in great part the\\nmuscle-fibres. As the ovum enlarges the tube-walls become\\nthinned out, the thickest part being at the site of the placental\\nattachment, and the thinnest directly opposite. Closure of\\nthe abdominal ostium usually takes place at the sixth or\\nseventh week rupture of the tube takes place before the end\\nof the second month in probably two-thirds of the cases.\\nThe tube is movable to a limited degree until fixed by peri-\\ntonitis. From its increased weight it tends to fall below its\\nnormal level, and it may be found in Douglas s pouch. As the\\novum enlarges the uterus is pushed to one side. In some\\ncases the tube remains closely attached to the uterus, while in\\nothers it forms a distinct mass.\\nIn the pregnant tube a decidua is formed Avhich is composed\\nof the usual two layers, a superficial compact and a spongy\\nlower layer. That portion of the decidua which is to form\\nthe maternal placenta, and which corresponds to the serotina,\\ngrows more rapidly than that in the rest of the tube. A de-\\ncidua reflexa is also formed, but it tends to degenerate rapidly,\\nand gives rise to hemorrhages very early in the pregnancy.\\nThese hemorrhages result in inflammatory changes which alter\\nthe general texture of the mass.\\nThe placenta is formed in the same way as in intra-uterine\\ngestation, but the lack of space in the tube results in trauma-\\ntisms which altogether change its character, converting it into\\na liver-like mass. When the tube ruj^tures the torn walls\\nof the tube spread out, and should the ovum survive, the pla-\\ncenta forms attachments to neighboring structures and con-\\ntinues its growth.\\nThe amnion and chorion are only altered from their usual\\nconditions by the results of trauma and sepsis.\\nSymptoms of Ectopic Gestation.\\nThe phenomena which indicate the existence of ectopic ges-\\ntation are irregular hemorrhages from the vagina accompanied\\nwith more or less severe pelvic pain; and the presence of a mass\\nclose to and often associated with the iderus.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0211.jp2"}, "206": {"fulltext": "206 PATHOLOQY OF PREGNANCY.\\nIn a typical case the patient has been regular in menstrua-\\ntion for some time, when she misses a period. Shortly after\\nthis she has irregular attacks of bleeding, accom})anied with\\nsharp, cutting pelvic pain. These symptoms may lead to the\\nsuspicion of abortion, which is strengthened by the passage\\nof portions of decidua. One of these attacks may be exces-\\nsively severe and cause collapse. Not infrequently these\\nattacks are accompanied by dysuria and rectal tenesmus.\\nThe amount of blood lost varies from a mere show to a\\nsevere hemorrhage with the blood may be found small shreds\\nof mucosa, or even a complete cast of the decidual lining of\\nthe uterus.\\nThe pelvic pain is usually of a sharp, tearing character\\nwhen excruciating, and accompanied with collapse, it indicates\\na serious rupture.\\nA vaginal examination in such a case will reveal the pres-\\nence of a mass in close proximity to the uterus, which may\\nbe found somewhat enlarged. The character of the mass de-\\npends upon the situation of the ovum and whether it has rupt-\\nured or not. In cases in which rupture has taken place early\\ninto the general peritoneal cavity no mass may be felt.\\nIf the first attack be survived, other similar attacks may\\nfollow and the internal hemorrhages be fatal. In other cases\\nthe effused blood may be absorbed after the perishing of the\\novum.\\nThe ovum if it survive may go on developing, in which case\\nsigns of pregnancy will continue, an abdominal tumor develop,\\nand finally evidences of a living foetus will manifest them-\\nselves. Such cases may go on to full term and a spurious\\nlabor occur.\\nIn other cases secondary rupture takes place at a later period\\nwhen the patient usually dies of hemorrhage or peritonitis or\\nif the patient survive, the foetus becomes mummified or forms\\na lithopsedion, being retained for some time, and finally is cast\\nout piecemeal through a fistulous opening.\\nDiagnosis.\\nTo make a positive diagnosis of ectopic gestation previous\\nto rupture of the sac, while possible in a large majority of", "height": "3712", "width": "2632", "jp2-path": "obstetricsmanual00evan_0212.jp2"}, "207": {"fulltext": "TREATMENT OF ECTOPIC GESTATION. 207\\ncases, is always a matter of difficulty. The liistory of the\\nsigns of early pregnancy, associated with aggravated reflex\\nnervous phenomena the early appearance of sharp, cramp-\\nlike pelvic pain increasing in severity, make a diagnosis pos-\\nsible.\\nUsually the condition is not recognized until rupture has\\ntaken place. At this time the history of delayed menstrua-\\ntion, the occurrence of a paroxysm of frightful pain, sudden\\ncollapse, and symptoms of internal hemorrhage make the\\ndiagnosis very simple.\\nA microscopical examination of the shreds contained in the\\nvaginal blood will reveal their decidual character, and make a\\ndifferential diagnosis from abortion possible, as no chorionic\\nvilli will be found unless the pregnancy is intra-uterine.\\nIn cases of advanced ectopic gestation the diagnosis is, as a\\nrule, not difficult. Owing to the great displacement of con-\\ntiguous organs, abdominal pain is often excessive. This pain\\nis due in part to pressure, and in part to the development of\\nperitonitis of a chronic type.\\nPrognosis.\\nEctopic gestation is one of the most serious obstetrical condi-\\ntions. If left to nature, the mortality is over 60 per cent., the\\nremainder recovering by death of the ovum and absorption\\nof the contents of the gestation-sac.\\nWhen treated by abdominal section. Hirst states the mor-\\ntality should be about 5 per cent, or lower, if the operator\\nsees the patient in time.\\nTreatment.\\nAs soon as a diagnosis of ectopic gestation is established\\nthe only rational treatment consists in the immediate removal\\nof the gestation-sac, whether it has ruptured or not.\\nAbdominal section is the most satisfactory metliod of operat-\\ning, though some operators prefer the vaginal route. The\\nlatter method has many disadvantages, and should only be\\nresorted to by those operators having special experience in\\noperating by the vaginal route.\\nAs it is a matter of considerable difficulty in many cases to", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0213.jp2"}, "208": {"fulltext": "208 PATHOLOGY OF PREGNANCY.\\ncontrol the hemorrhage and to separate the gestation-sac, the\\noperation of (ibdominal section for the removal of an ectopic\\ngestation should not be undertaken by an unskilled operator.\\nThe technique of the operation Though the operation has\\nfrequently to be performed in an emergency, plenty of time\\nshould be taken to secure an aseptic condition of the abdomen\\nof the i)atient, of the operator, of the assistants, and of the\\ninstruments and dressings.\\nThe operator, having opened the abdomen by a median\\nincision, should at once insert his hand and seize the affected\\ntube at its uterine end, so as to control the hemorrhage. The\\nbroad ligament should then be transfixed by a pedicle-needle\\nto the inner side of the round ligament, and the tube ligated\\neii masse. After the tube and ovary have been cut away, the\\nabdominal cavity should be cleared of clots, if necessary flush-\\ning it with a large quantity of warm sterile water. The\\nincision may then be closed without the insertion of a drain-\\nage-tube, unless a considerable number of adhesions have been\\nencountered. The subsequent treatment is the same as for an\\nuncomplicated ovariotomy.\\nWhen the hemorrhage has been very considerable a quan-\\ntity of sterile salt solution should be injected under each\\nbreast, during the operation, by an assistant. After the oper-\\nation it is advisable in all cases to inject at least a quart of\\nthe same solution into the bowel, by means of a long rubber\\ntube and gravity syringe.\\nIn advanced ectopic pregnancy many advise that interference\\nbe delayed until just short of term. In this case effort should\\nbe made to enucleate the foetal sac whole.\\nWhen this is found to be impossible, after the foetus has\\nbeen removed the cord should be cut as close as possible to\\nthe placenta and the edges of the sac stitched to the edge of\\nthe abdominal wall, and the sac drained by packing it lightly\\nwith iodoform gauze.\\nThe after-treatment in such cases consists in daily irrigation\\nof the sac with antiseptic solutions, dusting it well with an\\nantiseptic powder, and introducing fresh packing.\\nFor further information on this subject reference should be\\nhad to standard gynaecological works, as ectopic gestation has", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0214.jp2"}, "209": {"fulltext": "DIAGNOSIS OF OCCIPITO POSTERIOR CASES 209\\npassed from the domain of obstetrics to that of gynaecology,\\nsince the treatment of the condition is purely surgical.\\nPATHOLOGY OF LABOR.\\nThe term eutocia is applied to normal labor which termi-\\nnates easily Avithout serious damage to mother or foetus and\\nwithout artificial aid.\\nDystocia is the term applied to abnormal labor. If the\\nabnormality of the labor depends upon some form of foetal\\nirregularity, the condition is termed foetal dystocia while if it\\nbe dependent upon some abnormal condition in the mother it\\nis known as maternal dystocia.\\nThe cause of the dystocia may be in any of the three factors\\nwhich constitute the mechanical problem of labor. The foetus\\nor its appendages may be abnormal in size, shape, or position\\nthe expelling forces may be insufficient or excessive or the\\nresistance offered by the maternal passages may be too great\\nor too little.\\nAYhen called upon to render assistance in a case of dystocia\\nthe physician should first ascertain which of the factors is at\\nfault. The recognition of the disturbing cause forms the basis\\nof rational treatment.\\nDYSTOCIA DUE TO MALPOSITIONS OF THE FCETUS.\\nOCCIPITOPOSTERIOR CASES.\\nOccipitoposterior positions of the head are primary or\\nacquired.\\nPrimary, if the head enters the brim of the pelvis with the\\nocciput posterior.\\nAcquired, if the occiput rotates from an anterior position at\\nthe beginning of labor to a posterior at its close the latter is\\nvery rare.\\nDiagnosis of Occipitoposterior Cases.\\nAbdominal examination The back of the foetus may be\\nfelt in the maternal flank but is frequently difficult to out-\\nline. The foetal members may be felt over the whole anterior\\naspect of the abdomen. The head can be felt at the pelvic\\n14\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2384", "jp2-path": "obstetricsmanual00evan_0215.jp2"}, "210": {"fulltext": "210\\nPATHOLOGY OF LABOR.\\nbrim, wliile the anterior shoulder can easily be distinguished\\nat a point about midway between the middle of Poupart s\\nligament and the umbilicus. The foetal heart-sounds may be\\nheard in the flank at about the level of the umbilicus.\\nVaginal examination If the cervix is dilated sufficiently,\\nthe sagittal suture may be felt in the line of the oblique\\ndiameter of the pelvis, while the posterior fontanelle is\\ndirected toward the right or left sacro-iliac joint. Labor in\\noccipitoposterior j)ositions is generally tedious, due to the\\nirregular and ineffectual pains which characterize the first\\nstage in these cases, and also because of the long internal rota-\\ntion which must take place before the occiput is directed\\nunder the pubic arch.\\nMechanism of Occipitoposterior Cases.\\nIn normal cases the mechanism is much the same as in\\nanterior positions of the occiput. Flexion is more difficult\\non account of the maladaptation of the head to the pelvis in\\nthese posterior positions, as the widest part of the head, the\\nbiparietal, is in relation with the narrowest part of the inlet,\\nthe diameter between the iliopectineal prominence and the\\nFig. 67.\\nFig. 68.\\nRight occipitoposterior position of\\nhead. The arrow shows the direction of\\nthe long internal rotation made by the\\nocciput in delivery. (.Jewett.)\\nLeft occipitoposterior position of head.\\nThe arrow shows the direction of the long\\ninternal rotation made by the occiput in\\ndelivery. (Jewett.)\\npromontory. AVhen flexion is complete and the head de-\\nscends to the pelvic floor, internal rotation is prolonged on\\naccount of the great distance the occiput must traverse to\\ncome under the pubes hence there is greater pain, and the\\nlabor is prolonged (Figs. 67 and 68).", "height": "3712", "width": "2628", "jp2-path": "obstetricsmanual00evan_0216.jp2"}, "211": {"fulltext": "MECHANISM OF OCCIPITOPOSTERIOR CASES. 211\\nAbnormal Mechanism.\\n(1) Extended position of head The disproportion between\\nthe occipital end of the head and that portion of the brim in\\nrelation to it already referred to, may result in interference\\nwith flexion to such an extent that the head may enter the\\npelvis in an extended position^ as in brow or face presenta-\\ntions.\\n(2) Face to pubes When the head enters the pelvis imper-\\nfectly flexed the sinciput may reach the pelvic floor first, and\\nis then directed toward the pubic arch, while the occiput\\nFig. 69.\\nFaulty mechauism in a right occipltoposterior case. The occiput is shown rotating\\nto the back. (After Schultze.)\\nrotates into the hollow of the sacrum. This mechanism\\nresults in delivery face to pubes.\\nIn such persistent occipitoposterior cases the head con-\\ntinues to descend until the glabella (the root of the nose)", "height": "3696", "width": "2480", "jp2-path": "obstetricsmanual00evan_0217.jp2"}, "212": {"fulltext": "212\\nPATHOLOGY OF LABOR.\\npivots under the piibes, when flexion takes place to permit the\\nescape of the occiput over the perineum. When the occiput is\\ndelivered the head extends and the face escapes from under the\\npubes (Fig. 69). Spontaneous delivery in a face to pubes case is\\nonly accomplished with difficulty, and requires strong pains,\\nlax maternal parts, and not too large a head. After the birth\\nof the head the mechanism is the same as in other cases.\\n(3) In other cases the head may enter the pelvis poorly\\nflexed, descend until it reaches the pelvic floor, and there\\nremain fixed with its long diameter (O. F.) transverse in the\\npelvic cavity, generally at the level of the ischial spines,\\nbetween which it becomes impacted.\\nMoulding of head in face to pubes cases The occipito-\\nmental and occipitofrontal diameters of the foetal head are\\nshortened and the suboccipitobregmatic lengthened, as a\\nresult of the head pivoting at the glabella (Fig. 70).\\nManagement of Labor in Occipitoposterior Cases.\\nProphylaxis Attention has been drawn to the desirability\\nof making an abdominal examination to determine the posi-\\ntion of the foetus some time before\\n70. the expected onset of labor. If at\\nthis examination the foetus be found\\nto occupy a posterior position, it is\\npossible to rectify it by postural treat-\\nment in many cases. The woman\\nshould be instructed to assume the\\nknee-chest position as frequently as\\nj)0ssible, and to remain in this position\\nfor some time before turning upon\\nthe side to which it is desired to\\ndirect the occiput. In this posture\\nthe tendency is for the child to sag\\naway from the brim under the influ-\\nence of gravity, as the fundus and\\nanterior uterine wall become the\\nlowest portions of the uterus. The\\nchild thus becomes free to rotate upon its own axis, and as\\nits dorsum is heavier from the presence of the spinal column\\nDiafjram showing head un\\nmoulded and mouldedinaper\\nsistent occipitoposterior case,\\nBlack, unmoulded.\\nRed, moulded.", "height": "3708", "width": "2652", "jp2-path": "obstetricsmanual00evan_0218.jp2"}, "213": {"fulltext": "LABOR IN OCCIPITOPOSTERIOB CASES. 213\\nit is brought into apposition with the anterior wall of the\\nuterus. Hence as the woman assumes the erect position\\nthe child s head tends to settle down against the brim in\\nan anterior position.\\nAt the Pelvic Inlet.\\nFrequent examinations should be made to ascertain whether\\nflexion is being maintained as the head descends into the brim.\\nShould extension of the head take place without descent,\\ninterference is demanded, as there is but little likelihood that\\nthe head will pass the brim by natural efforts.\\nThree methods of delivery are possible\\n1st. Version This is probably the most popular as well as\\nthe easiest method of dealing with these cases, because, as a\\nrule, the general practitioner can perform this operation with\\ngreater ease to himself and less danger to the patient than\\neither of the other methods.\\n2d. Normal restoration of flexion and rotation of the foetal\\nhead and body to an anterior position, with the subsequent ap-\\nplication of the forceps This is a rather difficult operation, and\\nshould only be undertaken by those who are thoroughly\\nskilful in the use of forceps. To perform this operation\\nproperly the patient should be placed under the influence of\\nchloroform, so as to relax thoroughly the uterus. The opera-\\ntor, after the usual antiseptic precautions have been observed,\\nshould then pass his whole hand into the uterus so as firmly to\\ngrasp the brow and face of the child. The head having been\\nraised slightly, so as to free it from the brim, is then gently\\nrotated to an anterior position. The external hand of the\\noperator should be used to promote rotation of the trunk,\\nwhich should accompany rotation of the head. The rotation\\nshould be carried out slowiy and with the utmost gentleness.\\nAfter this has been accomplished the head should be urged\\ninto the brim by external pressure, and should be maintained\\nin position by an assistant while forceps application is made.\\nAs in all high operations, only the axis-traction forceps should\\nbe used.\\n3d. Application of the forceps without alteration of position\\nThis operation should only be undertaken as a last resort, as", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0219.jp2"}, "214": {"fulltext": "214 PATHOLOGY OF LABOR.\\nit is very dangerous both to mother and child. As a pre-\\nliminary to this operation the head should be flexed.\\nIn the Pelvic Cavity.\\nAs in all posterior positions the head tends to pass the brim\\nin a somewhat extended position, it is important to secure a\\nspeedy restoration of flexion, in order that the labor may be\\naccomplished as easily and rapidly as possible, and to spare\\nthe patient unnecessary suffering.\\nFlexion may be restored by pressure upward upon the\\nsinciput with two fingers during the intervals between the\\npains. During the pains the descent of the sinciput may be\\nretarded by maintaining this pressure from below. Occasion-\\nally it is possible to hook the finger of the other hand over\\nthe occiput and draw it down, while at the same time the\\nsinciput is being pressed up but to do this the head must be\\nvery low and the parts lax.\\nWhen rotation fails and signs of exhaustion occur, then the\\nforceps must be applied. During this operation care should\\nbe taken to prevtmt the blades slipping, as this accident is very\\nliable to occur. Between the tractions the blades should be\\nseparated, because sometimes the occiput tends to rotate spon-\\ntaneously. As the head emerges it should flex and the root of\\nthe nose pivot under the pelvic arch. It should be delivered\\nslowly and with extreme caution, so as to favor moulding and\\nto control the extent of perineal laceration. In many cases\\nit is necessary to perform episiotomy, in order to prevent the\\nlaceration of the perineum extending into the rectum.\\nPrognosis.\\nThe prognosis for both mother and child is not so favorable\\nas in anterior positions. Backward rotation of the occiput\\ntakes place in about IJ per cent, of all cases of labor.\\nLaceration of the maternal soft parts is frequent and often\\nextensive. The mortality of the foetus is somewhat over\\n9 per cent., as compared with 5 per cent, in anterior posi-\\ntions.", "height": "3712", "width": "2664", "jp2-path": "obstetricsmanual00evan_0220.jp2"}, "215": {"fulltext": "DIAGNOSIS OF FACE PRESENTATIONS. 215\\nFACE PRESENTATIONS.\\nOccurrence Face presentations rarely exist prior to the\\nonset of labor they may be considered as altered vertex pres-\\nentations. Presentation of tlie face cannot be said to be com-\\nmon, for it occurs once in about every 250 cases of labor.\\nPositions The chin is the denominator, as it replaces the\\nocciput in the mechanism when compared to vertex presenta-\\ntions, for the head is extended instead of being flexed.\\nThe long diameter of the face, the frontomental, usually\\noccupies the right oblique diameter of the pelvic brim hence\\nthe most common positions are R. M. P. and L. M. A.;\\nrarely, R,. M. A. and L. INI. P. positions may be met with.\\nCauses Any condition wliich tends to interfere with proper\\nflexion of the head may be set down as a cause of face pres-\\nentation. The most common causes are\\n1. Obliquity of the uterus, which acts by altering the line\\nof foetal-axis pressure.\\n2. Tumors of the foetal neck, thyroid, or thymus.\\n3. Coils of thick cord around the neck.\\n4. Dead foetus.\\n5. Excessive liquor amnii.\\n6. Small size of foetus.\\n7. Deformed pelvis.\\n8. Tumors of uterus or neighboring structures.\\n9. Tumors upon the back, as meningocele.\\n10. Dolichoceplialic head.\\n11. Occipitoposterior positions, in which there is a tight fit\\nat the brim.\\nDiagnosis of Face Presentations.\\nAbdominal examination It is sometimes a matter of diiB-\\nculty to make a diagnosis of face presentation when the\\nabdominal Avail is thick or tense. Usually the bulky cranial\\nvault can be felt in one hypogastric region, and a deep groove\\nmay be made out between it and the foetal back. On the\\nopposite side of the abdomen the foetal members may be dis-\\ntinguished (Fig. 71). As the foetal back is displaced from\\nthe uterine wall by the extended head, the heart-sounds are to", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0221.jp2"}, "216": {"fulltext": "216\\nPATHOLOGY OF LABOR.\\nbe heard most distinctly on the same side of the abdomen\\nupon which the foetal extremities are felt.\\nVaginal examination Early in labor before rupture of\\nthe membranes, the rounded head to be felt in the vertex\\nFig. 71.\\nTransverse position of face at superior strait.\\ncases is wanting, and usually nothing can be reached but the\\nbulky bag of waters, as the face is arrested high up, Care\\nshould be taken not to rupture the membranes in attempting\\nto reach the presenting part of the foetus. Should the bag of\\nwaters be ruptured, then it may be possible to distinguish the\\nI", "height": "3712", "width": "2628", "jp2-path": "obstetricsmanual00evan_0222.jp2"}, "217": {"fulltext": "MECHANISM OF FACE PRESENTATIONS. 217\\nsuperciliary riclges, the eyes, the nose, and especially the mouth.\\nThe latter is distinguished by feeling the tongue and the\\nalveolar margins. If the caput succedaneum has formed over\\nthe face, it may be mistaken for a breech, unless care be taken\\nto distinguish clearly the relationship of the parts within\\nreach of the finger.\\nMechanism of Face Presentations.\\nThe first stage of labor is delayed because the head does\\nnot fit the lower uterine segment so well as in vertex presen-\\ntations.\\nThe mechanism of face cases differs from that of the\\nvertex in that\\n1. The chin takes the place of the occiput in being the\\nleading part of the head in descent. It does not come down\\nso far in advance of the rest of the head as the occiput in\\nvertex cases, so that internal rotation of the chin forward to\\nthe pubic arch occurs rather late and is slow.\\n2. Moulding takes place with more difficulty than in vertex\\ncases.\\n3. The head is delayed longer at the brim, as extension\\nhas to be very marked before descent can begin hence, as a\\nrule, labor is delayed.\\nE.. M. P. As this is probably the commonest position, its\\nmechanism will be described in detail.\\nThe long diameter of the face, the frontomental, descends\\nthrough the inlet in the right oblique diameter of the pelvic\\nbrim. The chin descends along the posterior pelvic groove\\non the right side till it strikes the pelvic floor, then it rotates\\nforward through three-eighths of a circle on the right side of\\nthe pelvis till it comes under the pubic arch. The brow\\nrotates into the hollow of the sacrum, and the frontomental\\ndiameter thus corresponds to the anteroposterior diameter of\\nthe outlet. The chin then appears at the vulva and escapes\\nbeneath the pubic arch. The movement of flexion then be-\\ngins, the chin pivoting under the pubic arch, and the face,\\nforehead, vertex, and occiput successively clear the perineum\\n(Fig. 72\\\\ The head now being free assumes its relationship\\nto the shoulders, which occupy the right oblique diameter of", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0223.jp2"}, "218": {"fulltext": "218 PATHOLOGY OF LABOR.\\ntlie pelvis the rest of the mechanism is the same as in a case\\nof L. O. A.\\nL. M. A. The mechanism is the same as in a vertex case,\\nexcept that the occiput is replaced by the chin, which pivots\\nFig. 72.\\nDiagrammatic view of mechanism in a right mentoposterior position of a face\\npresentation, chin rotating to pubes.\\nunder the pubes then the head is delivered by flexion.\\nSometimes in a large pelvis the head may be pushed through\\nin extension without any special mechanism.\\nIn mentoposterior positions the head may descend into the", "height": "3712", "width": "2620", "jp2-path": "obstetricsmanual00evan_0224.jp2"}, "219": {"fulltext": "MANAGEMENT OF FACE PRESENTATIONS. 219\\npelvis sufficiently far to prevent completely the anterior rota-\\ntion of the chin, which is then forced into the hollow of the\\nsacrum. This condition is practically fatal to the child, for\\nthe author has been able to find but one case recorded in which\\na living child was born after this accident had occurred.\\nHead-moulding The vault of the head becomes flattened\\nand pushed backward the diameters lengthened are the\\noccipitofrontal and the occipitomental the diameters short-\\nened are the suboccipitobregmatic and the cervicobregmatic.\\nThe caput succedaneum is found on the face, chiefly around\\nthe eye which lies anterior when the face is at the brim\\nowing to the laxity of the tissues of the face the swelling is\\noften very great and the discoloration considerable. The\\neye may be closed for days, and the child may be unable to\\nsuckle from the swelling of the lips.\\nPrognosis.\\nThe foetal mortality in face cases is about 15 per cent.\\nthe maternal mortality is given as being over 6 per cent.,\\nfor these cases are frequently mismanaged. The labor is\\ntedious, as a rule. Anterior positions of the chin are better\\nthan posterior, as the labor is quicker. There is usually\\nmore or less serious laceration of the perineum.\\nManagement of Face Presentations.\\nThe important point in the first stage is to preserve the bag\\nof waters intact as long as possible, because the face is a poor\\ndilator of the cervix. The patient should therefore be kept\\nin bed all through this stage.\\nFlexion by Schatz s method: If the chin is posterior an\\nattempt should be made to restore flexion and thus convert\\nthe position into a vertex anterior. This may be accomplished\\nby gentle external manipulations according to the method\\nrecommended by Schatz (Fig. 73). The woman is placed in\\nthe Trendelenburg position, which may be accomplished by\\narranging an ordinary wooden chair (first sawing off* the legs\\nclose to the wooden seat) on the bed so that its back forms\\nan inclined plane, covering it with a folded blanket and", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0225.jp2"}, "220": {"fulltext": "220\\nPATHOLOGY OF LABOR.\\ndrawing the patient up over it so that her buttocks rest on\\nthe back edge of the seat. The operator then presses on the\\nocciput of the cliiki with one hand, so as to force it into the\\npelvis, while he presses the other against the child s neck on\\nthe opposite side, thus flexing the head and straightening the\\nvertebral column of the foetus. When flexion has thus been\\naccomplished, pressure is then maintained upon the fundus, so\\nas to force the head into the pelvic brim in the flexed position.\\nIf this be found impossible, the case may be left until the\\nOS has dilated, when, after rupturing the membranes, an effort\\nFig. 73.\\nSchatz s method of rectification by external manipulation,\\nmay be made to restore flexion by introducing the hand into\\nthe uterus.\\nIf it be found impossible to maintain the head in the\\nflexed position after this manoeuvre, the forceps should be ap-\\nplied and the head drawn down into the cavity in a flexed\\nposition, when the blades may be withdrawn and the delivery\\nleft to nature.\\nIf the patient is a multipara with lax parts and the uterine\\ncontractions are powerful, the case may be left to nature but\\ncare should be exercised to secure good extension as the head\\ndescends, in order that the chin may reach the pelvic floor in\\nadvance of the rest of the head.\\nIn a primipara in whom the presentation is posterior and it", "height": "3728", "width": "2628", "jp2-path": "obstetricsmanual00evan_0226.jp2"}, "221": {"fulltext": "BREECH PRESENTATIONS. 221\\nis found impossible to restore flexion, internal version may\\nbe employed.\\nForceps If version be impossible in anterior positions\\nwhere delay occurs at the brim, then forceps may be applied\\nbut the operation is difficult and dangerous, as the blades\\ntend to slip off the head when traction is made.\\nIf all these efforts fail and the child has perished, then\\ncraniotomy must be performed to secure delivery\\nWhen the head has passed the brim and fails to advance fur-\\nther, there is danger to the child from tension on the vessels of\\nthe neck causing engorgement of the cerebral circulation. In\\nsuch cases the forceps slioidd be employed to hasten delivery.\\nSymphysiotomy has been recommended in cases of persistent\\nmentoposterior positions if the child is living.\\nBrow Presentations.\\nMany authorities describe a half-way stage in the develop-\\nment of face presentations. It can scarcely be classified as a\\nspecial presentation, but should be considered as simply a dis-\\nplacement of the vertex.\\nShould such a presentation be met with, it can only be diag-\\nnosed by vaginal examination. The extension of the head is\\nrecognized by the fact that, instead of the vertex, the finger\\ncomes in contact with the brow possibly the anterior fonta-\\nnelle may be distinguished, as well as the supra-orbital ridges.\\nTreatment consists in the manual restoration of flexion\\nand if this be impossible, version must be resorted to in order\\nto effect delivery with a minimum of risk to the mother and\\nchild. In rare instances in which the brow is directed ante-\\nriorly tlie head may descend to the pelvic floor in this partially\\nextended condition in such cases the sinciput, being in\\nadvance of the rest of the head, is directed to the pubes,\\nthe root of the nose pivots under the pubic arch, and the head\\nis delivered in flexion, precisely the same as has been de-\\nscribed in speaking of ^face to pubes cases.\\nBEEECH PEESENTATIONS.\\nDefinition The presentation of any part of the pelvic pole\\nof the foetal ovoid at the inlet is termed a breech presenta-", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0227.jp2"}, "222": {"fulltext": "222\\nPATHOLOGY OF LABOR.\\ntion. The term, therefore, includes a presentation of the but-\\ntocks, kneeSy or fed. The denomination is taken from the\\nposition of the sacrum.\\nFrequency Breech presentations occur in the proportion of\\n1 in 30 labors; if premature births be excluded, then the\\nFig. 74.\\nBreech presentation. Right sacroposterior. Feet and cord in relation to os inter-\\nnum. (After A. R. Simpson.)\\nproportion is about 1 in 60. The positions in order of fre-\\nquency are L. S. A. R. S. P. R. S. A. L. S. P. (Figs.\\n74 and 75).\\nCauses: Certain conditions favor presentation of the breech.\\nThese are lax uterine or abdominal walls, excessive liquor\\naranii, uterine obliquity, multiple pregnancy, death or prema-", "height": "3712", "width": "2652", "jp2-path": "obstetricsmanual00evan_0228.jp2"}, "223": {"fulltext": "DIAGNOSIS OF BREECH FRESENTATIOXS. 223\\nturity of the foetus, placenta pravia, contracted pelvis, tumors\\nof the uterus or neighboring structures, monstrosity, and\\nhydrocephalus.\\nFig. 75.\\nBreech presentation. Left sacro-anterior position. (After A. R. Simpson.)\\nDiagnosis of Breech Presentations.\\nAbdominal examination On exploring the excavation of the\\npelvis it will be found empty, while at the brim a large, bulky,\\nirregular, movable mass may be distinguished, Avhich is not\\nengaged unless labor has well advanced. At the fundus the\\nhard, well-defined contour of the head will be easily recog-\\nnized. The foetal heart-sounds will be heard on the side to\\nwhich the back is directed, at or above the level of the um-\\nbilicus.", "height": "3700", "width": "2392", "jp2-path": "obstetricsmanual00evan_0229.jp2"}, "224": {"fulltext": "224 PATHOLOGY OF LABOR,\\nVaginal examination Care must be taken not to rupture\\nthe membranes if they be found intact, in making the vaginal\\nexamination. Generally the breech is situated so high up\\nthat it cannot be reached without risk of rupturing the bag\\nof waters if the examination is made early in labor. After\\nlabor has advanced and the membranes have ruptured the\\nbreech may be recognized by feeling the sacrum, coccyx, and\\nischial tuberosities of the foetus. The anus may be recognized\\nby the grasp of the sphincter ani, and l)y the presence of me-\\nconium on the examining finger. If the child is a male, the\\nscrotum and penis may be felt. Occasionally the former may\\nbe oedematous and may then be mistaken for the bag of Avaters.\\nOne or both feet may be felt; the foot may be distinguished\\nfrom the hand by the projections of the heel and the malleoli.\\nThe knee may be distinguished from the elbow by the pres-\\nence of the patella and by the larger size. Care must be\\ntaken to distinguish the breech from the face, for which it is\\noften mistaken.\\nMechanism of Breech Presentations.\\nThe first stage of labor is very prolonged, for the breech\\nforms a poor dilator of the cervix, and on account of its soft-\\nness acts imperfectly as an irritator of reflex uterine contrac-\\ntions.\\nThe breech descends generally with the anterior hip slightly\\nin advance of the other. The anterior hip in striking the\\npelvic floor is rotated forward to the pubic arch, Avhere it be-\\ncomes fixed, while the trunk is driven down and the posterior\\nhip moves forward ov^er the perineum (Fig. 76). Generally\\nboth hips emerge through the vulva at the same time, then\\nfollow the thighs and trunk. If the legs are flexed properly,\\nthey generally escape with the thighs and breech.\\nThe shoulders pass the brim with their long diameter trans-\\nverse they then turn into the oblique, and finally, at the out-\\nlet, into the anteroposterior diameter. The anterior shoulder\\nis generally delivered first, followed by the posterior.\\nThe head by this time, if flexion has been maintained by\\nactive external contractions, has entered the brim with its\\nlong diameter in the opposite oblique diameter of the pelvis", "height": "3712", "width": "2628", "jp2-path": "obstetricsmanual00evan_0230.jp2"}, "225": {"fulltext": "MECHANISM OF BREECH PRESENTATIONS. 225\\nto that in which the shoulders engaged. The occiput usually\\nstrikes the pelvic floor first and rotates to the front, while the\\nface is directed to the hollow of the sacrum. The face and\\nforehead are then born, followed by the rest of the head.\\nAbnormalities in the mechanism: 1. The breech may be ar-\\nrested at the brim or may not engage. This may be due\\neither to pelvic contraction or to excessive size of the foetus.\\n2. The breech may descend into the cavity of the pelvis\\nand there be arrested. This may be due to excessive size of\\nthe foetus, to imperfect dilatation of the external os, to pelvic\\ndeformity, or to the extended position of the limbs along the\\nbody of the child preventing its lateral flexion.\\nFig. 76.\\nPassage of buttocks over perineum in a breech case. (After Barnes.)\\n3. The arms may become extended and cause arrest of the\\nhead at tlie pelvic brim. This accident may be due to an\\nimperfectly dilated os or to pelvic contraction. It is very apt\\nto occur if traction is made upon the body of the foetus to\\naccelerate delivery.\\n4. The head may become arrested at the brim or in the\\npelvic cavity, as a result of extension or from pelvic deformity.\\nOccasionally when the face is directed anteriorly the chin may\\ncatch on the upper border of the pubes and cause delay.\\nMoulding of the foetus The breech is generally swollen and\\noften discolored from ecchymoses the discoloration is generally\\n15\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2392", "jp2-path": "obstetricsmanual00evan_0231.jp2"}, "226": {"fulltext": "226 PATHOLOGY OF LABOR.\\nmore marked over the anterior hip. If the child is a male, the\\nscrotum is generally anlematous.\\nPrognosis of Breech Presentations.\\nThe foetal mortality varies from 10 to 30 per cent., depend-\\ning upon the skill of the physician. The risks to the child\\nare great, due to the prolapse of the cord and the pressure of\\nthe after-coming head upon it. Fractures and dislocations\\nmay be caused by efforts at rapid delivery.\\nThe risks to the mother are increased only by the tendency\\nto laceration and to bruising of the soft parts on account of\\nthe necessity for rapid and sometimes violent extraction of\\nthe after-coming head.\\nManagement of Labor in Breech Presentations.\\nGeneral A^ery early in labor, before the membranes have\\nruptured or the breech has become engaged in the brim, it\\nmay be possible to perform an external version. The opera-\\ntion is not always practicable, and therefore should not be\\nattempted unless there is certainty that it can be successfully\\naccomplished.\\nThe position of the physician in charge of a breech case\\nshould be one of armed expectancy. As long as the natural\\nprocesses are progressing satisfactorily he should be watchful\\nbut inactive, and should be prepared to interfere promptly on\\nthe appearance of danger to the child.\\nWhen possible a skilled assistant should be obtained, whose\\nduty it is to give the anaesthetic and attend to the maintenance\\nof pressure upon the fundus, so as to prevent extension of the\\nhead during the delivery.\\nPreparations should be made for treating asphyxia of the\\nnewborn infant. At hand should be placed, sterilized and\\nready for use, the ligatures for the cord, scissors, two pairs of\\nartery-forceps (to be used instead of ligatures in cases in which\\nspeed is demanded), a basin containing warm sterile water in\\nwhich are a couple of sterile towels for wrapping around\\nthe child s body during delivery, and the ordinary obstetric\\nforceps.", "height": "3712", "width": "2644", "jp2-path": "obstetricsmanual00evan_0232.jp2"}, "227": {"fulltext": "MANAGEMENT OF LABOR IN BREECH PRESENTATIONS. 227\\nThroughout labor the patient should be kept in bed, and\\nshould be cautioned against straining during the first stage, as\\nit is desirable to retain the membranes without rupture as long\\nas possible, to favor complete dilatation of the os uteri. The\\nfoetal heart-sounds should be frequently auscultated during the\\nsecond stage of labor, since there is always danger of com-\\npression of the cord. Irregularity of the heart-beats is suf-\\nficient cause for interference.\\nWhen delivery is imminent the patient should lie in the\\ndorsal position, with the thighs flexed. In cases in which it is\\nnecessary to effect a speedy delivery the patient should be\\nplaced across the bed in the lithotomy position. As soon as\\nthe buttocks emerge they should be wrapped in a warm sterile\\ntowel, to prevent the child making efforts at respiration.\\nFrom the moment the buttocks appear at the vulva till the\\nplacenta is delivered the fundus uteri should be constantly\\nunder the control of an assistant. The trunk, as it emerges,\\nshould be supported, so as to prevent undue strain upon the\\nperineum and traction upon the after-coming head. As soon\\nas the feet appear the legs may be gently drawn down in such\\na way as to make no traction upon the body of the child.\\nAs soon as the umbilicus comes within reach of the finger,\\na loop of cord may be gently drawn down and examined. If\\nit is pulsating well, the case may be allowed to deliver slowly\\nbut sliould there be evidence of compression upon it, then the\\ndelivered portion of the child s body should be pressed back-\\nward and upward, and an attempt made to loosen the cord\\nand to place it in one or other iliac fossa out of harm s way\\nif this eflbrt fails, then delivery should be accomplished as\\nspeedily as possible.\\nAs the elbows appear at the vulva the arms should be\\ndrawn down, and then the child s body should be Avell ele-\\nvated, so as to prevent the escape of the head.\\nIn the delivery of the head there is no need for rapidity in\\nnormal cases, when once the mouth and nostrils have cleared\\nthe perineum. These must be wiped off to prevent aspira-\\ntion of mucus should the child attempt to breathe. Then the\\nhead should be delivered slowly and carefully, so as to avoid\\nrupturing the perineum.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0233.jp2"}, "228": {"fulltext": "228\\nPATHOLOGY OF LABOR.\\nTreatment of Arrest of Breech at the Brim.\\nArrest of the breech at the brim may be due to the excessive\\nsize of the child or to pelvic deformity. The precaution\\nshould always be taken of measuring the mother s pelvis,\\nunless this has been done, before any operative measures are\\nadopted.\\nTo secure descent five methods are available (1) by\\nbringing down the anterior leg (2) traction with a finger in\\nthe groin (3) the blunt hook (4) the fillet and (5) appli-\\ncation of forceps.\\nTraction after bringing down a leg The hand, the palm of\\nwhich corresponds to the abdominal aspect of the child, is\\nFig. 77.\\nBreech presentation\u00e2\u0080\u0094 legs extended.\\nslowly introduced in the uterus, care being taken to ascertain\\nthe position of the foetal cord so as to avoid dragging it down.\\nIt is well also to press gently back the breech, so as to dis-\\nengage it from the brim before seizing a foot. The anterior\\nfoot should always be selected, and when firmly grasped may", "height": "3728", "width": "2628", "jp2-path": "obstetricsmanual00evan_0234.jp2"}, "229": {"fulltext": "3JAXA GEMEXT OF LABOR IX BREECH PRESENT A TIOXS. 229\\nbe gently drawn tlirough the os and vagina. Occasionally the\\nlegs may be found extended along the chest of the child (Fig.\\n77). In such a case the foot may be brought within reach by\\npassing two fingers along the back of the thigh, at the same\\ntime abducting it so as to press the knee to one side thus the\\nfoot tends to drop down in the median line of the chest, and\\nmay be grasped by slipping the fingers down along the leg.\\nProvided there are no indications necessitating speedy delivery,\\nthe case may be left to nature as soon as the foot has been\\ndrawn down to the vulva.\\nShould the patient be exhausted, delivery may be hastened\\nby combined traction on the foot which has been brought down,\\nand pressure on the fundus from above. The latter should be\\nmanaged by the assistant, so that the operator may give his\\nwhole attention to the child. When it is desired to effect a\\nspeedy delivery the patient should be placed in the AValcher\\nposition, and when possible on a table. The foot should be\\ngrasped between the first and second fingers, and the line\\nof traction should be downward and backward in the axis\\nof the pelvic brim. When the leg is beyond the vulva it\\nshould be wrapped in a warm sterile towel, and then as much\\nof the limb as possible should be grasped in the whole hand.\\nThe operator should introduce the forefinger of his free hand\\ninto the vagina and hook it into the posterior groin as soon as\\nit comes within reach, in order to distribute the tractive force\\nas widely as possible, and thus reduce the risks of injury to\\nthe child. As the breech distends the perineum it should be\\ndrawn forward against the pubes, so as to avoid laceration.\\nAs soon as possible the posterior limb should be gently drawn\\nout, in doing this^ pressure on the thigh should be avoided,\\ncare being taken to seize the foot and draw down the leg in\\nsuch a way that the knee comes down in the median line of\\nthe child s body.\\nWhen it is impossible to bring down a foot it may be pos-\\nsible to hook the forefinger in the groin, which may be done in\\nany manner convenient to the operator. Traction may then\\nbe made downward and backward, care being taken to avoid\\npressure on the shaft of the femur, on account of the danger\\nof its snapping.\\nThe blunt hook or fillet may be used as a tractor. The latter", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0235.jp2"}, "230": {"fulltext": "230 PATHOLOGY OF LABOR.\\nshould be used by preference as mucli less liable to do damage\\nto mother or child.\\nThe fillet is usually composed of a strip of sterilized cotton\\nor gauze bandage. The best instrument for placing the fillet\\nis a gum elastic catheter. The catheter should be threaded\\nwith a loop of string and then, with its stilet, should be bent\\nso as to form a large hook. After it has been sterilized the\\nhook should be guided over the anterior hip and rotated so\\nthat its point passes between the child s thigh and abdomen.\\nThe finger should then be passed between the thighs, and the\\nloop of string dragged down until the fillet can be threaded\\nthrough it, when by withdrawing the catheter and string the\\nfillet can be drawn into place. The line of traction should\\nthen be toward the child s sacrum, so as to avoid breaking the\\nfemur.\\nAs a last resort, should all other means fail, the forceps\\nshould be applied to the breech.\\nImpaction in the Pelvic Cavity.\\nWhen the breech becomes impacted in the pelvic cavity (Fig.\\n78) it is generally impossible to draw down a leg.\\nTraction may be exerted by hooking an index-finger into\\nthe groin or the fillet may be used. When these means fail\\nforceps may be employed. If the child is alive and moderate\\ntraction with the forceps fails, then symphysiotomy may be\\nresorted to. When the child has perished embryotomy is\\nnecessary.\\nRapid Extraction of the Trunk.\\nAs soon as the legs and the pelvis of the child have escaped\\nfrom the vulva they should be wrapped in a warm towel and\\ngrasped with both hands in such a way that the thumbs of the\\noperator lie along the sacrum, while the fingers seize the\\nthighs. This gives the most secure grasp. Traction is then\\nmade downward and backward with both hands, while the\\nassistant presses firmly on the fundus. As soon as the cord\\ncan be reached a loop should be drawn down, as is done in\\nnormal delivery of the breech.\\nWhen the angles of the scapulae come into view the delivery", "height": "3712", "width": "2612", "jp2-path": "obstetricsmanual00evan_0236.jp2"}, "231": {"fulltext": "MANAGEMENT OF LABOR IN BREECH PRESENTATIONS. 231\\nof the arms should be attempted. To do this, two fingers of\\nthe operator s hand which corresponds to the arm it is desired\\nto reach, should be passed up over the shoulder and down the\\narm to the elbow, which may then be swept across the chest\\nso as to bring down the forearm and hand, the child s body\\nbeing held in such a position as to give the greatest freedom\\nFig. 78.\\nDelivery of child in a breech case bv traction made with fingers placed in groin.\\n(After A. R. Simpson.)\\nof movement pos.sible to the operator. Having released one\\narm, the operator should then change hands and deliver the\\nother arm by a similar manoeuvre.\\nUpward displacement of the arms Not infrequently the\\narms are found to be displaced upward alongside the head.\\nThis is generally indicated by greater resistance to traction", "height": "3704", "width": "2460", "jp2-path": "obstetricsmanual00evan_0237.jp2"}, "232": {"fulltext": "232 PATHOLOGY OF LABOR.\\nafter the scapulae have oome into view. When this complica-\\ntion is found the body of the foetus should be pushed up in\\nthe axis of the brim, so as to diminish the pressure on the\\narms at that level. The body should then be rotated until its\\nback is directed to one or other side of the mother. Usually\\nthe posterior arm is most accessible, and is therefore brought\\ndown first. Holding the child s body up against the pubes\\nthe operator presses two fingers up over the posterior shoulder\\nto the elbow, and sweeps the arm doAvn across the face and\\nchest, as directed above. Having released the posterior arm,\\nthe child s body is pressed over against the perineum, and the\\nanterior arm is brought down by a similar manoeuvre.\\nThe anterior arm may be so firmly caught between the head\\nand the pubes that it may be impossible to dislodge it. In\\nthis case it should be rotated so as to come into a posterior\\nposition. This rotation is accomplished by grasping the trunk\\nof the child s body firmly with both hands, lowering it so as to\\nbring its long axis to correspond to that of the pelvic brim,\\nand then shoving it up so as to release the anterior arm from\\npressure. As soon as the arm is loose alongside of the head,\\nthe child is rotated about its long axis, so that the arm which\\nhas been anterior passes along the same side of the pelvis\\nbackward and rests in front of the sacro-iliac synchondrosis.\\nBy this manipulation the back is moved from one side to the\\nfront, and then to the opposite side. The arm is then deliv-\\nered as was the posterior arm in the first instance. Occasion-\\nally the anterior arm may be folded behind the occiput. In\\nthis case the revolution of the body must be made in the\\nopposite direction. First turn the abdomen of the child for-\\nward and then to the opposite side, thus causing the shoulder\\nto rotate through three-quarters of a circle.\\nConstriction of the head by the cervix Occasionally the\\ncervix may become tightly constricted about the child s neck\\na condition which generally endangers the life of the child.\\nThe patient should be deeply anaesthetized, and traction made\\non the shoulders with one hand, while the fingers of the\\nother, placed in the child s mouth, give what assistance is\\npossible.", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0238.jp2"}, "233": {"fulltext": "MANAGEMENT OF LABOR IN BREECH PRESENTATIONS. 233\\nDelivery of the After-coming Head.\\nDeventer s method Probably the easiest method of effect-\\ning a speedy delivery in a case in which the pelvis permits the\\ndescent of the head with the arms extended alongside is\\nDeventer s. The body of the child is dropped downward,\\nthe feet are grasped with one hand, while the other presses\\nupon the upper surface of the shoulders, the neck being be-\\ntween the first and second fingers. Traction is made downward\\ntoward the floor, the patient being in the lithotomy position.\\nFig. 79.\\nAnterior rotation of occiput.\\nThus the occiput appears at the vulva, the vertex slips under\\nthe pelvic arch, and the head is delivered in extension, being\\nfollowed by the arms. This method is applicable only in cases\\nin which the pelvic space is sufficient to permit the descent\\nof the head and arms together. When the foetus is small, as\\nin premature cases, this, in the experience of the writer, is\\nthe easiest and most rapid method of delivery. Contrary to\\nexpectation, laceration of the perineum is rare in cases in\\nwhich this method of delivery is possible.", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0239.jp2"}, "234": {"fulltext": "234 PATHOLOGY OF LABOR.\\nArms Delivered Head Still Retained.\\nHaving delivered the arms, the head being still retained,\\nthe operator has five methods of delivery at his disposal.\\n1. The Smellie method The body of the child having been\\nwrapped in a warm towel, is placed on the flexor surface of\\nthe operator s left arm, the legs hanging on either side. The\\nfingers of this hand are passed into the vagina, so that the\\nFig. 80.\\nThe Smellie-Veit method of extracting the after-coming head. (Doderlein.)\\ntips rest on the fossa on either side of the child s nose. The\\nfinger-tips of the right hand are then placed on the child s\\nocciput. Before making efforts at extraction the head is\\nwell flexed by pushing upward with the fingers on the occiput,\\nand at the same time pulling down with the fingers on the\\nface. Having secured good flexion, the operator pulls down-\\nward until the occiput is well under the pubic arch (Fig. 79),\\nand then, but not till then, the trunk is raised, at the same\\ntime that traction is made so as to pivot the occiput under", "height": "3732", "width": "2636", "jp2-path": "obstetricsmanual00evan_0240.jp2"}, "235": {"fulltext": "MAX A GEMEST OF LABOR IN BREECH PRESENT A TIONS. 235\\nthe pubic arch, and thus the face sweeps over tlie periueum\\nand the head is delivered. Care must be exerted not to make\\ntraction with any degree of force once the head distends the\\nperineum, otherwise the head will deliver with a snap and\\nthe result will probably be an extensive laceration.\\n2. The Smellie-Veit or Mauriceau method The child s body\\nis placed on the operator s arm as described above, but one or\\ntwo fingers are inserted into the mouth instead of on either\\nside of the nose. The other hand is passed along the child s\\nback until the middle finger rests on the occipital protuber-\\nance, while the index and ring fingers are flexed over the\\nFig. 81.\\nThe Wigand-Martin method of delivering the after-coming head. (Doderlein.)\\nshoulders on either side of the neck (Fig. 80). Having\\nloosened the head and secured good flexion, traction is then\\nmade with both hands at once, in the axis of the pelvic out-\\nlet, until the occiput pivots under the pubes then the child s\\nbody is carried upward toward the mother s abdomen, this\\nmovement being made very slowly and deliberately, to avoid\\nlaceration of the perineum. Care must be taken not to fract-\\nure or dislocate the lower jaw.", "height": "3708", "width": "2480", "jp2-path": "obstetricsmanual00evan_0241.jp2"}, "236": {"fulltext": "236\\nPATHOLOGY OF LABOR.\\n3. Wigand-Martin method The child s body is held on the\\nleft arm, tlie index-finger of the left hand being inserted into\\nthe mouth in order to fiex the head. The right hand is then\\nplaced on the mother s abdomen over the pubes, so as to\\nsecure a firm grasp of the head\\nFig. 82. (l^^ig- ^1)- Firm pressure is then\\nmade with the right hand in the\\naxis of the parturient canal at\\nthe same time traction is made\\nwith the left hand, and as the\\nhead descends the child s body is\\nelevated toward the mother s ab-\\ndomen.\\n4. Prague method Having wrap-\\nped the body in a warm towel, the\\noperator seizes the child s feet with\\nthe right hand, the middle finger\\nbeing placed between the internal\\nmalleoli, the index and ring fingers\\nbeing above the external malleoli.\\nThe left hand is then placed on the\\nchild s shoulders in such a way as\\nto secure a firm grasp (Fig. 82).\\nFlexion is then made downward\\nwith both hands until the occiput\\nappears under the pubes. Then\\nthe right hand swings the body\\nupward, at the same time making\\ntraction, while the left hand is held\\nfirmly in position, being used as a\\nfulcrum around which the head\\nmoves, until it is finally forced\\nout of the parturient canal by\\nthis lever-like movement of the\\nPrague grasp. body.\\nThe force exerted by this method\\nis very considerable, and therefore it should be used only after\\nthe foregoing methods have been attempted.\\n5. Forceps Manual efforts at extraction having failed, the\\nforceps may be used. To permit the application of the blades,", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0242.jp2"}, "237": {"fulltext": "TRANSVERSE PRESENTATIONS. 237\\nthe chilcFs head must be held up toward the mother s abdo-\\nmen by an assistant. Properly directed suprapubic pressure\\nby an assistant increases the efficacy of all methods of deliv-\\nering the after-coming head. Six minutes is the maximum\\ntime at the operator s disposal once the placental circulation\\nhas been completely cut oif. Therefore it is advisable to have\\nthe assistant call off the minutes as the time passes, so that\\nthe last two may be utilized for the application of the forceps\\nshould recourse to these instruments be required.\\nTRANSVERSE PRESENTATIONS.\\nDefinition Any presentation of the trunk of the child s\\nbody is termed a transverse presentation. As the result of\\nuterine action after the onset of labor transverse presenta-\\ntions resolve into shoulder presentations. The term Gross-\\nbirth is frequently applied to a transverse presentation.\\nFrequency Less than 0.5 per cent, of all cases of labor\\npresent transverse presentations.\\nCauses The same causes that result in breech presentations\\nalso act in producing transverse presentations.\\nVarieties The long axis of the tnmk is very rarely trans-\\nverse, but is usually obliquely placed as regards the long axis\\nof the uterus thus any part of the foetus may present at the\\nbrim.\\nPositions: Some writers classify transverse presentations\\naccording to the position of the lowest shoulder, making use\\nof the scapula as the denominator e. g., S. L. A. S. R. P.,\\netc. It is generally sufficient to classify the positions as\\nfollows\\n1 Dor so-anterior\\n(a) Head on the right side of mother.\\n(b) Head on left side (Fig. 83).\\n2. Dorsoposterior\\n(a) Head on right side.\\n(6) Head on left side.\\nThe most frequent position is dorso-anterior, head to the\\nright side of the mother.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0243.jp2"}, "238": {"fulltext": "238\\nPATHOLOGY OF LABOR.\\nDiagnosis of Transverse Presentations.\\nAbdominal examination: On inspection the shape of the\\nuterine tumor will be noticed to be abnormal. The longest\\ndiameter, instead of being vertical, will be found to be oblique,\\nFig. 83.\\nTransverse presentation. Dorso-anterior, head on left side, arm prolapsed.\\n(Farabeuf.)\\nor even transverse. The head Avill generally be found in one\\nor other iliac fossa, while it is impossible to explore the pelvic\\nexcavation from above, for the trunk, as a rule, completely\\nfills the false pelvis. If the back is to the front, its smooth", "height": "3712", "width": "2636", "jp2-path": "obstetricsmanual00evan_0244.jp2"}, "239": {"fulltext": "MECHANISM OF TRANSVERSE PRESENTATIONS. 239\\nsurface can be felt across the lower zone of the mother s abdo-\\nmen. If the back is directed posteriorly, the foetal limbs can\\nbe felt in front. The foetal heart-sounds are heard below the\\numbilicus, plainly when the back is to the front faintly, if at\\nall, when the limbs are anterior.\\nVaginal examination If the membranes are unruptured, no\\npart of the foetus can be reached by the examining finger\\nwithout great difficulty. Occasionally a limb or the prolapsed\\ncord may be felt within the bag of waters. When the mem-\\nbranes have ruptured the finger may come in contact with an\\narm or the shoulder. The landmarks to be felt are the clav-\\nicle, the humerus, and the spine of the scapula. The finger may\\nbe forced into the axilla and the ribs felt, thus distinguishing\\nit from the groin. Very frequently in transverse presen-\\ntations a hand is found prolapsed, which hand it is being\\ndistinguished by shaking hands with it.\\nPrognosis.\\nAs spontaneous delivery is very rare in transverse presen-\\ntations, the prognosis in cases left to Nature is very grave,\\nboth for the mother and the child. As artificial delivery is\\nthe rule in these cases, the prognosis depends on the length\\nof time the case has been allowed to go on without treat-\\nment and the nature of the operative interference.\\nThe dangers to the mother are exhaustion, rupture of the\\nuterus from thinning out of the lower uterine segment, risks\\nof operative interference and of subsequent sepsis.\\nMechanism of Transverse Presentations.\\nAs a rule, natural delivery is impossible in transverse pres-\\nentations, but in extremely rare instances Nature may effect\\ndelivery by one of th^ee methods\\n1. Spontaneous version Uterine contractions may result in\\ndisplacement of the foetus and its gradual version, so that its\\nlong axis finally corresponds to the long axis of the uterus.\\nThus the transverse presentation becomes altered to that of\\nthe breech or the head, the delivery then taking place accord-\\ning to the new presentation. Spontaneous version may take", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0245.jp2"}, "240": {"fulltext": "240\\nPATHOLOGY OF LABOR.\\nplace before or after rupture of the membranes, and is more\\nlikely to occur in multiparse and when the child is living.\\n2. Spontaneous evolution This mechanism is favored by\\nexcessively strong uterine contractions, a roomy pelvis, and a\\nsmall foetus.\\nBy the strong uterine contractions the anterior shoulder is\\nforced down into the pelvis, and rotates to the front, while the\\nhead lies above the brim and over the pubes the breech and\\ntrunk are then compressed, and gradually forced past the\\nhead and anterior shoulder, which pivots on the pubic arch.\\nFig. 84.\\nSpontaneous evolution. First stage.\\nThus the chest and breech slip past the shoulder, over the\\nperineum, and are delivered. Finally the head enters the pel-\\nvis and rotates, so that the occiput pivots under the pubic arch\\nand the face sweeps over the perineum, thus completing the\\ndelivery (Figs. 84-88).\\n3. Delivery with the body doubled up (Evolutio con duplicato\\ncorpore) The conditions favoring this mechanism are strong\\nI", "height": "3712", "width": "2648", "jp2-path": "obstetricsmanual00evan_0246.jp2"}, "241": {"fulltext": "MECHANISM OF TBANSVEBSE PRESENTATIONS. 241\\nFig. 85.\\nSpontaneous evolution. Second stage.\\nFig. 86.\\nSpontaneous evolution. Third stage.\\n16\u00e2\u0080\u0094 Obit.", "height": "3708", "width": "2456", "jp2-path": "obstetricsmanual00evan_0247.jp2"}, "242": {"fulltext": "242\\nPATHOLOGY OF LABOR.\\nFig. 87.\\nSpontaneous evolution. Fifth stage.", "height": "3712", "width": "2652", "jp2-path": "obstetricsmanual00evan_0248.jp2"}, "243": {"fulltext": "MECHANISM OF TRANSVERSE PRESENTATIONS. 243\\nuterine contractions, a roomy pelvis, and a small dead foetus.\\nThe presenting shoulder is driven down into the pelvis and is\\nFig. 89.\\nBirth of child doubled. Evolutio con duplicato corpore. (Kleinwachter.)\\ndelivered first, the head and chest of the foetus are com])ressed\\ntogether and forced through the canal, being thus delivered,\\nand are followed by the breech and legs (Fig. 89).", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0249.jp2"}, "244": {"fulltext": "244 rATHOLOGY OF LABOR.\\nManagement.\\nTransverse presentations should never be left to Nature to\\ndeliver. If seen early and the foetus is alive, version should\\nbe performed.\\nIf seen late, when impaction has taken place and the foetus\\nhas perished, then, if version cannot be easily performed,\\ndecapitation and evisceration should be done, so as to reduce\\nthe risk to the mother to the smallest possible limit.\\nPROLAPSE OF THE FCETAL LIMBS.\\nIn Head Presentations.\\nAny or all of the foetal extremities may prolapse alongside\\nthe head.\\nThe most common form of this accident is a prolapse of a\\nhand, which, when it occurs, is found close to the temporal\\nregion. The worst form is when an arm lies across the back\\nof the neck.\\nTreatment.\\nIf the condition is discovered before the rupture of the\\nmembranes, an attempt should be made to overcome the d\\\\^-\\nQ\\\\x\\\\iy hy postural treatynent. The woman should lie on the\\nside opposite the prolapsed extremity, with the hips slightly\\nelevated.\\nAfter the membranes have ruptured an attempt should be\\nmade to dislodge and push up the prolapsed extremity. To\\ndo this the woman should be placed as recommended above.\\nShould the attempt fail ihefoixeps may be applied, care being\\ntaken to avoid including the hand in the grasp of the blades,\\nand the head drawn down to the outlet. This very often\\ncauses the arm to slip up out of the way. Should it be found\\nimpossible to dislodge the arm sufficiently to apply the forceps,\\nversion may be carried out.\\nWhen the condition is not discovered till the head is low\\ndown in the cavity, the forceps should be applied and the case\\nterminated as rapidly as is possible.", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0250.jp2"}, "245": {"fulltext": "TWIN LABORS. 245\\nIn Breech Presentations.\\nThe prolapse of the hand is of no importance in breech\\npresentations, and no attention need be paid to it.\\nIn Transverse Presentations.\\nThe prolapse of a foot is, of course, favorable.\\nShould a hand or arm l)e found prolapsed, if it cannot be\\npushed up out of the way, it may be drawn down sufficiently\\nto fasten a broad piece of tape about the wrist. After version\\nhas been performed the tape may be held so as to prevent the\\narm from rising alongside the head and complicating its\\ndescent.\\nPLURAL BIRTHS.\\nTwin Labors.\\nThese are usually easy and uncomplicated.\\nTwin pregnancy occurs about once in 130 cases of gesta-\\ntion while triplets occur about once in 5088 cases.\\nThe tendency to twin pregnancy is very frequently heredi-\\niary. The greatest number of reported cases have occurred in\\nfirst pregnancies.\\nAccording to the origin of the ova will arise the various\\npeculiarities in the development of the placentae and mem-\\nbranes.\\nIf the two ova have been derived from separate Graafian\\nfollicles, each will have its own placenta, cord, chorion, and\\namnion, each being indej^endent of the other.\\nShould the two ova have been derived from a single\\nGraafian follicle, the amniotic sacs will be distinct, but the\\nchorion and placenta will be in common, the two cords aris-\\ning from the same placenta.\\nUsually twins arising from ova from a single Graafian\\nfollicle, are of the same sex while when the original ova\\nare distinct each is of an opposite sex. Male twins are\\nslio^htlv more common than female twins.\\nDiagnosis Very frequently the diagnosis of twins is not\\nmade until after the birth of the first child. The only certain", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0251.jp2"}, "246": {"fulltext": "246 PATHOLOGY OF LABOR.\\nsigns of twin pregnancy are the presence of two foetal heart-\\nsounds, heard at different points over the abdominal surface,\\nand having a different rhythm and the palpation of two dis-\\ntinct heads.\\nOtJier signs are, excessive size of the abdomen, with in-\\ncreased uterine distention, irregularity of the uterine outline,\\nand the presence of a number of foetal extremities.\\nPrognosis The maternal prognosis is somewhat graver than\\nin single births. The dajigers are uterine inertia due to\\noverdistention of the uterine walls; abnormal presentation\\nalbuminuria and eclampsia, more frequent in plural preg-\\nnancies hemorrhage in the third stage of labor from trouble\\nin the delivery of the placenta.\\nThe foetal prognosis is always more serious than in single\\nbirths. The dangers are deficient development from over-\\ncrowding in the uterus; malposition and malpresentation\\nand hydramnios.\\nMechanism The following table from Spiegelberg, based\\non 1138 labors, gives the combined presentations in their\\norder of frequency.\\nBoth heads presenting 49.00 per cent.\\nHead and breech 31.70\\nBoth pelvic presentations 8.60\\nHead and transverse 6.18\\nBreech and transverse 4.14\\nBoth transverse 0.37\\nThe order of delii^ery varies. When both heads present,\\nusually the larger is delivered first. If one twin presents by\\nthe breech and the other by the head, usually the latter is\\ndelivered first if one presents transversely and the other\\nlongitudinally, the latter is usually expelled first.\\nManagement of labor: When the presentation of the first\\nchild is normal no special treatment is indicated. When the\\nfirst child has been delivered and its respiratory function well\\nestablished, before cutting the cord the physician should pal-\\npate the mother s abdomen to ascertain the position of the\\nsecond child. If any abnormality exists, it should be at once\\ncorrected by external manipulations and the fundus uteri\\ngently kneaded to stimulate retraction. The fundus may then\\nbe placed in charge of the nurse or assistant while the physi-", "height": "3728", "width": "2660", "jp2-path": "obstetricsmanual00evan_0252.jp2"}, "247": {"fulltext": "TWiy LABORS. 247\\ncian attends to the cord of the first child. This should be\\ntied in two places and then divided between the ligatures, in\\ncase there should be communication between the placental\\ncirculations and the second child bleed to death.\\nFriction on the fundus should be sustained until the uterine\\ncontractions are firmly established. It is not advisable to\\nwait more than half an hour for the birth of the second child.\\nThe second amniotic sac should then be ruptured and the\\nuterine contractions reinforced by firm pressure on the fundus\\nso as to expedite the delivery of the second child.\\nFrom this time until retraction has been firmly established,\\nafter the complete emptying of the uterus, the fundus should\\nbe kept constantly under control in order to prevent its relax-\\nation and the occurrence of hemorrhage.\\nShould hemorrhage follow the delivery of the first child,\\nthe second should be delivered as rapidly as possible, either\\nby forceps or version, and the uterus emptied artificially. It\\nis not advisable to inform the mother during labor, should a\\ndiagnosis of twins be established, as the shock may inhibit\\nuterine action.\\nComplications of Twin Births.\\nCompound presentations Occasionally both foetuses tend to\\nengage simultaneously in the brim. AVhen both heads tend\\nto present at the same time, the highest should if possible be\\npushed up, and the forceps then applied to the lower head\\nand traction exerted until it is firmly engaged. During the\\ntraction an assistant may be able to hold the head of the other\\nchild out of the way, by pressure on the abdominal wall of\\nthe mother.\\nWhen the head of one child and the breech of the other\\ntend to engage at the same time, the breech should be pushed\\nup and the head drawn down.\\nAVhen foetal extremities are found to present along with a\\nhead, they should be replaced and the head drawn down by\\nmeans of the forceps.\\nInterlocking twins: Occasionally both heads enter the\\npelvis, one being generally well in advance of the other. The\\nupper head then becomes jammed against the neck and thorax\\nof the first child.", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0253.jp2"}, "248": {"fulltext": "248 PATHOLOGY OF LABOR.\\nTreatment: The most advanced head should be delivered\\nby forceps, as unlocking is generally out of the question.\\nThe second head should then be delivered, and when this is\\ndone the body of the first child may be extracted, the head\\nof the second being held out of the way by an assistant.\\nSometimes it is necessary to perforate one of the heads in\\norder to permit the delivery of the other. When this opera-\\ntion is required it should be performed on the head of the first\\nchild, because the second is more likely to be alive, there being\\nless risk of compression of its cord.\\nIn cases in which the breech of one child and the head of the\\nother become impacted in the pelvis an endeavor should be\\nmade to push up the head and deliver the breech. The body\\nof the child presenting by the breech should only be delivered\\nas far as the neck, as the two heads usually become locked at\\nthe brim by the overlapping of the chins or of the occiputs, or\\nby the face of one child being pressed against the back of the\\nother child^s neck.\\nShould it be impossible to push back the head of the second\\nchild or to apply forceps and deliver it, the head of the breech\\nchild should be perforated and extracted before attempting to\\ndeliver the other.\\nTriplets.\\nAs a rule no difficulty is encountered in the delivery of trip-\\nlets, as the greater the number of foetuses the greater the\\ntendency to prematurity of delivery.\\nThe labor is generally prolonged on account of delay in\\nthe first stage from imperfect uterine contractions.\\nThe third stage must be very carefully managed, and it is\\nadvisable to empty the uterus artificially in order to insure\\nthat no portions of placenta are retained.\\nDYSTOCIA DUE TO ANOMALIES OF FCETAL\\nDEVELOPMENT.\\nOvergrowth of the Foetus.\\nDefinition A child may be said to be overgrown when it\\nweighs eleven pounds, or over, at the time of birth. It is but\\nvery seldom that a child is born weighing twelve pounds but", "height": "3704", "width": "2676", "jp2-path": "obstetricsmanual00evan_0254.jp2"}, "249": {"fulltext": "PREMATURE OSSIFICATION OF THE SKULL. 249\\ncases are recorded in which the birth- weight was over twenty\\npounds.\\nCause Nothing definite is known as to the cause of\\nthis overgrowth. Multi parity, advanced age of one or both\\nparents, and prolongation of pregnancy are generally regarded\\nas the probable causes.\\nMechanism When the head presents in these cases it\\ngenerally enters the pelvis in extreme flexion. Moulding is\\ngenerally very marked as the result of a prolonged second\\nstage.\\nTreatment.\\nThe best treatment is prophylactic. When the condition is\\nsuspected, which is rare, a careful palpation should be made\\nand the size of the head estimated. The head should then\\nbe forced into the brim by the pressure from above, to give\\none an approximate idea of the relative size of the pelvis. If\\nit be found that it is a tight fit, then labor should be at once\\ninduced, as no advantage can be gained by waiting on nature.\\nWhen the condition is not discovered until labor, then the\\nproper course to pursue is to support the patient s strength\\nand control the pains by means of hypodermics of morphine as\\noften as required, until the head has had time to mould thor-\\noughly, when forceps may be applied and an attempt made to\\ndeliver the child. Care should be taken to avoid excessive\\nforce in traction.\\nIf no advance is made, and the child is alive, symphysiotomy\\nis then necessary.\\nWhen the condition is recognized early and the disproportion\\nbetween the head and the pelvis is not marked, inteimal ver-\\nsion may offer the child a greater chance of life than a high\\nforceps operation. The choice of operation depends in great\\nmeasure on the skill of the operator in performing the one or\\nthe other.\\nIf the child has perished, embryotomy should be the operation\\nof choice.\\nPremature Ossification of the Skull.\\nPremature ossification of the bones of the skull, causing\\nmore or less obliteration of the sutures and fontanelles, greatly", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0255.jp2"}, "250": {"fulltext": "250 PATHOLOGY OF LABOR.\\nmodifies the moiildability of the head, and may thus lead to\\ndelay in labor.\\nPosition The head may be arrested at the brim or in tlie\\ncavity.\\nTreatment Forceps or symphysiotomy may be necessary to\\nsecure delivery of a living child.\\nHydrocephalus.\\nThis is probably the commonest cause of excessive size of\\nthe foetal head.\\nEtiology The condition is due to the accumulation of the\\nserum in the ventricles of the brain. The accumulation of\\nfluid may be so great as to cause obliteration of the cerebral\\nconvokitions and excessive thinning of the cranial bones,\\nwhich become widely separated. From the excessive size of\\nthe vault the face appears small. Spina bifida or some other\\nmalformation is generally present in these cases.\\nDiagnosis In about a third of all cases of hydrocephalus\\nthe breech presents. The condition should always be sus-\\npected when in vertex presentations the head fails to engage\\nin the brim, although the pelvis is normal in size and no\\ngood reason can be found for the delay.\\nBy abdominal examination the gaping fontanelles and\\nsutures may be made out and fluctuation may be obtained in\\nthese regions. The cranial bones may be felt to be excessively\\nthin, and pressure on them may give the sensation of crepita-\\ntion. The head is felt to be enlarged and soft.\\nThese conditions may be better felt by a bimanual examina-\\ntion when this is possible.\\nPrognosis The life of the child is to be considered as of\\nlittle moment, for should it survive birth death generally\\ntakes jilace shortly after.\\nDeath of tlie mother may result from exhaustion or from\\nrupture of the uterus. The rupture generally occurs in the\\nlower segment, which becomes greatly stretched and thinned.\\nTreatment When the head presents (Fig. 90), it should be\\nperforated and the fluid permitted to drain away. When the\\nhead collapses delivery may be effected either by version or\\nby means of a cranioclast.", "height": "3712", "width": "2684", "jp2-path": "obstetricsmanual00evan_0256.jp2"}, "251": {"fulltext": "HYDROCEPHAL US.\\n251\\nForceps should never be applied to a hydrocephalic head\\nif the condition is at all marked, as it is impossible to secure\\na good grasp on account of its compressibility.\\nWhen the breech presents, the trunk and arms may be ex-\\ntracted and an attempt made to perforate the cranial vault by\\nFig. 90.\\nThinning of lower segment of uterus in obstruction from hydrocephalus.\\nI After Bandl.)\\nthe temporal fontanelle. If this cannot be reached, then the\\nspinal canal should be opened in the dorsal region by means\\nof a pair of scissors, and a catheter passed through it into\\nthe cranial cavity and the fluid thus evacuated (Van HuevePs\\nmethod: Fig. 91).", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0257.jp2"}, "252": {"fulltext": "252\\nPATHOLOGY OF LABOR.\\nFig. 91.\\nPuncture of spinal canal in a case of hydrocephalus obstructing labor.\\n(After Herrgot.)\\nEncephalocele Meningocele Hydrencephalus.\\nThese conditions when present do not often seriously com-\\nplicate labor, as the tumors are either small or are so situ-\\nated that they fail to affect materially the progress of the\\ncase. If obstruction to labor occur, the growth should be\\nperforated, when its contents will drain away and make de-\\nlivery possible.\\nTumors of the Foetal Trunk.\\nCertain tumors arising in connection with the foetal trunk\\nmay by their bulk or situation induce dystocia.", "height": "3712", "width": "2692", "jp2-path": "obstetricsmanual00evan_0258.jp2"}, "253": {"fulltext": "DYSTOCIA DUE TO ABNORMALITIES, ETC. 253\\nVarieties Spina bifida teratomata situated on the spine,\\njaw, or orbit hydrothorax ascites cystic degeneration of\\nthe kidneys malignant conditions of the liver, spleen, or\\npancreas distention of the urinary bladder, and hernia of\\nviscera through clefts in the abdominal or thoracic walls, may\\nbe mentioned under this heading.\\nTreatment Should delivery be delayed, forceps or version\\nmay be resorted to, or some form of embryotomy. Tumors\\nwith fluid contents should be evacuated.\\nMonstrosities.\\nAnencephalus or hemicephalus is the form most commonly\\nmet with. Delay is generally caused in the first stage by the\\nabsence of the head as a dilator. When the diagnosis is\\nmade, version, if possible, should be performed.\\nDouble monsters These may very seriously complicate\\nlabor; but, as a rule, the foetuses are small and delivery\\noccurs naturally. In difficult cases craniotomy or some other\\nform of embryotomy is necessary to effect delivery.\\nDYSTOCIA DUE TO ABNORMALITIES OF THE F(ETAL\\nAPPENDAGES.\\nShort cord Cases have been recorded in which the cord\\nhas not measured more than two inches in length. Relative\\nshortness of the cord may occur from its coiling around the\\nneck and limbs of the foetus.\\nThe condition may lead to premature detachment of the\\nplacenta, rupture of the cord, or compression of its vessels\\nfrom stretching, which results in death of the foetus.\\nThe diagnosis is difficult. Sometimes the patient com-\\nplains of marked pain at the placental site during each con-\\ntraction. Occasionally a portion of the uterine wall may be\\nfelt to be drawn downward and inward during each contrac-\\ntion. Frequently the presenting part is retracted rapidly as\\nthe uterine contraction subsides.\\nTreatment consists in rapid delivery with the forceps or by\\nversion.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0259.jp2"}, "254": {"fulltext": "254 PATHOLOGY OF LABOR\\nProlapse of the Cord.\\nA loop of the umbilical cord may prolapse alongside or in\\nfront of the presenting part. As labor progresses the cord\\nis exposed to pressure between the presenting part and the\\npelvic wall, which results in interruption of the foetoplacental\\ncirculation, and possibly in the death of the foetus.\\nProlapse of the cord may occur either before or after rupt-\\nure of the membranes.\\nFrequency This accident occurs once in about 250 cases of\\nlabor. It is met with most frequently in presentations of\\nthe pelvic pole of the foetus.\\nEtiology The essential cause of prolapse of the cord is\\nfailure of the presenting part of the foetus to fill, completely\\nand continuously, the lower segment of the uterus.\\nThe foetal conditions which predispose to this accident are:\\nmalpositions and malpresentations small size and increased\\nmobility of the foetus anomalies of other fcetal appendages,\\nas marginal insertion or excessive length of the cord, hydram-\\nnios, placenta prsevia and sudden escape of the liquor amnii\\nwith the patient in the erect position.\\nThe predisposing maternal conditions are pelvic deformity\\nrelaxed abdominal wall, as in some multiparae uterine and\\nother tumors uterine obliquity.\\nThe accident is also more liable to occur in cases of multi-\\nple pregnancy.\\nDiagnosis.\\nBefore the rupture of the membranes it is a somewhat diffi-\\ncult matter, as a rule, to recognize a prolapse of the cord on\\naccount of its non-resisting nature and the ease with which\\nit recedes before the examining finger.\\nAfter rupture of the membranes it may be generally recog-\\nnized without difficulty, on account of its twists and the pulsa-\\ntions of its vessels.\\nIt has been not infrequently mistaken for a prolapsed loop\\nof intestine and occasionally a portion of intestine has been\\nmistaken for the cord. Care in examination should make\\nsuch an error in diagnosis impossible.\\nThe position the cord usually occupies is at one or other", "height": "3704", "width": "2692", "jp2-path": "obstetricsmanual00evan_0260.jp2"}, "255": {"fulltext": "PROLAPSE OF THE CORD. 255\\nside of the pelvis somewhat posteriorly rarely it may lie\\neither in front of the promontory or behind the symphysis\\npubis.\\nWhen the foetal heart- sounds grow progressively weaker\\nand no cause is apparent, prolapse of the cord should be\\nsuspected and appropriate treatment inaugurated.\\nPrognosis.\\nThis complication rarely influences the prognosis for the\\nmother, save in so far as the operative treatment exposes her\\nto risks of shock and sepsis.\\nFor the child the prognosis is somewhat grave, the mortality\\nrising to somewhat over 50 per cent. The cause of foetal\\ndeath is occlusion of the foetoplacental circulation from press-\\nare on the cord. This pressure results in asphyxiation of\\nthe child. Should the prolapsed portion of the cord show an\\nabsence of pulsation for ten or fifteen minutes, and abdominal\\nauscultation fail to permit the detection of heart-sounds, the\\ndeath of the foetus is assured.\\nTreatment.\\nIf the child has perished, no treatment is indicated, and\\nthe case may be left to Nature.\\nBefore rupture of the membranes The indications for\\ntreatment are to prevent rupture of the membranes as long as\\npossible, and to favor the replacement of the cord by appro-\\npriate posturing of the patient. The woman should be made\\nto adopt the genupectoral posture (Fig. 92). While the\\npatient is in this position the influence of gravity causes the\\ncord to settle slowly toward the fundus, and thus the pro-\\nlapsed loop is gradually withdrawn. During the intervals be-\\ntween the pains this may be gently pushed back with the\\nhand, care being taken not to rupture the membranes. When\\nthe condition has been correeted, the patient may be permitted\\nto recline on the side opposite to that occupied by the cord.\\nThe change of position should be made slowly and carefully,\\nso as to avoid forcing the cord down again. The membranes\\nmay then be ruptured, care being taken to force the head\\ndown by pressure from above while this is being done.", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0261.jp2"}, "256": {"fulltext": "256\\nPATHOLOGY OF LABOR\\nAfter rupture of the membranes Before attempting to re-\\nplace the prolapsed loop of cord after rupture of the mem-\\nbranes, care should be taken to find out whether the child is\\nalive. If pulsation has ceased in the cord, the heart may still\\nbe beating if this is the case, the presenting part should be\\npushed up, and the cord replaced after pulsation returns.\\nThe woman should be placed in the Sims position on the\\nside opposite to the prolapsed cord. The hips should be ele-\\nvated by means of a folded pillow. The operator should then\\npush back the presenting part so as to release the cord. This\\nFig. 92.\\nPostural treatment of prolapse of the cord.\\nmay then be loosely twisted, care being taken not to interfere\\nwith its pulsations, and the twisted mass gently pushed up\\nbeyond the presenting part.\\nIf it be found impossible to replace the cord with the woman\\nin the Sims position, she should be placed on her knees and\\nchest and another attempt made, if necessary giving an anaes-\\nthetic so as to relax the uterus completely. Tlie objection\\nto the knee-chest position is the tendency for air to enter the\\nuterine cavity if this accident occurs, the subsequent labor\\nshould not be unduly prolonged.\\nShould manual efforts fail, a suitable instrument for replac-", "height": "3712", "width": "2672", "jp2-path": "obstetricsmanual00evan_0262.jp2"}, "257": {"fulltext": "PROLAPSE OF THE CORD.\\n257\\nmg the cord may be improvised with a No. 10 or No. 12 gum\\nelastic catheter and some tape. A loop of tape is made to\\nencircle the cord loosely, and its free ends are attached to the\\ntip of the catheter. The catheter, with its stylet inserted, is\\nthen pushed well up into the uterus, carrying the cord with it\\n(Figs. 93, 94, and 95). The stylet is then withdrawn and the\\nFig. 93.\\nFig. 94.\\nReposition of cord.\\n(Witkowski.)\\nBraun s reposition of cord.\\n(Witkowski.)\\ncatheter left in the uterus to come away with the child. Care\\nshould be taken to remove the bone button from the end of\\nthe catheter.\\nIf all attempts at reposition of the cord fail, then either\\nversion or forceps, with rapid delivery, must be resorted to\\nin order to save the life of the child. Before either of these\\noperations the loop of the cord should be placed opposite the\\nsacro-iliac joint, where it will be least pressed upon.\\n17\u00e2\u0080\u0094 Obst.", "height": "3700", "width": "2484", "jp2-path": "obstetricsmanual00evan_0263.jp2"}, "258": {"fulltext": "258\\nPATHOLOGY OF LABOR\\nCoiling of the Cord about the Foetal Neck.\\nQuite frequently the f(ietal cord is found to be coiled about\\nthe neck of the child. It may encircle the neck several times,\\nand thus produce a relative shortening\\nFig. 95. of the cord.\\nThe condition is difficult to diagnose\\nbefore delivery of the head. It may\\nbe suspected if the head descends well\\nwith each pain, but rapidly recedes in\\nthe interval between the contractions.\\nResults Occasionally the traction is\\nso severe as to interfere with the foeto-\\nplacental circulation and has been\\nknown to cause premature detachment\\nof the placenta.\\nThe only treatment that can be sug-\\ngested is the application of the forceps\\nand the rapid delivery of the head\\nwhen the cord may be cut and un-\\ncoiled from the neck before the birth\\nof the trunk takes place.\\nPlacenta Praevia.\\nThe placenta is normally implanted\\nentirely within the upper uterine seg-\\nment.\\nWhen it is implanted, in whole or in\\npart, upon the lower uterine segment the\\ncondition is known as placenta praevia.\\nVarieties Three varieties are de-\\nscribed\\n(1) Placenta praevia centralis: The\\nplacenta is so situated that its centre\\ncorresponds with the internal os (Fig.\\n96).\\n(2) Placenta praevia marginalis The\\nplacenta is situated so that but a portion of its margin over-\\nlaps the internal os (Fig. 97).\\n(3) Placenta praevia lateralis The placenta is situated on\\nAnother method of reposi\\ntion of cord.", "height": "3712", "width": "2684", "jp2-path": "obstetricsmanual00evan_0264.jp2"}, "259": {"fulltext": "PLACENTA PREVIA.\\n259\\nthe lateral wall of the uterus, extending well down into the\\nlower segment, but not reaching as far as the internal os\\n(Fig. 98).\\nIn the central and marginal varieties the hemorrhage may\\nbegin early in pregnancy it is repeated frequently, and in\\nlabor is much more serious than in the lateral variety.\\nFig. 97.\\nPlacenta prsevia centralis. Placenta prsevia marginalis.\\nFig. 98.\\nPlacenta praevia lateralis. (After Dakin.)\\nFreciuency Placenta pra^via centralis is very rare lateral\\nand marginal placenta praevia are the commonest varieties.\\nPlacenta prsevia occurs about once in 1000 cases. Tt is more\\nfrequently met with in multiparse than in primiparse.\\nEtiology: A satisfactory explanation of the occurrence of", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0265.jp2"}, "260": {"fulltext": "260 PATHOLOGY OF LABOR.\\nplacenta praevia has never been advanced. Chronic inflamma-\\ntory changes in the mucous membrane certainly predispose to\\nits occurrence. Other probable causes are subinvolution,\\natrophy of the decidua, new growths, and malformations of\\nthe uterus.\\nSymptoms and Physical Signs.\\nThe symptoms of placenta prsevia do not usually present\\nthemselves until after the sixth month of pregnancy.\\nThe first indication of the condition is a sudden gush of\\nblood from the genitals, usually without apparent cause and\\nwithout pain. The bleeding then recurs at intervals as preg-\\nnancy advances. The amount of blood lost is proportionate\\nto the extent of the placental separation. When hemorrhage\\ntakes place during pregnancy it is probably due to a partial\\nseparation of the placenta in the lower uterine segment, Avhere\\nits attachment is imperfect. This separation is caused by the\\nnormal uterine contractions which constantly occur through-\\nout pregnancy.\\nThe first hemorrhage when it occurs during labor may be so\\nsevere as to threaten the patient s life. As a rule, the bleeding\\nis most profuse in the intervals between the pains but this\\ncannot be said to be diagnostic of the condition.\\nBy abdominal examination the location of the placenta may\\nbe recognized, when the implantation is on the anterior uterine\\nwall, by feeling its edge, which presents as a resisting ring.\\nBelow this point the uterus feels soft and boggy, and the foetal\\nparts can only be felt indistinctly, while elsewhere they may\\nbe readily made out. Over this boggy area the placental bruit\\nis to be heard with great distinctness. If the larger portion\\nof the placenta occupies the lower uterine segment, malpres-\\nentations of the fretus may occur, as the presenting part is\\nthus prevented entering the pelvic brim.\\nBy vaginal examination the cervix and lower uterine seg-\\nment are found to be softer than usual. If the insertion of\\nthe phicenta is marginal, one side of the cervix and lower seg-\\nment may be softer and more boggy than the other. Pul-\\nsating vessels may be felt around the cervix.\\nThe external os is usually patulous, and through it the\\nfinger may be pushed till the internal os is reached, where the", "height": "3712", "width": "2668", "jp2-path": "obstetricsmanual00evan_0266.jp2"}, "261": {"fulltext": "PLACENTA PRMVIA. 261\\nmaternal surface of the placenta may be felt, a gritty feel dis-\\ntinguishing it from a blood-clot or the membranes.\\nDiagnosis.\\nWhen hemorrhage takes place in the later months of preg-\\nnancy a careful examination should be made to ascertain its\\ncause. The rupture of a varicosed vein in the vagina and\\npremature detachment of the normally situated placenta may\\nlead to severe hemorrhage in the later months of pregnancy.\\nA careful and systematic examination will generally permit a\\ndiagnosis to be made.\\nTreatment of Placenta Praevia.\\nThe control of hemorrhage is the principal indication of\\ntreatment.\\nIn the rare cases in which the condition of placenta prsevia\\nis recognized before the foetus is viable it may be possible to\\ncarry out an expectant plan of treatment until the seventh\\nmonth of the pregnancy is reached. The patient must be\\nkept in bed, not being permitted to rise for any purpose. It\\nmay be well to administer chloral (gr. xv) or liq. opii sed.\\n(trixv) two or three times daily to control the nervous system.\\nWhen the seventh month has been reached labor should be\\ninduced, as after this period the woman may bleed to death\\nbefore medical aid can reach her.\\nBeing satisfied that the condition of placenta prsevia is\\npresent, it is the duty of the physician at once to empty the\\nuterus if the child is viable.\\nThe patient should be anaesthetized and placed in the\\nlithotomy position, with her hips at the edge of the bed. A\\nKelly pad should be placed under her. The vulva and vagina\\nshould then be scrubbed and douched with formalin or bi-\\nchloride solution. The operator having sterilized his hands\\nand arms, should then dilate the cervix by inserting one\\nfinger, then a second, and then the thumb of the right hand.\\nSearch should then be made for the edge of the placenta. If\\nthe placenta is lateral or marginal, it may be sufficient to\\nrupture the membranes, tearing them freely, and to sweep the", "height": "3700", "width": "2472", "jp2-path": "obstetricsmanual00evan_0267.jp2"}, "262": {"fulltext": "262 PATHOLOGY OF LABOR.\\nfingers round under the margin of the placenta so as to sepa-\\nrate it from the uterus for a short distance. The fingers may\\nthen be withdrawn if the head of the foetus is presenting.\\nFirm pressure on the fundus, so as to crowd the head into the\\npelvis, may then be sufficient to control the hemorrhage if\\nso, the case may now be left to Nature. If the os has been suf-\\nficiently dilated, the forceps may be applied and the head\\ndrawn down, after which the case may be left to Nature to\\ndeliver.\\nIf the placenta is central, or if a considerable portion of the\\nplacenta is found over the internal os, the proper treatment is\\nto perform internal version. A foot is seized and drawn\\ndown until the hemorrhage is checked. From time to time\\nthe protruding leg may be drawn upon to hasten dilatation of\\nthe cervix. Plenty of time must be allowed for the cervix to\\ndilate completely, otherwise there will be difficulty in extract-\\ning the after-coming head.\\nIf there has been a great loss of blood and the cervix is\\nfound to be rigid, it is better to pack the cervix and vagina\\nwith sterile iodoform gauze, which may be left in place until\\nthe patient has had time to rally under appropriate treatment\\n(see Post-partum Hemorrhage). The gauze tampon not only\\nchecks the hemorrhage, but also assists in softening and di-\\nlating the cervix and os.\\nMany authors recommend the employment of hydrostatic\\ndilators instead of the gauze tampon. The Champetier de\\nRibes bag is the best for this purpose. It is claimed that the\\nbag controls the hemorrhage and dilates the cervix more effiict-\\nually than does the vaginal packing, while it as a rule causes\\nless discomfort to the patient. For the introduction of the bag\\nthe patient is placed in the lithotomy position, the anterior lip\\nof the cervix is seized with a tenaculum and drawn well\\nforward, being then held by an assistant. The dilating bag is\\nfolded into a cylinder, grasped w^ith a pair of forceps, and\\nguided carefully into the cervix and through the internal os.\\nBefore withdrawing the forceps the distention of the bag\\nshould be commenced by injecting into it boiled water by\\nmeans of a syringe attached to the tube of the bag. Then as\\nthe bag distends the forceps may be unlocked and carefully\\nwithdrawn. As a precaution against rupture of the bag, the", "height": "3712", "width": "2708", "jp2-path": "obstetricsmanual00evan_0268.jp2"}, "263": {"fulltext": "PREMATURE SEPARATION OF PLACENTA, 263\\noperator should ascertain beforehand how many bulbfals of\\nwater are required to dilate it completely.\\nThe most rigid precautions as regards asepsis should be\\nobserved in the treatment of placenta prsevia, as the risk of\\ninfection is greater than in ordinary cases, on account of the\\nlow position of the placental site.\\nAfter the child has been delivered the operator should intro-\\nduce his hand into the uterus to remove the placenta and any\\nclots that may be found there. This sliould be followed by a\\nprolonged hot intra-uterine douche of sterile salt solution or\\n1 500 formalin. A full dose of the fluid extract of ergot\\nshould be administered as soon as the uterus is emptied, or\\nelse a hypodermic of ergotin.\\nPrognosis Placenta prsevia constitutes a most serious com-\\nplication of pregnancy or labor for both mother or child.\\nUnder prompt and aseptic treatment the maternal mortality\\nshould be practically nil. As premature delivery is frequent,\\nthe infant mortality-rate is high.\\nPremature Separation of a Normally Situated Placenta\\nAccidental Hemorrhage.\\nThe hemorrhage associated w^th premature detachment of\\na normally situated placenta is termed accidental, to dis-\\ntinguish it from the unavoidable hemorrhage of placenta\\nprsevia.\\nVarieties Accidental hemorrhage may be apparent or con-\\ncealed.\\nIn apparent accidental hemorrhage the blood dissects its\\nway between the membranes and decidua, and escapes through\\nthe cervix.\\nIn concealed accidental hemorrhage the blood fails to find\\na^ way of escape, and may collect within the uterus in suffi-\\ncient quantity to cause serious symptoms, or even death of the\\npatient.\\nIn this form any of the following conditions may obtain and\\nprevent the escape of blood\\n1. The placenta may be detached only at the centre, the\\nmargin remaining adherent", "height": "3692", "width": "2472", "jp2-path": "obstetricsmanual00evan_0269.jp2"}, "264": {"fulltext": "2()4\\nPATHOLOGY OF LABOR\\n2. The upper margin may be detached, so that blood accu-\\nmulates between the membranes and the uterine wall\\n3. A portion of the edge\\nFig. 99. of the placenta and of the\\nadjacent membranes may be\\ndetached the latter may\\nrupture and permit the blood\\nto mingle with the liquor\\namnii in the sac.\\n4. The cervix may be ob-\\nstructed by a clot, the de-\\ntached membranes, or the\\npresenting part of the foetus\\n(Fig. 99).\\nEtiology: The predispos-\\ning causes may be given as,\\ntubercular and syphilitic de-\\ngeneration of the decidua,\\nplacental degenerations, ne-\\nphritis, ansemia, and the\\nacute infectious diseases. In\\nthe presence of these but a\\ntrivial exciting cause is re-\\nquired to produce separation\\nof the placenta. A sudden\\njar, a blow on the abdomen,\\nor violent muscular exertion\\nmay be all that is required\\nto brinff about such a separa-\\nFrozen section of the uterus of a\\nwoman who dierl of accidental hemor- tion.\\nrhage at the Maternlte de Beaujon.\\n(Pinard and Varnier.)\\nSymptoms and Diagnosis of Accidental Hemorrhage.\\nThe symptoms resemble those of rupture of the uterus,\\nbut are not so severe.\\nIn the apparent variety the fact of hemorrhage is obvious.\\nIt usually takes place early in labor or during the later\\nmonths of pregnancy. Severe localized pain at the placental\\nsite is not infrequent. The uterus may bulge at this point.", "height": "3712", "width": "2708", "jp2-path": "obstetricsmanual00evan_0270.jp2"}, "265": {"fulltext": "PREMATURE SEPARATION OF PLACENTA. 265\\nPlacenta prsevia is readily distinguished by a careful vaginal\\nexamination.\\nConcealed hemorrhage is generally revealed by the systemic\\neffects. Rapid pulse, pallor, cold extremities, restlessness,\\nsighing respiration, and collapse may be present. If labor\\nhas begun, the uterine contractions cease or become weak,\\nthough the patient may complain of more or less continual\\npain at the placental site. On abdominal examination the\\nuterine wall may be found bulging at the seat of the hemor-\\nrhage and the foetal heart-sounds are feeble and irregular.\\nRupture of the uterus may be distinguished from concealed\\naccidental hemorrhage by the fact that the former occurs late\\nin labor, usually after rupture of the membranes, and that the\\npresenting part of the foetus recedes.\\nPrognosis.\\nIn apparent hemorrhage the prognosis is good for the\\nmother, but not favorable for the child. If labor does not\\ncome on at once, there is danger of infection of the blood-\\ntract between the edge of the placenta and the os, resulting\\nin sepsis.\\nIn the concealed hemorrhage the percentage of mortality for\\nboth mother and child is high. Death results from hemor-\\nrhage, shock, extreme anaemia, or sepsis. The foetal mortality\\nis due to interference with the uteroplacental circulation.\\nTreatment.\\nExternal variety If the external hemorrhage is moderate\\nin amount, a full dose of opium (liq. opii sed., TTLxxv) and\\nrest in bed for a few days will be the only treatment required.\\nThe patient s temperature should be taken twice daily for a\\nweek or ten days, and if evidences of infection of the blood-\\ntract occurs the uterus should be emptied. When the blood-\\nloss is alarming it may be necessary to induce labor. The os\\nshould be dilated digitally to permit rupture of the mem-\\nbranes. A Barnes or Champetier de Ribes bag may then be\\nintroduced into the cervix and left there till it is expelled,\\nwhen forceps may be applied, should the forces of Nature fail\\nin promptly effecting delivery. When it is required to empty", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0271.jp2"}, "266": {"fulltext": "266 PATHOLOGY OF LABOR.\\nthe uterus immediately, the cervix sliould be dilated rapidly\\nif necessary, it should be incised and version performed.\\nConcealed variety If the patient s condition is such as to\\nforbid active obstetric interference, the treatment should be\\ndirected to combating the effects of the shock and hemor-\\nrhage (see Treatment of Post-partum Hemorrhage).\\nTiie fundus should be compressed by means of a snugly\\nfitting binder and pad. The foot of the bed should be ele-\\nvated.\\nAVhen the patient s condition permits, the uterus should be\\nemptied by means of manual dilatation of the cervix and ver-\\nsion. The placenta in these cases should be removed manu-\\nally, and a hot intra-uterine injection should be given after\\nthe uterus has been emptied.\\nThe after-treatment should be directed to controlling the\\neffects of severe hemorrhage, and to securing good uterine\\ncontraction.\\nRetained Placenta.\\nThis condition is of frequent occurrence. The placenta is\\nusually completely detached, and lies in the dilated lower\\nuterine segment or in the upper part of the vagina.\\nCauses Feeble uterine contractions, or, more frequently,\\nimproper methods of placental expression, generally give rise\\nto the condition. A full bladder or rectum may lead to reten-\\ntion of the placenta.\\nTreatment The proper application of Crede s method of\\nexpression is usually all that is required in the way of treat-\\nment. The uterus may be steadied and held in position by\\nlaying one hand across the suprapubic region of the abdomen,\\nwhile the other firmly squeezes the fundus and at the same\\ntime exerts pressure in the axis of the pelvic inlet during a\\nuterine contraction. This method will rarely fail to secure ex-\\npulsion of the placenta. Very occasionally it may be neces-\\nsary to introduce a couple of fingers into the vagina, so as to\\nreach the lower edge of the placenta and hook it forward.\\nAdherent Placenta.\\nIn this condition, which is rare, the placenta is not only\\nretained, but is also adherent to the uterine wall. The adhe-", "height": "3728", "width": "2712", "jp2-path": "obstetricsmanual00evan_0272.jp2"}, "267": {"fulltext": "A DHERENT PL A CENT A\\n267\\nsion is rarely complete a part of the placenta is usually\\ndetached. The torn sinuses bleed profusely, as the uterus\\nFig. 100.\\nArtificial removal of adherent placenta. (Modified from Ribement-Dessaignes and\\nLepage\\ncannot contract properly on account of the portion of the\\nplacenta which remains adherent.\\nCauses The most frequent cause is a placentitis (or de-\\ncidual inflammation) of specific origin. Chronic endometritis", "height": "3708", "width": "2460", "jp2-path": "obstetricsmanual00evan_0273.jp2"}, "268": {"fulltext": "268 PATHOLOGY OF LABOR.\\nand placental degenerations, due to clironie nephritis in the\\nmother, may give rise to adherent placenta.\\nTreatment If Credo s method of expression fails and the\\nhemorrhage is profuse, the cavity of the uterus must be entered\\nand the placenta gently separated and removed.\\nTo perform this operation one hand grasps the fundus\\nsecurely, while the other is inserted into the vagina and fol-\\nlows up the cord as a guide till the placenta is reached. A\\ndetached edge is then felt for, the finger-tips inserted between\\nthe placenta and the uterine wall, and by gentle lateral move-\\nments of the hand the separation is completed and the\\nplacenta gently grasped. The outer hand then makes fric-\\ntion over the fundus until a contraction has been stimulated,\\nwhen the internal hand and placenta are slowly withdrawn\\n(Fig. 100).\\nThe internal hand and the placenta should never be with-\\ndrawn until uterine contraction has occurred, on account of\\nthe danger of producing inversion of the uterus. The hand\\nshould then be re-introduced and the whole uterine cavity\\nexplored to make sure that no fragments of placental tissue\\nhave been retained. A hot intra-uterine douche should then\\nbe given. It is advisable to administer a full dose of ergot as\\nsoon as the uterus has been emptied.\\nMATERNAL DYSTOCIA.\\nThe subject of maternal dystocia may be divided into three\\nheadings\\n1. Anomalies in the forces of labor\\n2. Anomalies in the pelvis\\n3. Anomalies in the maternal soft structures.\\n1. ANOMALIES IN THE FORCES OF LABOR.\\nPrecipitate Labor.\\nExcessive power in the expulsive forces of labor may result\\nin the very speedy completion of the act.\\nEtiology The condition is usually due to undue excitability\\nof the sympathetic nervous system, rather than to excessive", "height": "3712", "width": "2728", "jp2-path": "obstetricsmanual00evan_0274.jp2"}, "269": {"fulltext": "PRECIPITATE LABOR. 269\\nmuscular development. It may therefore be met with in\\nyoung primij^arse, as well as in women of more advanced age\\nand of greater muscular development. The rule is that the\\nprecipitancy occurs in the second stage of labor, the first stage\\nbeing quite normal.\\nConditions causing relaxation of the pelvic floor, as debili-\\ntating diseases, previous laceration, etc., favor the occurrence\\nof precipitate labor.\\nPowerful emotions, such as fear or anxiety, may act by\\nincreasing the force of the uterine contractions.\\nSudden and powerful uteynne contraction with the patient in\\nthe erect posture may result in the rapid expulsion of the\\nfoetus, which may fall to the floor and receive serious injury.\\nThus it not infrequently happens that women are suddenly\\ndelivered while sitting in a priv^y or water-closet, and the\\nchild may fall into the cesspit or bowl of the closet and\\nperish before aid is secured.\\nPrognosis Lacerations of the vagina and perineum, hemor-\\nrhage from partial or complete separation of the placenta,\\ninversion of the uterus, and occasionally retention of the\\nplacenta, associated with hour-glass contraction of the uterus,\\nmay be mentioned as sequelae of precipitate labor.\\nThe sudden evacuation of the uterine contents may lead to\\nsevere or even fatal syncope on the part of the mother. The\\nfoetal mortality is somewhat greater than normal.\\nTreatment When the uterine action is powerful and the\\nfoetus descends rapidly, it may be held hack by inserting the\\nfingers in the vagina and resisting the advance of the pre-\\nsenting part, while at the same time chloroform is administered\\nto the mother. The patient should be instructed to keep the\\nmouth open, and to pant or cry out during each pain.\\nIf a previous labor has been precipitate, the woman should\\nbe kept constantly in bed after the onset of labor. If the\\npains tend to become too powerful, chloral should be freely\\nadministered. Fifteen or twenty grains may be given at a\\ndose, and repeated at intervals of twenty minutes until a\\ndrachm has been given or the action of the drug has been\\nobtained. It is advisable to administer chloroform while\\nwaiting for the chloral to be absorbed into the system.\\nThe management of the third stage of labor demands special", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0275.jp2"}, "270": {"fulltext": "270 PATHOLOGY OF LABOR.\\ncare, for in these cases there is often a complete absence of\\ncontraction after delivery of the child hence the uterus becomes\\nextremely relaxed in the intervals between the pains. The\\nfundus should be kept well under control, firm friction made\\nbetween each pain to stimulate contraction, and plenty of time\\nshould be given before attempting to expel the placenta.\\nIf, after the expulsion of the placenta the uterus does not\\nremain contracted, a hot (120\u00c2\u00b0 F.) intra-uterine douche should\\nbe given, followed by a hypodermic injection of ergot (aseptic)\\nm XX. The fundus should be controlled until the uterus\\nremains firmly contracted.\\nDelayed Labor; Uterine Inertia.\\nWhen the expulsive action of the uterus is unable to over-\\ncome the normal resistance of the maternal passages, labor is\\ndelayed and the pains are said to be weak.\\nCauses The commonest causes of uterine inertia are pre-\\nmature rupture of the membranes, rigid os, a distended bladder\\nor rectum, and general debility of the patient. Obliquity of the\\nuterus overdistention, as in multiple pregnancy or hydramnios\\ndegeneration of the uterine muscle-fibres from inflammation\\nor too frequent childbearing malpresentation uterine tumors\\nor tumors of neighboring structures and low attachments of\\nthe placenta, may all be mentioned as causes of uterine inertia.\\nDiagnosis Before making a diagnosis of uterine inertia\\ncare should be taken to ascertain if the bladder and rectum\\nhave been emptied. By external examination the contraction\\nof the uterus may be felt to be weak, for the organ will not\\nassume the intense hardness associated with good uterine\\naction. By vaginal examination in the first stage the bag of\\nwaters does not become tense during a pain, or if the mem-\\nbranes have ruptured the presenting part does not descend.\\nExamination should then be made to ascertain that the\\nlabor is not delayed by some obstruction.\\nThe prognosis depends on the stage of labor and the cause\\nof the inertia. In the first stage there is little danger to\\neither mother or child unless the membranes have been long\\nruptured. In the second stage of labor there is danger to\\nboth mother and child from prolongation of the labor.", "height": "3712", "width": "2716", "jp2-path": "obstetricsmanual00evan_0276.jp2"}, "271": {"fulltext": "DELAYED LABOR; UTERINE INERTIA. 271\\nNo hard-and-fast rule as to how long delay might be with-\\nout danger can be laid down. When the head is low in the\\npelvis prolonged delay may cause serious injury to the mater-\\nnal parts from pressure of the head. The condition of the\\nmother and child should be carefully watched. Danger to\\nthe child is manifested by a slowing of the foetal heart s\\naction, while danger to the mother is indicated by local\\noedema and a rising pulse and temperature. It may be said\\nthat a delay of over six hours in the second stage warrants\\nthe artificial termination of the labor.\\nTreatment This depends on the stage of labor and the\\ncause of the inertia. The first duty is to ascertain the cause\\nof the delay, and, if possible, remove it. The bladder\\nand rectum should be emptied. The prolongation of the\\nfirst stage of labor may have exhausted the patient, and when\\nthis is the case no effort should be made to stimulate uterine\\ncontractions until the patient has been restored by a good\\nrest, and, if possible, sleep. This may be accomplished by\\ngiving her a hypodermic injection of morphine gr.), and\\nrepeating it in half an hour if necessary. At the same time\\nshe may be given some hot broth or milk, or some sherry and\\na biscuit, to maintain her strength.\\nChloral is to be preferred to morphine, as it seldom arrests\\nthe progress of labor. Two drachms of the syrup of chloral\\nmay be given in a cupful of warm milk, and repeated in\\nhalf an hour if required. On waking, the patient may be\\ngiven some hot broth or egg-nog. If the contractions do not\\nthen set in w^ith increased power, efforts may be made to\\nstimulate the uterus to action.\\nStrychnine (gr. administered hypodermically, is proba-\\nbly the most valuable uterine stimulant. Quinine in large\\ndoses (gr. xv), repeated in half an hour, acts well in some\\ncases but the author has failed to find it completely satis-\\nfactory.\\nErgot is only mentioned to be condemned, for it tends to\\ninduce tetanic uterine action, and thus interferes with the\\nplacental circulation. It should never be used until the uterus\\nhas been emptied. Hot vaginal douches (120\u00c2\u00b0 F.), given at\\nintervals of half an hour, often prove of great value.\\nAlcohol has proved a very satisfactory uterine stimulant in", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0277.jp2"}, "272": {"fulltext": "272 PATHOLOGY OF LABOR.\\nthe author s experience it is best given in the form of sherry,\\nas recommended by Hirst, and should be slowly sipped, the\\npatient being informed that it will surely bring back the\\npains and hasten the delivery.\\nIn ver}^ obstinate cases a sterilized bougie may be inserted\\ninto the uterus, and the vagina packed lightly with iodoform\\ngauze, as for the induction of premature labor. The intro-\\nduction into the cervix of a Champetier de Ribes bag or of a\\nBarnes bag is a very useful but troublesome method of treat-\\nment. These not only stimulate the uterus to action, but\\ndilate the cervix, and thus assist in overcoming the resistance\\noffered by the os.\\nThe bag of icaters should not be ruptured until the os is\\ndilated, unless it is evident that there is an excess of liquor\\namnii present, and that this is the probable cause of inefficient\\nuterine action.\\nWhen inertia is present in the second stage of labor the\\npatient may be allowed to walk about, in the hope that the\\ndescent of the head under the influence of gravity will set up\\nuterine action by reflex stimulation of the pelvic floor.\\nPressure on the fundus with the patient in the dorsal posi-\\ntion may prove of value when employed during uterine con-\\ntractions. When other measures fail resource must be had\\nto the forceps to terminate labor.\\n2. ANOMALIES OF THE PELVIS.\\nThe great majority of anomalies of the pelvis are of the\\nnature of contraction. Contractions in the diameters of the\\npelvic brim give rise to the most serious consequences both\\nto mother and to child, in proportion to the degree of ob-\\nstruction offered to the passage of the foetus.\\nFrequency: Until recently it was commonly believed that\\nabnormal pelves were much more rarely met with in America\\nthan in Europe but the more general j^ractice of pelvimetry\\nwhich has prevailed in obstetric clinics during tlie past decade\\nhas revealed the fact that in America deformity of the pelvis\\nis met with in about the same proportion of women as in\\nEurope.\\nThe records of European clinics show a wide variation in", "height": "3712", "width": "2712", "jp2-path": "obstetricsmanual00evan_0278.jp2"}, "273": {"fulltext": "ANOMALIES OF THE PELVIS. 273\\nthe percentages reported, the difference extending from 1.2\\nper cent, in Russia, to 24.3 per cent, in Saxony. Von\\nWinckel considers that from 10 to 15 per cent, of German\\nwomen have deformed pelves but that in only 5 per cent, is\\nthe obstruction serious enough to be noticed.\\nAmong American observers/ Flint, in New York, found\\n1.42 per cent, of pelvic contraction; Reynolds, in Boston,\\n1.13 per cent.; Crossen, in St. Louis, 7 per cent.; Dobbin,\\nin Baltimore, 11.45 per cent. and Williams, in Baltimore,\\n13.1 per cent. Davis, from the records of 1224 patients,\\nconcludes that 25 per cent, of the women in the United\\nStates have pelves smaller than the average, while 7 per cent,\\nhave pelves larger than the average.\\nHirst states that deformed pelves are by no means rare\\namong native-born women in the Eastern States.\\nClassification Various classifications of pelvic anomalies\\nhave been employed in different countries, but the following,\\ntaken from Jewett s Practice of Obstetrics, will be found suf-\\nficiently comprehensive to meet all requirements\\nI. Pelves normally proportioned but abnormal in size\\n1. Uniformly enlarged (justomajor).\\n2. Uniformly contracted (justominor).\\nII. Pelves with anomalies of size, shape, inclination, or\\ncombinations of these\\n1. Those with minor developmental peculiarities\\n(a) Masculine\\n(6) Shallow;\\n(c) Deep\\n(d) Funnel-shaped.\\n2. Anteroposteriorly contracted\\n(a) Flat non-rachitic\\n(b) Flat rachitic.\\n3. Obliquely contracted\\n(a) By imperfect development of one sacral ala\\n(Naegele pelvis)\\n(b) By imperfect or abolished use of one limb\\n(c) By spinal curvature.\\nDavis, E. P., American Journal of Obstetrics, Jan., 1900.\\n18\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2460", "jp2-path": "obstetricsmanual00evan_0279.jp2"}, "274": {"fulltext": "274 PATHOLOGY OF LABOR.\\n4. Transversely contracted\\n(a) By imperfect development of both sacral alse\\n(Robert pelvis)\\n(b) By kyphosis of the spine.\\n5. Compressed pelvis\\n(a) Malacosteon\\n(6) Psendomalacosteon rachitic.\\n6. Spondylolisthetic.\\n7. Pelves distorted by injury, tumors, anchylosis of\\njoints.\\n8. Deformity due to spinal curvature\\n(a) Kyphotic\\n(6) Scoliotic\\n(c) Kyphoscoliotic\\n{d) Lordosis.\\nDiagnosis Theoretically it is the duty of the physician to\\ntake careful measurement of the pelvis of every woman he is\\ncalled upon to attend in labor practically, this is rarely done\\nuntil delay in the progress of labor calls attention to the fact\\nthat possibly some obstruction exists in the pelvis.\\nDeformity of the pelvis is most frequently met with in those\\nwomen who in childhood have suffered from malnutrition,\\nrickets, or tuberculosis of the vertebrae or joints of the lower\\nlimbs, or who early in life have suffered from accident to a\\nlimb which has resulted in shortening, dislocation, etc.\\nMalnutrition and hard work early in life not infrequently\\nresult in flattening of the pelvic brim. Rickets may lead to\\nvarious serious pelvic deformities. A history of late denti-\\ntion, prolonged indigestion, of not walking after the second\\nyear, would suggest this disease. An examination of such a\\npatient might reveal the square head, pigeon-breast, bead-\\ning of the ribs, or bending or twisting of the long bones\\ncommon to this disease. tJsually these patients are of short\\nstature.\\nDiseases or accidents resulting in deformity of the spine or\\nlower limbs when they have occurred early in life result in\\nabnormal development of the pelvis.\\nFailure of the head to descend into the jyelvis at or before the\\nonset of labor, associated with undue prominence of the abdo-", "height": "3712", "width": "2728", "jp2-path": "obstetricsmanual00evan_0280.jp2"}, "275": {"fulltext": "PELVIMETRY.\\n275\\nmen, si\\nixacii, should always suggest obstruction at the pelvic brim\\nwhen these conditions are found present in a primipara with a\\nvertex presentation.\\nPelvimetry.\\nDeformities of the pelvis may be detected by external and\\ninternal palpation and by measurements, both external and\\ninternal, of those diameters of the pelvis which are accessible.\\nFor taking pehic measurements the examiner s fingers, a\\ntape-measure, and a pair of modified calipers, known as a pel-\\nvimeter, are usually employed. The pelvimeter devised by\\nBaudelocque in 1775 (Fig. 101) is probably the best, though\\nmany others have since been invented.\\nFig. 101.\\nBaudelocque s pelvimeter.\\nMethods of Taking Pelvic Measurements.\\nExternal measurements Tlie clothing of the patient having\\nbeen rolled well out of the way and the lower part of the body\\ncovered with a sheet, she lies on her back close to the edge of", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0281.jp2"}, "276": {"fulltext": "276 PATHOLOGY OF LABOR\\nthe bed, while the physician stands beside her looking toward\\nher head. He then takes the pelvimeter and holds a rod in\\neach hand, the tip of an index-linger being on each knob, and\\nthe reading surface of the scale held so as to be easily read.\\nThe knobs of the pelvimeter are then placed on the anterior\\nsuperior spines of the ilia or on the tense fascia lata just below\\nthem, as suggested by Winckel. In the normal pelvis this\\nmeasurement should be about 10 J inches (26 cm.) the knobs\\nof the pelvimeter are then moved along the external edges of\\nthe iliac crests until the greatest distance is found, the measure-\\nment of which should be about 11 inches (28 cm.). The\\nlength of these measurements, as well as any important differ-\\nence between them, enables us to draw our conclusions as to\\nthe development of the innominate bones, and the width of\\nthe transverse diameter at the inlet.\\nThe patient is then made to turn on her side, with the\\nthighs slightly flexed. The knob of one rod is then placed in\\nthe depression just below the spine of the last lumbar vertebra\\nand firmly held in this position, while the other knob is placed\\non the symphysis pubis at a point about one-eighth of an inch\\nbelow its upper border, and pressed firmly into position. The\\nmeasurement thus obtained should be about 7 J inches (19\\ncm.), and is known as the external conjugate, or the diame-\\nter of Baudelocque. To obtain an idea of the true conju-\\ngate 3 J inches (9 cm.) should be deducted from the meas-\\nurement of the external conjugate, to allow for the thickness\\nof bone and soft tissues this would give the normal true\\nconjugate, 4 inches (10 cm.).\\nThe oblique diameters of the brim may be measured by placing\\none knob of the pelvimeter in the depression marking the\\nposterior superior spine of one side, and the other knob on\\nthe anterior superior spine of the opposite side. In sym-\\nmetrical pelves these measurements are usually equal, and\\nshould be about 9 inches (22.5 cm.).\\nThe circumference of the pelvis may be measured by placing\\na tape-line around the body, so that it will pass just over the\\nsymphysis, under the iliac crests, and over the middle of the\\nsacrum behind. In a woman of average development and\\nwith a normal pelvis this measurement should be about 35 J\\ninches (90 cm.).", "height": "3712", "width": "2700", "jp2-path": "obstetricsmanual00evan_0282.jp2"}, "277": {"fulltext": "PELVIMETRY. 277\\nThe other external measurements of importance are those\\nof the outlet of the pelvis. The transverse diameter of the out-\\nlet is measured by placing the knobs of the pelvimeter on the\\ninner sides of the ischial tuberosities. The anteroposterior\\ndiameter may be measured by placing one knob of the pelvim-\\neter on the under border of the symphysis pubis and the\\nother knob on the skin over the lower border of the tip of the\\nsacrum. From this 1.3 cm. must be deducted to allow for\\nthickness of the bone, etc. This measurement can be better\\nobtained by placing the tip of the middle finger of the left\\nhand, inserted into the vagina, against the end of the sacrum\\nand pressing the edge of the hand against the lower border\\nof the symphysis, the point of contact being marked by the\\nindex-finger of the right hand and the distance measured\\nafter the left hand has been withdrawn.\\nInternal measurements A good general idea of the capacity\\nof the pelvic canal may be obtained from a careful vaginal\\nexamination. The points of importance in this examination\\nare the thickness, height, and inclination of the pubis the\\ncondition of the lateral walls as regards projections, etc. the\\ncondition of the sacrococcygeal joint the curve of the sacrum\\nand the condition of the promontory, if this can be reached.\\nThe diagonal conjugate i. e., the measurement from the\\npromontory to the subpubic ligament can usually be ob-\\ntained without much difficulty provided the examination is\\nmade carefully and methodically.\\nThe patient is put in the lithotomy position with the but-\\ntocks projecting over the edge of the bed or table. The\\nexaminer then introduces the first two fingers of the left hand\\ninto the vagina and extends them inward and upward until\\nthe tip of the second finger rests upon the promontory of the\\nsacrum (Fig. 102). Care must be taken not to mistake the\\nlast lumbar vertebra for the first sacral, or vice versa. The\\nradial side of the hand is then raised until the impress of\\nthe subpubic ligament is felt upon it. With a finger-nail of\\nthe other hand the point of contact is marked, and both hands\\nthen withdrawn. With a pelvimeter the distance between the\\nmark and the tip of the second finger is then measured. This\\nis the length of the diagonal conjugate. From this measure-\\nment t inch (1.75 cm.) should be deducted to obtain the true", "height": "3712", "width": "2456", "jp2-path": "obstetricsmanual00evan_0283.jp2"}, "278": {"fulltext": "278 PATHOLOGY OF LABOR.\\nconjugate diameter. This average difference between these\\ntwo diameters depends upon the height of the symphysis (1 J\\ninches, 4 cm.), a normal angle between- the axis of the pubis\\nand the true conjugate (105 degrees), a normal thickness of the\\nsymphysis, and a normal lieight of the promontory.\\nWhen the height of the symphysis is greater than 1^ inches\\n(4 cm.), about inch (2 cm.) should be deducted from the\\ndiagonal conjugate.\\nThe true conjugate may be measured Avith almost perfect\\naccuracy by means of a special pelvimeter invented by Hirst,\\nFig. 102.\\nInternal pelvimetry. Measuring the diagonal conjugate with the hands. (Jewett.)\\nof Philadelphia. Hirst s measurement is from the promontory\\nto a point one-eighth of an inch below the upper, outer border\\nof the symphysis pubis. Hirst s pelvimeter consists of a long,\\nstraight rod, to which is attached a movable bar having a\\nslight curve.\\nThe physician having placed the middle finger of the left\\nhand u})on the ])romontory, the tip of the straight end of the\\npelvimeter is pushed into place alongside, where he holds it\\nfirmly, while an assistant adjusts the tip of the movable bar\\nover a point one-eighth of an inch below the outer upper\\nborder of the symphysis. This bar is then screwed tight, the\\npelvimeter removed, and the distance between the tips meas-\\nured by means of a ta2)e. The thickness of the symphysis", "height": "3712", "width": "2720", "jp2-path": "obstetricsmanual00evan_0284.jp2"}, "279": {"fulltext": "PELVES ABNORMAL IX SIZE. 279\\npubis is then measured by guiding one tip of the pelvimeter,\\nintroduced into the vagina, to a point one-eighth of an inch\\nfrom the top the outer bar is then adjusted to the same point\\nas before and screwed tight, and the distance between the tips\\nmeasured after the pelvimeter has been withdrawn.\\nPelves Normally Proportioned but Abnormal in Size.\\nUniformly Enlarged Pelvis (Justomajor).\\nDefinition This form of pelvis preserves all the characters\\nof the normal, but all its measurements are increased. It is\\ngenerally to be found in women of great stature, though it is\\nmet with occasionally in women below the medium height.\\nDiagnosis: All the measurements are found to be in excess\\nof the normal while preserving their relative proportion.\\nInfluence on pregnancy and labor: During pregnancy the\\nuterus tends to remain longer in the pelvis than in tlie normal\\ncondition, thus giving rise to disturbances of the bladder and\\nof the rectum. For the same reason the pressure-symptoms\\nin the latter part of pregnancy are often severe, and may\\nrender locomotion difficult.\\nThe condition predisposes to precipitate delivery. The\\nimperfect resistance offered to the head in its descent may\\nlead to loss of flexion, and thus retard rotation.\\nUniformly Contracted Pelvis (Justominor).\\nDefinition In this type of pelvis the form is preserved, but\\nits size is diminished.\\nThree varieties of the justominor pelvis are usually de-\\nscribed of these, the most common is the juvenile, in which\\nthe bones are small and slender the masculine, in which the\\nbones are heavy and thick and the dicarf, or pelvis nana, in\\nwhich the bones are thin and fragile, and the cartilaginous\\njunctions between the constituents of the ossa innominata are\\nretained.\\nOccurrence: The uniformly contracted pelvis is usually to\\nbe found in under-sized women, though it may be met with\\nin women of average height, or even in tall women. It is", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0285.jp2"}, "280": {"fulltext": "280 PATHOLOGY OF LABOR.\\nmost commonly met with in America in shop- and factory-\\ngirls.\\nEtiology The causation of the justominor pelvis has not\\nbeen satisfactorily explained. It is generally the result of\\narrested development due to unfavorable hygienic surround-\\nings and bad nutrition in early life.\\nCharacteristics The generally contracted pelvis approaches\\nthe infantile in type (Fig. 103). The alge of the sacrum are\\nFig. 103.\\nGenerally contracted dwarf pelvis. (After Winckel.)\\nnarrow, while the sacrum itself is short and has lessened for-\\nward inclination as compared with the normal. The promon-\\ntory is high but not prominent. The pubic bones and sym-\\nphysis have a lessened inclination outAvard. Thus when the\\npatient stands erect the inclination of the pelvic entrance to\\nthe abdominal axis makes a more obtuse angle than would be\\nthe case in a normal pelvis (Fig. 104).\\nUsually the contraction is not very great. The conjugate\\ndiameter is seldom below 9 cm. (3^ inches).\\nDiagnosis Careful pelvimetry will show that all the meas-\\nurements are below normal, with the exception possibly of the\\nexternal conjugate diameter, which is longer than would be", "height": "3728", "width": "2724", "jp2-path": "obstetricsmanual00evan_0286.jp2"}, "281": {"fulltext": "PELVES ABNORMAL IN SIZE. 281\\nexpected, on account of the posterior position and lessened\\ninclination forward of the sacrum. In this form of contracted\\npelvis the measurement of the pelvic circumference is gener-\\nally far below ih^ normal, 90 cm. (35^ inches).\\nInfluence of labor: The increased resistance offered to the\\ndescent of the head results in flexion being more marked than\\nit is in the normal pelvis. The head generally enters the brim\\nin the oblique diameter.\\nIn breech cases the child s head must be well flexed, by the\\noperator putting his finger in its mouth and drawing down\\nFig. 104.\\nDiagram showing difference between normal and justominor pelvis on vertical\\nmesial section. Black, normal. Red, justominor.\\nthe chin before an attempt is made to secure engagement in\\nthe brim.\\nLabor is usually prolonged, and the head undergoes much\\nmoulding, the caput succedaneum being unusually large.\\nThe suboccipitobregmatic diameter of the head is com-\\npressed and the occipitomental elongated (Fig. 105).\\nTreatment If the head is advancing under the influence\\nof uterine action, no interference is called for. The patient s\\nstrength must be sustained by appropriate nourishment, and\\nopium may be used hypodermically to relieve her suflPerings.\\nPlenty of time must be allowed to secure good moulding of\\nthe head.", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0287.jp2"}, "282": {"fulltext": "282\\nPATHOLOGY OF LABOR.\\nFig. 105.\\nWhen labor is delayed and advance of the head ceases, then\\nforceps should be tried. The axis-traction forceps should be\\nemployed. As a rule, when the\\ncontraction is not over one centi-\\nmetre the head can be extracted if\\nit be fairly soft and has been al-\\nlowed to become well moulded.\\nIf moderate efforts at extraction\\nwith the forceps fail to bring about\\nadvance of the head and the child\\nis still living, symphysiotomy should\\nbe performed.\\nVersion is not to be recommended\\non account of the difficulty in secur-\\ning the proper amount of flexion\\nDiagram showing head un- necessarv to permit the engagement\\nmoulded and moulded by labor i fi i\\nin a justominor case. ot the aiter-coming head in the pel-\\nBlack, unmoulded. u\u00e2\u0080\u009e* _\\nRed, moulded. VIC brim.\\nPelves with Anomalies of Size, Shape, Inclination; or\\nCombinations of These.\\nMinor Developmental Peculiarities.\\nMasculine pelvis In this pelvis the bones are heavy and\\nstrong, and the whole pelvis is masculine in character.\\nLabor may be prolonged and difficult on account of delay\\neither in the brim or the outlet. Forceps are frequently re-\\nquired to accomplish delivery.\\nShallow pelvis The distance between the brim and the\\noutlet is relatively less in this form of pelvis than in the\\nnormal. As a rule, labor is easy, though occasionally forceps\\nare required.\\nDeep pelvis There is an abnormal increase in the distance\\nbetween the inlet and the outlet in this form of pelvis. Pro-\\nvided the diameters are normal, labor is not interfered with.\\nFunnel-shaped pelvis In this form of pelvis the sacrum is\\nnarrow and has little perpendicular curve, and thus the depth\\nof the canal is increased (Fig. 106). In this form of pelvis\\nthe contraction is most marked at the outlet, and may be in", "height": "3712", "width": "2692", "jp2-path": "obstetricsmanual00evan_0290.jp2"}, "283": {"fulltext": "PELVES WITH ANOMALIES OF SIZE, ETC. 283\\nthe anteroposterior diameter, or in the lateral, or in both.\\nThe pelvis thus approaches the masculine in type.\\nInfluence on Labor The mechanism of labor is interfered\\nwith and the head tends to become extended in the cavity of\\nthe pelvis thus backward rotation of the occiput is likely to\\noccur. Labor is usually prolonged, the delay occurring when\\nthe head is at the outlet. There is greater risk of extensive\\nrupture of the perineum. The soft parts at the pelvic outlet\\nare likely to be injured by undue pressure of the head.\\nFig. 106.\\nFunnel-shaped pelvis. (After Winckel.)\\nTreatment: In the lesser grades of contraction the woman\\nmay be delivered spontaneously or by forceps. In the higher\\ngrades the Csesarean operation may be required. Symphy-\\nsiotomy may be employed when the contraction in the outlet\\nis not marked and efforts at extraction by means of the for-\\nceps fail.\\nFlat Pelves.\\nShortening of the conjugate diameter of the brim is the\\nmain characteristic of flat pelves.\\nSimple Flat Pelves; Non-rachitic.\\nSchroder states that this variety of deformed pelvis is more\\nfrequently seen in Europe than all the other forms put", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0291.jp2"}, "284": {"fulltext": "284\\nPATHOLOGY OF LABOR\\ntogether. In America the simple flat, and the generally con-\\ntracted, are the two varieties of pelvic deformity most fre-\\nquently met with.\\nHirst, in a series of 316 pelves in women of American\\nbirth, found flattening to exist in 5.6 per cent. Davis, in a\\nseries of 1224 pelves, found the simple flat in 5.7 per cent.\\nCharacteristics The sacrum is small, and pressed down-\\nward and forward between the iliac bones as it is not rotated\\nFig. 107.\\nFlat non-rachitic pelvis. (After Kleinwachter\\nforward on its transverse diameter, the anteroposterior diam-\\neter of the pelvis is therefore contracted throughout its whole\\nextent. The transverse diameter remains as great as in the\\nnormal pelvis (Fig. 107).\\nFrequently in flat pelves there is a double promontory, so\\nthat a line drawn between the second sacral vertebra and the\\nsymphysis is often as short as, or shorter than, the true con-\\njugate!", "height": "3732", "width": "2736", "jp2-path": "obstetricsmanual00evan_0292.jp2"}, "285": {"fulltext": "PELVES WITH ANOMALIES OF SIZE, ETC. 285\\nThe degree of contraction is usually not great, as it is rarely\\nbelow 8 cm. (3|^ inches), and usually not under 9.5 cm. (3}\\ninches).\\nEtiology The condition is usually congenital, though hard\\nwork in youth, too early walking, and excessive standing on\\nthe feet may be mentioned as causative factors.\\nDiagnosis This pelvis may be found in small or in large\\nwomen. There is usually nothing in the patient s history or\\nappearance to suggest the deformity, unless she has had diffi-\\nculty in previous labors. By pelvimetry the transverse\\nmeasurements will be found to be normal, while the antero-\\nposterior diameter will be diminished.\\nThe Flat Rachitic Pelvis.\\nCharacteristics Eachitis leads to increased condensation in\\nthe bones hence in the flat rachitic pelvis they are heavier,\\nthicker, and somewhat smaller than in the normal. The\\nsacrum is wider than in the normal pelvis.\\nThe iliac crests are more or less everted at their anterior\\nends, so that the interspinal diameter is equal to or greater\\nthan the intercristal. The ilia are flattened, so that the fossae\\nare not so distinctly hollowed out nor are the iliac wings as\\nexpanded as in the normal pelvis. The pelvic brim is kidney-\\nshaped, not heart-shaped, as in the normal pelvis. The con-\\njugate is diminished and the trans-\\nverse diameter relatively or absolutely _ 1^^-\\nincreased. At the outlet the transverse\\ndiameter may be widened and the\\nanteroposterior be either normal or\\nincreased (Fig. 108).\\nThe pubic arch is wider than nor-\\nmal, and the symphysis is deeper\\nand is rotated on its transverse\\ndiameter, so that its upper border of ^S^/nSS and Sf\\nconverges toward the promontory, flat rachitic pelvis.\\nr^^^ .V i n,} Black, normal. Red, flat.\\nInus the relation ol the true conjugate\\nto the diagonal conjugate is not the same as in the normal\\npelvis (Fig. 109).", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0293.jp2"}, "286": {"fulltext": "286\\nPATHOLOGY OF LABOR.\\nIn the rachitic pelvis the conjugata vera may be diminished\\np, ,Qg to any extent, depending on the\\ndegree of deformity present.\\nEtiology Rachitis in its early\\nstages causes a softening of the\\nbones and ligaments. The weight\\nof the body tends to push the\\npromontory of the sacrum down-\\nward and forward this causes a\\nrotation of the sacrum on its\\ntransverse diameter, and tends\\nto elevate the lower part of this\\nbone and the coccyx upward and\\nbackward. The strong ligaments\\nattached to the lower part of the\\nsacrum prevent its movement\\nupward and backward, and the\\nresult is a sharp bending of the\\nbone produced in the neighbor-\\nhood of the fourth sacral verte-\\nbra.\\nBesides the weight of the body, the action of the muscles\\nattached to the pelvis helps to bring about the deformity. The\\nincreased separation of the ischial tuberosities is due to the\\naction of the abductor and rotator muscles of the thighs. The\\ndegree of deformity produced by rachitis depends on the date\\nof its appearance, its severity, its duration, and the habits of\\nthe child.\\nDiagnosis The history of the woman, her appearance, and\\nthe examination and measurements of her pelvis will permit\\nthe establishment of a diagnosis.\\nThe rachitic woman is usually under-sized. She may have\\na square-shaped head or deformed thorax (pigeon-breast), bead-\\ning of the ribs, and curved long bones, whicli may be enlarged\\nat the ends. When she lies on a flat surface with the limbs\\nwell extended lordosis is generally present.\\nPelvic measurement will show that the relation of the spines\\nand crests of the ilia is altered. The external conjugate and\\nthe diagonal conjugate diameters will be found diminished. On\\naccount of the increased depth of the symphysis and the diver-\\nDiagram showing difference be-\\ntween normal and rachitic pelvis\\non vertical mesial section.\\nBlack, normal. Red, rachitic.", "height": "3712", "width": "2724", "jp2-path": "obstetricsmanual00evan_0294.jp2"}, "287": {"fulltext": "PELVES WITH ANOMALIES OF SIZE, ETC. 287\\ngeDce of its lower margin, inch (2 cm.) must be deducted\\nfrom the diagonal conjugate, instead of the average f inch\\n(1.75 cm.).\\nCare must be taken to ascertain if a double promontory is\\npresent and if so, the conjugate should be measured from the\\nprojection of the sacrum which is nearer the symphysis.\\nMechanism of Labor in Flat Pelves.\\nThe contracted condition of the conjugate prevents the\\nentrance into the pelvic inlet of the presenting part hence the\\nabdomen is usually more or less pendulous.\\nThe presenting part, if it is the head, is usually found at the\\nonset of labor to be resting in one or other iliac fossa; or it\\nmay be firmly pressed down upon the brim in a transverse\\nposition, so that its longest diameter is accommodated to the\\nlongest diameter of the pelvic inlet.\\nMalpresentations are common, and prolapse of the cord and\\nof the extremities is not infrequent.\\nThe first stage of labor is usually prolonged, because of the\\nnon-descent of the head. The membranes protrude from the\\nOS in a cylindrical pouch. Unfortunately the bag of waters\\nusually ruptures early and in this case dilatation can only be\\neffected by a retraction of the cervix over the head.\\nIn the second stage of labor the descent of the head is\\nresisted by the projection of the sacral promontory. Thus the\\nocciput is pushed to one side till it comes into contact with the\\nlateral brim of the pelvis, the iliopectineal line, where it is\\narrested. The sinciput not being resisted, then descends, and\\nthus extension of the head occurs this brings the small bi-\\ntemporal, instead of the larger biparietal, diameter of the head\\ninto relation with the contracted conjugate.\\nThe movement rounding the promontory then takes\\nplace. The posterior parietal bone becomes arrested on the\\npromontory, so that the head becomes obliquely displaced by\\nturning on its anteroposterior diameter. Thus the sagittal\\nsuture, instead of remaining in the middle of the pelvic inlet,\\napproaches the promontory, as the anterior parietal bone slips\\npast the upper border of the symphysis and enters the cavity\\nof the pelvis. Then the posterior parietal bone slips past the", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0295.jp2"}, "288": {"fulltext": "288 PATHOLOGY OF LABOR.\\npromontory, and the head enters the pelvic cavity in an extended\\nposition (Fig. 110).\\nOnce the obstruction at the superior strait is passed, the\\nhead usually descends with ease and raj)idity, the rest of the\\nmechanism going on normally. Occasionally rotation of the\\nhead fails, and owing to the width of the transverse diameter\\nof the pelvis it is expelled from the vulva in its original trans-\\nverse or in an oblique position.\\nHead-moulding The caput succedaneum is generally not\\nexaggerated. Usually the child s\\nFig. 110. head shows what is known as the\\npromontory mark. This may be\\nonly a red mark on the parietal re-\\ngion, between the anterior fontanelle\\nand the parietal eminence which was\\nin contact with the promontory. Oc-\\nMouiding of head during casionally there may be an actual de-\\npassage through flat rachitic p^ession of the parietal bone in this\\nregion. Sometimes a gutter-like\\ngroove may be noted in a line running outward and forward\\non the child s skull. Usually the posterior parietal bone is\\ndepressed below the anterior, which overlaps it at the sagittal\\nsuture.\\nTreatment of Labor in Flat Pelves.\\nCare should be taken to keep the membranes intact as long\\nas possible, by keeping the patient in bed during the first stage\\nof labor, and by warning her against bearing down during\\nthe pains.\\nIf the conjugate is not greatly diminished, the head will\\nusually engage, provided it be given plenty of time to mould.\\nTo this end the uterine contractions should be controlled by\\nmeans of hypodermic injections of morphine or of Battley s solu-\\ntion. The patient s strength should be maintained by the\\nadministration of nourishing broths, egg-noggs, ect. If the\\nchild s head be not unduly ossified, this treatment in the large\\nproportion of cases will prove successful.\\nShould the head not descend, interference should not be\\ndelayed too long, for there is danger that the pressure of the\\nhead may result in [necrosis of the cervical tissue over the", "height": "3712", "width": "2720", "jp2-path": "obstetricsmanual00evan_0296.jp2"}, "289": {"fulltext": "PELVES WITH ANOMALIES OF SIZE^ ETC.\\n289\\npromontory and of the anterior vaginal wall behind the sym-\\nphysis.\\nDelivery by the employment of axis-traction forceps must\\nthen be attempted for this operation the patient should be\\nplaced in Walcher^s position. Should the forceps operation\\nfail, delivery of a living child can only be effected by recourse\\nto symphysiotomy or to Csesarean section.\\nObliquely Contracted Pelves.\\nObliquely contracted pelves result from\\n(a) Imperfect development of one sacral ala\\nFig. 111.\\nSingly obliquely contracted pelvis. (After Winckel.)\\n(6) Imperfect or abolished use of one limb or\\n(c) Lateral curvature of the spine.\\n19\u00e2\u0080\u0094 Obst.", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0297.jp2"}, "290": {"fulltext": "290 PATHOLOGY OF LABOR.\\nIn these pelves the pelvic inlet has an oval shape, with the\\nsmall point directed to the atrophied side of the pelvis (Fig.\\n111).\\nThe diagnosis is based npon the history of the woman, and\\na careful examination and measurement of her pelvis.\\nInfluence on labor The mechanism of the head in passing\\nthrough an obliquely contracted pelvis is the same as in the\\ncase of a justominor pelvis. The head usually enters the brim\\nFig. 112.\\nTransversely contracted pelvis. (After E. Martin.)\\nin extreme flexion, with its long diameter in relation to the\\nlong, oblique diameter of the pelvis. The long, oblique\\ndiameter is usually that of the diseased side. As the head\\ndescends rotation may fail and the occiput may turn toward\\nthe sacrum.\\nTreatment: The long diameter of the head should always\\nbe brought into relationship with the long oblique diameter of\\nthe pelvis by manual rotation, should Nature have failed to\\naccomplish this before the onset of labor.\\nShould descent of the head be delayed, the axis-traction\\nforceps should be tried. Should these fail, Csesarean section is\\nthe only operation available.\\nShould the condition be diagnosed early in pregnancy, pre-", "height": "3728", "width": "2740", "jp2-path": "obstetricsmanual00evan_0298.jp2"}, "291": {"fulltext": "PELVES WITH ANOMALIES OF SIZE, ETC.\\n291\\nmature labor may be induced, provided the deformity of the\\npelvis is not extreme.\\nTransversely Contracted Pelves (Fig. 112).\\nTransverse contraction of the pelvis results from\\n(a) Imperfect development of both sacral alee (Robert pelvis)\\n(6) Kyphosis of the spine.\\nThis is a very rare deformity.\\nAs delivery per vias naturales is impossible, Csesarean\\nsection must be employed.\\nCompressed Pelves.\\nTwo varieties of compressed pelves have been described, the\\nmalacosteon and the pseudomalacosteon.\\nMalacosteon.\\nCharacteristics The whole pelvis is greatly altered in shape.\\nThere is a m.arked bending of the iliac wings, the anterior\\nsuperior spines turning inward. The pelvic brim is tri radiate.\\nFig. 113.\\nFig. 114.\\nDiagram showing diflFerence be-\\ntween normal and malacosteon pel-\\nvis on vertical mesial section.\\nBlack, normal.\\nRed, malacosteon.\\nDiagram showing outline of brim of normal\\nand of malacosteon pelvis.\\nBlack, normal.\\nRed, malacosteon.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0299.jp2"}, "292": {"fulltext": "292 PATHOLOGY OF LABOR.\\nowing to the promontory and the acetabula being approx-\\nimated. The pubic bones are close together and project as a\\nbeak. The curve of the sacrum is greatly exaggerated and\\nthe coccyx points upward into the pelvic canal (Figs. 113, 114\\nand 115).\\nEtiology The condition is brought about by great softening\\nof the bones resulting from osteomalacia (mollities ossium).\\nThis disease is met with chiefly in Europe, and is characterized\\nFig. 115.\\nMalacosteon pelvis, seen from above. (After Winckel.)\\nby a removal of the lime salts from the bones. It usually\\ndevelops during the puerperium, but also occurs in pregnancy.\\nThe deformity results from transmission of the weight of the\\nbody through the pelvis to the lower limbs.\\nDiagnosis This is based upon the history of the woman\\nand an examination of the pelvis.\\nTreatment When the bones are soft delivery may be effected\\nby means of forceps when the bones are hard and the deform-\\nity permanent, Csesarean section must be performed should the\\npelvic contraction be extreme.\\nPseudomalacosteon (Rachitic).\\nThis deformity of the pelvis, produced by severe rachitis,\\nmay closely approximate that produced by osteomalacia.", "height": "3728", "width": "2740", "jp2-path": "obstetricsmanual00evan_0300.jp2"}, "293": {"fulltext": "PELVES WITH ANOMALIES OF SIZE, ETC.\\n293\\nWhile the deformity of the true pelvis is very much as in\\nthe malacosteon, the iliac wiogs are widely separated as in the\\ntypical rachitic condition.\\nSpondylolisthetic Pelves.\\nDefinition The name applied to this variety of pelvic de-\\nformity indicates the condition spondylolisthesis, a slipping\\ndown of the v^ertebra, being derived from anovouko^j ver-\\ntebra/ and olLadr^atZy a slipping down.\\nFig. 116.\\nSpondylolisthetic pelvis. (After E. Martin.)\\nThe deformity is due to a dislocation of the last lumbar\\nvertebra in front of the sacrum. The body of the former is\\nusually found to have slipped down in front of the first sacral\\nvertebra, to which it has become attached by bony union. An\\nexaggerated lordosis is produced, so that two or more of the\\nlumbar vertebrae descend into the pelvic inlet and obstruct its\\nanteroposterior diameter. The sacrum is pushed downward\\nand backward, and to compensate this the anterior half of the", "height": "3712", "width": "2416", "jp2-path": "obstetricsmanual00evan_0301.jp2"}, "294": {"fulltext": "294 PATHOLOGY OF LABOR.\\nj)elvi3 is raised, so that the height of the symphysis is increased\\n(Fig. 116).\\nTlie pelvic iulet is thus diminished both laterally and antero-\\nposteriorly.\\nEtiology: Injury, disease, and developmental defects are\\nusually mentioned as predisposing causes.\\nThe diagnosis is somewhat difficult unless the condition is\\nwell marked. The stature of the woman is diminished, and\\nthe ribs may come into actual contact with the iliac crests.\\nLordosis is extreme and the shoulders are carried wtII back\\nwhen the patient is erect. The posterior superior iliac spines\\nare widely separated. The pelvic inclination is altered, so that\\nthe vulvar region is carried somewhat forward.\\nLiterncd examination reveals the projection of the lumbar\\nvertebrae. It may be possible to feel the lower end of the\\naorta pulsating.\\nTreatment: The deformity is of the nature of a flattening\\nof the pelvis, so that the mechanism of labor resembles that\\nwhich occurs in the flat rachitic pelvis. The obstruction to\\nlabor depends entirely upon the projection of the lumbar ver-\\ntebrae. The treatment is conducted on the same lines as in flat\\npelvis.\\nPelves Distorted by Injuries, Tumors, or Disease.\\nLuxation of the femur: This condition, which is usually\\ncongenital, rarely produces such deformity of the pelvis as\\nseriously to obstruct labor.\\nTumors The commonest tumors which occur in connection\\nw ith the pelvis are exostoses of the joints. Fibroma, sarcoma,\\ncarcinoma, and enchondroma of the pelvic bones may distort\\nthe pelvis and so lead to obstruction (Fig. 117).\\nTreatment: When the growth is not excessive delivery by\\nthe natural passages may be possible. When such is not the\\ncase Csesarean section must be performed. Symphysiotomy\\nmay be employed in suitable cases, when the sacro-iliac joints\\nare not involved in the tumor.\\nFractures of the pelvis Deformity the result of fracture of\\nthe pelvic bones is rare.\\nSeparation of the symphysis pubis This accident may occur\\nI", "height": "3728", "width": "2752", "jp2-path": "obstetricsmanual00evan_0302.jp2"}, "295": {"fulltext": "PELVES WITH ANOMALIES OF SIZE, ETC. 295\\nas a result of great force being exerted in the extraction of the\\nliead by means of forceps, or after version has been performed.\\nOsteomalacia, rachitis, syphilis, and tuberculosis, or any pro-\\nfound cachexia, may predispose to the occurrence of this acci-\\ndent.\\nDiagnosis The patient generally complains of sharp pain at\\nthe moment of separation of the joint. Tlie condition may be\\nrecognized by introducing the index-finger into the vagina\\nbehind the joint and grasping it. between the finger and thumb.\\nFig. 117.\\nMalignant growth of posterior wall of pelvis which necessitated Csesarean section\\nin a case of Dr. Cameron.\\nTreatment This consists in the application of a firm pelvic\\ngirdle as recommended for use after the operation of sym-\\nphysiotomy.\\nAnchylosis of pelvic joints This condition may affect any\\nof the pelvic joints. When the symphysis is affected it has\\nbut little influence on labor. Anchylosis of the sacro-iliac\\njoints may result in serious pelvic deformity. Not uncom-\\nmonly the sacrococcygeal joint is affected, in which case ob-\\nstruction may occur at the outlet. Fracture of the coccyx is\\nthe usual result.", "height": "3708", "width": "2372", "jp2-path": "obstetricsmanual00evan_0303.jp2"}, "296": {"fulltext": "296\\nPATHOLOGY OF LABOR.\\nSplit pelvis Waut of complete development of the anterior\\nwall of the pelvis results in this condition. It does not cause\\nany obstruction to labor, but is likely to be associated with\\nprecipitate delivery.\\nPelvic Deformities Due to Spinal Curvature.\\nKyphosis The degree of pelvic deformity resulting from\\nkyphosis depends on the situation of the hump the nearer this\\nis to the sacrum the greater is the deformity of the pelvis.\\nGenerally the kyphosis occurs about the junction of the dorsal\\nand lumbar vertebrae.\\nTreatment: If the degree of contraction is slight, labor is\\nusually easy. There exists an old saying that hunchbacks\\nFig. 118.\\nLordotic pelvis. (After Klein wachter.)\\nhave easy labors. When delay takes place forceps may be\\nrequired to eflPect delivery. In extreme contraction the\\nCaesarean operation is demanded.\\nLordosis is a rare condition, and is usually secondary to spinal\\ndisease or pelvic deformity. To a certain degree it affords", "height": "3712", "width": "2752", "jp2-path": "obstetricsmanual00evan_0304.jp2"}, "297": {"fulltext": "ANOMALIES OF UTERINE DEVELOPMENT. 297\\ncompensation but, as a rule, it is not sufficient, and a rota-\\ntion of the sacrum occurs, so that the upper end is thrown\\nbackward and downward (Fig. 118). The pelvic canal tends\\nto become funnel-shaped on account of the projection forward\\nof the lower part of the sacrum and the partial obliteration of\\nthe promontory.\\nAt the inlet the conjugate is increased while the antero-\\nposterior diameter is diminished. The diameters at the outlet\\nare usually more or less diminished.\\nScoliosis The effect of scoliosis on the pelvis depends on the\\nsituation and extent of the spinal curvature. The lower it is\\nand the earlier it occurs, the more serious are the effects pro-\\nduced in the pelvis. There is usually some degree of oblique\\ncontraction present in the pelvis of a patient the subject of\\nscoliosis. The condition is frequently associated with rachitis.\\nThe innominate bone, toward which the lumbar vertebrae are\\ncurved, receives the greater part of the body-weight, and is\\ntherefore pushed upward, inward, and backward by the extra\\npressure exerted on it by the head of the femur. The acetabu-\\nlum on this side is displaced upward and inward toward the\\nsacrum. The symphysis is thus pushed toward the opposite\\nside. Thus the greatest degree of pelvic contraction is on the\\nside of the spinal convexity.\\nIn labor the largest part of the head generally descends on\\nthe roomier side of the pelvis, through which it may pass\\nwhen in a state of good flexion.\\nIn cases in which the pelvic deformity is extreme the Caesa-\\nrean operation must be resorted to.\\nKyphoscoliosis Rachitis may produce both kyphosis and\\nscoliosis in the same woman. If the kyphosis is situated high\\nup, but little effect may be produced on the pelvis.\\n3. ANOMALIES OF THE MATERNAL SOFT STRUCTURES.\\nAnomalies of Uterine Development.\\nVarieties: Labor may be complicated in many ways in a\\npatient who has a double or septate uterus. Malpositions of\\nthe foetus are common. The unimpregnated half may cause\\nobstruction by its bulk, as it usually undergoes considerable", "height": "3712", "width": "2420", "jp2-path": "obstetricsmanual00evan_0305.jp2"}, "298": {"fulltext": "298 PATHOLOGY OF LABOR.\\nincrease in size in sympathy with the impregnated half. If\\nthe placenta is attached to the septum, severe hemorrhage may\\ntake place owing to imperfect contraction. Rupture of the\\nseptum or of the uterus may occur.\\nThe decidual membrane which has formed in the impreg-\\nnated half of the uterus may be retained, and, undergoing pro-\\nliferation after delivery, may give rise to septic infection.\\nIn all cases of anomalous development of the uterus labor-\\npains are usually short and inefficient.\\nPregnancy in a rudimentary horn is a ^^t dangerous condi-\\ntion, and when diagnosed it should be ated as a case of\\nectopic gestation.\\nTreatment Forceps or version must be resorted to in most\\nof these cases in order to effect delivery. The former should\\nbe chosen in preference to the latter when possible. Caesarean\\nsection may be necessary.\\nAbnormal Conditions of the Cervix.\\nVarieties Atresia, cicatricial conditions, contraction, and\\nrigidity of the cervix, may all give rise to more or less ob-\\nstruction in the first stage of labor.\\nAtresia is a very rare condition, and it is very seldom com-\\nplete. The situation of the external os may be recognized as\\na dimple. Pressure upon this with a blunt instrument, such\\nas the tip of a uterine sound, is usually all that is required to\\nperforate it, after which dilatation usually proceeds rapidly.\\nCicatricial contraction of the cervix is usually due to old\\nlaceration, or it may arise from a repair operation, from cauter-\\nization, or from syphilis or cancer.\\nRigidity of the Cervix.\\nEtiology When not due to organic changes, it is said to be\\nfunctional. Functional rigidity is common in highly sensitive\\nyoung women and in elderly primiparse. It is usually due to\\nsome imperfection in the nerve-supply of the uterus, and is\\nfrequently associated with inefficient uterine contractions.\\nTreatment When the rigidity of the cervix is functional in\\norigin it may usually be overcome by the employment of nerve", "height": "3712", "width": "2740", "jp2-path": "obstetricsmanual00evan_0306.jp2"}, "299": {"fulltext": "DISPLACEMENTS OF THE UTERUS. 299\\nsedatives and hot douches. Syr. chloral, hydrat., siss, should\\nbe administered in warm milk. Ten minutes later a hot vag-\\ninal douche (115\u00c2\u00b0 F.) should be given, at least two quarts of\\nwater being used. Every succeeding ten minutes a dose of\\nchloral and a hot douche should be given in alternation, till\\nthe patient has received three doses of chloral and three hot\\ndouches, should the cervix not yield before. In the author s\\nexperience this plan of treatment has rarely failed.\\nIn some cases a hypodermic injection of morphine, gr. J, is\\nall that is required. Painting the cervix with a 2 per cent,\\nsolution of cocaine has been highly recommended. Occasion-\\nally a few whiffs of chloroform with each pain act like a charm\\nin relieving this condition when it occurs in a highly nervous\\npatient.\\nWhen these methods fail, artificial dilatation by means of\\nthe fingers or by the introduction of a Barnes or Champetier\\nde Ribes bag may be necessary.\\nIn extreme cases it may be necessary to make several small\\nincisions, one-quarter to one-half inch deep, in the cervix be-\\nfore proceeding to artificial delivery.\\nImpaction of the Anterior Lip of the Cervix.\\nOccurrence This condition may occasionally obstruct the\\nadvance of the head at the outlet. The anterior lip in these\\ncases is caught between the head and pubes, and, becoming\\nswollen and oedematous, may actually protrude at the vulva.\\nAfter labor it may slough.\\nThe proper treatment is to attempt to push it up in the\\nintervals between the pains. If it be very oedematous, it may\\nbe necessary first to make a number of small incisions into it\\nto permit the escape of serum, when its reduction may be ac-\\ncomplished without difficulty.\\nDisplacements of the Uterus.\\nAnterior displacement of the uterus at the time of labor is\\nnot infrequent. It is generally due to a lax condition of the\\nabdominal walls.\\nTreatment consists in the application of a tight abdominal", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0307.jp2"}, "300": {"fulltext": "300 PATHOLOGY OF LABOR.\\nbinder, and in keeping the patient on her back in a half-reclin-\\ning posture during labor.\\nLateral displacement to one or other side may take place.\\nThe pregnant uterus is usually tilted slightly to the right side.\\nWhen the lateral inclination is excessive part of the propulsive\\nforce of the uterus is lost, on account of the pressure of the\\npresenting part against the lateral wall of the pelvis.\\nTreatment Lateral displacement of the uterus may be cor-\\nrected by making the patient lie on the side opposite to that to\\nwhich the fundus is directed.\\nRetrodisplacement of the gravid uterus has already been re-\\nferred to. Should the case go on to full term the distention of\\nthe uterus to accommodate the foetus is accomplished by the\\nstretching of the anterior wall, while the fundus and the pos-\\nterior wall remain within the pelvis. The condition is known\\nas posterior sacculation of the uterus.\\nIn these cases the cervix is always displaced anteriorly and\\nis pressed close to the abdominal wall.\\nTreatment: Caesarean section is seldom necessary in these\\ncases, as delivery can usually be effected by artificial dilatation\\nof the cervical canal and subsequent internal version.\\nProlapse of the pregnant uterus is possible, but these cases\\nnever go to full term. The prolapse of the uterus at term is\\nusually partial, and only the elongated cervix escapes from the\\nvulva, the fundus being in its usual position (Fig. 119). In\\nlabor the cervix may be retracted within the vagina or if it\\nbe rigid it may become oedematous, and by its bulk prevent\\ndelivery of the child.\\nTreatment: When possible the cervix should be pushed into\\nthe vagina, and retained there till dilatation occurs, when\\nforceps may be applied and the child delivered. When the\\ncervix is rigid and oedematous it should be freely incised and\\ndilated, to permit the application of forceps to the child s\\nhead. An assistant may counteract the traction of the forceps,\\nby pushing up the cervical tissues during the extraction of\\nthe child.\\nVentrofixation or suspensio uteri may lead to obstruction in\\nlabor if the fundus has been attached too low down on the an-\\nterior wall. If the fundus is so firmly attached to the abdom-\\ninal wall that it is prevented from rising, the anterior wall of", "height": "3732", "width": "2760", "jp2-path": "obstetricsmanual00evan_0308.jp2"}, "301": {"fulltext": "DISPLACEMENTS OF THE UTERUS.\\n301\\nthe uterus remains crowded down over the pelvic inlet, while\\nthe posterior is distended and greatly thinned.\\nFig. 119.\\nElongated cervix with procidentia during labor. (Barnes.)\\nThe complications of labor which have been recorded in such\\ncases are inertia uteri, transverse position of the child, dis-\\nplacements of the head, cervical rigidity, rupture of the uterus,\\nand severe hemorrhage during the third stage of labor.", "height": "3712", "width": "2420", "jp2-path": "obstetricsmanual00evan_0309.jp2"}, "302": {"fulltext": "302 PATHOLOGY OF LABOR.\\nTreatment: If the obstruction olFered by the folded and\\nthickened anterior uterine wall be so great as completely to cut\\noff the pelvic inlet, Csesarean section must be performed. In\\nsome cases it may be possible to deliver the child by means of\\nversion, the danger of this operation being rupture of the\\nthinned-out posterior wall of the uterus. The writer in one\\ncase was able to push the anterior wall out of the way suf-\\nficiently to permit the application of the forceps to the head,\\nwhich was then drawn down.\\nAbnormal Conditions of the Vagina and Vulva.\\nLongitudinal and transverse septa may be present in the\\nvagina and obstruct the advance of the presenting part of the\\nfoetus. They are seldom very dense in structure and are easily\\nruptured. If they do not yield, they may be divided between\\nligatures.\\nUnruptured hymen This condition may be found present in\\nlabor it causes but slight obstruction occasionally it may be\\nnecessary to incise it.\\nAtresia of the vagina Narrowing of the vagina may be\\ndue to maldevelopment or to cicatricial contractions after pre-\\nvious injury.\\nTreatment Hot douches followed by injections of sterilized\\nsweet oil may be employed to soften the part. Dilatation may\\nbe eifected by the use of Champetier de Ribes s bag.\\nRigidity of perineum The perineum mav be so rigid as to\\nprevent advance of the foetus. This condition is common in\\nmuscular women and in elderly primiparse.\\nTreatment In these cases the forceps may be required to\\ndraw down the foetus. During delivery the perineum may be\\nsoftened by the free use of hot fomentations, care being taken\\nto smear the parts with vaseline, to prevent burning. When\\nlaceration is certain, episiotomy may be performed.\\nHaematoma This condition is, when present, found at the\\nvaginal orifice.\\nTreatment: If large enough to obstruct labor, the tumor\\nshould be excised and the contents cleared out after delivery,\\nif hemorrhage from the cavity takes place, it should be packed\\nwith iodoform gauze.", "height": "3704", "width": "2728", "jp2-path": "obstetricsmanual00evan_0310.jp2"}, "303": {"fulltext": "TUMORS OF THE GENITAL CANAL, ETC. 303\\nVaricose veins when present seldom obstruct labor. They\\nmay rupture or be so bruised as to slough afterward.\\n(Edema of the vulva due to heart or kidney disease may ob-\\nstruct labor. Multiple punctures should only be resorted to in\\nextreme cases, as there is great risk of sepsis or gangrene fol-\\nlowing delivery.\\nAbnormal Conditions of the Bladder.\\nDistended bladder This is a not uncommon cause of delay\\nin labor, and should always be borne in mind. The urine\\nshould be removed with a sterile, long, soft catheter, the pre-\\nsenting part being pushed up so as to permit access to the\\nbladder. In cases in which it is impossible to pass the cathe-\\nter perforation through the abdominal wall may be required.\\nCystocele In this condition the bladder may protrude\\nthrough the vulva.\\nTreatment The urine must be drawn by means of a soft\\ncatheter, and the prolapsed part afterward pushed gently up\\nabove the presenting part of the foetus. If reduction prove\\nimpossible, the part must be held up while the child is ex-\\ntracted by means of the forceps.\\nVesical calculus If small, the calculus may not obstruct\\nlabor. If possible, it should be pushed up above the sym-\\nphysis.\\nWhen large, it may be extracted after dilating the ure-\\nthra or it may be necessary to incise the bladder through the\\nanterior vaginal wall. After labor the incision may be\\nsutured.\\nTumors of the Genital Canal and Neighboring Organs.\\nCarcinoma of the cervix It may be said that, as a rule,\\nwhen this condition is present at full term serious obstruction\\nto labor results. Spontaneous delivery may occur if the dis-\\nease is limited to the anterior lip and is not surrounded by a\\nlarge area of cicatricial infiltration.\\nHemorrhage and sepsis are likely to arise during the puer-\\nperium.\\nCsesarean section is the proper treatment, if the disease is\\nfairly extensive.", "height": "3712", "width": "2424", "jp2-path": "obstetricsmanual00evan_0311.jp2"}, "304": {"fulltext": "304\\nPATHOLOGY OF LABOR.\\nFibromyomata,\\nThe obstructions to labor resulting from the presence of fibro-\\nmyomata depend on the situation of the new growth. If it\\nsprings from the lower uterine segmen or cervix, it may\\nbecome incarcerated in the pelvis and absolutely prevent the\\ndescent of the child (Fig. 120).\\nFig. 120.\\n/?ec^am\\nB/odder\\nPer/nei//7i\\nMyoma uteri complicating pregnancy. (After Spiegelberg.)\\nEffects They lead to mal presentations and malpositions of\\nthe foetus, to prola])se of the cord, to adherent placenta, and to\\nhemorrhage. The labor-pains are likely to be inefficient. A\\ntetanic condition of the uterus is not infrequently met with in\\nthese cases.\\nThe pressure of the tumor may produce severe contusions\\nor fractures of the foetal skull. The tumor may be so injured\\nduring labor that sloughing and gangrene may follow and\\ngive rise to septic infection.\\nIi", "height": "3712", "width": "2748", "jp2-path": "obstetricsmanual00evan_0312.jp2"}, "305": {"fulltext": "TUMORS OF THE GENITAL CANAL, ETC. 305\\nWhen the tumor is situated on the anterior wall it may be\\ndisplaced upward by uterine contraction, and thus cease to\\nobstruct the advance of the child.\\nDiagnosis When situated low down in the uterus a fibroid\\ntumor may be mistaken for the foetal head. A careful exami-\\nnation should prevent this mistake.\\nPrognosis This depends upon the early recognition of the\\ncondition and the treatment adopted. The experience of the\\nwriter leads him to consider the presence of myoma a grave\\ncomplication of labor. In a series of 300 of these cases col-\\nlected by Lafleur the mortality for the mothers, of delivery by\\nthe natural passage, was 25 to 55 per cent, and 77 per cent,\\nfor the children.\\nTreatment When the tumor or tumors are situated high up\\nlabor may terminate naturally. In some cases labor is pro-\\nlonged on account of uterine inertia, and must be terminated\\nby version or forceps.\\nWiien the tumor is small and situated low down, it may be\\npossible to push it up out of harm s way by placing the patient\\nin the knee-chest position. If this fails, it may be possible to\\nextract the child by means of the forceps with the woman in\\nWalcher s position. If this be impossible, Csesarean section\\nmust be performed, or else Porro s operation.\\nIf the tumor is submucous and attached to the cervix, it\\nmay be possible to remove it by enucleation even after labor\\nhas begun. After labor the tumor cavity should be packed\\nwith iodoform gauze.\\nIn all cases in which delivery takes place through the natu-\\nral passages there is great danger of hemorrhage from imper-\\nfect contraction of the placental site. Should hot intra-uterine\\ndouches and hypodermics of ergot fail to control the hemor-\\nrhage, the cavity of the uterus must be packed with sterilized\\niodoform gauze. The gauze may be left in the cavity for three\\nor four days, and if necessary it may then be renewed.\\nPolypi.\\nMucous polyps usually spring from the cervical canal or\\nanterior lip of the cervix, and when present may obstruct\\nlabor.\\n20\u00e2\u0080\u0094 Obst.", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0313.jp2"}, "306": {"fulltext": "306 PATHOLOGY OF LABOR.\\nEven if small, these polypi should be removed at the time\\nof labor, by transfixing and tying the pedicle, and cutting\\nthem away.\\nOvarian Cysts.\\nThese rarely complicate labor. If discovered during preg-\\nnancy, they should be removed. Small ovarian tumors may\\nprolapse and cause obstruction in the pelvis.\\nTreatment If the tumor be found below the brim at the\\ntime of labor, efforts should be made to push it up into the\\nabdominal cavity. To do this it may be necessary to anaes-\\nthetize the patient and to place her in the knee-chest position.\\nIf it be impossible to reduce the tumor, it may be tapped from\\nthe vagiua. This operation cannot be recommended, as it\\nexposes the patient to the danger of peritonitis, from escape of\\nthe contents into the peritoneal cavity. It is better to perform\\nCaesarean section, and at the same time remove the tumor. If\\nthe cyst only partially occludes the pelvic inlet, it may be pos-\\nsible to effect delivery by version or forceps.\\nVaginal cysts, dermoid cysts, swellings of the tubes and\\nbroad ligaments, prolapse of a floating kidney to the pelvic\\ninlet, hydatid cysts of the pelvis, and tumors of the liver or\\nspleen may be found to cause obstruction in labor.\\nRupture of the Uterus.\\nOccurrence Rupture of the uterus may take place during\\npregnancy, labor, or the puerperal period. In the vast major-\\nity of these cases the rupture takes place during the second\\nstage of labor, and consists of a laceration of some portion of\\nthe uterine wall.\\nFrequency: This accident is said to occur about once in\\n4000 cases, but the writer is of the opinion that it occurs\\nmuch more frequently than is generally thought, as prac-\\ntitioners are not prone to report these cases when they occur in\\nprivate practice.\\nEtiology The most frequent cause of rupture of the uterus\\nis overdistention of the lower uterine segment, the result of\\nsome obstruction which prevents the descent of the presenting\\npart of the child.", "height": "3728", "width": "2760", "jp2-path": "obstetricsmanual00evan_0314.jp2"}, "307": {"fulltext": "RUPTURE OF THE UTERUS. 307\\nThus pelvic deformity, overgrowth of the child, hydro-\\ncephalus, a tumor blocking the pelvis, rigidity of the soft\\nparts, or malpresentations, result in contractions of the uterus\\nforcing the child s body into the lower uterine segment, which\\nbecomes enormously distended, while the upper segment, with\\nits walls greatly thickened, is drawn up until it forms a dis-\\ntinct tumor, w4iich can be felt through the abdominal wall\\nabove the child.\\nThere is usually a well-defined line between the thickened\\nupper segment and the distended lower segment. This line is\\ngenerally visible, as well as palpable, running obliquely across\\nthe abdomen somewhat below the umbilicus. This is the\\nretraction-ring, or so-called contraction-ring of Bandl.^\\nWhen the limit of the capacity of the lower uterine wall in\\nstretching and thinning is reached rupture takes place.\\nWhen the uterine wall is iceakened from any cause, such as a\\nblow or fall during pregnancy, fatty or other degeneration, or\\nfrom malignant or other disease, rupture may take place early,\\neven without much distention of the lower segment.\\nFinally, rupture may occur during unskilful attempts at ver-\\nsion, the high application of forceps, or separation of an adher-\\nent placenta.\\nRupture of the uterus has been recorded as following the\\nadministration of ergot to hasten the expulsion of the child.\\nJolly has collected thirty-three such cases.\\nSite of the rupture The tear usually begins in the wall of\\nthe lower uterine segment and runs transversely. When the\\nrupture is spontaneous it usually occurs in the lateral wall.\\nWhen due to traumatism the anterior wall is usually the site\\nof the laceration.\\nThe extent of the tear varies from a small rent limited to the\\nmuscular coat to complete penetration into the abdominal\\ncavity. Usually tlie edges of the wound are jagged and irreg-\\nular, and infiltrated with blood.\\nWhen only the muscular coat is torn, tlie peritoneal covering\\nof the uterus may be stripped off for a considerable distance\\nbeyond the tear, the sac thus formed becoming filled with\\nblood-clot.\\nThe foetus and placenta may escape into the peritoneal cavity", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0315.jp2"}, "308": {"fulltext": "308 PATHOLOGY OF LABOR.\\nwhen the rent is extensive, and the intestines may prolapse into\\nthe vagina.\\nSymptoms Rupture of the uterus when extensive is usually\\naccompanied with alarming symptoms. The uterine contrac-\\ntions have probably been vigorous for some time, and the\\nwoman s suffering becomes extreme. Complaint is usually\\nmade of continuous and severe cramp-like pain in the lower\\npart of the abdomen.\\nOn abdominal examination the uterus will be found in a\\nstate of almost tetanic contraction with the lower segment\\ngreatly distended. The retraction-ring may be palpable, or\\neven visible. Suddenly there is a peculiar sharp, lancinating\\npain, the woman gives a loud cry, and asserts that something\\nhas torn. The sound of the tear may be audible. Then\\nfollows absolute cessation of uterine action. Blood flows from\\nthe vagina, and symptoms of profound shock rapidly develop.\\nOn making a vaginal examination, the presenting part will be\\nfound to have receded a loop of intestine may be encountered,\\nor the hand may pass through the rent into the abdominal\\ncavity.\\nWhen the rupture is only partial, there may be no symptoms\\nuntil after the birth of the child. There may be a moderately\\nsevere hemorrhage before the placenta comes away. Uterine\\naction is usually poor, and there may be some difficulty in ex-\\npelling the placenta. The uterus tends to remain flaccid, and\\nthere may be some post-partum hemorrhage. None of these\\nsymptoms may suggest the condition actually present. The\\nrapid development of septic peritonitis may lead to an intra-\\nuterine examination being made within twenty- four or forty-\\neight hours, when a partial laceration will be discovered if\\nthe uterine cavity be carefully explored.\\nThe author has had experience of one case in which there\\nwere no symptoms to indicate that rupture had taken place,\\nbeyond a somewhat severe hemorrhage with the expulsion of\\nthe placenta. On the second day of the puerperal period the\\npatient developed a slight temperature, and on the third a\\nsevere hemorrhage took place. On making an intra-uterine\\nexamination a rent, sufliciently large to admit two fingers was\\nfound in the posterolateral wall just above the external os.\\nThe prognosis depends on the site and extent of the lacera-", "height": "3712", "width": "2736", "jp2-path": "obstetricsmanual00evan_0316.jp2"}, "309": {"fulltext": "RUPTURE OF THE UTERUS. 309\\ntion as well as upon the treatment. The maternal mortality\\nunder the best treatment runs as high as 60 per cent., while\\nthe mortality of the infants is as high as 90 per cent.\\nComplete rupture is much more likely to prove fatal than is\\npartial rupture, on account of the involvement of the peritoneal\\ncavity. More than one-half of the cases perish within twenty-\\nfour hours of the accident. The causes of death are sepsis,\\nhemorrhage, and shock.\\nTreatment When vigorous uterine contractions fail to cause\\nadvance of the presenting part, the condition of the lower\\nuterine segment should be ascertained. When the retraction-\\nring of Bandl is to be felt half-way between the pubes and the\\numbilicus labor should be terminated as rapidly as possible, in\\norder to guard against the occurrence of rupture. The pro-\\ncedure to be adopted will depend on the conditions present.\\nBefore operating the patient should be ansesthetized to the\\nsurgical degree, and if this fails to relax the uterus completely\\na hypodermic injection of morphine may be given.\\nWhen rupture has taken place the physician^s first duty is to\\nempty the uterus and to control hemorrhage. If the child has\\nnot escaped into the peritoneal cavity, it should be delivered\\nrapidly by the application of forceps or by craniotomy. The\\nplacenta should then be removed manually, and the site and\\nextent of the laceration examined.\\nIn incomplete laceration it is sufficient to irrigate the cavity\\nof the rent with a hot antiseptic solution, such as formalin\\n(1 500), and to pack it gently with iodoform gauze. This\\ntreatment should be repeated at intervals of from twenty-four\\nto forty-eight hours until the rent has healed.\\nWhen the rupture is found to be complete the treatment\\ndepends on its site and extent. When it is small and situated\\nlow down, and but little if any foreign matter has escaped into\\nthe peritoneal cavity, the rent may be irrigated and packed\\nwith iodoform gauze. In such a case a close watch should be\\nkept for symptoms of peritonitis and if such develop the abdo-\\nmen should be promptly opened, the peritoneal cavity cleansed,\\nand thorough vaginal and abdominal drainage provided.\\nWhen the rupture is extensive the abdomen should be\\npromptly opened and the peritoneum cleansed of all clots and\\nother foreign matter. If the edges of the wound are ragged", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0317.jp2"}, "310": {"fulltext": "310 PATHOLOGY OF LABOR.\\nand infiltrated with blood, no sutures will hold in this case\\nsome authors recommend that the uterus be removed, while\\nothers claim excellent results from merely providing for good\\nvaginal and abdominal drainage.\\nThe condition of shock, if present, should be treated by saline\\ninjection, strychnine, digitalis, and brandy, and the application\\nof heat to the surface of the body.\\nIn the author s experience, limited to four cases in which\\ntreatment was possible, most excellent results followed careful\\nirrigation and gauze packing. In two of these cases the per-\\nforations, though small, extended completely through the\\nuterus. The hemorrhage was severe in all four cases, but\\ncould be fairly well controlled by pressing the uterus firmly\\ndown into the pelvis from above.\\nAfter the hot douche the blood ceases to flow for a short\\nperiod this time must be utilized by quickly packing the\\ncavity of the rent with gauze, which may be guided into place\\nalong the fingers of the left hand placed in the cervix.\\nGreat care must be exercised in removing the gauze packing,\\nwhen this is necessary it must be drawn out bit by bit, slowly\\nand gently, in order to avoid starting a hemorrhage. The most\\nrigid asepsis is required in the performance of each dressing of\\nthe laceration. The gauze packing should not be too firm,\\nthough sufficient should be inserted to prevent bleeding, but\\nnot so tightly packed as to prevent free drainage.\\nInversion of the Uterus.\\nOccurrence This accident is fortunately extremely rare. It\\nis met with more frequently in private than in hospital prac-\\ntice. Inversion of the uterus may be acute or chronic. It is\\nwith the acute form the obstetrician has to deal. The inver-\\nsion may be pcuilal or complete.\\nIn partial inversion the fundus may be the site of a cup-\\nshaped depression, or it may actually prolapse sufficiently to\\nprotrude from the os.\\nIn complete inversion the uterus is turned inside out, and\\nmay j)rotrude from the vulva, appearing as a rounded mass\\nbetween the patient s thighs.\\nEtiology Complete inertia uteri, or uterine paralysis, at the\\ni", "height": "3712", "width": "2740", "jp2-path": "obstetricsmanual00evan_0318.jp2"}, "311": {"fulltext": "INVERSION OF THE UTERUS. 311\\nclose of the second stage of labor, is the most important pre-\\ndisposing cause. It may occur spontaneously, and immediately\\nfollow the birth of the child.\\nIt has been produced by unskilful attempts at placental ex-\\npulsion. Traction on the cord, to aid the expulsion of the pla-\\ncenta, has brought about inversion. When there is an actual\\nor relative shortening of the cord it is possible that the trac-\\ntion on the placental site may drag down the fundus so as ulti-\\nmately to produce inversion.\\nSymptoms The inversion usually takes place suddenly, and\\nis associated with severe shock, pain, and hemorrhage. Vesical\\nand rectal tenesmus may be present. The pain is usually severe,\\nwhile the hemorrhage is rarely profuse. By abdominal exam-\\nination the absence of the uterine tumor will be noticed. On\\nmaking an internal examination the inverted fundus will be\\nfound either protruding from the os or possibly completely fill-\\nins^ the vagina.\\nDiagnosis Inversion of the uterus can usually be diagnosed\\nby a careful external and internal examination. The only con-\\ndition from which it must be differentiated is prolapse of a\\nuterine polypus. The most important point in distinguishing\\nbetween these conditions is the presence or absence of a uterine\\ncavity. This can usually be demonstrated or excluded satis-\\nfactorily by the introduction of a uterine sound.\\nPrognosis In the acute form the mortality-rate is extremely\\nhigh. Death may take place in a few hours from shock, hem-\\norrhage, or exhaustion, or later from septicaemia.\\nRecovery has followed spontaneous reposition, and after sep-\\naration of the inverted organ by sloughing.\\nSpontaneous reposition is more likely to occur when the\\ninversion is partial than when it is complete.\\nTreatment Reposition by taxis is the only treatment usually\\navailable. If the placenta is still attached to the uterus, it\\nshould be separated before reposition is attempted. The uterus\\nshould be douched with a hot antiseptic solution. The patient\\nshould then be anaesthetized and placed in the lithotomy posi-\\ntion. The body of the uterus should be gently pushed back\\nwithin the vulva, and the operator s hand inserted into the\\nvagina and well back toward the sacrum, having the palm\\ndirected upward. The finger-tips then grasp the lower uterine", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0319.jp2"}, "312": {"fulltext": "312 PATHOLOGY OF THE PUERPERAL PERIOD.\\nsegmeDt and exert pressure upon it, in a direction upward and\\nforward, toward the anterior abdominal wall, and in the axis\\nof the pelvic inlet.\\nAfter the reposition has been completed the hand should be\\nkept within the cavity until a contraction occurs, when it may\\nbe gently withdrawn. A hot intravaginal douche should then\\nbe given, and strychnine (gr. combined with ergotine (gr.\\n\u00e2\u0096\u00a0Jq) administered hypodermically.\\nIf efforts at immediate reposition fail, it should be attempted\\nagain within a few hours.\\nIf it be impossible to reduce the inversion, measures should\\nbe taken to prevent the occurrence of septic infection, and the\\ncase left for operative treatment at a later date. If infection\\noccur, the best method is vaginal hysterectomy.\\nPATHOLOGY OF THE PUERPERAL PERIOD.\\nHEMORRHAGES DURING THE PUERPERIUM.\\nPost-partum Hemorrhage.\\nDefinition Excessive loss of blood from the genital canal\\nimmediately following the birth of the placenta, or taking\\nplace within twenty-four hours of labor, is usually termed post^\\npartum hemorrhage.\\nEtiology The commonest cause of this grave accident is mis-\\nmanagement of the third stage of labor. Spiegelberg has\\nstated that severe post-partum hemorrhage is almost without\\nexception the fault of the medical attendant. It is certain that\\nthis accident is met with much more frequently in private prac-\\ntice than in well -organized maternities, the reason being that in\\nthese institutions the attendants are individuals of special skill.\\nUterine inertia is a frequent cause of post-partum hemor-\\nrhage. The uterus fails to retract properly after the expulsion\\nof the placenta; hence the placental sinuses remain patent, and\\nblood is poured out into the uterine cavity, where clots form,\\nwhich acting as a foreign body may stimulate contractions.\\nThese contractions are usually weak and inefficient, while the\\nintra-uterine clots are more or less firmly attached to the walls,", "height": "3712", "width": "2736", "jp2-path": "obstetricsmanual00evan_0320.jp2"}, "313": {"fulltext": "POSTPARTUM HEMORRHAGE. 313\\nand hence difficult to dislodge. In the intervals between the\\ncontractions more blood is poured out, until finally by this proc-\\ness the uterus may become distended to its full capacity. The\\nexternal hemorrhage may be insignificant in amount, though it\\nis usually greatly in excess of the normal.\\nOther conditions which predispose to hemorrhage are pre-\\ncipitate labor overdistention of the uterus, as in hydraranios,\\ntwin pregnancy, etc. a distended bladder or rectum the reten-\\ntion of small portions of the placenta or membranes tumors\\nand other new growths in the uterus and exhaustion following\\na prolonged and difficult labor.\\nCertain constitutional conditions predispose to this accident,\\nas nephritis, extreme anaemia, and haemophilia.\\nSevere post-partum hemorrhage may result from lacerations\\nin the lower part of the birth-canal. Lacerations of the cer-\\nvix involving the circular artery, or of the vulva involving\\none of the bulbs of the vestibule, may occasion severe hemor-\\nrhage.\\nSymptoms The hemorrhage may occur with or after the ex-\\npulsion of the placenta. It may be an abrupt, sharp hemor-\\nrhage, or simply steady dribbling which by its persistence\\nresults in an extensive loss of blood. The bleeding may be\\nexternal, internal, or both.\\nThe pidse is the most certain indicator of the severity of the\\nhemorrhage. If after delivery the pulse-rate shows a tendency\\nto become more rapid, the possibility of hemorrhage must be\\nborne in mind. It is a good rule not to leave a patient whose\\npulse-rate is 100 or more to the minute till all possibility of\\nthe occurrence of hemorrhage has passed.\\nIn a severe case symptoms indicative of extensive blood-loss\\nrapidly develop. The pulse becomes rapid and thready res-\\npiration is shallow^, rapid, and sighing; the patient becomes\\nrestless in her movements, tossing herself about and calling for\\nair. She may complain of thirst. Her skin becomes cold and\\ncovered with a clammy sweat. If the liemorrhage continues,\\nsyncope, convulsions, and death bring the jiainful scene to a close.\\nThe diagnosis is seldom difficult, though in conditions of\\nsevere shock occurring immediately after labor all the symp-\\ntoms of severe hemorrhage may be present, except evident loss\\nof blood and a relaxed uterus.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0321.jp2"}, "314": {"fulltext": "314 PATHOLOGY OF THE PUERPERAL PERIOD.\\nThe blandied face, clammy skin, rapid, thready pulse, and\\nsighing respiration, all indicate hemorrhage though the ex-\\nternal h)ss of blood may have been out of all proportion to the\\nsymptoms present. On palpation of the abdomen the hard\\nglobular uterus will be missed from its usual location half-way\\nbetween the umbilicus and symphysis, and the soft, boggy fundus\\nmay be found reaching almost up to the ensiform cartilage.\\nIn cases in which the hemorrhage arises from lacerations of\\nthe lower part of the birth-canal the fundus will be found in\\nits usual position, firmly contracted, in spite of the fact that\\nblood is escaping from the vulva. An internal examination\\nby means of a speculum, if necessary, will reveal the bleeding\\npoint.\\nPrognosis These cases rarely terminate fatally when skilled\\nassistance is at hand. The greater the loss of blood the graver\\nis the prognosis. The most unfavorable cases are those in\\nwhich tiie blood lost is thin and watery, and fails to clot\\nproperly, as this is indicative of a blood dyscrasia.\\nTreatment of Post-partum Hemorrhage.\\nThis accident can usually be prevented by the proper man-\\nagement of the third stage of labor. The directions given for\\nthe management of the third stage of labor constitute an out-\\nline of the preventive treatment of post-partum hemorrhage.\\nThe prompt, energetic treatment of a case of post-partum\\nhemorrhage calls for self-control, readiness in resource, and\\npresence of mind on the part of the physician. His object is\\nto secure good, firm contraction of the uterus. It is well to\\nhave clearly in mind a routine treatment to secure this object.\\nThe first things to be done is to stimulate the uterus to action\\nby making vigorous friction over the fundus, through the\\nabdominal wall. As the organ becomes outlined on contract-\\ning, pressure may be exerted in the manner recommended for\\nthe expulsion of the placenta. Such compression may lead to\\nthe expulsion of clots from the genital canal, and further\\nhemorrhage may cease. If this fortunate result does not follow,\\nthe free hand should be inserted into the vagina and passed\\ninto the uterus, and adherent clots may be loosened and broken\\nup by scraping the walls with the finger-tips. The uterus\\nshould then be rubbed and kneaded between the external and", "height": "3728", "width": "2740", "jp2-path": "obstetricsmanual00evan_0322.jp2"}, "315": {"fulltext": "POST-PARTUM HEMORRHAGE. 315\\ninternal hands, so as to stimulate contractions. As soon as\\ncontraction has been secured the internal hand should be with-\\ndrawn and an intra-uterine douche of hot sterilized water should\\nbe giv^en. To be effectual, the water should be between 115\u00c2\u00b0\\nand 125\u00c2\u00b0 F., and at least a gallon should be employed. A\\nfountain-douche should be used, and the nozzle, either of glass\\nor metal, should be carried to the fundus. While the douche\\nis being given the fundus should be kneaded through the\\nabdominal wall.\\nIf the hemorrhage is not checked by this means, the injec-\\ntion should be repeated, after adding to the sterilized water\\nenough acetic acid to make a 3 per cent, solution e., four\\nounces to the gallon. If this fails to stop the bleeding, then\\nthe uterine cavity must be tamponed with strips of iodoform\\ngauze.\\nThe technique of this procedure is very simple. The ante-\\nrior lip of the cervix is seized with a tenaculum-forceps and\\ndrawn down to the vulva. The end of a strip of gauze is then\\nseized by means of a pair of uterine dressing-forceps and\\nguided to the fundus then the whole cavity is firmly packed\\nwith successive layers. It is not necessary to pack the vagina\\nas well, but after removing the tenaculum from the cervix a\\nstrip of gauze may be placed in the upper part of the vagina\\nto keep the cervix in place. The gauze may be left in place\\nfrom twenty-four to forty-eight hours and then gently removed.\\nIt is seldom necessary to repeat the intra-uterine packing.\\nAs soon as the uterus has been emptied of clots a hypoder-\\nmic of ergot (aseptic, Parke, Davis Co.), 3ss, should be\\ngiven, and repeated in half an hour if required. If after\\nthe first hot douche no acetic acid is available, a piece of\\nsterilized gauze, or even a clean pocket handkerchief, may be\\nsaturated with vinegar, carried to the fundus, and there squeezed\\nout. The vinegar should be strained through cotton-wool\\nbefore being used for this purpose.\\nHaving cliecked the hemorrhage, the physician s duty is\\nthen to combat the evil eflPects of severe loss of blood.\\nTreatment of Acute Ancemia.\\nThe pillows should be removed from beneath the patient^s\\nhead and the foot of the bed raised on some books or bricks.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0323.jp2"}, "316": {"fulltext": "316 PATHOLOGY OF THE PUERPERAL PERIOD,\\nHot-water bottles should be applied to the extremities of the\\npatient, and she should be covered with warm blankets. If\\nthere is a tendency to syncope, a hypodermic injection of\\nstrychnine nitrate (gr. and nitroglycerin (gr. yl^) should\\nbe given.\\nAs soon as possible a quart of water at 110\u00c2\u00b0 F., containing\\ntwo teaspoonfuls of common salt, should be injected into the\\nrectum. For this purpose a soft-rubber catheter should be\\nattached to the nozzle of a fountain-syringe, so that the injec-\\ntion may be carried as far up as possible.\\nIf the hearths action fails to improve, hypodermic injections\\nof ether, strychnin, and nitroglycerin may be employed.\\nNausea and vomiting are frequent in these cases, and there is\\nbut little absorption from the stomach until these cease. As\\nsoon as the stomach will retain anything, small quantities of\\nhot coffee, hot brandy and water, or warm milk may be given\\nand frequently repeated. When reaction has been established\\na hypodermic of morphine (gr. -1^) should be given to quiet the\\npatient.\\nIn desperate cases the saline solution may be sterilized, and\\ninjected beneath the breasts or directly into the median basilic\\nvein\\nTo insert the salt solution beneath the breasts a large ex-\\nploring-needle may be used. A glass funnel and a piece of\\nrubber tubing complete the apparatus. These should be ster-\\nilized after being fitted together for use. The breasts are then\\nwashed with soap and hot water, and rubbed with alcohol.\\nHaving filled the funnel, the physician grasps the breast firmly\\nwith one hand, lifts it from the chest-wall, and with the other\\nhand the needle (with the solution flowing from it) is plunged\\nboldly into the loose tissue beneath the breast. Care should\\nbe taken to prevent the entrance of air.\\nIntravenous injection is seldom used on account of the time\\nrequired to perform the operation, and because the methods\\nbefore given answer the purpose just as well. For the method\\nof operation the reader is referred to works on surgery.\\nConvalescence in these cases is slow and tedious. The\\npatient should not be allowed to sit upright for two or three\\nweeks. The diet should consist largely of fluids, and iron in\\nsome form should be administered.", "height": "3712", "width": "2764", "jp2-path": "obstetricsmanual00evan_0324.jp2"}, "317": {"fulltext": "HEMATOMA. 317\\nPuerperal or Secondary Hemorrhage.\\nDefinition This term is used to denote hemorrhage from\\nthe genital canal of a woman occurring at any time after the\\nfirst twenty-four hours to the end of the puerperium.\\nEtiology The most frequent cause of secondary hemorrhage\\nduring the puerperium is the retention of portions of placenta\\nand membranes. Clots in the uterine cavity or the dislodge-\\nment of clots in the placental site, displacements of the uterus,\\nrelaxation of the uterus, fibroids, polypi, partial rupture, the\\nseparation of a slough, and overdistention of the bladder or\\nrectum may be mentioned as giving rise to puerperal hemor-\\nrhage. Sudden emotion or constitutional causes may result in\\nhemorrhage during the puerperium.\\nDiagnosis Having the causes in- mind, it is the duty of the\\nphysician to make a careful external and internal examination\\nin all cases of secondary hemorrhage. The diagnosis should\\nrarely prove difficult.\\nThe treatment depends on the cause of the hemorrhage.\\nAfter emptying the bladder the cavity of the uterus should be\\nexplored. Fragments of placenta and menibranes or clots\\nshould be removed and a hot intra-uterine douche given. If\\nthe cause is found to be other than those just mentioned, ap-\\npropriate treatment should be inaugurated.\\nHsematoma.\\nDefinition In this form of hemorrhage the effusion of blood\\nis interstitial. The result of this accident is the formation of\\na tumor varying in size with the degree of the hemorrhage.\\nThe most frequent situation of ha^matoma is in one or other\\nlabium, rarely in both. It may occur in any portion of the\\ngenital canal outside of the uterus.\\nEtiology A varicose and congested condition of the pelvic\\nveins predispose to the occurrence of this accident. The de-\\ntermining cause is usually direct injury of the tissues from\\npressure of the foetal head or from forceps. Forcing or strain-\\ning on the part of the woman may lead to the rupture of an\\nengorged vein, and so give rise to the condition. It may occur\\nbefore or after the completion of labor.", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0325.jp2"}, "318": {"fulltext": "318 PATHOLOGY OF THE PUERPERAL PERIOD.\\nTreatment: If possible, the absorption of the effused blood\\nshould be encouraged. Care should be taken to avoid its\\nmanipulation in performing the toilet of the vulva. Frequent\\ngentle irrigation with warm, mild antiseptic solutions may be\\nemployed. If absorption is delayed, the tumor should be in-\\ncised, the contents turned out, and the cavity packed with\\niodoform gauze. If on incising the tumor a bleeding vessel is\\nfound, it should be tied before packing the cavity. Frequent\\ndressing and rigid asepsis are necessary to prevent the occur-\\nrence of infection.\\nSUBINVOLUTION.\\nDefinition: When the process of involution of the puerperal\\nuterus is arrested or retarded the organ is said to be in a con-\\ndition of subinvolution.\\nEtiology.\\nAny condition which prevents a rapid diminution in the blood-\\nsupply of the puerperal uterus may be said to be a cause of\\nsubinvolution. Any condition which interferes unth contrac-\\ntions of the muscular tissues of the puerperal uterus tends to\\ngive rise to subinvolution.\\nThe following conditions which tend to interfere with the\\ndiminution of the blood-supply of the puerperal uterus may be\\nmentioned as giving rise to subinvolution hyperplasia of the\\nendometrium, the result of local congestion or of mild septic\\ninfection laceration of the cervix small fibroids metritis,\\ngenerally septic in origin retention of secundines or clots\\nuterine displacements chronic constipation and the resump-\\ntion of the ordinary duties of life too soon after abortion or\\nlabor.\\nConditions giving rise to subinvolution by interfering with\\nuterine contractions are the retention of large clots or frag-\\nments of the placenta, or placentae succenturiatse displace-\\nment of the uterus from overdistention of the bladder large\\nintramural fibroids and peritoneal adhesions from old or\\nrecent inflammatory attacks.\\nSubinvolution is practically always the result of some local\\ndisorder. Constitutional disturbances very exceptionally give\\nrise to the condition, though in women with general lack of", "height": "3712", "width": "2740", "jp2-path": "obstetricsmanual00evan_0326.jp2"}, "319": {"fulltext": "TREATMENT OF SUBINVOLUTION. 319\\ntone, with flabby muscles and diminished eliminative powers,\\nsubinvolution may occur without any evidence of a distinct\\nlocal cause.\\nDiagnosis of Subinvolution.\\nThe diagnosis is usually easy.\\nBy the tenth day of the puerperal period the fundus uteri\\nshould be on a level with or a little below the brim of the\\npelvis. Later, if the condition is suspected, the depth of the\\nuterus may be measured by means of the intra-uterine sound.\\nThe lochia, instead of becoming pale and puriform, remains\\nbloody and its discharge is prolonged. The condition is\\nusually associated with constipation and a coated tongue.\\nAhlfeld has drawn attention to the fact that free perspiration\\nduring the puerperium is usually associated with firm uterine\\ncontractions when perspiration fails to appear he always looks\\nfor uterine relaxation.\\nTreatment of Subinvolution.\\nIn the earlier period of the puerperium the uterus may be\\nstimulated to contraction by gentle friction of the fundus\\nthrough the abdominal wall for ten minutes or so, three or\\nfour times daily. A pill containing ergotin, gr. j quinine,\\ngr. j and strychnine, gr. may be given three times daily.\\nShould this treatment fail to improve matters and there is\\nno diminution in the loss of blood, the cavity of the uterus\\nshould be explored with the finger. If necessary, the curette\\nand placental forceps may be used, being followed by a douche\\nof hot formalin solution (1 500), and the introduction of a\\nwick of iodoform gauze to the fundus. The latter acts by\\nstimulating the uterus to contraction and by favoring drainage.\\nThe gauze should be removed at the end of forty-eight hours\\nand a hot vaginal douche once or twice daily may be ordered.\\nDaily free evacuation of the bowels should be secured.\\nIf the uterus be displaced, it should be put in proper position\\nand retained there by means of a pessary.\\nOccasionally the condition of subinvolution is not discovered\\nuntil late in the puerperal period, after the woman has been\\nwalking about for some time. In such cases the cavity of the", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0327.jp2"}, "320": {"fulltext": "320 PATHOLOGY OF THE PUERPERAL PERIOD.\\nuterus should be painted with ChurchilPs solution of iodine,\\nand a vaginal tampon of wool saturated with boroglycerin\\nshould be inserted two or three times a week.\\nANOMALIES AND DISEASES OF THE NIPPLES AND\\nBREASTS.\\nAnomalies of the Nipples.\\nSupernumerary nipples are of frequent occurrence.\\nDefects of the nipples are chiefly important as they may\\ninterfere with nursing.\\nInversion of the nipple is a very common condition, which\\nmay be congenital or acquired. This defect may constitute an\\nabsolute impediment to lactation.\\nDuring the last month of pregnancy attempts should be\\nmade to draw out the nipples by means of a breast-pump.\\nWhen the nipples are small or imperfectly developed daily\\ngentle traction upon them by the nurse or physician may result\\nin improvement. If this fails, a nipple-shield must be em-\\nployed to enable the child to nurse.\\nAnomalies of the Breasts.\\nAbsence of mammae While imperfect development of the\\nmammae is common, their complete absence is a very rare con-\\ndition. It is usually associated with deformities of the pelvic\\nsexual organs.\\nHypertrophy of the mammae This condition is also rare.\\nWhen present it does not of necessity contraindicate nursing.\\nSupernumerary mammae Supernumerary breasts are to be\\nmet with comparatively frequently. They occur with no\\nregularity of situation the most frequent position is below the\\ntrue mammae they have been found over the pubes, on the\\nbuttocks, shoulders, and in the axillae. In most cases no\\nhereditary influence can be traced.\\nAnomalies in Milk Secretion.\\nDeficient Secretion.\\nComplete absence of milk-secretion is a rare condition but\\ndeficient milk Secretion is only too frequently encountered.", "height": "3732", "width": "2732", "jp2-path": "obstetricsmanual00evan_0328.jp2"}, "321": {"fulltext": "ANOMALIES IN MILK SECRETION. 321\\nEtiology Lack of development of the glandular tissue of the\\nbreasts is the most common cause of deficient secretion of milk.\\nThis lack of development may be due to hereditary causes, or\\nto continuous pressure from tight clothing or it may be\\nassociated with maldevelopment of the other sexual organs of\\nthe body.\\nThe size of the breasts is no indication of their ability to\\nfurnish milk. This function depends entirely upon the\\namount of glandular tissue present in the breasts. Some\\nwomen with well-developed breasts have but little glandular\\ntissue, and therefore make poor nurses; while others with\\napparently but poor development of these organs have a rich\\nand abundant supply of milk for their offspring.\\nThe secretion of milk may be diminished by the occurrence\\nof fever, hemorrhages, chronic diarrhoea, and insufficient nour-\\nishment; serious organic diseases also result in diminished\\nmilk-secretion. Emotions profoundly affect the secretion of\\nmilk prolonged grief is a well-known cause of deficient\\nsecretion.\\nThe return of menstruation w^hile it may affect the quantity\\nand quality of the milk secreted, cannot be said invariably to\\nproduce this result. It may be stated that, as a rule, the re-\\nturn of this function has but little influence on milk-secretion.\\nTreatment But little can be suggested in the way of treat-\\nment good, plain food and plenty of it moderate exercise in\\nthe open air three or four glasses of milk daily between\\nmeals, and a wineglassful of extract of malt thrice daily, con-\\nstitute about all the treatment possible. There is no medicinal\\ngalactagogue of any value in the experience of the writer.\\nExcessive Secretion Polygalactia.\\nIn this condition, which is not infrequently met with, the\\nsecretion of milk is in excess of the demands of the child.\\nTreatment: The bowels should be kept relaxed and the\\nquantity of fluids imbibed reduced. The breasts may be\\ncompressed by means of a tightly fitting breast-binder. The\\nwoman should take plenty of hard exercise daily in the open\\nair. If this treatment fails, the excess of milk must be\\npumped out at regular intervals.\\n21\u00e2\u0080\u0094 Obst.", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0329.jp2"}, "322": {"fulltext": "322 PATHOLOGY OF THE PUERPERAL PERIOD.\\nGalactorrhoea.\\nThis term is applied to an excessive secretion of milk which\\npersists after weaning. The flow of milk is not necessarily\\nexcited by suckling the child. The milk is thin and watery,\\nthe quantity being excessive. One or more breasts may be\\naffected, and the condition seriously impair the general health.\\nThe condition may last for years.\\nEtiology Nothing definite is known as to the causation of\\nthis condition. It has been attributed to a relaxation or paral-\\nysis of the circular muscular fibres surrounding the milk-\\nducts.\\nTreatment These cases frequently offer very stubborn re-\\nsistance to all treatment. Firm compression of the breasts by\\nmeans of a breast-binder and the administration of potassium\\niodide (gr. x t. i. d.) and of fl. ext. ergot (TTL x). for a consid-\\nerable period constitute the usual treatment. General tonics\\nand iron should be administered.\\nEngorgement of the Breasts.\\nEtiology Keference has already been made to the fact that\\noccasionally with the establishment of lactation the breasts\\nmay become congested and engorged. This condition of en-\\ngorgement may occur at any time throughout the period of\\nlactation. Exposure of the breasts to cold air and hypersecre-\\ntion of milk are the most common causes of this condition.\\nSymptoms: The breasts quite suddenly become engorged\\nwith milk, to such an extent as to occasion very considerable\\ndistress to the patient. The pain and tenderness may be the\\noccasion of more or less elevation of temperature.\\nTreatment.\\nTo relieve the patient it is necessary to remove the excessive\\namount of milk and to prevent further engorgement of the\\nbreasts. The breasts may be em])tied by permitting the infant\\nto nurse by the breast-pump and by massage.\\nIf the child fails to empty the breasts, the milk remaining\\nmay be drawn off by means of the breast-pump. Probably", "height": "3712", "width": "2676", "jp2-path": "obstetricsmanual00evan_0330.jp2"}, "323": {"fulltext": "ANOMALIES IN MILK SECRETION. 323\\nthe most satisfactory breast-pump is that known as the\\nEnglish pump. That part of the pump which is applied\\nto the breasts should be free from jagged, rough edges, other-\\nwise these may produce some abrasions.\\nMassage of the breasts When properly performed this is\\na very efficient aid in relieving congestion and engorgement.\\nIt should never be employed if there is evidence of interstitial\\ninflammation of the breasts.\\nThe patient, being in the dorsal position, is directed to sup-\\nport her breast by placing her forearm under it and drawing it\\nup. The breast is then anointed, with warm oil, after which\\nthe operator begins the manipulations by placing his finger-\\ntips, separated as widely as possible, at the periphery of the\\nbreast. A rapid though gentle stroking movement is then\\nmade toward the nipple, the finger-tips being brought grad-\\nually together so as to meet at the termination of the stroke.\\nEach segment of the gland is thus rapidly stroked in succes-\\nsion, each movement terminating at the nipple. The pressure\\nexerted by the finger-tips should be gradually increased, short\\nof producing severe pain. This stroking movement in about\\nfive minutes usually ceases to cause pain. Then the operator\\nsupporting the breast in the palm of one hand, Avith the finger-\\ntips of the other hand selects a nodule of induration, which he\\nstrokes toward the nipple, gradually employing deeper and\\nfirmer pressure. Each nodule of induration is thus treated in\\nsuccession.\\nXodules which this manipulation fails to soften may then\\nbe compressed by placing the hand flat upon them and exerting\\nsteady gentle pressure downward against the chest- wall. The\\npressure thus exerted should be greatest at the periphery of the\\ngland. After a few moments of steady pressure, gentle rotary\\nmovements of the hand may be made over the lumps. If pain\\nis complained of, the stroking movements should be resumed.\\nThe breast should then be grasped with both hands so as to\\nencircle it completely and the whole gland gently raised and\\ncompressed, while the two index-fingers are quickly stroked\\ntoward the nipple to favor the escape of milk. These various\\nmanipulations should be repeated at short intervals until the\\nglands have been softened and emptied of their contents, when\\na pressure-bandage should be applied.", "height": "3704", "width": "2484", "jp2-path": "obstetricsmanual00evan_0331.jp2"}, "324": {"fulltext": "324 PATHOLOGY OF THE PUERPERAL PERIOD.\\nThe most satisfactory breast-bandage, in the opinion of the\\nwriter, is the Y-bandage, which was first employed in the\\nBoston Lying-in Hospital. This may be made of two pieces\\nof soft, unbleached cotton or bird s eye towelling, about thirty-\\nsix inches long and ten or twelve inches wide. I have used\\nordinary hand towels for this purpose, and find they answer\\nadmirably. These are folded into strips about three or four\\ninches wide one of these is folded end to end, and the doubled\\nend turned over so as to convert the strip into an L-shape,\\nwdien the free ends are separated. The apex of this strip is\\nthen pinned with three or four safety-pins to one end of the\\nother strip, so as to form the Y-bandage.\\nThe breasts are then dusted with powdered starch or other\\ndusting-powder, and the longer arm of the bandage slipped\\nunder the patient s back at the lower part of the scapular\\nregion until the apex of the fork is just external to the outer\\nedge of the left breast. The patient then lifts her breasts\\nupward and toward each other, while the lower arm of the\\nfork is drawn tightly across the chest beneath the breasts the\\ninferior border of this arm should extend at least an inch below\\nthe lower margins of the breasts.\\nThe upper arm of the fork is then drawn across the chest\\nabove the breasts in such a way that its upper border extends\\nan inch beyond the upper margins of the breasts. The free\\nends of the two arms of the fork should thus meet at the outer\\nmargin of the right breast, where they should then be drawn\\ntight and securely pinned with safety-pins to the strip which\\nhas been passed beneath the back. The free end of the back\\nstrip may then lie over the apices of both breasts. The strip\\npassing underneath the breasts is then pinned to the binder to\\nkeep it from slipping up; shoulder-straps may then be pinned\\nto the upper arm of the fork and fastened behind to the back\\nstri])s, thus keeping the upper arm of the fork from slipping\\ndown. The hollow between the breasts may then be filled with\\ncotton, and this held in place by two safety-pins joined together\\nand pinned to the upper and lower arms of the fork.\\nIn place of this the Murphy binder may be employed. It is\\nmade of a strij) of thick gray cotton, forty inches long and ten\\ninches wide. In tlie upper border of this strip a narrow notch\\nis cut for the neck, and two deep notches for the arms. The", "height": "3732", "width": "2708", "jp2-path": "obstetricsmanual00evan_0332.jp2"}, "325": {"fulltext": "SORE NIPPLES. 325\\nbinder Is applied tightly over the breasts and pinned in front.\\nAVhen it is desired to make applications to the nipples, two\\ncircular holes the size of a silver half dollar can be cut in the\\nMurphy binder the margins of these holes should be button-\\nhole stitched.\\nIn cases in which the engorgement is intense and the breasts\\nso sensitive that manipulation is impossible much relief can be\\ngiven by the application of hot compresses. Flannel soaked\\nin hot water and carbonate of ammonium (sj to the pint),\\nwrung dry, and then applied to the breasts, and repeated at\\nintervals of five minutes, soon gives relief and permits the\\napplication of the breast-binder.\\nIn these cases a free action of the boicels should be obtained\\nby the administration of teaspoonful doses of Rochelle salt in\\nwarm water, at intervals of fifteen minutes till purgation is\\ninduced.\\nSore Nipples.\\nEtiology and symptoms The child in nursing may macer-\\nate the superficial epithelium of the nipples. Small superficial\\nulcers may thus be formed at the apices or at the bases of the\\nnipples, which are difficult to heal because the child in nursing\\nseparates their edges. The pain caused by this condition\\nvaries between simple tenderness at the moment the child\\nseizes the nipple, and the acutest agony during the whole act\\nof suckling. Erosion of the nipples occurs most frequently\\nin primiparae.\\nTreatment.\\nProphylactic treatment should be begun toward the end of\\npregnancy, as has been mentioned. Close attention to cleans-\\ning of the nipples and of the child s mouth is of supreme im-\\nportance. After nursing, the nipples should be washed with\\nboric-acid lotion and carefully dried. At least once a day the\\nchild s mouth should be swabbed with pledgets of cotton soaked\\nin glycerinum boracis. The bismuth paste recommended in the\\nsection on Management During the Puerperal Period may\\nbe employed, following the precautionary cleansing after nurs-\\ning. To this ointment it may be well to add balsam of Peru\\n(Sss) should there be evidence of abrasion.", "height": "3688", "width": "2496", "jp2-path": "obstetricsmanual00evan_0333.jp2"}, "326": {"fulltext": "326 PATHOLOGY OF THE PUERPERAL PERIOD.\\nPainting the nipples, by means of a camePs-hair brush, with\\nthe compouud tincture of benzoin, or a 10 grain to the ounce\\nsolution of silver nitrate, will be found very satisfactory treat-\\nment in more severe cases. Deep fissures are best treated by\\ndaily touching them carefully with the solid stick of nitrate\\nof silver.\\nIn some cases extreme tenderness of the nipples may be\\ncomplained of, and yet the most careful examination fail to\\nreveal any trace of either erosion or fissure. In these cases\\nextract of witch-hazel (ext. hamamelidis) will be found very\\nuseful it may be employed pure or diluted with two or three\\nparts of boiled water.\\nThe writer has had very satisfactory results from painting\\nthe tender nipples with a saturated alcoholic solution of ortho-\\nform, at least as far as giving relief from pain while nursing is\\nconcerned. This should be applied with a camePs-hair brush\\njust before each application of the child to the nipple. Cer-\\ntain writers claim to have had severe inflammatory reaction\\nfollow its employment, so that it should always be used with\\ncaution.\\nIn all cases in which the nipples are tender a glass and rub-\\nber nipple-shield should be employed while nursing. The shield\\nshould be kept surgically clean.\\nIn some cases it may be necessary for the mother not even\\nto attempt to nurse the child for twenty-four hours, or even\\nlonger. In these cases the breasts may be emptied by means\\nof massage, the breast-pump not being used unless it prove\\nabsolutely necessary.\\nIn very exceptional cases nothing but weaning will result in\\npermanently relieving the condition.\\nInflammation of the Breasts Mastitis.\\nVarieties Three forms of mastitis are usually described\\nthe most frequent variety is the parenchymatous, or glandular^\\nin which the acini of the gland are primarily the site of the\\ninflammation. In the subcutaneous variety the connective\\ntissue immediately beneath the skin is attacked. In the sub-\\nglandular or post-mammary form the connective tissue between\\nthe gland and the chest-\\\\vall is the site of the inflammation.", "height": "3728", "width": "2688", "jp2-path": "obstetricsmanual00evan_0334.jp2"}, "327": {"fulltext": "INFLAMMATION OF THE BREASTS\u00e2\u0080\u0094 MASTITIS. 327\\nThe inflaramation is but rarely confined to one of these lo-\\ncalities, so that clinically two or all three may be combined,\\nespecially in cases which do not receive prompt treatment.\\nUsually mastitis begins in the acini of the gland, whence it\\nspreads to the connective tissue and approaches the skin sur-\\nface.\\nFrequency Mastitis occurs in about 6 per cent, of all nurs-\\ning women, though it is most frequently met with in prim-\\niparse. It may terminate by resolution or by suppuration.\\nEtiology: All forms of mastitis are of microbic origin. The\\ninfection is usually due to the entrance of staphylococci, either\\nthe aureus or albus, though streptococci or other pus-producing\\norganisms may give rise to the condition.\\nThe infection usually arises in a fissure or abrasion of the\\nnipple, and spreads either by means of the lymph-channels into\\nthe connective tissue or directly along the epithelium of a\\ndud to an acinus, possibly to several. The inflammation may\\nat first be confined to the epithelium, but soon spreads to the\\nsurrounding connective tissue. Impaired general health and\\nlocal mechanical injuries are important predisposing causes.\\n3Iilk stasis as at one time thought to be the cause of mas-\\ntitis, but pathologists have proved that stasis alone will not\\nproduce the condition. It is possible that stasis of milk results\\nin impairment of the epithelium of the ducts and thus renders\\ninfection more liable to occur.\\nA possible source of infection is the blood. Escherich states\\nthat staphylococci which have gained access to the blood\\nthrough infection of the genital canal are excreted in the milk.\\nSymptoms of Mastitis.\\nAll forms of mastitis are accompanied by the signs of\\ninflammation.\\nThe onset of the inflammation is generally characterized by\\na distinct chill or by a sense of chilliness. The temperature\\nbegins to rise and the patient complains of pain and tenderness\\nin the affected breast.\\nIn the parenchymatous form one or more tender nodules will\\nbe found in tlie affected breast. The skin overlying these nod-\\nules may or may not be reddened. Pressure on these nodules", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0335.jp2"}, "328": {"fulltext": "328 PATHOLOGY OF THE PUERPERAL PERIOD.\\nusually produces a sharp, cutting pain. The temperature may\\nrise to 104\u00c2\u00b0 F., or even higher.\\nIn the low interstitial form the pain is not so distinctly local-\\nized and no nodule can be felt in the breast. The temperature\\nrises more gradually and chilly sensations are more frequent\\nthan a distinct rigor. The skin over the affected area quickly\\nbecomes reddened, and it will be frequently noticed that the\\nsite of the inflammation corresponds to a fissure in the nipple.\\nThis form of inflammation is very difficult to abort and usu-\\nally results in abscess formation, though if the breast be opened\\nearly but very little pus may be found.\\nTreatment of Mastitis.\\nAbortive The indications are to secure complete rest for the\\naffected gland by (a) absolutely prohibiting nursing from either\\nbreast; (h) removing by means of massage and the breast-\\npump the contents of the glands, and (c) reducing the local\\nblood-supply.\\nIt is important to decide if possible whether the inflamma-\\ntion is of the parenchymatous or of the interstitial form. The\\nmode of onset, condition of the nipple, appearance and feel of\\nthe breast, and the fact that the parenchymatous form occurs\\nmost frequently, will afford assistance in making a diagnosis.\\nIf the type of inflammation present is parenchymatous, the\\nroutine of treatment may be given as follows the breasts are\\nemptied by means of massage and the breast-pump, all manipu-\\nlations being as gently carried out as possible. The nipples\\nare then cleansed and an antiseptic dressing applied, as pre-\\nviously recommended. A tightly fitting Murphy binder is\\nthen applied so as to secure as firm compression of both breasts\\nas is possible, without increasing the pain in the affected parts.\\nThen an ice-bag may be placed outside the binder over the\\naffected portion of the gland. The ice-bag should be kept\\nconstantly applied for from twelve to twenty-four hours, the\\nlength of time being determined by the relief of pain and sub-\\nsidence of temperature.\\nThe lessening of the local blood-supply of the gland may\\nbe obtained by the derivative action of saline cathartics, which\\nshould be freely administered as previously recommended.", "height": "3712", "width": "2708", "jp2-path": "obstetricsmanual00evan_0336.jp2"}, "329": {"fulltext": "INFLAMMATION OF THE BREASTS\u00e2\u0080\u0094 MASTITIS. 329\\nIf after twenty-four hours the temperature has dropped and\\nthe paiu disappeared, the pressure on the breasts may be re-\\nduced by loosening the binder somewhat. The ice-bag may\\nthen be removed for an hour or two, but should be used inter-\\nmittently till all tenderness of the breast disappears and the\\nHow of milk has been re-established. In rare instances the ice-\\nbag is not well borne by the patient, in which case a compress\\nwrung out of a solution of lead and opium (1 40) should be\\napplied over the affected portion of the gland and covered with\\noiled silk or a layer of non-absorbent cotton, over which the\\nMurphy binder may be lightly applied.\\nThe treatment of the interstitial form of mastitis differs\\nsomewhat from the preceding. In this form massage should\\nbe avoided, as only tending to aggravate the condition. The\\nMurphy binder should be applied so as merely to support the\\nbreasts, but not to compress them otherwise the treatment of\\nthe two forms is the same. In spite of all treatment a large\\nproportion of these cases terminate in abscess formation.\\nMammary Abscess.\\nThe pus may be located in the gland-substance or in the\\nsubmammary connective tissue.\\nSymptoms It is not always possible to be certain that sup-\\npuration has taken place from the symptoms given. Fluctua-\\ntion, the most certain sign of abscess formation, is rarely to be\\nfound until late.\\nSevere throbbing or stabbing pain suggests abscess forma-\\ntion, especially when accompanied with chilly sensations, a\\nhigher grade of temperature, and greater rapidity of pulse.\\nUsually a bluish discoloration and some oedema of the skin\\nmark the locality where the abscess will point, especially in\\nthe more common parenchymatous form.\\nIn the interstitial form the pus tends to burrow extensively,\\nand no actual abscess may be discernible though the whole\\ngland is found to be riddled with pus-tracts. If such a case be\\nleft too long, the pus will be found pointing in several places.\\nSurgical Treatment.\\nPreliminary: The patient should always be anaesthetized\\nbefore attempting to open or treat a mammary abscess, unless", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0337.jp2"}, "330": {"fulltext": "330 PATHOLOGY OF THE PUERPERAL PERIOD.\\nit be superficial and about to point. The whole breast should\\nbe well scrubbed with soap and hot water, followed by solu-\\ntions of permanganate of potassium and oxalic acid.\\nIncision By careful palpation the pus collection is located,\\nand an incision is then made in the skin over its most depen-\\ndent portion in a line radiating from the nipple. Through this\\nopening a grooved director is then inserted and passed in all\\ndirections until pus is encountered, when a pair of artery-\\nforceps is introduced and opened so as to dilate the tissues\\nsufficiently to permit the introduction of a finger into\\nthe abscess-cavity. All adjacent cavities should then be\\nsearched for and freely opened, and all friable tissue broken\\ndown. Additional openings should be made to secure free\\ndrainage. The walls of the abscess-cavity should be gently\\nscraped with a Volkmann spoon. All the openings should\\nthen be irrigated freely with an antiseptic solution, such as\\nfoi malin, 1 500.\\nDrainage Instead of employing rubber tubes for drainage,\\ngutta-percha tissue which has been stei ilized by soaking in\\nformalin solution, and then folded in strips about half an inch\\nwide and six or eight inches long, will be found much more\\nserviceable. Several of these strips sliould be drawn through\\nthe openings, so as to secure drainage in all directions. An\\nantiseptic surgical dressing is then applied, and the breast\\nfirmly bandaged with a broad roller bandage, so as to secure\\neven compression throughout, or a Murphy bandage may be\\napplied.\\nAfter twenty-four or thirty- six hours the dressings should be\\nremoved and the abscess-cavity thoroughly irrigated with boric-\\nacid or formalin solution. The gutta-percha tissue drains\\nshould be reinserted and a fresh dressing applied. As soon as\\nthe discharge has almost ceased, the gutta-percha tissue drain-\\nage may be dispensed with and firm compression of the walls\\nof the cavity secured by means of antiseptic compresses placed\\nunder the bandage or binder. The most equable pressure is\\nsecured by means of a large bath-sponge which has been boiled\\nand then wrung out of 1 5000 bichloride solution. This\\nshould be sli^rhtly hollowed out so as to fit over the breast, to\\nwhich it is directly ap])liod and covered with oiled silk and the\\nbandage or binder. This dressing should be removed daily", "height": "3732", "width": "2688", "jp2-path": "obstetricsmanual00evan_0338.jp2"}, "331": {"fulltext": "ARREST OF LACTATION. 331\\nand the sponge cleansed in a solution of 1 5000 bichloride.\\nThe breast should also be washed with the same solution\\nbefore the dressing is reapplied.\\nNursing The child may be applied to the sound breast to\\nkeep up the flow of milk, provided the mother s general health\\nis such that it is not desirable to discontinue nursing.\\nIn the interstitial form of abscess but very little pus may\\nbe found on incising the breast. All nodules should be opened,\\nas the pus tends to burrow very extensively in this form, and\\nspecial care should therefore be given to providing for free\\ndrainage.\\nAbscesses of the areola The glands of ^Montgomery may\\nbecome infected and result in the formation of small superficial\\nabscesses in the areola.\\nTreatment Each suppurating gland should be opened, and\\nits walls curetted and then swabbed with strong bichloride or\\nformalin solution.\\nGalactocele This is a milk tumor which may form as the\\nresult of occlusion of one of the lactiferous ducts. Beyond\\ncausing a little pain these milk tumors are of no importance.\\nTreatment Massage may result in causing the milk to flow\\nand thus relieve the condition. Earely these tumors persist\\nfor a long time, and may become so large as to necessitate\\ntheir being tapped and drained.\\nArrest of Lactation.\\nIndications: When the child has perished at birth or when\\nthe constitutional condition of the mother is such as to pre-\\nclude the possibility of nursing, it is necessary to prevent the\\nactivity of the mammary glands.\\nMethod Before the first appearance of breast engorgement\\na tightly fitting Murphy hinder should be applied. Free\\npurgation should be induced by means of salines when the\\npatient s strength will permit. The amount of fluids ingested\\nshould be restricted, the patient s thirst being relieved by\\nrinsing the mouth frequently with weak tea.\\nIf the engorgement of the breasts tends to become excessive,", "height": "3704", "width": "2376", "jp2-path": "obstetricsmanual00evan_0339.jp2"}, "332": {"fulltext": "332 PATHOLOGY OF THE PUERPERAL PERIOD.\\nthe binder may be removed once or twice daily to permit of\\nmassage or the use of the breast-pump. Tlie breasts may then\\nbe covered with giycerite of belladonna and the binder or\\nbandage reapplied. Usually under this treatment the breasts\\nbecome inactive in less than a week.\\nTo arrest lactation when the woman has been nursing for\\nsome time, firm compression of the breasts by means of the\\nY-binder combined with the use of salines will be sufficient.\\nThe milk usually flows away readily under the compression\\nexerted by the Y-binder, and there is no disposition of the\\nbreasts to become engorged and caked.\\nMassage and the use of the pump should be omitted as\\nlong as the milk flows away freely. In a few days the breasts\\nwill cease flowing, when a Murphy binder may be applied and\\nworn till the breasts become soft.\\nAfter prolonged lactation there is but little difficulty in\\ndrawing away the milk when the child is weaned gradually.\\nShould secretion persist it may be necessary to employ com-\\npression and to give atropine internally.\\nINTERCURRENT DISEASES IN THE PUERPERIUM.\\nMiscellaneous Diseases.\\nScarlet fever This is a rare complication of the puerperium.\\nIt almost always appears within three days of labor; the\\nthroat complications are slight, the rash appears quickly, is\\nrapidly diffiised, and is usually of an intense dark-red color.\\nConvalescence is usually tedious. Occasionally the pelvic\\norgans are profoundly affected by this disease, and when this\\nis the case the prognosis is very grave.\\nAYhen the attack is a frank one and the genitalia are not\\nmuch involved the prognosis is not unfavorable, though the\\ncondition is a grave one.\\nMeasles The puerperium is rarely complicated by this dis-\\nease unless the attack has occurred during pregnancy and has\\nled to premature expulsion of the ovum. The condition pre-\\ndisposes to hemorrhage and also to pneumonia.\\nVariola This is a very grave complication of the puer-\\nperium.", "height": "3712", "width": "2672", "jp2-path": "obstetricsmanual00evan_0340.jp2"}, "333": {"fulltext": "MISCELLANEOUS DISEASES. 333\\nRotheln This disease does not markedly affect the puer-\\nperiam. In two or three cases which have come under my\\nnotice the disease w^as very mild in character, thougli in one\\nthe rash w^as very marked.\\nErysipelas This disease usually affects the genitals when\\nit occurs during the puerperal period. It is seldom mani-\\nfested by a cutaneous eruption. When the genitals only\\nare affected the prognosis is very grave, and it is impossible\\nto distinguish the case from one of ordinary streptococcus\\ninfection.\\nErythematous rashes Puerperal erythema is not an infre-\\nquent condition.\\nIn simple cases there is apt to be a moderate elevation of\\ntemperature, and the lochia may become offensive. There\\nmay be some uterine or pelvic tenderness. The condition is\\ntherefore looked upon as a mild septic infection.\\nIodoform when freely used about the genitals may set up\\nan extensive erythematous rash in this case the temperature\\nand pulse remain unaffected unless the skin irritation causes\\nthe patient much distress.\\nErythema may be mistaken for scarlet fever, and it is not\\ninfrequently associated with grave septicaemia.\\nDiphtheria This disease may affect the throat or the genitals,\\nin the latter case a variety of general sepsis ensues.\\nPneumonia This disease constitutes a very grave complica-\\ntion of the puerperium. It not infrequently occurs secondary\\nto septic infection. Its treatment will be discussed in the\\nsection on puerperal infection.\\nRheumatism arthritis The diagnosis between septic arthri-\\ntis and simple acute rheumatism is a matter of great difficulty\\nduring the puerperium. Simple rheumatism tends to affect\\nseveral joints, while the arthritis is septic in origin and usually\\nonly one large joint is affected. In the latter case there may\\nbe little evidence of general septic infection. Simple rheuma-\\ntism usually runs its ordinary course and does not affect the\\npuerperium, nor is it affected greatly by it.\\nThe treatment of acute rheumatism is the same as when it\\noccurs at any other time. In septic arthritis recovery is the\\nrule, but with a greatly damaged joint. Local treatment only\\nis of service, general medication being of little use.", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0341.jp2"}, "334": {"fulltext": "334 PATHOLOGY OF THE PUERPERAL PERIOD.\\nMalaria.\\nThe puerperal state, it is generally admitted, predisposes to\\nmalarial attacks. Womeu who are subject to malaria usually\\nmanifest the disease after delivery, probably as a result of the\\ntraumatism of labor.\\nThe malarial attack is usually of a mild type, but occasion-\\nally it may be extremely severe. The disease, which usually\\nmanifests itself about the third day after delivery, predisposes\\nto puerperal hemorrhage it also modifies milk secretion, espe-\\ncially during the exacerbation of fever. It is not generally\\nadmitted that the germs of disease can be transmitted in the\\nmilk to the nursing infant.\\nDiagnosis Malaria occurring during the puerperium must\\nbe differentiated from septic infection or typhoid fever. The\\ndiagnosis is occasionally a matter of considerable difficulty.\\nThe fever in malaria is frequently continuous at first, but soon\\nbecomes remittent in type.\\nIn doubtful cases the blood shoidd be examined for malarial\\norganisms, and WidaFs test for typhoid reaction should be\\napplied. A bacteriological examination of the uterine lochia\\nshould also be made, for it is quite possible that malarial pois-\\noning may be associated with septic infection in some cases.\\nWith these tests at one s disposal we should not remain long in\\ndoubt as to the origin of the fever in any given case.\\nTreatment: Usually it is necessary to give large doses\\nof quinine to control the fever during the puerperium.\\nWhen the daily dose of quinine is 20 grains or under, it is\\nseldom necessary to remove the child from the breast; but\\nwhen this dose is exceeded the infant is likely to suffer from\\nthe effects.\\nPuerperal Anaemia.\\nAfter delivery the blood begins to undergo a change in con-\\nstitution by which it is converted from the hydrsemia of preg-\\nnancy to the normal proportion of its constituent parts in the\\nnon-(rravid condition.\\nThis change is usually completed by the end of the second\\nweek of the puerperal period.\\nMany causes may interfere with this process of involution", "height": "3732", "width": "2676", "jp2-path": "obstetricsmanual00evan_0342.jp2"}, "335": {"fulltext": "DISEASES OF THE URINARY ORGANS. 335\\nof the blood, such as sepsis, severe blood-loss at the time of\\nlabor, or any wasting or depressing disease. In such cases\\nthe anaemia tends to assume a pernicious form if treatment is\\nneglected.\\nCareful blood examinations should be made from time to\\ntime in these cases in order to judge of the effect of treatment.\\nThe treatment consists in the administration of tonic drugs\\nand careful feeding. Iron and arsenic, in the form of the com-\\npound Blaud pill, usually give satisfactory results. In some\\ncases in which iron is not well borne arsenic alone will succeed.\\nHemorrhoids.\\nGreat discomfort is frequently caused by an attack of hem-\\norrhoids during the earlier days of the puerperal period.\\nTreatment The bowels should be freely opened, and great\\nrelief may be obtained by the application of hot compresses\\nwrung out of hot lead-and-opium solution (1 40). In some\\ncases the application of ice is more comforting to the patient.\\nAn ointment composed of equal parts of ung. gallse cum opio,\\nung. stramon. and ung. bellad. will further relieve pain.\\nDiseases of the Urinary Organs.\\nRetention of urine Patients not infrequently complain of\\ninability to urinate after delivery. The condition may be the\\nresult of injury to the urethra or the anterior vaginal wall\\nduring labor. Many women are unable to empty the bladder\\nwhile lying in bed. In others the flow of the urine over\\nsmall abrasions of the vulva sets up irritation, Avhich they\\nseek to avoid by holding the urine as long as j)Ossible. The\\nrelaxed condition of the abdominal walls and the consequent\\ndiminution of intra-abdominal pressure to some extent inter-\\nfere with the function of micturition during this period.\\nTreatment The nurse should be instructed to see that the\\npatient empties the bladder at least twice daily. For this pur-\\npose, if unable to pass water otherwise, the patient may assume\\na kneeling posture, or may be raised carefully so as to be able\\nto sit on the bed-pan. Hot applications may prove of assist-\\nance, as may also the stimulus caused by the sound of running", "height": "3708", "width": "2488", "jp2-path": "obstetricsmanual00evan_0343.jp2"}, "336": {"fulltext": "336 PATHOLOGY OF THE PUERPERAL PERIOD.\\nwater. If these means fail, the nurse should be instructed to\\npass the catheter into the bladder, and to observe the strictest\\nantiseptic precautions in so doing.\\nIncontinence of urine Tiiis condition may result from over-\\ndistention of the bladder from retention of urine. This is the\\ncommonest cause. Other causes of the condition are paresis of\\nthe sphincter muscle and vesicovaginal or vesico-uteriiie fistula.\\nA careful examination will reveal the cause of the condition.\\nThe treatment must vary with the cauvse of the incontinence.\\nCystitis This is unfortunately a common complication of\\nthe puerperal state. It is usually due either to injury from\\noverdistention of the bladder or to careless catheterization.\\nSymptoms: Frequent micturition, associated with burning\\nand tenesmus, is the most usual symptom the temperature\\nmay rise to 102\u00c2\u00b0-103\u00c2\u00b0 F., and the pulse become rapid. The\\nurine is usually found to contain mucus and pus in varying\\nquantities.\\nTreatment: Prompt and energetic treatment is usually de-\\nmanded to prevent the infection spreading to the ureters and\\nkidneys. The bladder should be irrigated daily with a warm\\nsolution of boric acid (gr. xv-^j). The diet should consist of\\nmilk only, and the following mixture should be ordered\\nSod. bibor.,\\nAc. benzoic, aa ^ss\\nInf. buchu, ^vj. M.\\nSig. A tablespoonful in a wineglassful of water three\\ntimes daily.\\nIf the condition persist after irrigating with boric solution,\\nthe bladder should be distended with a solution of silver nitrate\\n(gr. ss-^j), all of which should be allowed to drain away with\\nthe exception of about an ounce, which may be left in the\\nbladder.\\nPyelonephritis This condition may follow an infection of\\nthe bladder by extension of the disease along the ureters, or it\\nmay result from a general septic infection.\\nDiagnosis can usually be made by an examination of the\\nurine.\\nTreatment: Stimulation, support, the administration of", "height": "3732", "width": "2636", "jp2-path": "obstetricsmanual00evan_0344.jp2"}, "337": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM. 337\\nbland diuretics, and daily irrigation of the bladder constitute\\nthe treatment of this condition.\\nHaematuria Bloody urine is sometimes seen after labor, and\\nmay follow severe contusion of the bladder either by the child^s\\nhead or the forceps. Xot infrequently the condition is due to\\nthe persistence of vesical hemorrhoids which developed during\\npregnancy. Usually the blood disappears from the urine in a\\nfew days without treatment.\\nDiseases of the Nervous System.\\nNeuritis and Myelitis.\\nXeuritis following labor is due either to (a) nerve injury\\nthe result of pressure by the child s head or by forceps or to\\n(6) nerve disease the result of septic infection.\\nNeuritis due to injury The injury to the lumbosacral\\nplexus may be so slight as to produce nothing but a partial\\nloss of power associated with but slight pain or tenderness on\\nmovement, which subsides without special treatment in a few\\ndays. In more severe cases the pain may be intense and con-\\nstant, while paralysis and atrophy of the aifected muscles may\\nfollow, being associated with anaesthesia. Pressure on the\\nsacral plexus by means of the finger introduced into the rectum\\ngives rise to intense pain.\\nNeuritis due to septic infection may assume almost any\\ntype, being multiple, diffused, or isolated, while either motor\\nor sensory nerves may be affected. Occasionally in this form\\nthe median or ulnar nerves may be affected.\\nMyelitis is generally the result of septic infection, though\\nHirst mentions having met with a case which proved fatal, and\\nin which no septic focus or apoplexy could be discovered at the\\npost-mortem.\\nTreatment In the acute stage fixation and extension of the\\npart affected will give the greatest relief. Alternate hot and\\ncold applications, and the administration of phenacetin or, if\\nnecessary, opium, will secure further relief from pain. When\\nthis stage has subsided massage, electricity, and passive move-\\nment, combined with the administration of pot. iod. (gr. x-xv\\nt. i. d.), will hasten the restoration of the part to usefulness.\\n22\u00e2\u0080\u0094 Obst.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0345.jp2"}, "338": {"fulltext": "338 PATHOLOGY OF THE PUERPERAL PERIOD.\\nCerebral Hemorrhage and Embolism.\\nA woman the condition of whose arteries predisposes her to\\ncerebral hemorrhage is much more likely to be stricken with\\nthis accident during labor than at any other time. Hemiplegia\\nis not infrequently found to follow an attack of eclampsia.\\nCerebral embolism when it is not within the puerperium\\ngenerally follows an endocarditis or phlebitis of septic origin.\\nPuerperal Insanity.\\nOccurrence Mental derangement manifests itself in connec-\\ntion with child bearing most frequently during the puerperal\\nperiod, rarely during lactation, and but exceptionally during\\npregnancy.\\nThe term puerperal insanity is here used to designate the oc-\\ncurrence of mental derangement at any time between the birth\\nof the child and the termination of lactation. The condition\\nis most likely to occur in connection with the first confinement,\\nthough in a small number of cases mental derangement may\\nfirst manifest itself with the second or third parturition.\\nEtiology: Predisposing causes: Jn many cases there is\\npresent a hereditary disposition to mental derangement. A\\nwoman with an unstable nervous system is manifestly unsuited\\nto bear the nervous strain incident to pregnancy, parturition,\\nor lactation. Chorea, epilepsy, and hysteria previously exist-\\ning predispose to the development of insanity in connection\\nwith the puerperal period. Alcoholism and the narcotic habit\\nshould be mentioned as predisposing causes.\\nExciting causes Marked anaemia, sepsis, albuminuria,\\neclampsia, great physical or mental exhaustion, and profound\\nemotion have been cited as exciting causes of this condition.\\nMental anxiety in connection with domestic Avorry, desertion,\\nand illegitimate pregnancy may be mentioned as an exciting\\ncause.\\nForms Two forms of insanity are ordinarily met with, the\\nmaniacal and the melancholic the former occurs much more\\nfrequently during the ])uerperal period while the latter is\\ngenerally associated with lactation.\\nPuerperal insanity symptoms In both forms j^ odromal", "height": "3728", "width": "2668", "jp2-path": "obstetricsmanual00evan_0346.jp2"}, "339": {"fulltext": "DISEASES OF THE NERVOUS SYSTEM, 339\\nsymptoms usually manifest themselves. These are irritability,\\nrestlessness, complaints of petty annoyances, and periods of\\ndepression, alternating with conditions of nervous tension. A\\ncondition of general ill-health is usually manifested by loss of\\nappetite, indigestion, constipation, and flatulence. The patient\\nis usually pale, the pulse is irritable and quick, and she is\\ninclined to sudden outbreaks of tearfulness.\\nThe condition may deepen rapidly, and fever develop, and\\ndelusions and hallucinations become manifest. The language\\nbecomes obscene, and frequently erotic manifestations become\\nevident. The patient becomes uncontrollable, and is violent\\nin her actions she may attempt to destroy her infant or attack\\nher attendants.\\nIn the melanchoUe form the patient becomes morose, de-\\npressed, and listless; delusions of persecution are of frequent\\noccurrence. She accuses her husband of infidelity, or of even\\nworse crimes. She hears voices telling her to kill herself,\\nwhich she may attempt to do unless closely watched.\\nIn some cases the prodromal symptoms may be so slight as\\nto escape observation or the condition may be regarded as\\none of ordinary neurasthenia, w^hen suddenly the patient may\\nattack and destroy her infant or attendant, or may accomplish\\nsuicide.\\nWhen a woman during the puerperal period manifests ex-\\ncessive irritability or unusual loquacity or taciturnity, associated\\nwith sleeplessness and constipation, a close watch should be\\nkept on all her actions, and she should on no account be left\\nalone with her infant.\\nDiagnosis Usually this can be made without difficulty.\\nThe delirium of mania must be distinguished from that of\\nfever and that of delirium tremens.\\nPrognosis About two-thirds of all cases recover their reason\\nin from two to six months. Of the other third, 10 per cent,\\ndie of sepsis or exhaustion, and the balance remain perma-\\nnently insane.\\nMania is less likely to result in permanent insanity than is\\nmelancholia but it may be said that the patient s life is in\\ngreater danger from mania than from melancholia. The older\\nthe patient, the more rapid the pulse, and the more persistent\\nthe elevation of temperature, the more grave is the prognosis.", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0347.jp2"}, "340": {"fulltext": "340 PATHOLOGY OF THE PUERPERAL PERIOD,\\nWhen eclampsia bears a causal relation to the condition the\\nprognosis is distinctly more favorable, for these patients re-\\ncover much quicker than in any other variety.\\nTreatment of Puerperal Insanity.\\nWhen possible, patients suffering from this affliction should\\nbe removed to special institutions for treatment, and the earlier\\nthis is done the better. When this is impossible the patient\\nshould be isolated with two or three attendants who are\\nstrangers to her. She should never be left for one minute\\nalone, the windows should be securely fastened, and all un-\\nnecessary furniture removed from the room.\\nWhen in mania it is necessary to keep the patient in bed,\\nthis may be done by covering her with a strong sheet fastened\\nat the sides and foot of the bed; otherwise instruments of\\nrestraint should never be employed, but a sufficient number of\\nattendants should always be at hand to control the patient\\nif this be necessary.\\nThe treatment otherwise should be largely symptomatic.\\nNutrition should be promoted by every means possible, but\\nsedation should be avoided.\\nIt is always well to begin by securing a free action of the\\nbowels. This may be accomplished by the administration of\\na mercurial with a subsequent saline. The regular adminis-\\ntration of intestinal antiseptics, as salicylate of sodium or\\nnaphthaliu (gr. v t. i. d.), is advisable.\\nSleep may be promoted by giving paraldehyde (^j-ij) at\\nnight. Instead of this, sulfonal or trional in 20 grain doses\\nmay be employed.\\nHydrotherapy is of advantage both as controlling the tem-\\nperature and in securing sleep.\\nThe diet should consist of milk in generous quantities at\\nfirst later, eggs and meat may be added as digestion improves.\\nStimulants should be employed when necessary. Malt ex-\\ntracts are valuable adjuvants to the diet.\\nForced feeding by means of the oesophageal tube may be\\nrequired in rare instances, and it may be replaced at intervals\\nby nutrient enemata.\\nIron and arsenic should be given regularly in full doses, as", "height": "3712", "width": "2684", "jp2-path": "obstetricsmanual00evan_0348.jp2"}, "341": {"fulltext": "SUDDEN DEATH IN THE PUERPERIUM. 341\\nsoon as the condition of the digestive tract permits of their\\nemployment.\\nAs soon as possible the patient should be kept constantly in\\nthe open air during the daytime and exercise short of fatigue\\nshould be encouraged.\\nThe fact that pelvic conditions have much to do with the\\ndevelopment of this condition renders it necessary to make a\\ncareful examination of the state of these organs in all cases.\\nAll abnormal conditions should be corrected as far as possible.\\nIn manv cases operative treatment has been followed by bril-\\nliant results but to accomplish this, such procedure should be\\nadopted early in the history of the case.\\nSudden Death in the Puerperium.\\nThe most common causes of sudden death in the puerperal\\nperiod are pulmonary embolism, entrance of air into the uterine\\nsiniises, and heart-failure.\\nPulmonary Embolism and Thrombosis.\\nEtiology Some authorities claim that primary and sponta-\\nneous coagulation of blood may take place in the pulmonary\\nartery.\\nThe most generally accepted view is that pulmonary em-\\nbolism results from the separation of a portion of a thrombus\\nwhich has formed in some peripheral vein. Thrombosis most\\ncommonly takes place either in an iliac, femoral, or uterine\\nvein.\\nSymptoms and diagnosis: This accident may occur at any\\ntime during the earlier weeks of the puerperal period. The\\nsymptoms usually develop with great suddenness, and their\\nseverity depends on the size of the embolus. When the ob-\\nstruction of the pulmonary artery is complete, death may be\\npractically instantaneous or it may be preceded by precordial\\noppression, great dyspnoea, and cyanosis. Usually the patient\\nutters a sharp cry the respirations become shallow, gasping,\\nand irregular, and in a few seconds cease altogether. In casea\\nin which the embolus is small the onset of symptoms is not\\nso sudden but they are similar, though not so severe. Death", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0349.jp2"}, "342": {"fulltext": "342 PATHOLOGY OF THE PUERPERAL PERIOD.\\nmay not take place for several days, and very rarely recovery\\nmay follow. The symptoms usually follow some sudden\\nmovement, such as sitting up, laughing, straining at stool, etc.\\nThe following may be cited as an illustrative case the\\npatient, a multipara, had made a perfect convalescence after an\\nuneventful labor, when on the morning of the thirteenth day,\\nafter being gently moved to a sofa placed alongside of her\\nbed, she suddenly gave a gasp, fell back on the pillows, and in\\na moment lost consciousness. Cyanosis rapidly developed, and\\nthe respirations became labored and ceased inside of five min-\\nutes. The pulse at first was rapid and strong, but quickly\\nbecame thready, and ceased shortly after the failure of respira-\\ntion.\\nAt the autopsy there were found in certain of the larger\\nveins in connection with the uterovaginal plexus large, well-\\nformed thrombi a thrombus was found to extend into the\\nright internal iliac vein, where it ended abruptly with a trun-\\ncated and apparently broken-off end. Both right and left\\npulmonary arteries were found absolutely occluded with firm\\nred clot at their very origin. Nothing abnormal was found\\nelsewhere in the body.\\nTreatment Usually death takes place before any treatment\\ncan be inaugurated. In all cases in which there is evidence of\\nvenous thrombosis prolonged and complete red should be en-\\njoined. From an examination of the records of four of these\\ncases which caine under the observation of the writer, in none\\nof which there existed any evidence of thrombosis before the\\nonset of the fatal symptoms, the only abnormal condition com-\\nmon to all was a somewhat increased pulse-rate. In all four\\nthe pulse-rate is never recorded as being below 80, though\\ndeath took place in each between the tenth and the fifteenth\\ndays of the puerperal period. In view of this fact the writer\\nis in the habit of keeping all cases having an unusually high\\npulse- rate as quiet as possible for at least four weeks after the\\nbirth of the child, or until the pulse-rate becomes normal.\\nIn 7nild cases in which treatment is possible the indications\\nare to keep up the body-temperature by the application of\\nheat externally, to stimulate the cardiac and respiratory organs\\nby the administration of approjM iate remedies, and to secure\\nthe most absolute physical and mental rest for the patient.", "height": "3712", "width": "2676", "jp2-path": "obstetricsmanual00evan_0350.jp2"}, "343": {"fulltext": "FEVER DURING THE PUEBPERIUM, ETC. 343\\nEntrance of Air into the Uterine Sinuses.\\nCausation Tliis is a very rare accident. Air may find\\nentraoce into the uterine sinuses in the course of intra-uterine\\nmanipulations, such as the introduction of the hand, the giving\\nof an intra-uterine douche, or by aspiration following a change\\nin posture of the patient.\\nSymptoms These are practically the same as in pulmonary\\nembolism.\\nTreatment This consists in the hypodermic administration\\nof stimulants and the employment of artificial respiration.\\nInhalation of oxygen gas, in order to inflate the lungs and to\\nexpel the air emboli, has been suggested.\\nFever during the Puerperium due to Other than Septic\\nCauses.\\nElevation of temperature may occur in the course of the\\npuerperal period quite independently of septic infection^ from\\nsuch causes as exposure to cold, constipation, emotion, or reflex\\nirritation of any kind.\\nEmotional fever Profound psychical impressions, such as\\ngrief, anger, fear, or even excessive joy, may give rise to some\\nelevation of temperature, especially ^Yhen experienced during\\nthe early puerperium. The mechanism of this elevation of\\ntemperature is not susceptible of explanation in the present\\nstate of onr knowledge.\\nJn maternity hospitals emotional fever is frequently met Avith\\nin cases of illegitimate pregnancy about the tenth day of the\\npuerperium, as a result of anxiety on the part of such patients\\nin regard to their ability to provide for themselves and their\\nchildren in the immediate future. In emotional fever the\\ntemperature may rise to 104\u00c2\u00b0-105\u00c2\u00b0 F. but the cause being\\nusually transient the temperature quickly falls to normal.\\nExposure to cold: Elevation of temperature may follow\\nexposure of the breasts or abdomen to cold too low a tem-\\nperature in the lying-in room or insufficient bed-clothing may\\nexpose the patient to a chill, which is usually followed by some\\nelevation of temperature.\\nThe administration of some warm drink and the application\\nof external heat usually cause the fever to disappear promptly.", "height": "3708", "width": "2488", "jp2-path": "obstetricsmanual00evan_0351.jp2"}, "344": {"fulltext": "344 PATHOLOGY OF THE PUERPERAL PERIOD.\\nConstipation This is a not infrequent cause of elevation of\\ntemperature during the earlier part of the puerperium. The\\nfever is probably clue to the irritation of retained animal\\nalkaloids.\\nThe administration of a dose of castor oil will probably\\nresult in a drop of the temperature to normal as soon as\\nthe bowels have been evacuated.\\nFever from reflex irritation The effect of constipation when\\nit occurs in the puerperium is an example of reflex irritation of\\nthe nervous system producing fever which at other times would\\nhave no such result.\\nIrritation from engorgement of the breasts frequently results\\nin elevation of temperature, as has been mentioned elsewhere.\\nSeveral times we have met with cases of fever in which no\\ncause could be found to explain the condition until segments\\nof a tapeworm or a round worm appeared in the stools. Fol-\\nlowing the administration of appropriate remedies the worms\\nwere expelled and the temperature promptly returned to\\nnormal.\\nTympanites Tympanites, or overdistention of the intestines\\nwith gas, is not infrequently met with in the earlier part of the\\npuerperal period. This condition may or may not be attended\\nwith fever. When this condition is associated with elevation\\nof the temperature care must be taken to distinguish it from\\nperitonitis.\\nTreatment Turpentine enemata at short intervals, com-\\nbined with the internal administration of small doses of calo-\\nmel, usually relieve the patient.\\nUsually it is necessary to start the treatment with an enema\\nof hot soap-water and turpentine (sij to Oj). Then calomel\\n(gr. -jlg-) should be given every hour. At the end of six hours\\na dose of Epsom salt (^ss, in tw^o ounces of hot water) may be\\ngiven and if this is not effectual in an hour an enema con-\\ntaining glycerin (,|j), turpentine (3ij), Epsom salt (^ss), and\\nwater (|iij) should be given.\\nThe calomel should be kept up for two days, and then\\nreduced to two or three doses daily. As these cases are due to\\nparalysis of the muscular coats of the intestine, a hypodermic\\nof strychnine (gr. -^-q) should be given every four or six hours\\nuntil the condition improves.", "height": "3712", "width": "2664", "jp2-path": "obstetricsmanual00evan_0352.jp2"}, "345": {"fulltext": "PUERPERAL SEPTIC INFECTION. 345\\nPuerperal Septic Infection.\\nThe general term puerperal septic infection is here employed\\nto designate the many and varied diseased conditions resulting\\nfrom infection of the female genital tract during labor and the\\npuerperium, by microorganisms.\\nFrequency: Previous to the introduction of the antiseptic\\nmethod of conducting labor the mortality-rate from septic\\ninfection varied between 10 and 15 per cent, in the large\\nmaternity institutions. As the result of the application of\\nrigid antisepsis and asepsis to hospital practice the mortality\\nfrom septic disease has been reduced to a low fraction of 1 per\\ncent.\\nIn private practice the beneficial results of the antiseptic\\nmethod are much less marked than in hospital practice. Epi-\\ndemics of puerperal infection are now but rarely heard of, but\\nthe mortality-returns still show a large proportion of deaths\\nfollowing parturition.\\nThat septic conditions frequently complicate the puf.Tperium\\nis evidenced by the overcrowded condition of the gynaeco-\\nlogical clinics in all parts of the country. A very large pro-\\nportion of these gynaecological cases present conditions which\\nowe their origin to febrile affections arising during the puer-\\nperal period.\\nBacteriology.\\nThe streptococcus is the microorganism most frequently\\nassociated with the occurrence of puerperal sepsis. It is to be\\nfound in nearly all fatal cases.\\nThe staphylococcus aureus is the next most frequent cause\\nof puerperal septic infection. Not infrequently mixed infec-\\ntions with streptococci and staphylococci are encountered.\\nThe gonococcus, bacillus coli communis, bacillus diphtheriae,\\nbacillus aerogenes capsulatus, pneumococcus, and bacillus\\ntyphosus may be mentioned as rare causes of puerperal septic\\ninfection. These may be found pure or mixed with strepto-\\ncocci when the latter is the case the infection is generally\\nexceptionally virulent.\\nThe gonococcus plavs an important part in the production\\nof puerperal sepsis. Kronig has found it to be present in 50", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0353.jp2"}, "346": {"fulltext": "346 PATHOLOGY OF THE PUERPERAL PERIOD.\\nout o\u00c2\u00a3 179 cases presenting febrile puerperia. It appears usu-\\nally to cause a mild infection, unless associated with a strepto-\\ncoccus, in which case the infection is usually very virulent.\\nSapraemia There is a considerable class of cases in which\\nthe symptoms are due to the absorption of toxic products pro-\\nduced by organisms within the genital tract which do not\\nmake their way into the blood-current. These are mostly of\\nan anaerobic nature, belonging to the putrefactive class of\\nmicroorganisms, of which little is know^n. They usually pro-\\nduce gas, and hence give rise to frothy, foul-smelling dis-\\ncharges.\\nRecently a great deal of bacteriological worlv has been carried\\nout in the study of the vaginal secretion. It has been prac-\\ntically proved that the normal vagina in pregnancy is free\\nfrom pathogenic microorganisms, at least in its upper third.\\nThe vaginal secretions are commonly strongly acid in their\\nreaction, due to the presence of a so-called vaginal bacillus,\\nwhich in its life-processes produces lactic acid. It is probably\\nthis acid condition of the vaginal secretions, associated with a\\ncertain leukocytosis due to chemotaxic action, which results in\\nthe rapid destruction of the pathogenic bacteria should they\\nfind entrance to the vagina.\\nIt has been proved that pathogenic bacteria introduced into\\na normal vagina perish in from eleven to twenty hours through\\nthe germicidal action of the normal secretions. Preliminary\\nantiseptic vaginal douches have been proved to inhibit the\\ngermicidal action of normal vaginal secretions. Pathogenic\\nbacteria have been found to flourish from eight to sixteen\\nhours longer in the healthy vagina after antiseptic douching\\nthan when no douching was employed.\\nThe cervix has been usually found to contain in its lower\\npart a few pathogenic bacteria of greatly diminished virulence.\\nIts upper part is invariably sterile in the normal condition.\\nThe uterine cavity normally is entirely free from microorgan-\\nisms, both in the pregnant and in the non-pregnant condition.\\nThe microorganisms to be found in the lower part of the\\nvagina are usually non-infectious but should j)athogenic bac-\\nteria be present, their virulence is invariably greatly dimin-\\nished as a result of the germicidal action of the normal secre-\\ntions.", "height": "3732", "width": "2708", "jp2-path": "obstetricsmanual00evan_0354.jp2"}, "347": {"fulltext": "PUERPERAL SEPTIC INFECTION. 347\\nPathology of Puerperal Septic Infection.\\nThe consequences of infection of the genital tract of the\\npuerperal woman by microorganisms are extremely variable.\\nThe infection may be limited to lesions of the vnlva or vaginal\\noutlet, or may rapidly spread from this locality to the uterine\\ncavity. In the most virulent cases no lesion may mark the\\nlocality in which the germs have effected an entrance, and yet\\nthe patient may succumb with extreme rapidity.\\nIt is the endometrium which is atfected in the majority of\\ncases of puerperal septic infection. This endometritis may be\\nseptic or pxdrid, according as it is the result of infection by\\npyogenic or putrefactive microorganisms.\\nThe mildest form of puerperal septic infection is the puer-\\nperal ulcer. These puerperal ulcers are simply infected lacera-\\ntions of the vaginal outlet and vulva. They usually present a\\ndirty, greenish-yellow appearance and are bathed in a purulent\\nsecretion. Formerly these were termed diphtheritic ulcers, but\\nit is very rare that they result from infection with the Klebs-\\nLoflfler bacillus.\\nUsually they cause but little symptomatic disturbance, and\\ntherefore their presence may pass unnoticed.\\nTrue puerperal vaginitis may occur, but is rare it is char-\\nacterized by an inflammation of the vaginal mucosa, which\\nswells and softens, becoming bathed in a purulent secretion.\\nLacerations in the vagina when infection occurs usually become\\ncovered with a pseudodiphtheritic membrane. Karely, true\\ndiphtheritic vaginitis may occur.\\nEndometritis After labor the more or less lacerated condi-\\ntion of the endometrium, and the uneven placental site with\\nits thrombosed sinuses, render the uterine cavity specially sus-\\nceptible to the reception and propagation of infective organisms.\\nHence the most common lesion associated witli puerperal septic\\ninfection is endometritis.\\nThe infection may be limited to the placental site or may\\nextend over the whole of the endometrium.\\nWhen the infection is limited to the j^^Ictcentcd site the organ-\\nisms develop in the thrombi in the placental sinuses, setting up\\na phlebitis which may be limited to the uterine wall, or may", "height": "3712", "width": "2476", "jp2-path": "obstetricsmanual00evan_0355.jp2"}, "348": {"fulltext": "348 PATHOLOGY OF THE PUERPERAL PERIOD.\\nextend to the suiTouiidin vein\\nsecondary infection elsewliere.\\nand thns\\nto\\nWhen the lohole endometrium is involved the mucosa is con-\\nverted into a stinldng, necrotic layer, which is bathed in a\\nbloody discharge. The quantity of necrotic material formed\\nis often considerable, and it recurs with great rapidity after its\\nremoval by the curette. It consists of necrotic decidual debris\\nFig. 121.\\nuterus from patient dying on the tenth day from a pure streptococcus infection.\\nand fibrin-exudate loaded with microorganisms (Figs. 121\\nand 122).\\nWlien the infection is due to the streptococcus or to the\\nstaphylococcus the odor of tlie lochia may not be aifected.\\nThus in the most virulent cases the lochia may remain sweet\\nthroughout but when the colon bacillus or any of the putre-", "height": "3712", "width": "2760", "jp2-path": "obstetricsmanual00evan_0358.jp2"}, "349": {"fulltext": "PUERPERAL SEPTIC INFECTION.\\n;49\\nfacfive germs are present the discharges become foul in the\\nextreme.\\nIn a large number of oases Nature succeeds in limiting the\\ninfective process to the endometrium, which it does by forming\\nFig. 122.\\nUterus from patient dying on the tenth day from a mixed infection\u00e2\u0080\u0094 streptococcus\\nand colon bacilli.\\na barrier or obstruction immediately below the necrotic layer.\\nThis barrier consists of a layer of small-cell infiltration, desig-\\nnated the zone of reaction. Beneath this zone the tissues are\\nusually quite normal.", "height": "3708", "width": "2484", "jp2-path": "obstetricsmanual00evan_0359.jp2"}, "350": {"fulltext": "350 PATHOLOGY OF THE PUERPERAL PERIOD.\\nThus on section we find an internal layer consisting of\\nnecrotic deoidua and fibrin-exudate swarming with micro-\\norganisms; below this is a layer, of small-cell infiltration, the\\nzone of reaction/ containing few if any bacteria, while under\\nthis is the normal uterine tissue.\\nSuch is the condition found when the infection is due to\\nputrefactive microorganisms, as in putrid eiidomefr dis, so-called\\nby Bumm and Doderlein or when, if due to pyogenic bacteria,\\nthese are possessed of but little virulence.\\nIn the so-called septic endometritis (Bumm and Doderlein),\\nwhen the infective organisms are virulent streptococci or\\nstaphylococci, the zone of small-cell infiltration may be but\\nimperfectly formed, or even entirely absent; while the super-\\nficial necrotic layer may be lacking, or if present be very thin.\\nIn this case the extension of the infective process occurs by\\nmeans of the lymphatics, and soon spreads through the uterine\\nwall to the peritoneal layer, thus setting up a metritis, lym-\\nphangitis, and finally a septic peritonitis. This lymphangitis\\nusually results in the formation of numerous small abscesses\\nthroughout the uterine wall, though usually most marked just\\nbeneath the peritoneum.\\nParametritis This inflammation of the connective tissue\\ncontiguous to the uterus frequently follows intra-uterine infec-\\ntion during the puerperium. The extension of the microorgan-\\nisms usually proceeds along the lymphatics from the endomet-\\nrium to the peri-uterine connective tissue. Occasionally the\\ninfection may originate in laceration of the cervix.\\nThe infective inflammation of the peri-uterine connective\\ntissue produces extensive oedema. This may result in resolu-\\ntion, or in suppuration and abscess-formation. When ex-\\ntension of the infection occurs along the lymphatics in the\\nanterior portion of the pelvis, the inflammatory oedema sur-\\nrounds the greater vessels of the thigh in the neighborhood of\\nthe inguinal region, giving rise to one form oi jMegmasia alba\\ndolens.\\nSalpingitis The Fallopian tubes in a certain number of\\ncases become infected by direct extension of the inflammation\\nfrom the uterine cavity. Occasionally the infection may be\\ncarried to the tubes as well as ovaries, by means of the lym-\\nphatics.", "height": "3708", "width": "2740", "jp2-path": "obstetricsmanual00evan_0360.jp2"}, "351": {"fulltext": "PUERPERAL SEPTIC INFECTION. 351\\nPeritonitis This condition usually arises as the result of the\\nrapid extension of infection from the uterine cavity by means\\nof the lymphatics as already described.\\nPeritonitis may rarely occur in consequence of the rupture\\nof a pus-tube, or of an ovarian or parametritic abscess. Septic\\nperitonitis is usually the direct cause of death in the vast ma-\\njority of fatal cases.\\nPyaemia As already mentioned, the infective microorgan-\\nisms may penetrate the thrombi at the placental site. This\\nresults in a condition of septic phlebitis, which may be limited\\nto the veins in the uterine wall or may extend to the veins in\\nthe neighborhood. The thrombosis may extend as far as the\\ninferior vena cava. These infected thrombi may break down,\\nand small portions may be swept by the blood-current to dis-\\ntant parts of the body, thus setting up a condition of pyaemia.\\nThese infected emboli may be deposited in the abdominal vis-\\ncera, the lungs, the brain, spinal cord, the joints, or in the sub-\\ncutaneous tissue at any portion of the body surface, where they\\ngive rise to abscesses. In these cases there is very little\\ninvolvement of the uterus, infection then being limited\\nusually to the placental site. Death in these cases is usually\\ndue to exhaustion folloAving a long suppurative process.\\nPhlegmasia alba dolens This condition is known to the\\nlaity as milk leg/ as* it was popularly supposed at one time\\nto be due to a metastasis of milk. It occurs as the result\\neither of the extension of a thrombosis from the uterine veins\\nto those of the lower extremities, or of a septic parametritis\\nspreading to the connective tissue of the thigh.\\nIn thrombotic phlegmasia the swelling of the affected limb\\nusually begins about the foot, and rapidly extends to the thigh.\\nIn celhditic phlegmasia the swelling begins in the thigh and\\nspreads down the limb.\\nIn both forms the affected limb becomes enormously swol-\\nlen. In the first form there is usually more or less tenderness\\nalong the course of the femoral vein, which is usually marked\\nby a line of inflammatory redness.\\nModes of infection: The most common mode of infection is\\nthe introduction of septic material into the genital canal, on\\nthe hands or instruments of the physician or midwife con-\\ntact vdth secretion from tcounds of anv kind, such as infected", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0361.jp2"}, "352": {"fulltext": "352 PATHOLOGY OF THE PUERPERAL PERIOD.\\nabrasions on the hands of a nurse or physician. Air-infedion\\nmay account for a very small proportion of cases.\\nThe water used to douche the patient after labor may carry\\npathogenic germs into the genital canal. Contact of the vulva\\nwith dirty bed-clothes or personal linen, or with infected vulvar\\npads, may account for some cases.\\nIn one case in the author s experience infection was probably\\ndue to the dirty hand of the patient, who could not be restrained\\nfrom scratching the vulva.\\nAs has been shown, the normal vagina is practically sterile,\\nso that when infection occurs it is generally the result of the\\nintroduction of pathogenic material from without. Epidemics\\nof septic infection have been stamped out in maternities by\\navoiding all internal examinations. The best morbidity and\\nmortality records have been obtained in institutions where\\nvaginal examinations have been eliminated as far as possible.\\nAuto-infection may he held to account for a very small pro-\\nportion of cases of puerperal sepsis. In these cases the patho-\\ngenic germs are held to be resident in the body, and not to\\nhave been introduced from without, during or after labor.\\nThe microorganisms may be lodged in the vagina, cervix, or\\nurethra, as in cases of gonorrhoea. Endometritis antedating\\nconception may account for the lodgement of germs in the\\nuterine mucous membrane, which in the favorable conditions\\nexisting after delivery may become virulent and set up septic\\ninfection. In the same way an old pus-sac in one of the\\ntubes may rupture during labor and cause a septic peritonitis.\\nSymptomatology.\\nThe symptoms of septic infection may develop within the\\nfirst twenty -four hours after delivery but, as a rule, nothing\\nout of the ordinary is to be noted until the third or fourth day.\\nThe onset of infection may be attended with a sense of\\nmalaise and possibly a slight headache. As the temperature\\nbegins to rise the patient develops a more or less severe chill,\\nwhich may amount to an actual rigor. The temperature\\nquickly rises to 103\u00c2\u00b0 F. or higher, and the pulse becomes\\nvery rapid. Usually there is only one chill, but the tempera-\\nture remains persistently elevated.", "height": "3712", "width": "2676", "jp2-path": "obstetricsmanual00evan_0362.jp2"}, "353": {"fulltext": "PUERPERAL SEPTIC INFECTION. 353\\nThe lochia may become scant, but as a rule the discharge in-\\ncreases in amount. It may remain bloody or may rapidly be-\\ncome purulent. In the most virulent cases and in those due\\nto pure streptococcus infection, very little, if any, odor is to be\\nnoticed.\\nProfuse foul-smelling lochial discharge indicates a putrid\\nendometritis or a mixed infection due to pyogenic as well as\\nputrefactive organisms.\\n\\\\Yith the onset of endometritis either of the septic or the\\nputrid form, involution of the uterus at once ceases, thus favor-\\ning the spread of the infection, in that the lymph-channels,\\nbeing free from compression, remain patent and thus offer less\\nresistance to the passage of microorganisms.\\nIf the infective process extends beyond the uterus, the\\nsymptoms which then develop depend upon the tissues in-\\nvolved. Symptoms indicative of peritonitis, parametritis, or\\npyaemia may thus ensue.\\nPeritonitis The onset of this complication is indicated by\\nthe occurrence of intense pain, which is at first limited to the\\nlower zone of the abdomen, but gradually extends as the\\nwhole peritoneum becomes affected. As paralysis of the in-\\ntestines takes place marked tympanites occurs. In fatal cases\\ndeath usually takes place within the first ten days of the\\npuerperium.\\nParametritis This complication, as a rule, develops when\\nthe endometritis is apparently subsiding. Its onset is fre-\\nquently attended with a chill the temperature, which has\\nprobably fallen, again becomes elevated and pursues a more or\\nless irregular course. The extension of the inflammatory proc-\\ness to the parametrium may usually be detected by a vaginal\\nexamination. The infiltrated tissues surrounding the uterus\\nbecome hard and tense to the feel. This inflammation may\\nend in resolution or in abscess-formation one large or several\\nsmall abscesses may form. The pus may burrow about and\\nmake its way into the bladder, rectum, vagina, or peritoneal\\ncavity. Occasionally such an abscess may point at Poupart s\\nligament, or even above the crest of the ilium.\\nPyaemia In cases of pyaemia the initial symptoms of in-\\nfection are not so marked as in the other forms. The temper-\\n23\u00e2\u0080\u0094 Ob.\u00c2\u00abt.", "height": "3700", "width": "2472", "jp2-path": "obstetricsmanual00evan_0363.jp2"}, "354": {"fulltext": "354 PATHOLOGY OF THE PUERPERAL PERIOD.\\nature does not remain constantly elevated, but assumes the\\nhectic type. Chills are usually of frequent occurrence.\\nThe subsequent symptoms depend upon the organs invaded\\nby the infected thrombi. Most commonly with pyaemia we\\nhave symptoms of an infectious bronchopneumonia developing.\\nThis generally proves rapidly fatal.\\nIn true septicssmia, which is the most virulent form of septic\\ninfection, the organisms make their way so rapidly into the\\ngeneral blood-current that they fail to become localized in any\\none organ. This Is the most rapidly fatal form of infection;\\ndeath may occur on the third or fourth day of the puerperiura,\\nthe poison being so virulent as to induce a condition of pro-\\nfound shock.\\nDiagnosis of Puerperal Septic Infection.\\nIf on the third or fourth day of the puerperal period a\\nwoman develops a temperature of 101\u00c2\u00b0 F., or more, which\\npersists for twenty-four hours, the condition present is almost\\ncertainly one of septic infection provided there is no other ap-\\nparent cause to account satisfactorily for the sym])toms.\\nThe most common causes of an elevation of temperature\\nearly in the puerperium, not associated with septic infection,\\nare constipation, irritation from the breasts, and emotional\\nexcitement, fright, or grief. Malaria and typhoid fever may\\ncomplicate the puerperium, and may be confounded with septic\\ninfection.\\nA diagnosis of malaria is only possible when the presence\\nof the Plasmodium has been demonstrated in the blood.\\nA diagnosis of typhoid fever is not permissible in the\\nabsence of Widal s blood-serum test.\\nBefore making a diagnosis of septic infection, careful, syste-\\nmatic physical examination of the patient should be made.\\nA careful examination of the characters of the lochial dis-\\ncharge may render possible a diagnosis of which variety of\\nendometritis is present in a given case of puerperal septic in-\\nfection.\\nIn all cases the physician should make an ocular examination\\nof the vulva J vagina, and cervix in a good light, employing for\\nthis purpose a large speculum,", "height": "3712", "width": "2664", "jp2-path": "obstetricsmanual00evan_0366.jp2"}, "355": {"fulltext": "PUERPERAL SEPTIC INFECTION. 355\\nAs it is desirable to know what organisms are concerned in\\nthe production of the infection, a culture may be taken from\\nthe interior of the uterus. This may be accomplished with\\nbut little difficulty by the method recommended by Professor\\nWilliams, of Baltimore.\\nThe apparatus necessary consists of a glass tube, 20 to 25\\ncm. in length and 3 to 4 mm. in diameter, with a slight bend\\nat one end so as to facilitate its introduction into the uterus.\\nThis may be sterilized after placing it in a long test-tube of\\nthick glass, which contains in its lower extremity a pledget of\\ncotton-wool, while its upper end may be closed by a cotton\\nplug (Figs. 123-125).\\nWilliams thus describes the method to be followed in ob-\\ntaining a culture from the uterine cavity When we wish to\\nmake cultures from the uterus, our hands and the external\\ngenitalia should be thoroughly disinfected, the patient placed\\niu the Sims position, and a sterilized Sims or Simons speculum\\nintroduced so as to retract the posterior vaginal wall; then the\\ncervix is caught with a volsellum forceps and brought down to\\nthe vulva the vaginal portion of the cervix is then carefully\\ncleansed with a bit of sterilized cotton, and the sterile lochial\\ntube is removed from its tube and introduced into the uterus as\\nhigh up as it will go, care being taken to avoid touching the\\nexternal genitals in the operation. To the end of the lochial\\ntube which protrudes from the vulva a syringe, which draws\\nwell, is attached by means of a rubber tube. Suction is made\\nwhereby a certain amount of the uterine contents is drawn up\\nin the tube. The tube is then withdrawn and its ends sealed\\nWMth sealing-wax, when it can be carried to the laboratory\\nwithout fear of contamination. On reaching the laboratory it\\nis broken in its middle portion and cultures are taken from its\\ncontents, which we know represent the uncontaminated lochia\\nfrom the upper part of the uterus.\\nWhen there is undoubted evidence of endometritis the interior\\nof the uterus should be explored by means of tlie sterile finger.\\nThis procedure can be carried out when the culture has been\\nobtained. By this means important information may be ob-\\ntained which Avill indicate the line of treatment to be pursued.\\nWhen the ivalls of the uterine cavity are rough, the probability\\nis that we have to deal with a putrefactive endometritis or", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0367.jp2"}, "356": {"fulltext": "356 PATHOLOGY OF THE PUERPERAL PERIOD.\\nFig. 124.\\nFig. 123.\\nFig. 125.\\none due to a pyogenic organism of a low degree of virulency.\\nWhen the cavity is perfectly smooth the infection is probably\\ndue to virulent streptococci or staphylococci.", "height": "3728", "width": "2648", "jp2-path": "obstetricsmanual00evan_0368.jp2"}, "357": {"fulltext": "PUERPERAL SEPTIC INFECTION. 357\\nTreatment of Puerperal Septic Infection.\\nProphylaxis The occurrence of puerperal septic infection is\\nto be prevented by the observance of the most scrupulous\\nasej^sis in the method of conducting labor. This subject has\\nbeen fully dealt with in the section on the management of\\nlabor, to which the reader is again referred.\\nProphylactic douches should not be employed except when\\nthe vaginal secretion presents marked evidences of abnormality.\\nVaginal examinations should be made as infrequently as possible\\nduring labor in normal cases more than one or two are seldom\\nnecessary.\\nAll vaginal and vulvar lacerations which extend deeper than\\nthe mucosa should be sutured immediately after the conclusion\\nof labor.\\nDuring the first two weeks of the puerperal period the most\\nrigid asepsis should be observed in the care of the external\\ngenitals. The subject has been discussed in this work on the\\nsection in the management of the puerperium.\\nLocal Treatment.\\nIf on examination of the vulva sloughing surfaces are dis-\\ncovered, these should be painted daily with tincture of iodine.\\n^yhen sutured wounds of the vaginal outlet present evidences\\nof infection, the stitches should be removed in order to secure\\nfree drainage.\\nEndometritis is the condition most frequently present in\\npuerperal septic infection.\\nAs previously mentioned, the cavity of the uterus should be\\nexplored and a portion of the lochia removed for examination.\\nThe method of treatment to be followed will depend in a\\nlarge measure on the conditions present in the uterine cavity.\\nThe indications are to remove all debris and shreds of broken-\\ndown tissue, and to cleanse thoroughly the interior of the uterus.\\nThe routine use of the curette in all cases of puerperal endo-\\nmetritis is mentioned only to be condemned, as in certain con-\\nditions this treatment may result in the production of far more\\nharm than good.\\nWhen the walls of the uterine cavity are found to be perfectly", "height": "3688", "width": "2472", "jp2-path": "obstetricsmanual00evan_0369.jp2"}, "358": {"fulltext": "358 PATHOLOGY OF THE PUERPERAL PERIOD.\\nsmooth there is absolutely no indication for the employment of\\nthe curette, as there is nothing present that can be removed by\\nit. The cavity should be douched thoroughly with a gallon or\\ntwo of hot eterile formalin solution (1 500), after which a strip\\nof sterilized iodoform gauze, rolled so as to form a double wick\\neight to ten inches long, may be introduced as high as the\\nfundus. This wick of gauze favors drainage, and by its\\npresence in the cavity stimulates the uterus to contract. Some\\nobstetricians prefer to pack lightly the uterus with strips of\\ngauze after douching, but this rather tends to interfere with\\nfree drainage, and therefore the gauze wick is to be preferred.\\nIf the bacteriological examination of the lochia reveals that the\\ninfection is due to streptococci, further local treatment is to be\\navoided and the gauze removed in forty-eight hours.\\nIf the interior of the uterus be found rough and jagged, and\\ncovered with more or less false membrane, the walls of the\\ncavity should be systematically scraped with a blunt curette\\n(Mund^ s), though many prefer the fingers for this purpose.\\nAfter curetting the walls should be explored by the finger-tips\\nto make sure that all debris has been removed by the curette.\\nA douche of hot formalin solution (1 500) may then be em-\\nployed to cleanse the cavity thoroughly, after which a bougie or\\ntwo composed of iodoform (sss) and sufficient ol. theobrom. to\\nmake a bougie two inches long, of the thickness of an ordinary\\nlead-pencil, may be introduced as high as the fundus. These\\nbougies are held in position by the gauze wicking, which should\\nbe introduced as recommended above.\\nThis treatment usually results in a marked improvement\\nof the symptoms, the temperature falls within a few hours,\\nand the lochia becomes more normal in type. Should the\\ntemperature not yield to the first injection, the treatment may\\nbe repeated daily, provided there is no evidence that the in-\\nfection has extended beyond the uterus, in which case local\\ntreatment should be abandoned.\\nBichloride of mercury solution should not be employed in\\nintra-uterine douches, as when this salt comes in contact with\\nblood it forms an innocuous albuminate. Bumm has shown\\nthat bichloride injections penetrate the tissue to only a slight\\nextent. The antiseptic does not remain long enough in contact\\nwith the infected tissue to exert much germicidal action. For", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0370.jp2"}, "359": {"fulltext": "PUERPERAL SEPTIC INFECTION. 359\\nthis latter reason, aucl because the main object of the douche\\nis to wash away debris which has been detaclied by the curette\\nor finger, many prefer to employ for this purpose simple sterile\\nwater or salt sohition.\\nIn gonococcal endometritis it is better to employ no local\\ntreatment, as the majority of these cases recover without it\\nor at the worst are left with a chronic endometritis which can\\nbe treated to better advantage later.\\nLocal treatment should not be persisted in when it is evi-\\ndent that it fails to improve the condition of the patient. In\\nthese cases all that can be done is to direct our efforts to the\\ngeneral improvement of the condition of the patient.\\nGeneral Treatment.\\nThese patients should receive all the food they can assimilate.\\nThe diet should consist chiefly of milk, eggs, and meat-juice.\\nThese should be given in large quantities, at short intervals,\\nand if necessary should be predigested.\\nThe depressant action of the toxins should be combated by\\nfree stimulation, and for this purpose our most potent remedies\\nare alcohol and strychnine.\\nAs much alcohol should be given as can be consumed with-\\nout producing its physiological effects. It is surprising what a\\nquantity of alcohol these patients can take without apparently\\nproducing any untoward result.\\nStrychnine should also be given in large doses, from to\\n2^0- grain may be administered every three hours in serious\\ncases. Digitalis may be combined with the strychnine when\\nthe pulse-rate is high.\\nTo control the temperature, cold wet packs should be em-\\nployed, as well as the ice-cap. As a rule, antipyretic drugs\\nshould be avoided on account of the depressant action they\\nexert.\\nBumm has recommended the routine em})loyment of ergot\\nin cases of puerperal endometritis, in order to secure better\\ncontraction, and thus occlude to some degree the lymphatics in\\nthe uterine wall. Fl. ext. ergotse (ifTLx) may be given every six\\nhours, or it may be combined with quinine (gr. v) and given\\nin a suitable mixture.", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0371.jp2"}, "360": {"fulltext": "360 PATHOLOGY OF THE PUERPERAL PERIOD.\\nThe bowels should be kept active b\\\\ means of a daily saline\\nwhich acts favorably by draining the pelvic lymphatics.\\nThe subcutaneous injection of large quantities of normal\\nsaline solution has been employed in the treatment of puer-\\nperal sepsis with marked beneficial results. It is supposed to\\nact by diluting the blood, thus favoring the expulsion of toxic\\nmatter. The saline solution may be injected under the breasts,\\nas recommended in the treatment of hemorrhage or more\\nconveniently into the bowel, in which case at least two quarts\\nshould be given at each injection.\\nRecently it has been suggested that nuclein be employed in\\nthe treatment of these cases with a view of producing an arti-\\nficial leucocytosis. Hirst considers that this plan of treatment\\ngives promise of practical results, and that more is to be\\nexpected of it than of serum-therapy.\\nSerum-therapy When Marmorek in 1895 published the\\nresults he had obtained by the employment of antistrepto-\\ncoccic serum in the treatment of sepsis, brilliant results were\\nexpected to follow its use in puerperal cases. Recent statistics\\nseem to prove that the results thus far obtained by the employ-\\nment of the serum are not more favorable than those by other\\nmethods of treatment.\\nAs many cases of puerperal infection are due to other agents\\nthan streptococci, its routine employment in all cases can only\\nbe fraught with danger. When our means of diagnosis enables\\nus to prove in a given case that the infection is due to the\\nstreptococccus alone, then the serum should be employed, but\\nnot to the exclusion of other methods of treatment.\\nIf care is taken to make an accurate diagnosis that the infection\\nis due to the streptococcus alone, serum-therapy may be em-\\nployed with fair certainty of success, especially if it is used\\nearly and in large doses.\\nParametritis This condition may be treated by either hot\\nor cold applications, whichever prove more grateful to the\\npatient. The ice-bag will be found to control the extension\\nof the inflammation in many cases, while it usually relieves\\nthe local pain to a marked degree. When it is not well borne\\nhot flaxseed poultices may be applied to the lower abdomen\\nand hot vaginal douches given at regular intervals.\\nProbably most of these cases heal by resolution, but a close", "height": "3708", "width": "2668", "jp2-path": "obstetricsmanual00evan_0372.jp2"}, "361": {"fulltext": "EPISIOTOMY. 361\\nwatch must be kept for evidences of suppuration. When\\nfluctuation is obtained the abscess may be opened through the\\nvaginal vault when possible in some cases it may be neces-\\nsary to make the incision through the abdominal wall.\\nPeritonitis When peritonitis develops the treatment should\\nat first be expectant, in the hope that the inflammation wdll\\nbecome localized. Counterirritation and hot fomentations to\\nthe abdomen, combined with the free use of saline cathartics,\\nmay give good results. If the symptoms progress or do not\\nabate within thirty-six hours, then the abdomen may be opened\\nand the case treated according to the conditions found. Ab-\\nscess, if found, should be opened and drained. Distended\\ntubes and ovaries should be removed, and under certain con-\\nditions it may be necessary to perform hysterectomy.\\nThe indications for hysterectomy are the presence of multiple\\nabscesses in the uterine walls and putrid endometritis which\\nfails to yield to repeated intra-uterine irrigations and curetting.\\nPhlegmasia alba dolens The patient should be kept in bed\\nwith the aifected limb elevated so as to favor the return circu-\\nlation. The limb should be wrapped in cotton and bandaged\\nloosely. The general treatment should be supporting and stimu-\\nlating.\\nIn the cellulitic variety suppuration is very likely to take\\nplace in the connective tissue of the thigh. Abscesses should\\nbe watched for and promptly opened, so as to avoid burrowing.\\nOBSTETRIC OPERATIONS.\\nEpisiotomy.\\nDefinition Episiotomy is the term applied to any incision\\nof the external genitals to prevent extensive laceration taking\\nplace during the passage of the child at the time of birth.\\nThe operation cannot be said to be in general use in this\\ncountry, but is common in Germany and Austria.\\nIndications These are\\n1. Threatening central rupture of the perineum.\\n2. Great narrowness of the external genitals.\\n3. Rigidity of the perineum, especially when due to cica-\\ntricial tissue.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0373.jp2"}, "362": {"fulltext": "362 OBSTETRIC OPERATIONS.\\n4. Faulty position of the advancing part of the foetus at the\\noutlet.\\n5. Undue size of the foetal head.\\nOperation Tarnier has recommended an oblique incision\\npassing to one or other side of the anus. The Germans pre-\\nfer lateral oblique incisions directed toward the posterior com-\\nmissure. It is stated that such an incision 1 cm. inch) in\\nlength increases the circumterence of the vulvar orifice 2 cm.\\n(f inch).\\nThe instrument used is a blunt-pointed scissors. During a\\npain one blade of the open scissors is slipped sideways between\\nthe head and the vulva, and then turned and the tissues cut.\\nTlie advantage of episiotomy is the substitution of a clean cut\\nof definite size, in a place where it can do no harm, for an ir-\\nregular laceration of indefinite size which may cause perma-\\nnent injury to the patient. Also a clean incision is much more\\neasily sutured than a jagged laceration.\\nIMMEDIATE REPAIR OF VAGINAL AND PERINEAL\\nLACERATIONS.\\nWhether the pelvic fascia or the fibres of the levator ani\\nmuscles are the all-important structures concerned in the support\\nof the internal pelvic structures is still a matter of debate.\\nIt is, however, certain that the wedge of tissue between the\\nvagina and rectum composing the perineal body has practically\\nnothing to do with the support of the pelvic contents.\\nAccording to Kelly, the real supporting mechanism of\\nthe outlet is the anterior portion of the levator ani muscle. The\\nmore generally held opinion, however, is that the pelvic fascia\\nis the supporting mechanism of the outlet, and that the sheets\\nforming the ischioperineal layer of the rectovesical fascia are\\nmost important in this connection.\\nWhen it is considered that the vaginal orifice, normally 2 to\\n3 cm. in circumference, is dilated to 33 cm. at the moment of\\ndelivery to permit the passage of an ordinary sized child, it is\\nnot surprising that laceration commonly takes place.\\nAs a matter of routine, after the conclusion of labor, the\\nphysician should carefully examine the vulva and vaginal ori-\\nfice for lacerations. This examination may ordinarily be made", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0374.jp2"}, "363": {"fulltext": "REPAIR OF VAGINAL AND PERINEAL LACERATIONS. 363\\nwith the patient in the dorsal position, having the thighs\\neverted. A good light is absolutely necessary. When an ex-\\nternal superficial tear is found it may be repaired at once, as\\ndirected below.\\nIf, however, an extensive laceration should be present, further\\nexamination may be delayed until preparations have been com-\\npleted for a repair operation.\\nInjuries to the vaginal outlet the result of childbirth may be\\nclassified as follows\\n1. External superficial tear.\\n2. Internal tear, or combined internal and external tear.\\n3. Complete tear of the rectovaginal septum.\\nFig. 126.\\n1. External Superficial Tear.\\nThis form of injury from parturition is the most frequent\\nand also the least important, as it in no way affects the sup-\\nporting structures of the pelvic outlet.\\nThe tear involves simply the su])erficial\\nportion of the wedge of lax tissue between\\nthe vagina and rectum. It begins at the\\nintroitus vaginae and extends backward\\nthrough the skin in the median line; occa-\\nsionally it may extend inward as far as the\\nposterior column of the vagina (Fig. 126).\\nThis laceration can be inspected through-\\nout its whole extent by merely separating\\nthe labia.\\nWhen the tear simply extends through\\nthe fourchetfe strict cleanliness until it has\\nhealed is all that is required.\\nWhen the laceration has a base 2-3 cm.\\nto 1^ inches) in length it should be\\nsutured immediately.\\nWhen possible, it is the writer s habit\\nto suture these tears while waiting for the\\ndetachment of the placenta, as the patient\\nat that time is still more or less under\\nthe influence of chloroform. During the slight operation the\\nnurse is placed in charge of the fundus.\\nSuperficial tear ex-\\nposed by fingers parting\\nlabia minora.", "height": "3692", "width": "2500", "jp2-path": "obstetricsmanual00evan_0375.jp2"}, "364": {"fulltext": "364 OBSTETRIC OPERATIONS.\\nInstead of tying the sutures at once, the ends may be caught\\nin a pair of forceps and the tying completed after the delivery\\nof the placenta.\\nNecessary for the operation A couple of small curved nee-\\ndles, a needle-holder, three or four silkworm-gut or silk sutures,\\nand a pair of scissors should be sterilized. Many prefer to\\nemploy an Emmett perineum-needle in suturing these lacera-\\ntions; it consists of a needle with a large curve, mounted on a\\nhandle the needle is passed, threaded, and then withdrawn.\\nThe rule is to place the patient across the bed with the but-\\ntocks over the edge, the legs being flexed over the backs of\\ntwo chairs properly arranged. In many cases it is possible to\\nsuture these simple lacerations without disturbing the patient\\nbeyond separating and everting her thighs.\\nSuturing The patient being placed as most convenient, the\\nlips of the tear are held apart by the fingers of the left hand,\\nthe threaded needle is then introduced near the upper angle of\\nthe wound about J cm. inch) from its margin, brought out\\nat the floor, and reentered, to emerge on the skin surface op-\\nposite the point of entrance. A similar suture is then placed\\nnear the lower angle, and both sutures tied after the wound\\nhas been cleansed.\\nIf the approximation is not quite satisfactory, one or two\\nsuperficial sutures may be required. The end of the sutures\\nshould be left fairly long, so that they may be easily found\\nand prevented from causing the patient inconvenience by\\npricking. The sutures may be removed on the eighth day.\\n2. Internal Tear, or Combined Internal and External\\nTear.\\nConditions An internal tear when present is found to ex-\\ntend from the fourchette inward from one to two inches, in-\\nvolving one or both lateral sulci (Fig. 127). This tear always\\ndestroys the integrity of the pelvic supporting structures, and\\nif neglected leads to serious results.\\nSuch an internal laceration may be present witliout an ex-\\nternal wound; but usually the external injury (already de-\\nscribed) is to be found associated with the internal tear when\\nit is present. On inspection a ragged bleeding wound will be", "height": "3700", "width": "2684", "jp2-path": "obstetricsmanual00evan_0376.jp2"}, "365": {"fulltext": "REPAIR OF VAGINAL AND PERINEAL LACERATIONS. 365\\nfound in the posterior vaginal wall, associated probably with\\nmore or less external laceration.\\nMethod of Repair.\\nThe patient should be placed across the bed with the but-\\ntocks over the edge, as previously described.\\nSuperficial combined internal and external tear, showing portion of tear in vagina\\nthat may escape notice.\\nThe illumination of the field of operation should be the best\\nobtainable.\\nUnless the patient is prepared to suffer a little pain, an an-\\naesthetic, preferably ether, should be administered. Through-\\nout the operation an assistant should guard the fundus uteri to\\nprevent relaxation.\\nThe instruments required are the same as before mentioned,\\nwith the addition possibly of a couple of vaginal retractors.", "height": "3696", "width": "2480", "jp2-path": "obstetricsmanual00evan_0377.jp2"}, "366": {"fulltext": "366\\nOBSTETRIC OPERA TIONS.\\nFig. 129.\\nThe first step in tlie operation is to ascertain the nature and\\nextent of the Jaceration. To obtain a good view, it may be\\nnecessary to pack the upper part of the vaginal canal with\\nsterile gauze or cotton to prevent the flow of blood from above.\\nAll ragged and badly bruised tissue should be then cut away,\\nand the upper angle of the wound exposed by means of the\\nfingers of the left hand or by a retractor held by an assistant.\\nThe suturing should commence at the upper angle of the\\ntear, and the sutures should be about a centimetre apart as\\nmany should be employed as\\nare required to bring the edges\\nof the wound, or wounds, well\\ntogether.\\nThe method of inserting the\\nsutures is of very considerable\\nimportance, as the object is to\\nsecure the union of the sup-\\nporting structures of the pelvic\\nfloor (Fig. 128). The needle\\nshould be introduced on the\\nmucous surface 0.5 cm. (i\\ninch) from the margin of\\nSame as Fig. 127, with internal sutures\\npassed, ready to tie.\\nInternal stitches tied external stitches\\nin position.\\nthe wound and directed through the tissues in the direction\\nof the outlet, brought out at the base, then reintroduced, and\\ndirected inward and upward so as to emerjj^e on the mucous\\nsurface at a point opposite its insertion. Thus the loop of", "height": "3708", "width": "2692", "jp2-path": "obstetricsmanual00evan_0378.jp2"}, "367": {"fulltext": "REPAIR OF VAGINAL AND PERINEAL LACERATIONS. 367\\neach suture when in place is directed toward the operator (Fig.\\n129).\\nEach suture should be tied before the next is introduced.\\nThe last suture thus introduced should bring together the\\ntorn edges of remains of the hymen at the vaginal orifice.\\nThe external wound may then be repaired by a few super-\\nficial sutures introduced from the skin surface.\\nComplete tear, involving the rectovaginal septum.\\nDressing The temporary gauze tampon may then be removed,\\na vaginal douche given, and the wound dusted with an anti-\\nseptic poAvder before the vulvar pad is ap]^lied.\\nAfter-treatment: The wound should be kept well dusted\\nwith iodoform and boric acid powder (1:7), constipation\\nshould be avoided, and the patient forbidden to strain while", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0379.jp2"}, "368": {"fulltext": "368\\nOBSTETRIC OPERATIONS.\\nhaving a motion of the bowels. If there be much tension on\\nthe suture, catheterization may be necessary in order to relieve\\nthe bladder. The sutures may be removed on the eighth or\\ntenth day, but the patient should be kept in bed for at least\\nfourteen days.\\n3. Complete Tear.\\nConditions A complete tear of the perineum is one extend-\\ning from the fourchette backward through the sphincter ani,\\nand involving the rectovaginal septum to a greater or less\\nFig. 131.\\nComplete tear closing the rent in the bowel.\\nextent (Fig. 130). Such tears involve destruction of the\\nfunction of the sphincter ani muscle, and result in inconti-\\nnence of faeces and flatus. The condition of the patient thus\\nbecomes most distressino^.\\nOperation.\\nAnaesthesia in this instance is imperative for the proper per-\\nformance of the operation.", "height": "3712", "width": "2684", "jp2-path": "obstetricsmanual00evan_0380.jp2"}, "369": {"fulltext": "REPAIR OF VAGINAL AND PERINEAL LACERATIONS. 369\\nThe position of the patient should be as for the previously\\ndescribed operation. The nature and extent of the wound\\nshould be first ascertained and the field of operation thor-\\noughly cleansed.\\nThe rectum is first repaired by means of interrupted catgut\\nsutures introduced from the mucous surface. The ends of the\\nsphincter must be carefully approximated by means of buried\\ncatgut sutures.\\nThe vaginal rent should then be repaired as before recom-\\nmended and, finally, the shin surfaces of the perineal wound\\nmust be brought together.\\nFig. 132.\\nDeep interrupted lifting sutures in position.\\nIt is well to reinforce the catgut sutures uniting the torn\\nends of the sphincter, by means of a large suture of silkworm-\\ngut introduced on the skin surface so as to include in its loop\\na considerable portion of the muscle as well as of the septum\\nabove it (Figs. 131-134).\\nAfter-treatment: Constipation should be avoided, the\\n24\u00e2\u0080\u0094 Obst.", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0381.jp2"}, "370": {"fulltext": "370\\nOBSTETRIC OPERATIONS.\\nbowels being opened on the third day and every second day\\nafterward. An oil enema should be given just before a move-\\nment is expected, and the edges of the wound should be sup-\\nported by the nurse, the patient being warned not to strain\\nforce while evacuation is taking place. The wound\\nnor\\nFig. 133.\\nFig. 134.\\nAll sutures laid vaginal sutures tied.\\nInterual and external sutures tied.\\nshould be kept well cleansed and dusted with an antiseptic\\npowder. The sutures may be removed on the tenth to the\\ntwelfth day. The patient should remain in bed for three\\nweeks.\\nIMMEDIATE REPAIR OF CERVICAL LACERATIONS.\\nLacerations of the cervix are rarely repaired unless the cir-\\ncular artery is involved and severe hemorrhage results.\\nCervical lacerations, even when severe, frequently heal by\\nfirst intention without operation.\\nOperation The oj)eration can usually be performed without\\ndifficulty. The patient is placed as recommended in the pre-\\nI", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0382.jp2"}, "371": {"fulltext": "INBUCTIOX OF ABORTION. 371\\nvious operations, the cervix is seized with a tenaculum, drawn\\ndown, and held in position for suturing.\\nThe sutures should be placed about one inch apart, and the\\nfirst should be placed at the upper angle. Silkworm-gut\\nshould be employed, and the stitches may be removed on the\\ntwenty-first day.\\nINDUCTION OF ABORTION.\\nDefinition By the induction of abortion is meant the arti-\\nficial emptying of the uterus before the period of viability\\nof the child is reached that is, before the end of the twenty-\\neighth week of pregnancy. Some authors limit the term\\ninduction of abortion to the emptying of the uterus before\\nthe end of the sixteenth week, because the methods of opera-\\ntion differ before and after this period.\\nIndications The occurrence of pathological conditions con-\\nsequent upon pregnancy, and the aggravation of certain dis-\\neases by gestation, give rise occasionally to the necessity of\\nemptying the uterus by artificial means at the expense of the\\nchild s life in order to save the woman. Among the con-\\nditions which may render necessary the induction of abortion\\nthe following may be mentioned\\n1. Hyperemesis gravidarum.\\n2. Renal insufficiency, with threatened eclampsia.\\n3. Death of the foetus.\\n4. Insanity, resulting from or aggravated by pregnancy.\\n5. Incarceration of a retroflexed uterus.\\n6. Presence of benign or malignant tumors which w^ould\\npreclude the delivery of a viable child or render Csesarean\\nsection at term inadvisable.\\n7. Acute hydramnios and cystic degeneration of the\\nchorion.\\n8. Certain blood diseases, as leucocythsemia and pernicious\\nanaemia.\\n9. Rarely hemorrhage from placenta prsevia may render\\nnecessary the termination of pregnancy before the period of\\nthe viability of the child is reached.\\nThe attending physician should consult with a colleague\\nbefore deciding the question of interference, and a full ex-", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0383.jp2"}, "372": {"fulltext": "372 OBSTETRIC OPERATIONS.\\nplanation of the circumstances of the case should be made to\\nthe members of the family most directly concerned.\\nMethods of Inducing Abortion.\\nThe administration of drugs internally for the purpose of\\ninducing abortion is only mentioned to be condemned. Their\\naction is slow and uncertain, and their use is not infrequently\\nattended with danger.\\nUp to the end of the sixteenth week the quickest and most\\ncertain method of terminating the pregnancy is the following\\nDilating the Cervix and Curetting the Uterine Cavity.\\nAdvantages The operation can be done in from ten to\\ntwenty minutes it is certain in effect, and when properly car-\\nried out it is practically unattended with danger to the\\npatient.\\nThe instruments required for this operation are, a volsellum\\nforceps, a Simon perineal retractor, a set of Hegar s dilators,\\na pair of branched dilators, such as Goodell s, an Emmet\\ncurette-forceps, a sharp curette, and a pair of long uterine\\ndressing-forceps. Some strips of iodoform gauze (10 per\\ncent.) for packing the uterine cavity and vagina should also\\nbe prepared.\\nPreliminary to operation The patient, after being anaesthe-\\ntized, is placed in the lithotomy position on a table which is\\nin a good light, the limbs being held in position by means of\\na rolled sheet or by a crutch. The vagina and vulva are then\\nscrubbed with spirits of green soap and hot water, cotton-wool\\nswabs being employed. The parts are then disinfected by\\nmeans of a douche of 1 500 formalin solution. The hands\\nof the operator are then sterilized.\\nThe operation The perineal retractor is placed in the va-\\ngina, and the anterior lip of the cervix seized with a volsellum\\nand drawn well down. These instruments may then be held\\nby an assistant. The cervix is then dilated by means of\\nHegar s and Goodell s dilators till it easily admits the fore-\\nfinger. The Emmet curette-forceps is then inserted into the\\nuterine cavity and the ovum seized and crushed before the", "height": "3732", "width": "2676", "jp2-path": "obstetricsmanual00evan_0384.jp2"}, "373": {"fulltext": "INDUCTION OF PREMATURE LABOR. 373\\ninstrument is withdrawn with wliatever may have been\\ngrasped. The fcetiis and as much of the rest of the ovum as\\nis possible should be removed by these forceps after which\\nthe uterine walls should be carefully and systematically\\ncurefted, but without much force.\\nAfter operation The uterine cavity is then douched with\\nhot formalin solution, and afterward packed with iodoform\\ngauze. The volsellum and perineal retractor are then removed\\nand the operation is completed.\\nSome operators prefer not to empty the uterus at one sitting,\\nbut after removing the foetus to pack the cervix with gauze\\nand to tampon the vagina with antiseptic wool, Avhich are left\\nin place for twenty-four hours. On their removal, if the\\nremainder of the ovum is not discharged from the os, the cer-\\nvix being softened by the tampon, is further dilated and the\\nuterine cavity is thoroughly curetted and is then douched\\nand packed with gauze as above recommended. This gauze\\npacking should be removed in from twenty-four to thirty-six\\nhours.\\nThe patient should be kept in bed from one week to ten\\ndays after this operation.\\nAbortion, when induced after the sixteenth week is accom-\\nplished by means of the methods to be recommended for the\\ninduction of premature labor.\\nINDUCTION OF PREMATURE LABOR.\\nThe indications for the induction of premature labor are\\nmuch the same as those given for the induction of abortion.\\nIn addition, however, may be mentioned contracted pelves in\\nwhich it is desired to avoid the necessity of C?esarean opera-\\ntion or symphysiotomy. Placenta prsevia, while a rare indi-\\ncation for abortion, not infrequently necessitates the induction\\nof premature labor.\\nIt may be necessary to induce labor prematurely in ad-\\nvanced heart disease and in tuberculosis.", "height": "3696", "width": "2472", "jp2-path": "obstetricsmanual00evan_0385.jp2"}, "374": {"fulltext": "374 OBSTETRIC OPERATIONS.\\nMethods of Inducing Premature Labor.\\nKrause s method This is the simplest and the most satis-\\nfactory in the vast majority of cases. It consists in the intro-\\ndactlon of a bougie into the uterine cavity between the mem-\\nbranes and the wall of the uterus.\\nOne or two bougies (No. 10 or 12 English) are sterilized by\\nsoaking for an hour in a cold solution of formalin 1 500.\\nThe patient is prepared by having the vulva and vagina\\nwashed and douched as previously described. She is then\\nplaced in the dorsal position across the bed with her feet on\\ntwo chairs. The operator, after sterilizing his hands, intro-\\nduces two fingers of his left hand into the vagina as far as\\nthe external os. A bougie anointed with carbolized vaseline\\nis then guided along the fingers into the cervix and pushed\\nsteadily up until only an inch or so remains outside the ex-\\nternal OS, care being taken not to rupture the membranes.\\nSterile gauze is then packed about the butt of the bougie, to\\nkeep it in place and to prevent injury of the posterior vaginal\\nwall. If at the end of twenty-four hours labor-pains have\\nnot manifested themselves, the gauze and bougie should be\\nremoved, the vagina douched, and another bougie inserted.\\nTarnier s method This consists in the dilatation of the cervix\\nand the introduction of dilatable rubber bags. Tarnier s bag\\nis an oval affair, to which is attached a long rubber tube with\\na stopcock. The bag is introduced by means of a special for-\\nceps, and then dilated by pumping in sterilized water.\\nBarnes s bags may also be used for this purpose, though the\\nbest bag in shape and material is probablv Champetier de\\nRibes\\nMany other methods have been recommended for the induc-\\ntion of premature labor, but the methods described are practi-\\ncally the most commonly employed.\\nFORCEPS.\\nHistory It is probable that the obstetric forceps in crude\\nform were employed before the Christian era. The instru-\\nments seem to have fallen into disuse and were practically\\nunknown in the middle ages.", "height": "3712", "width": "2668", "jp2-path": "obstetricsmanual00evan_0386.jp2"}, "375": {"fulltext": "FORCEPS.\\n375\\nThe invention of the modern instrument is generally cred-\\nited to one Peter Chamberlan, the son of a French Huguenot\\nphysician, who had settled in England. The obstetric forceps\\nremained a family secret with the Chamberlans for three gen-\\nerations. It was not till 1725 that the secret of the Chamber-\\nIan family leaked out in England and the obstetric forceps\\nbecame public property.\\nThese forceps had only the cephalic curve, which permitted\\na firm grasp of the head. Later, Smellie in England and\\nLevret in France improved\\nthe forceps by adding a Fig. 135.\\nsecond curve, which adapted\\nthe instruments to the curva-\\nture of the pelvic cavity. The\\nmodern forceps are simply im-\\nproved models of those in-\\nvented by Smellie and Levret.\\nDescription The obstetric\\nforceps consists of two inter-\\nlocking branches or blades,\\neach of which is provided\\nwith a handle to facilitate\\ntraction.\\nThe blades are usually fen-\\nestrated, and have a double\\ncurve, a cephalic, adapting\\nthem to the shape of the\\nfoetal head, aud a pelvic, ac-\\ncommodating them to the\\nshape of the pelvic canal.\\nThe articulation of the\\nblades is in the form of an\\nopen lock in the English\\nmodels, while the Conti-\\nnental models generally have\\nthe French lock, which con-\\nsists of a mortise and tenon\\ntightened by means of a\\nscrew. The English lock, having the advantage of easy\\nSimpson s long forceps.", "height": "3712", "width": "2492", "jp2-path": "obstetricsmanual00evan_0387.jp2"}, "376": {"fulltext": "376\\nOBSTETRIC OPERATIONS.\\nadjustment, is to bo preferred to the more complicated and\\nrigid French lock.\\nThe JunuJles of the forcej)s are usually serrated or grooved\\ntransversely, to give a better hold. In the better models the\\nhandles are })rovided with projecting shoulders to facilitate\\ntraction. A good ohstetric forceps should be made of well-\\ntempered steel, polished and heavily nickel-plated throughout.\\nThe edges of the blades and the fenestra should be rounded\\nand smooth. In England and America the favorite forceps\\nis the Simpson-Barnes. It has the Barnes blades and the\\nSimpson handles (Fig. 135).\\nThe loriter has found that for general use the most satis-\\nfactory obstetric forceps is Dr. Cameron s model of the Simp-\\nson-Barnes instrument. Dr. Cameron has modified the pelvic\\nFio. 136.\\nCameron s model of Simpson-Barnes forceps.\\ncurve of the blades in such a manner as to permit a much\\nmore secure grasp of the foetal head being obtained than is\\nthe case in other models (Fig. 136).\\nFor low operations a simple, light instrument, such as\\nSawyer s, is very useful.\\nIn high operations the line of traction must correspond as\\nJ. IT. Chapman, Montreal.", "height": "3732", "width": "2708", "jp2-path": "obstetricsmanual00evan_0388.jp2"}, "377": {"fulltext": "FORCEPS. 377\\nmuch as possible to the axis of the pelvic inlet. In such\\noperations a great amount of traction force is lost because it is\\nimpossible to get the handles of the ordinary forceps back far\\nenough on account of resistance offered by the perineum\\nThis difficulty has been overcome by the invention of the\\naxis-tradion forceps by Taruier, in 1877 (Fig. 137). By\\nFig. 137.\\nTarnier s axis traction forceps.\\nmeans of traction rods attached to the base of each blade,\\nfitting at their lower ends into a specially curved perineal\\nbar, to which is attached a cross-bar as a handle, the line of\\nthe traction force is brought into relationship wnth the axis\\nof the brim. The Tarnier forceps is so constructed that\\nwhen the lower ends of the traction rods are held 1 cm. from\\nthe shanks the line of the pull will be in the axis of the birth-\\ncanal no matter what the position of the blades may be in the\\npelvis.\\n^lany other models of axis-traction forceps have been in-\\nvented, but none has proved so generally satisfactory as the\\nTarnier.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0389.jp2"}, "378": {"fulltext": "378 OBSTETRIC OPERATIONS.\\nIndications for the Use of Forceps.\\nIn general terms it may be stated that the faihire of a\\nwoman to deliver herself, when delay in delivery will en-\\ndanger the life of the mother or the child, or both, is an indi-\\ncation for the employment of forceps to terminate labor.\\nAnomalies of the mechanism of labor resnlting in failure\\nof the presenting part to advance have been fully discussed\\nin detail.\\nOther indications Insufficient expulsive power, as uterine\\ninertia from whatever cause increased resistance in the pel-\\nvic canal from moderate pelvic contraction or from unusual\\nrigidity of the soft structures over-size or undue ossification\\nof the foetal head abnormal presentations or positions of the\\nfoetal head, as face presentation and occipitoposterior positions;\\naccidental conditions, such as eclampsia, placenta prsevia, pro-\\nlapse of the funis or of a foetal member.\\nExhaustion of the mother is evidenced by a steady increase\\nin the rapidity of the pulse-rate, rising temperature, and a\\nprogressive failure in the force of the uterine contractions.\\nDanger to the child is indicated by the foetal heart beats\\nbecoming rapid and weak or slow and feeble.\\nIf in the course of the second stage of labor the head fails\\nto advance, and, either because of feeble contractions or from\\nincreased resistance, is arrested for half an hour, the labor\\nshould be terminated by forceps.\\nWhen forceps are indicated the following conditions must\\nbe present to render the application of the blades permissible\\n1. The OS must be completely dilated or easily dilatable;\\n2. The membranes must be ruptured\\n3. The child must be living and viable;\\n4. The head must be engaged in the brim or it must\\nbe possible to crowd the head down to the pelvic inlet by\\nexternal pressure;\\n5. The head must be of average size and consistence, or\\nelse the blades will not retain their hold\\n6. The relative proportion between the head and the pelvis\\nmust be such as to make extraction possible with safety to\\nmother and to child\\n7. The position of the head must be favorable for instance,", "height": "3712", "width": "2652", "jp2-path": "obstetricsmanual00evan_0390.jp2"}, "379": {"fulltext": "FORCEPS. 379\\nit is practically impossible to deliver a mentoposterior position\\nof the face.\\nPreparation for the Forceps Operation.\\nInstruments, etc. The obstetric forceps, as well as such in-\\nstruments and sutures as may be required for the repair of\\nlacerations subsequent to deliyery, should be wrapped in a\\nclean toM el and boiled for ten minutes, after which they may\\nbe placed in a basin containing cold sterile water, to cool off.\\nPreparation of the patient The bladder and rectum should\\nbe emptied after which the abdomen, thighs, and external\\ngenitals should be rendered as aseptic as possible. If there\\nbe reason to suspect contamination of the vagina, the internal\\npassages should be thoroughly scrubbed and douched as for a\\nsurgical operation. The lubricity of the parts may then be\\nrestored by the application of sterilized glycerin or vaseline.\\nAA^hen the operation has to be done with the patient in bed,\\na Kelly pad or rubber sheet should be arranged under the\\npatient s hips so as to conduct all discharges into a baby s\\nbath-tub or other vessel on the floor. The j^cifienfs limbs\\nshould then be wrapped about with freshly laundried or ster-\\nilized sheets.\\nThe operator s hands and forearms should be sterilized, and\\nhe should wear either a sterilized apron or a sheet, to protect\\nhis clothing.\\nPreliminary to operation The operator should then sit\\ndown facing the genitals of his patient. Close to his hand\\nshould be placed his instruments and a basin containing a\\nweak formalin solution (1 1000), as well as some pieces of\\nsterilized gauze or a plentiful supply of clean towels.\\nBefore proceeding to apply the forceps the quality and\\nfrequency of the foetal heart-beats should be ascertained and\\nan exact knowledge of the position and charade} of the fcetal\\nhead obtained. For this latter it may be necessary to pass\\nthe entire hand into the uterus hence the patient should be\\nanaesthetized before making this examination. Any mal-\\nposition of the head should then be altered if possible before\\nthe application of the blades is attempted.\\nAnaesthesia It is rarely possible to employ the obstetric", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0391.jp2"}, "380": {"fulltext": "380 OBSTETRIC OPERATIONS.\\nforceps satisfactorily unless the patient is under the influence\\nof an anaesthetic. For prolonged or difficult cases ether\\nshould be used in preference to chloroform, and its adminis-\\ntration entrusted to a medical assistant.\\nPosture of the Patient.\\nThe application of the obstetric forceps is possible with the\\npatient either in the dorsal or in the left lateral position.\\nMany consider that the application of the forceps is more\\ndifficult in the left lateral than in the dorsal position but\\nthis difficulty is more apparent than real.\\nGenerally speaking, the lateral position offers many advan-\\ntages, especially if the operator lacks a skilled assistant. In\\nthis position the patient s limbs do not require to be sup-\\nported. The application of both blades is accomplished with\\nthe right hand, while the fingers of the left hand placed\\nwithin the vagina serve to guide both the blades into position.\\nDuring traction the perineum is under constant observation,\\nand extraction is easier and safer.\\nWalcher s position On account of the increased mobility\\nof the sacro-iliac joints in the latter months of pregnancy a\\ncertain limited amount of rotation of the sacrum is possible\\non a transverse axis passing through its second vertebra.\\nAfter experiments with the live subject and with the\\ncadaver, Walcher demonstrated that by placing the woman at\\nfull term on a table in the dorsal position with the buttocks\\nclose to its edge, and the lower limbs hanging unsupported,\\nthe conjugate diameter is lengthened by from one half to\\none centimetre. This posture of the patient is known as\\nWalcher s position. The posture may be utilized to advan-\\ntage in high forceps operations or in difficult versions.\\nThe Forceps Operation.\\nThere are two methods of application of the forceps. That\\nknown as the EnglM method is to apply the blades so as to\\ncorrespond to the sides of the pelvis, quite regardless of the\\nposition of the head.\\nThe Continental method is to apply the blades to the sides\\nof the child s head regardless of the pelvis.", "height": "3712", "width": "2672", "jp2-path": "obstetricsmanual00evan_0392.jp2"}, "381": {"fulltext": "FORCEPS. 381\\nTlie pelvic application of the blades i. e., the English\\nmethod is on the whole safer and better, as less damage is\\npossible to the maternal soft parts.\\nThe cephalic application of the blades i. c, the Continental\\nmethod shonld only be employed by experienced and expert\\noperators, as it is the more complicated and difficult.\\nThe operation is divided into the high, the medium, and the\\nlow, according to the position of the head in the pelvis.\\nIn the high operation the head is arrested at or just engaged\\nin the pelvic brim. In the medium operation the head is\\narrested well within the pelvic cavity. In the loic operation\\nthe head rests upon the pelvic floor.\\nIn high operations the axis-traction forceps should be em-\\nployed, and the patient should be placed in AValcher s position\\nuntil the head has been drawn down into the pelvic cavity.\\nAs a rule, it is more convenient for the operator and better\\nfor the patient if she be placed on a table for the high forceps\\noperation.\\nIn medium and low operations the patient may be placed\\neither in the left lateral or in the dorsal position, whichever\\nis more convenient for the operator.\\nForceps Operation in the Dorsal Position.\\nThe patient having been prepared for the operation, is\\nplaced in the dorsal position, across the bed with the buttocks\\nprojecting slightly over the edge.\\nSupport of the limbs ^yhen assistants are not obtainable to\\nhold the limbs, they may be supported as in the lithotomy\\nposition by means of a rolled sheet passed under the neck\\nand over one shoulder, having the ends fastened at the\\npatient s knees.\\nA better method is to place two ordinary wooden chairs a\\nshort distance apart with their backs to the edge of the bed.\\nThe patient s knees are then flexed over the backs of the\\nchairs, fokled towels being so placed as to protect the pop-\\nliteal regions from injury. The operator sits facing the\\npatient.\\nIntroduction of the blades: Having made an internal ex-\\namination and having satisfied himself as to the exact position", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0393.jp2"}, "382": {"fulltext": "382 OBSTETRIC OPERATIONS.\\nof the foetal head, the operator selects the left, or lower, blade\\nof the forceps, which he grasps close to the shaft with the\\nfingers of the left hand, holding the instrument as he would a\\npen. Two or more fingers of the r ujM hand are inserted\\nwithin the vagina, and if possible, within the cervix, their\\npalmar surfaces being in contact with the child s head. The\\nfingers are carried as high as it is possible to introduce them,\\nand the maternal soft parts held outward away from the head.\\nThe left blade is then held perpendicularly to the woman s\\nbody, and the tip is guided along the fingers of the right\\nhand within the vulva. No force is required to introduce\\nthe blade^ which is guided along the fingers of the internal\\nhand, by slowly sweeping the handle downward along the\\ninternal surface of the mother s left thigh. This blade when\\nin position rests between the head and the left lateral wall of\\nthe pelvis.\\nThe upper blade is then held in the right ha,nd in similar\\nfashion, and is guided along the fingers of the left hand\\nwithin the vagina, the handle being depressed along the\\nmother s right thigh.\\nThe forceps are then locked by depressing the handles\\ntoward the perineum and gently rotating the blades into posi-\\ntion. Care should be taken not to include hair or a portion\\nof the vulva in the bite of the lock. In guiding the blades\\ninto position it is important to have the fingers of the internal\\nhand introduced as far as possible and to press the maternal\\ntissues well to one side.\\nAfter locking the forceps a careful internal examination\\nshould be made to ascertain if a good grasp of the head has\\nbeen obtained, and that nothing but the head has been in-\\ncluded in the bite of the forceps. The handles are then\\nfjrasped near the lock with one hand, the fingers being hooked\\nover the projecting shoulders while the back of the hand is\\ndirected upward.\\nExtraction is effected by steady pulling, or, better, by exert-\\ning a slight pendulum movement at the same time.\\nThe line of traction should corres]wnd to the axis of the\\nplane of the pelvis in which the head is engaged thus in high\\noperations the line of traction is directly backward to cor-\\nrespond to the axis of thfe brim in medium operations the", "height": "3728", "width": "2716", "jp2-path": "obstetricsmanual00evan_0394.jp2"}, "383": {"fulltext": "FORCEPS. 383\\nline of traction is directly horizontal while in loiv operations\\nit is upward, so that the handles are directed toward the\\nmother^s abdomen.\\nThe tractions should be intermittent, like the natural pains.\\nA good rule is to pull for one minute and then to rest for\\ntwo. During the intervals it is better to unlock the forceps,\\nso as to relieve the head from pressure and also to favor its\\nrotation as it descends.\\nTraction, when once the perineum begins to distend, must be\\nmade very carefully in order to avoid the sudden descent of\\nthe head.\\nThe line of traction should be pretty much liorizontal until\\nthe occiput pivots under the pubic arch. After this has\\noccurred no further traction is necessary, but the head is slowly\\nand carefully extended by pushing the handles upward in the\\ndirection of the mother s abdomen.\\nWhen the head can be retained In the perineum by pressure\\napplied from behind in the coccygeal region, the forceps may\\nbe gently removed and the head delivered without them. The\\nhead Is held In position by grasping it through the perineum\\nwith the left hand. On no account should the fingers be\\ninserted into the anus for this purpose, as it is unnecessary\\nand dangerous to do so.\\nWhen the head can be held in position the blades may be\\nremoved in the reverse order of their application. The utmost\\ngentleness sliould be employed in their removal, and no force\\nshould be exerted if any obstacle be encountered. When\\ngentle manipulation fails to release a blade, it should be left in\\nplace until the head is delivered.\\nAfter the forceps have been removed the head can be\\ndelivered by pressure over the perineum.\\nAs a general rule, forceps operations are performed with\\nexcessive speed, hence the frequency of lacerations of the\\nmaternal soft parts following their employment.\\nAxis Traction.\\nIn high operations axis-traction forceps should be used,\\nthough a certain degree of axis traction may be obtained with\\nthe ordinary forceps as will be described later.", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0395.jp2"}, "384": {"fulltext": "384\\nOBSTETRIC OPERATIONS.\\nThe patient having been placed on a table in the dorsal\\nposition, with the buttocks at the edge and the limbs held by\\nassistants, or supported by chairs, the blades are inserted in\\nthe ordinary manner with the traction-bars fastened (Fig.\\n138). After insertion the blades are locked, and, if Tarnier s\\nFig. 138.\\nGuiding-hand and forceps blade high application. (Faraboeuf and Varnier.)\\ninstrument is used, the lock-pin is screwed moderately tight.\\nThe bar connecting the handles is then thrown across, locked,\\nand the screw tightened until the blades have secured a firm\\nbut not too tight grasp of the foetal head. The lower ends of\\nthe traction-bars under the shanks are then loosened and\\nthe perineal handle adjusted to them and locked.", "height": "3712", "width": "2684", "jp2-path": "obstetricsmanual00evan_0396.jp2"}, "385": {"fulltext": "FORCEPS.\\n385\\nAfter ascertaining that a proper grip of the head has been\\nobtained and that the various screws are properly adjusted\\nwithout the inclusion of portions of vulvar tissue the patient\\ncan be placed in the Walcher position by removing the sup-\\nports from her limbs. By placing large blocks or books\\nunder the table-legs nearer the operator the table can be\\nFig. 139.\\nTraction with axis-traction forceps.\\ninclined in such a manner that the buttocks will not be pulled\\ntoo far over the edge when traction is exerted. The line of\\ntraction should be downward and backward as far as possible,\\nthe traction-rods being kept about a quarter of an inch from\\nthe shanks throughout the pull (Fig. 139).\\nBetween the tractions, the connecting-bar between the\\n25\u00e2\u0080\u0094 Obst.", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0397.jp2"}, "386": {"fulltext": "386 OBSTETRIC OPERATIONS.\\nhandles should be unscrewed and the pin-lock loosened in\\norder to relieve the foetal head from continued pressure.\\nWhen the head has been drawn down to the pelvic floor\\nthere is no further need either for the Walcher position or\\nfor the axis-traction rods. The patient may then be placed in\\nthe ordinary position, the perineal handle may be removed,\\nand the traction-rods fastened in their places beneath the\\nblades, the forceps then being used as the ordinary instru-\\nment. Some operators prefer to remove the Tarnier instru-\\nment as soon as the head reaches the pelvic floor, completing\\nthe delivery by means of Sawyer s small forceps.\\nIn high operations a certain amount of axis traction can be\\nexerted with the ordinary long forceps. By Paget s or\\nGalabin s manoeuvre the line of traction can be brought to\\ncorrespond fairly well with the axis of the pelvic inlet.\\nThus by pressing or pulling downward with one hand\\nplaced as near the shanks as possible, and by pressing or\\npulling upward with the other hand on the handles, two\\nforces are brought into action, with the effect that the\\nresultant acts in the line of descent of the head. The forceps\\nby this manoeuvre is used as a lever, the hand grasping the\\nshanks being the fulcrum.\\nIn employing this manoeuvre the greatest care must be\\nexercised to prevent the blades slipping.\\nForceps Operation in the Left Lateral Position.\\nThe patient is placed somewhat obliquely across the bed,\\nlying on her left side with her thighs well flexed, the hips\\nbeing brought well over the right edge of the bed. A folded\\npillow may be placed between her knees to keep the thighs\\nseparated. The operator sits facing the patient s buttocks.\\nThe preparations for the operation are otherwise the same\\nas mentioned in dealing with the application of forceps in the\\ndorsal position.\\nInsertion of the blades Two fingers of the operator s left\\nhand are inserted along the posterior wall of the vagina,\\nthrough the cervix when possible and well over the present-\\ning part, pivoting the finger-tips upon the head globe, while\\nthe cervix, the posterior vaginal wall, and the perineum are\\npressed back as far as possible out of the way.", "height": "3728", "width": "2684", "jp2-path": "obstetricsmanual00evan_0398.jp2"}, "387": {"fulltext": "FORCEPS.\\n387\\nThe lower blade being held in the right hand with the\\npelvic curve directed backward, so that the tip of the instru-\\nment is in contact with the left hand, is thus introduced\\nwithin the vagina. To facilitate the introduction of the tip of\\nthe blade in this position, the handle must be held low down,\\ncorresponding to the direction of the gluteal fold of the\\npatient s left buttock (Fig. 140). As soon as the tip of the\\nblade has been guided by the fingers of the left hand over the\\nFig. 140.\\nPosition of patient for forceps delivery and mode of introducing lower blade.\\n(Playfair.)\\nconvexity of the head the handle is raised, being swept up-\\nward over the mother s right thigh, and finally backward and\\ndownward, until the shank falls behind the operator s left\\nwrist. The handle thus sweeps through nearly three-quarters\\nof a circle as the blade is being introduced and pushed up.\\nThis movement of the liandle causes the tip of the blade to\\nsweep around and under the head.\\nThQ fingers of the left hand remain in contact with the head\\nthroughout the insertion of both blades, the first blade being", "height": "3700", "width": "2480", "jp2-path": "obstetricsmanual00evan_0399.jp2"}, "388": {"fulltext": "388\\nOBSTETRIC OPERATIONS,\\nheld in position after its introduction by resting against the\\nback of the left wrist while the second is being manipulated\\ninto position.\\nThe upper blade is then grasped in the right hand and its\\ntip introduced into the vulva above the shank of the first\\nblade with the pelvic curve directed forward. The tip is\\nguided into position over the convexity of the head by the\\nfingers of the left hand (Fig. 141). The handle is then swept\\nFig. 141.\\nIntroduction of the upper blade. (Playfair.)\\ndownward and backward along the mother\\\\s left thigh^ thus\\ncausing the blade to move around the upper surface of the\\nhead to take its position opposite the right ilium.\\nThe second blade, having been placed in position, is used\\nas a guide in locking the handles. It is held steady while\\nthe first blade, which may become displaced during the intro-\\nduction of the second, is manoeuvred into position so as to\\nlock (Fig. 142).\\nExtraction After examination to see that all is secure, the\\noperator, grasping the handles over the projecting shoulders\\nJ", "height": "3712", "width": "2704", "jp2-path": "obstetricsmanual00evan_0400.jp2"}, "389": {"fulltext": "FORCEPS.\\n389\\nwith his right hand, exerts traction as far backward as pos-\\nsible, at the same time steadying the patient s hips with his\\nleft hand. During extraction in the lateral position the\\nhandles describe a horizontal arc from left to right.\\nFig. 142.\\nForceps in position. Traction in the axis of the brim, downward and backward.\\n(Playfair.)\\nWhen the head can be retained in the distended perineum\\nthe forceps may be gently removed and the delivery com-\\npleted without them.\\nForceps in Persistent Occipitoposterior Cases.\\nOrdinarily, when it is necessary to terminate labor by means\\nof the forceps in posterior positions of the occiput, if tlie head\\nis well flexed before the instruments are applied, and if the\\nblades are disengaged completely by unlocking them after\\neach tractive effort, the occiput will be brought in contact\\nwith the pelvic floor first, and will thus rotate to the front\\nwithout special difficulty.", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0401.jp2"}, "390": {"fulltext": "390 OBSTETRIC OPERATIONS.\\nAVhen rotation forward of the occiput fails to take place\\nplenty of time should be given for proper moulding of the\\nhead to occur.\\nThe normal mechanism of delivery in face to pubes cases\\nmust be borne in mind, and the forceps so used as to aid\\nnature. The line of traction should be in the axis of the pel-\\nvic cavity that is, horizontally until the forehead emerges\\nsufficiently for the glabella to pivot under the pubic arch\\nthe handles are then raised so as to bring the occiput over the\\nperineum, after which the face generally delivers itself by\\nextension of the head.\\nOnce the glabella has pivoted many operators prefer to\\nremove the blades and deliver the head manually.\\nForceps in Face Presentations.\\nIn posterior positions of the chin in face presentations the\\nforceps are contraindicated.\\nIn mento-anterior positions, when nature s efforts are insuf-\\nficient to complete delivery, the forceps may be employed.\\nThe blades should be applied to the sides of the child s head\\nin such a way as to secure a firm grasp of the occiput. Trac-\\ntion should be made horizontally until the chin is brought\\nunder the pubic arch then by raising the handles and with-\\nout pulling, the head is flexed, thus sweeping the face, vertex,\\nand occiput successively over the perineum. This movement\\nof flexion should be made with great deliberation, and when\\nlaceration of the perineum takes place and threatens to extend\\ninto the rectum a lateral incision should be made in order to\\navoid this troublesome complication.\\nForceps in Breech Cases.\\nIndications When in breech cases it is impossible to reach\\na foot or to employ a fillet or the finger to draw down the\\npresenting part, the forceps may be used. When possible,\\nthe axis-traction forceps should be employed for this purpose.\\nThe grasp of the breech may be obtained by placing the\\ntip of the blades over each trochanter and below the iliac\\ncrests. When this hold cannot be obtained, the blades may", "height": "3728", "width": "2696", "jp2-path": "obstetricsmanual00evan_0402.jp2"}, "391": {"fulltext": "VERSIONS. 391\\nbe introduced so that one is in contact with the sacrum\\nand one ilium of the child, while the other is in contact\\nwith the posterior surface of the opposite thigh, as recom-\\nmended by Ollivier.\\nThe after-coming head has occasionally to be delivered by\\nforceps after the failure of other methods. The application\\nof the blades is not difficult, provided the child s body is\\nheld up over the abdomen of the mother by an assistant.\\nThe Dangers of Forceps Operations.\\nThe forceps judiciously and skilfully used should seldom\\nresult in the production of serious injury to either mother or\\nchild.\\nWhen forceps operations are undertaken by unskilled\\noperators and in unsuitable cases the most disastrous conse-\\nquences may follow the uterus has been perforated by the\\ntips of the blades the cervix and lower uterine segment\\nhave been torn away the pelvic joints have been sprung\\napart while most extensive vaginal lacerations are not in-\\nfrequent, as the result of improperly performed forceps\\noperations. The most common injuries are lacerations, more\\nor less extensive, of the perineum and vagina, and certain in-\\njuries of the child s head the result of compression of the\\nblades. Contusions and abrasions of the face or scalp are not in-\\nfrequent, and occasionally facial paralysis may follow pressure\\nupon facial nerve-trunks. Intracranial hemorrhages are not\\ninfrequent after forceps operations. Such hemorrhage may\\nresult in rapid death of the newborn child, or, if survived,\\nmay give rise to idiocy, hemiplegia, epilepsy, etc. Occasion-\\nally the cord may be around the child s neck, and be so ex-\\nposed to pressure from the tip of the blades that fatal\\nasphyxia may ensue.\\nVERSIONS.\\nDefinition The general term version is applied to such ob-\\nstetric operations as are designed to bring about any altera-\\ntion in the relation of the long axis of the child s head to the\\nlong axis of the uterus.\\nVarieties There are three varieties of versions", "height": "3712", "width": "2492", "jp2-path": "obstetricsmanual00evan_0403.jp2"}, "392": {"fulltext": "392 OBSTETRIC OPERATIONS.\\nCcphallCj resulting in presentation of the head\\nPelvic, of the breech and\\nPodalicj of one or both feet.\\nMethods There are three methods of performing version\\nExternal version, which is accomplished by manipulation\\nthrough the abdomen\\nBipolar version, accomplished by external and internal\\nmanipulations combined\\nInternal version, accomplished by the introduction of the\\nhand within the uterus.\\nExternal Version.\\nBy means of external version either the head or the breech\\ncan be made to present at the pelvic brim. It is probably\\nthe simplest and safest method of turning, as there is prac-\\ntically no danger connected with it.\\nThe more practised the operator is in abdominal palpation\\nof the pregnant uterus the more skilful will he prove in the\\nperformance of external version.\\nIndications The most common indication for external\\nversion is breech presentation, when diagnosed during the\\nlatter weeks of pregnancy. While the indications for this\\nform of version are in general the same as those that apply\\nto the other forms, the fact that it can be employed only be-\\nfore or very early in labor limits its availability.\\nConditions for external version The membranes should be\\nintact or but recently ruptured. The uterine and abdominal\\nwalls should be lax and the child freely movable. These\\nconditions are only present before the onset of labor or very\\nearly in its course, hence to these periods the operation is\\nlimited.\\nPreparations The bladder and rectum should be emptied.\\nThe patient should be in the dorsal decubitus, with her tliighs\\nslightly flexed and the head and shoulders supported by pil-\\nlows. The abdomen should be exposed or covered only by a\\nsheet, under which the liands of the operator are placed. An\\nanaesthetic is not required unless the patient is extremely\\nnervous.", "height": "3712", "width": "2696", "jp2-path": "obstetricsmanual00evan_0404.jp2"}, "393": {"fulltext": "VERSIONS. 393\\nMethod of Operation.\\nThe first duty of the operator is carefully to map out the\\nposition occu})ied by the child. This is done by palpation,\\nsupplemented by auscultation of the foetal heart.\\nHe should then plot out the manoeuvre he wishes to accom-\\nplish from beginning to end, before attempting to displace in\\nany way the foetus.\\nIn performing external version the most important point is\\nto keep the foetal ovoid intact throughout the operation.\\nThe manoeuvres The operator places a hand on each end\\nof the foetal ovoid, with the palms facing and the fingers of\\none hand directed toward the wrist of the other. By the\\nalternate flexion of the fingers of either hand the version is\\naccomplished. One hand gives a movement of ascent and\\nthe other a movement of descent, each acting alternately.\\nThe extremity of the foetal ovoid it is desired to bring\\ndown is made to follow the shortest route which will bring it\\ninto proper relationship with the pelvic brim. Should uterine\\ncontraction occur during the manipulations, the operator must\\nbe content to hold the foetus in the position gained until re-\\nlaxation occurs, when the operation may be proceeded with.\\nWhen the foetus has been placed in the desired position a\\nvaginal examination should be made to ascertain whether the\\npresenting part is properly over the inlet.\\nTo retain the foetus in position until the presenting part has\\nengaged, longitudinal pads composed of folded towels, may be\\nplaced on either side of the foetus and a firm abdominal\\nbinder applied.\\nOccasionally, when external version has been carried out\\nafter the onset of labor, it is advisable to rupture the mem-\\nbranes, so as to favor the retention of the foetus in its new\\nposition.\\nBipolar Version.\\nThe chief advantage of the bipolar method is that complete\\ndilatation of the cervix is unnecessary, as by this method ver-\\nsion can be accomplished as soon as tic o fingers can be inserted\\nthrough the os uteri.\\nBipolar version has the disadvantage that it fails to give", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0405.jp2"}, "394": {"fulltext": "394 OBSTETRIC OPERATIONS.\\nthe operator such control of tlie foetus as is obtainable by the\\ninternal method.\\nThis form of version is also known as the Braxton-Hicks\\nmethod.\\nIndications Placenta prcevia with but partial dilatation of\\nthe OS is given by most text-books as the chief indication for\\nselection of this method of performing version.\\nIn the experience of the writer, the very fact that the pla-\\ncenta is situated in the lower uterine segment contraincUcates\\nthe employment of this method, as, with only two fingers\\nthrough the os, the presenting part cannot be satisfactorily\\nreached for the pelvic inlet is occupied more or less by the\\nbulky placenta. For this reason in placenta prsevia, when\\nversion is desirable, the internal method should be selected\\nand the os dilated until the whole hand can be introduced into\\nthe uterus.\\nOther indications for this method are abnormal presenta-\\ntions or positions of the head, such as face or brow presenta-\\ntions and prolapse of the cord, when diagnosed early in labor.\\nIt is also very useful in transverse cases, whether it is desired\\nto bring down the breech or the head.\\nConditions for bipolar version The membranes should be\\nintact or so recently ruptured that the child is still freely\\nmovable. The cervix should admit two fingers, and the\\nvagina be capable of containing the operator s hand if neces-\\nsary. The uterine and abdominal walls should be lax.\\nPreparation The patient should be prepared as for a for-\\nceps operation. She should be placed in the dorsal position,\\nacross the bed, with her hips at the edge, the legs being sup-\\nported by chairs. The operator sits between tlie patient s\\nthighs, after having well sterilized his hands and forearms.\\nThe external hand can be kept from contamination by wrap-\\nping it in a sterilized towel.\\nAnaesthesia is desirable, but not necessary, provided the\\nvagina and vulva are lax and the patient not nervous.\\nMethod of operation Before proceeding to operate, the\\ndiagnosis of the position of the foetus should be confirmed by\\ncareful external and internal examination. The details of\\neach movement of the operation should then be planned so", "height": "3708", "width": "2684", "jp2-path": "obstetricsmanual00evan_0406.jp2"}, "395": {"fulltext": "VERSIONS. 395\\nthat the operator has clearly in mind exactly what he wishes\\nto accomplish by his manoeuvres.\\nIn head presentations, in which it is desired to bring down\\nthe breech, the head should be moved in the direction in\\nwhich the occiput points.\\nThe fingers of the hand, the palm of which points in the\\ndirection in which it is desired to move the presenting part,\\nare then introduced through the cervix. Thus, if presentation\\nis L. O. A. and it is desired to bring down the breech, two\\nfingers of the left hand are introduced within the cervix, while\\nthe right hand presses down the breech, through the abdominal\\nwall. The version is accomplished by a series of alternate\\npushes Avith either hand. Care should be taken not to rupture\\nthe membranes, should they be intact, until a foot or leg is\\nwithin reach of the internal fingers at the pelvic brim.\\nIq correcting an abnormal presentation of the head by\\ncombined manipulation the fingers of the internal hand push\\nthe lowest part of the foetal head upward and backward while\\nthe external hand, having located the occiput through the ab-\\ndominal wall, endeavors to force the vertex downward and\\nforward within the pelvic brira.\\nIn such cases, if the membranes liave not ruptured, they\\nshould be broken as soon as the position of the head is altered.\\nPressure should tlien be maintained upon the fundus until the\\nvertex has become firmly engaged in the brim.\\nInternal Version.\\nThis method of version is most commonly employed, as it\\nis probably the most rapid and effectual way of securing\\ndelivery when the head is not engaged in the pelvic brim. It\\nis the most dangerous method of version, as the hand must be\\nplaced into the uterine cavity in order to seize one or both\\nfeet.\\nLidicatioiis Eclampsia, placenta prsevia, threatened sud-\\nden maternal death, prolapse of the cord, and accidental\\nhemorrhage may be mentioned as indications for this method\\nof version, especially when rapid delivery is desired.\\nOther indications are transverse presentations, moderate\\npelvic contraction, prolapse of foetal members, and rupture\\nof the uterus.", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0407.jp2"}, "396": {"fulltext": "396 OBSTETRIC OPERATIONS.\\nConditions for internal version The cervix must be dilated,\\nor dilatable the pelvis must be sufficiently ample to permit\\nthe passage of the after-coming head, and the uterus must not\\nbe tetanically contracted about the child. The condition of\\nthe lower uterine segment should be ascertained before version\\nis attempted, and the position of the retraction-ring noted, if\\nit be present. The foetus must not be impacted in the pelvis,\\nbut should be sufficiently movable to permit the presenting\\npart to be pushed back. The child should be viable.\\nPreparations When possible the patient should be placed\\non a table for operation. Preparations should be made as for\\na forceps operation. The vagina should be scrubbed and\\nrendered antiseptic, being afterward smeared with sterilized\\nglycerin or oil. The most useful antiseptic for such cases is\\nlysol or creolin, as these substances have lubricating qualities\\nand render the employment of glycerin or oil unnecessary.\\nIt is Avell to have at hand some sterilized bandage-material\\nor broad tape, in case it may be necessary to pass a noose\\nabout the foetal limbs, to facilitate extraction. The patient\\nshould be ancesthetized and for this purpose chloroform is\\nusually recommended as bringing about better uterine relaxa-\\ntion than ether. It is desirable that the anaesthetic should be\\nadministered by a medical assistant.\\nThe patient should be placed in the lithotomy position with\\nher hips at the edge of the bed or table. The operator, with\\nhis hands and arms sterilized and his clothing protected by an\\napron, sits or stands facing the patient.\\nMethod of operating The first step in the operation is to\\nconfirm the diagnosis of the foetal position by a combined\\ninternal and external examination. The various steps of the\\noperation of turning the foetus are then planned, and a deci-\\nsion made as to which hand shall be introduced into the uterus\\nand which foot of the infant seized.\\nWhen the long axis of the foetus is in the long axis of the\\nuterus, the operator should introduce the hand ichich corresponds\\nto the side of the mother toward which the presenting part is\\ndirected. Thus in L. O. A. or L. O. P. positions the left hand\\nis introduced into the uterus. In such cases the anterior foot\\nshould always be seized. In case of doubt both feet may be\\nbrought down.", "height": "3728", "width": "2684", "jp2-path": "obstetricsmanual00evan_0408.jp2"}, "397": {"fulltext": "VEBSIONS. 397\\nWhen the long axis of the foetus is transverse to the axis\\nof the uterus the hand to be introduced is the one which corre-\\nsponds to the side of the mother to ichich the breech is directed.\\nAVhen the breech is directed to the mother s right side the\\noperator should introduce his right hand.\\nIn dorso-auterior positions the near foot should be seized\\nand brought down, and in dorsoposterior positions the remote\\nfoot. Thus when the child s back is directed to the front,\\nseize the front (near) foot when the back is directed to the\\nbach, seize the bach (remote) foot.\\nBefore introduction the hand and arm should be dipped in\\ncreolin solution or smeared with sterilized oil.\\nThe hand, with the tips of the fingers and thumb placed\\ntogether so as to form a cone, is then introduced through the\\nvagina and cervix with a rotary motion. The uterus should\\nalways be entered witli the palm of the hand directed toward\\nthe abdomen of the foetus. The hand should be pushed\\nsteadily though gently upward to the fundus, where the feet\\nare usually to be found. A common mistake of inexperienced\\noperators is to feel about for the feet before the hand has been\\nintroduced far enough. The foot can be easily recognized by\\nthe prominence of the heel and malleoli.\\nThe external hand, protected with a sterilized towel, should\\nco-operate by making counter-pressure on the fundus, in order\\nto steady the foetus as well as to press the breech down, so that\\nthe feet may more easily be reached.\\nIf the membranes be found intact, they should be ruptured.\\nand the hand pushed quickly up, in order that the forearm\\nmay plug the vagina and so prevent escape of the liquor\\namnii. Should uterine contraction occur, the hand with the\\nfingers extended should be held quiet until relaxation has\\ntaken place.\\nIf the shoidder be found impacted in the pelvis and an arm\\nprolapsed, a noose of gauze bandage or tape should be slipped\\nover the child s wrist, and then the impaction may be reduced\\nby gentle upward pressure upon the body of the foetus.\\nIn reducing an impaction of the foetus the same rule ap-\\nplies as in the reduction of an impacted hernia, The part\\nthat has come down last should be returned first. Thus the\\nupward pressure should first be applied to that portion of the", "height": "3688", "width": "2484", "jp2-path": "obstetricsmanual00evan_0409.jp2"}, "398": {"fulltext": "398 OBSTETRIC OPERATIONS.\\nfcietiis nearest the pelvic brim, and then successively along the\\nbody until the apex of the shoulder is reached.\\nAVhen a secure grasp of the desired foot has been obtained\\nit is drawn steadily down toward the pelvic outlet, the external\\nhand at the same time being employed in directing the head\\ntoward the fundus. This turning movement should only be\\nmade when the uterus is entirely relaxed.\\nThe operation may be considered as complete when the child s\\nbreech is engaged in the pelvic inlet. When possible the case\\nshould then be left to nature to complete the delivery.\\nAfter the completion of version the foetal heart should be\\nauscultated and the general condition of the mother ascer-\\ntained. Should either be at fault the case should be termi-\\nnated by rapid extraction of the foetus.\\nFor details as to the various methods of extraction of the\\nbreech^ the reader is referred to the section on the Management\\nof Breech Cases.\\nThe dangers of internal version are laceration or rupture\\nof the uterus from the employment of undue force, hemor-\\nrhage, shock, and subsequent sepsis from uncleanliness at the\\ntime of operation. In order to prevent the latter the uter-\\nine cavity should be douched with a hot antiseptic solution\\n(formalin, 1 500) as soon as the placenta has been delivered.\\nSYMPHYSIOTOMY.\\nDefinition Derived from aofxcpoacq, a joint, and rofrq, a\\ncutting, symphysiotomy is the term applied to the operation\\nof section of the symphysis pubis in a woman in labor. The\\nobject of the operation is to increase the diameter of a con-\\ntracted pelvis, and thus to permit the delivery of a living\\nchild through the natural passages.\\nHistory: The operation was first performed successfully by\\nSigault, in Paris, in 1777. It was comparatively popular dur-\\ning the early decades of the present century, but fell into dis-\\nrepute by 1858.\\nIn 1866 the operation was successfully revived by Morisani,\\nof Naples, to whom is due the chief credit of the improved\\ntechnique of the modern operation. It was reintroduced into", "height": "3712", "width": "2684", "jp2-path": "obstetricsmanual00evan_0410.jp2"}, "399": {"fulltext": "SYMPHYSIOTOMY. 399\\nParis by Pinard in 1892, and was first performed in America\\nby Jewett, on Sept. 30, 1892.\\nRationale of symphysiotomy The separation of the sym-\\nphysis causes a lengthening of the diameters of the pelvis, the\\nconjugate being the one affected most in consequence of the\\nends of the pubic bones moving dov/nward as well as outward\\nwhen separated. The descent of the separated ends is due to\\nthe fact that each of the sacro-iliac joints rotates upon an\\noblique line running from above downward and from without\\ninward. A separation of 3 cm. (li inches) causes a descent of\\n2 cm. (jinch) still further descent being caused by the down-\\nward pressure of the foetal head. The separation of the\\npubic bones also permits the anterior parietal eminence of the\\nfoetal head to project into the interpubic space.\\nThus symphysiotomy results in enlargement of the pelvic\\ncanal by the separation and descent of the ends of the pubic\\nbones, and by permitting a prominence of the foetal head to\\noccupy the interpubic space.\\nIndications Symphysiotomy holds a place between Csesa-\\nrean section and the minor operations of forceps and version.\\nIt is an operation designed to secure the birth of a living and\\nviable child, and its chief rivals, in moderate degrees of pelvic\\nnarrowing, are the induction of premature labor and version\\nor forceps at term. The following constitute the chief indica-\\ntions for symphysiotomy\\n1. Simple flat pelves with a conjugata vera between 7 and\\n9 cm. (2.6 and 3.1 inches).\\n2. Generally contracted pelves, with a conjugata vera\\nbetween 8.2 and 10 cm. (3.2 and 3.9 inches).\\n3. Impacted or irreducible mentoposterior positions of the\\nface.\\n4. Impacted occipitoposterior positions of the vertex.\\nAnkylosis or any diseased condition of the sacro-iliac joints,\\nand the presence of infection contraindicate the operation.\\nThe time for operation is at the completion of the first stage\\nof labor.\\nPreparations The instruments required for the operation\\nare a common scalpel, a slightly curved, blunt-pointed bis-\\ntoury, a Galbiati or a Faraboeuf knife, a metal female catheter,\\ncurved needles, needle-forceps, a few haemostatic forceps, an", "height": "3700", "width": "2484", "jp2-path": "obstetricsmanual00evan_0411.jp2"}, "400": {"fulltext": "400 OBSTETRIC OPERATIONS.\\nintra-uterine douche nozzle, and a pair of axis-traction\\nforceps.\\nThe following materials should also be prepared iodoform\\ngauze strips, pledgets of absorbent cotton, sutures of catgut,\\nsilkworm-gut, and silk, iodoform and boric poAvder (1 8), a\\nsurgical dressing composed of iodoform gauze and absorbent\\ncotton pads, all of which should be sterilized. Rubber adhe-\\nsive plaster should be provided to keep the dressing in place,\\nand also a binder of strong cotton, or, better still, of canvas,\\nfastening with two or three broad strips of the same material\\nprovided with suitable buckles.\\nThe patient should be prepared as for an abdominal opera-\\ntion, the pubic region shaved, and the vagina sterilized. A\\nsuitable table should be ready on which to place the patient\\nduring the operation. Three assistants are required, one to\\ngive the anaesthetic, and tAvo to support the patient s thighs\\nand give what other help the operator may require.\\nSterile saline solution should be prepared in case of severe\\nhemorrhage or shock, and other suitable restoratives should\\nbe handy.\\nPreparations should also be made for the establishment of\\nrespiration should the child be born asphyxiated.\\nThe operation There are two methods of performing sym-\\nphysiotomy, the Italian and the French.\\nItalian method The advantages of this method are that\\nthe wound is more readily kept from infection after delivery,\\nand that the bladder and urethra are less liable to injury\\nduring the operation.\\nThe patient, having been anaesthetized, is placed in the\\ndorsal position upon the table with her thighs somewhat\\nflexed and supported by two assistants. The operator then\\nnotes the depth, direction, and thickness of the pubis, and\\nlocates the central depression on its upper margin which\\nindicates the position of the symphysis.\\nStanding on the right-hand side of the patient, the operator\\nmakes a vertical incision an inch long in the abdominal wall\\nterminating at a })oint 1 cm. (f inch) below the upper\\nmargin of the symphysis. The incision should extend down\\nto the superficial fascia. An assistant then inserts a metal\\ncatheter in the woman s urethra, holding it down and to one", "height": "3712", "width": "2676", "jp2-path": "obstetricsmanual00evan_0412.jp2"}, "401": {"fulltext": "SYMPHYSIOTOMY. 401\\nside so as to be clear of the symphysis. The attachments of\\nthe recti to the pubes are then cut sufficiently to permit the\\nintroduction of the forefinger. The forefinger of the left\\nhand is then inserted into the wound and passed down behind\\nthe symphysis. Occasionally the foetal head may press so\\nclose to the pubes that tiie operator may find difficulty in\\ninserting his finger behind the symphysis. In such cases the\\nfoetal head should be pushed up out of the way by an assist-\\nant with his fingers in the vagina.\\nThe retropubic tissues are separated by the index-finger, as\\nit is pushed down behind the symphysis and hooked under\\nthe subpubic ligament. The curved blade of the Galbiati\\nknife is then guided along the index-finger of the left hand\\ninto a position behind the joint, so that its top passes under\\nthe subpubic ligament. In place of the Galbiati knife an\\nordinary blunt-pointed, slightly curved bistoury may be\\nused.\\nThe joint-structures are then divided with an upward, for-\\nward rocking movement of the knife. While the joint is\\nbeing cut through, the sides of the pelvis should be supported\\nby the assistants, in order to prevent the ends of the bones\\nseparating too much. Frequently one fails to cut the sub-\\npubic ligament in cutting through the joint, in which case it\\nshould immediately be severed by means of a blunt-pointed\\nbistoury.\\nUsually pretty severe hemorrhage follows the section of the\\njoint, but firm packing of the wound with iodoform gauze\\ninvariably checks it. After the joint has been divided the\\ncatheter may be removed from the urethra.\\nWhile occasionally a woman may be allowed to deliver\\nherself after the symphysis has been divided, as a general\\nrule it is better to terminate the labor at once hj forceps or\\nversion.\\nDuring the delivery the assistants should exert firm lateral\\npressure upon the pelvis, to prevent too wide separation of\\nthe pubic bones the bones should not be allowed to separate\\nmore than 6.5 to 7 cm. (2.5 to 2.7 inches).\\nAfter delivery has been completed the patient s thighs should\\nbe extended and her knees brought together. The operator,\\nafter having washed his hands, removes the gauze packing\\n26\u00e2\u0080\u0094 Ob?t.", "height": "3692", "width": "2484", "jp2-path": "obstetricsmanual00evan_0413.jp2"}, "402": {"fulltext": "402 OBSTETRIC OPERATIONS.\\nfrom the wound and passes his left index-finger behind the\\njoint to make sure that the bladder has not been caught\\nbetween the bones then having checked all hemorrhage, he\\nsutures the wound with three or four deep silkworm-gut\\nsutures. Most operators consider it unnecessary to attempt\\nto suture the bones together one or two sutures, however,\\nmay be placed so as to include the fibrous tissue on the ante-\\nrior surface of the joint.\\nVaginal and vulvar lacerations, if present, are then re-\\npaired, and the bladder and urethra examined for possible\\ninjuries. The abdominal wall is then dressed with a strip of\\niodoform gauze and covered with layers of absorbent cotton.\\nThis dressing is held in place by means of one or two broad\\nstrips of rubber adhesive plaster which pass well behind the\\nwings of the pelvis on either side.\\nA firm cotton binder is then applied, or a broad canvas\\nbelt which can be fastened by means of straps and buckles.\\nThe patient is then removed to a bed with a firm level mat-\\ntress, such as would be used for a fracture case. It is ad-\\nvantageous to support the sides of the pelvis with sand bags\\nreaching from the knees to above the waist. The patient s\\nknees should be tied together.\\nFrench method The chief advantage of this method is that\\non account of the long incision the operator can see what he\\nis doing at each step.\\nThe operation An incision three inches long is made begin-\\nming on the abdominal wall one and one-half inches above\\nthe symphysis and extending downward to the clitoris. The\\nedges of the wound are separated by retractors and the exact\\nlocation of the symphysis determined.\\nBy careful dissection first the lower and then the upper\\nmargins of the symphysis are exposed. An index-finger is\\nthen inserted behind the joint so as to detach the retropubic\\ntissues. A broad, flat, grooved director is then guided along\\nthe index-finger behind the joint, either from above down-\\nward or from below upward. The joint is then cut from\\nwithout inward by means of a Farabauif knife. During de-\\nlivery the wound is packed with iodoform gauze to prevent\\npossible infection.\\nAfter delivery the wound is sutured with strong silkworm-", "height": "3712", "width": "2644", "jp2-path": "obstetricsmanual00evan_0414.jp2"}, "403": {"fulltext": "SYMPHYSIOTOMY. 403\\ngut, the sutures being so passed as to include the firm fibrous\\nouter covering of the ends of the bones.\\nAfter-treatment The after-care of a symphysiotomy case\\nis usually very troublesome, the difficulties being to keep the\\nwound from infection and to prevent separation of the ends of\\nthe pubic bones. There is usually very considerable oedema\\nof the vulva present for several days after the operation.\\nSpecial attention should be paid to the toilet of the vulva.\\nGenerally the catheter must be used for several days each\\ntime it is desired to empty the bladder. A strong assistant\\nshould be at hand to support and lift the pelvis, ^vhile a nurse\\nslips the bed-pan under the buttocks. The knees should be\\nkept tied together for two weeks and the patient kept flat on\\nher back for three or four weeks. The sutures may be re-\\nmoved on the sixth to the tenth day.\\nShould it be necessary to disinfect the parturient canal\\nduring the piierperium, the patient s legs should be raised\\nstraight in the air without bending the knees and supported\\nby an assistant. In this Avay whatever treatment may be\\nrequired can be carried out without causing the patient\\nmuch inconvenience.\\nThe ])atient may be allowed to sit up in from three to four\\nweeks after the operation, but should not be allowed to w^alk\\nabout much before the sixth week.\\nDangers of symphysiotomy: In Italy 54 symphysiotomies\\nhave been performed, with but 2 maternal deaths. In\\nAmerica the mortality is 12 per cent. Under favorable con-\\nditions and at the hands of skilled operators the maternal\\ndeath-rate should be almost nil.\\nFailure of the separated pubic bones to unite may leave the\\nwoman with some looseness in the joint, and cripple her pow-\\ners of locomotion. The sacro-ih ac joints may be damaged by\\ntoo wide a separation of the pubic bones. Troublesome\\nhemorrhage frequently takes place, but can usually be con-\\ntrolled by pressure and haemostatic suture. Vesical and\\nurethral injuries have been reported. The anterior vaginal\\nwall is liable to laceration during extraction of the child.\\nIn the opinion of the writer, the chief drau hach of sym-\\nphysiotomy is the great dislocation of the internal organs\\nwhich accompanies forcible extraction. Xot infrequently", "height": "3700", "width": "2472", "jp2-path": "obstetricsmanual00evan_0415.jp2"}, "404": {"fulltext": "404 OBSTETRIC OPERATIONS,\\nthese cases suffer later from prolapsus uteri, on account of the\\nlax condition of the structures of the pelvic outlet which\\nremains after the operation on account of the pubic bones\\nbeing separated the whole mechanism of labor is interfered\\nwith, so that the head descends through the pelvis in a trans-\\nverse position, the occiput failing to rotate to the front. More\\nor less damage to the pelvic fascia results and fails to undergo\\nproper repair, so that the woman later develops cystocele,\\nrectocele, or even a prolapsus uteri.\\nFailure to carry out rigid aseptic precautions after opera-\\ntion may lead to infection of the wound with serious con-\\nsequences.\\nCESAREAN SECTION.\\nDefinition Csesarean section may be defined as an obstetric\\noperation for the delivery of a mature foetus by means of an\\nincision through the abdominal and uterine walls.\\nHistory The operation dates from prehistoric times. The\\nfirst recorded operation was performed by a butcher in Swit-\\nzerland, in 1500. Until the development of antiseptic surgery\\nthe operation was attended by enormous fatality, and was\\nonly performed as a last resort. The uterine incision was\\nformerly left unsutured, as it was supposed that sutures would\\nnot hold on account of uterine contractions.\\nSanger, of Leipsic, has done probably more than anyone\\nelse to perfect the modern operation. In 1882 he showed\\nthat the uterine incision could be sutured with safety provided\\nthe suture-material employed was sterile. Since that time the\\nmortality attending the operation has been steadily reduced.\\nUnder favorable circumstances and at the hands of skilful\\noperators the maternal mortality is about 5 per cent. but\\nin general practice the mortality, according to Harris, ranges\\nfrom 30 to 40 per cent.\\nThe indications for this operation may be absolute or relative\\nAn absolute indication is the presence of some condition\\nwhich renders impossible any other method of delivery e. g.\\nextreme degrees of pelvic contraction (conjugate under 6.5\\ncm.) marked pelvic deformity resulting from osteomalacia,\\nkyphosis, and spondylolisthesis foreign growths obstructing", "height": "3728", "width": "2644", "jp2-path": "obstetricsmanual00evan_0416.jp2"}, "405": {"fulltext": "CESAREAN SECTION. 405\\nthe pelvic canal cicatricial contraction of the vagina and\\ncarcinoma of the cervix or of the rectum.\\nA relative indication is the presence of some condition\\nwhich makes doubtful the delivery of a living child by the\\nnatural passages. In some cases the question to be decided\\nis whether Csesarean section or one of the alternative opera-\\ntions (symphysiotomy, forceps, version, craniotomy) will\\nsecure the best results. The individual peculiarities of each\\ncase as it arises must be studied before a decision can be made.\\nIn general, after consultation with a confrere^ the physician\\nshould leave the decision to the woman or her husband,\\nhaving explained to them the nature of the case.\\nThe commonest relative indications are a conjugate of\\n6 to 8 cm. (2J to 3J inches) and tumors which cause but a\\nmoderate degree of pelvic obstruction (Fig. 117).\\nThe best time for operation, when this is elective, is within\\na week of the expected date of labor.\\nPreparations for Csesarean Section.\\nThe patient, if possible, should be under observation for\\nsome days before the operation is undertaken. During this\\nperiod the urine should be examined, the diet restricted, and\\nthe bowels carefully regulated. General tonics, especially\\nstrychnine, should be given daily, if there be any indication.\\nThe evening before the operation the patient should be\\ngiven a full dose of castor oil, or half an ounce of Epsom\\nsalt in a tumblerful of water. The abdomen and pubes\\nshould be shaved and scrubbed with a soft brush, tincture of\\ngreen soap, and hot water. After being thoroughly rubbed\\nwith alcohol the abdomen is to be covered with sterile gauze\\nand a binder applied.\\nIf the patient is nervous and unable to sleep, sulphonal\\n(gr. x-xv) may be given in warm broth or milk. The fol-\\nlowing morning the patient may be given a cupful of broth\\ntwo hours before the operation. If the bowels have not been\\nfreely moved, an enema of turpentine and soapsuds (3J to Oj)\\nmay be given.\\nBefore the patient is placed on the operating-table she\\nshould be catheterized and the abdomen, vulva, and vagina", "height": "3704", "width": "2472", "jp2-path": "obstetricsmanual00evan_0417.jp2"}, "406": {"fulltext": "406 OBSTETRIC OPERATIONS.\\nfinally sterilized. The vagina is then lightly packed with\\niodoform gauze.\\nAfter the patient is placed on the operating- table the chest\\nand thighs are covered with blankets protected by sterilized\\ntowels, and a large piece of sterilized gauze composed of four\\nthicknesses is arranged so as to cover the whole body from\\nchest to knees.\\nThe usual dressings and accessories for an abdominal opera-\\ntion should be provided in addition to the following instru-\\nments\\n2 scalpels,\\n1 pair of ordinary scissors.\\n1 dozen artery-forceps,\\n1 pair of retractors,\\nCurved and straight needles,\\n1 needle-holder.\\nA large thin-walled rubber tube as a uterine ligature,\\nSilk, silkworm-gut, and catgut for sutures and ligatures.\\nFour assistants are required one to give the anaesthetic,\\none to compress the cervix and control hemorrhage, one to\\nreceive and attend to the child, and one to assist the operator\\nthroughout the operation.\\nThe Caesarean Operation.\\nThe operator first cuts a slit in the gauze extending from\\nthe pubes to a short distance above the umbilicus.\\nAn incision is then made in the linea alba extending from\\na point 4 cm. (1 J inches) above the pubes to a point the same\\ndistance below the umbilicus. The peritoneal cavity is then\\nopened with the usual precautions. Such an incision is\\nsufficient for the introduction of the hand and the withdrawal\\nof the child. Many operators prefer, however, to extend the\\nabdominal incision to a point above the umbilicus, and to\\nturn the uterus out of the cavity before incising it.\\nThe advantages claimed for this latter method are a saving\\nof time, better control of the uterus, and that it is easier to\\nprevent the entrance of fluids into the general peritoneal\\ncavity. Its disadvantages are the great length of the ab-\\ndominal incision, which predisposes to hernia later and the", "height": "3712", "width": "2692", "jp2-path": "obstetricsmanual00evan_0418.jp2"}, "407": {"fulltext": "CESAREAN SECTION. 407\\ngreater extent of adhesions occurring later between the ab-\\ndominal wall and the uterus. For these reasons the shorter\\nincision is generally to be preferred.\\nHaving exposed the uterus to view, the operator then passes\\na piece of rubber tubing over the fundus and down to the\\nlower segment, so that it will encircle the uterus below the\\npresenting part of the child the ends are given to an assist-\\nant, who, by exercising traction, compresses the uterus and\\nsteadies it against the symphysis, thus controlling hemorrliage.\\nAn incision is then made into the uterus extending from the\\nfundus to just above the retraction-ring. This incision must\\nbe made quickly and boldly in spite of the severe hemorrhage\\nwhicii occurs.\\nExtraction of child: The operator then plunges his hand\\ninto the cavity of the uterus, pushing to one side the placenta\\nif it be encountered, seizes the child by a foot, and extracts it\\nas rapidly as possible. While the uterine incision is being\\nmade the assistant should press the abdominal wall to the\\nsides of the uterus, to prevent the entrance of fluids into the\\nperitoneal cavity. As soon as the child is extracted the\\nuterus usually contracts. When the child is withdrawn from\\nthe uterus it is given to an assistant to hold, while the opera-\\ntor clamps the cord in two places with artery-forceps and cuts\\nbetween them.\\nThe placenta is then grasped on its foetal surface and\\nloosened from its attachment by simply squeezing it. The\\nmembranes peel off from the uterine wall as the placenta is\\nwithdrawn through the incision.\\nShould the uterus fail to contract properly, it may be\\nstimulated by the application of hot cloths and friction.\\nIt is then lifted out of the abdominal cavity and a large\\npiece of gauze slipped under it, to hold it and also to prevent\\nthe intestines protruding.\\nAfter some iodoform powder has been dusted into the\\ncavity the uterine wound is closed by means of silk sutures.\\nThese sutures are placed at intervals of about 1.5 cm., or\\nabout half an inch, and should include only the muscular coat.\\nThe peritoneal edges are then approximated by a second\\nlayer of interrupted silk sutures, placed at shorter intervals\\nthan the first layer. After the sutures have been tied there", "height": "3708", "width": "2504", "jp2-path": "obstetricsmanual00evan_0419.jp2"}, "408": {"fulltext": "408 OBSTETRIC OPERATIONS.\\nslioLild be no hemorrhage either from the wound or from the\\nneedle-punctures. When tlie uterine wound has been sutured\\nthe elastic ligature around the cervix may be withdrawn.\\nClosure of abdominal wound The abdominal cavity should\\nthen be sponged dry with cheesecloth sponges, particular\\nattention being paid to the renal fossse.\\nHaving returned the uterus to the abdominal cavity and\\nplaced it in proper position, the omentum is then to be brought\\ndown and carried behind instead of in front of it, in order to\\navoid omental adhesions.\\nThe abdominal incision is then closed in the usual manner\\nand a surgical dressing applied. The vaginal gauze is then\\nremoved and a vulvar pad applied.\\nAfter-treatment: The after-treatment should be much the\\nsame as after any abdominal operation. During the first\\ntwenty-four hours it may be necessary to give a hypodermic\\ninjection of morphine for the relief of pain. The child may\\nbe put to the breast after twenty-four hours have elapsed.\\nSpecial attention should be given to the care of the vulva,\\nin order to prevent infection of the vagina.\\nThe abdominal sutures may be removed from the tenth to\\nthe fourteenth day, and the patient may be allowed out of bed\\nat the end of three Aveeks. An abdominal support should be\\nworn for six months after the operation.\\nPorro Operation.\\nIn 1876 Porro suggested that the ordinary Csesarean opera-\\ntion should be supplemented by the amputation of the uterus\\nalong with the tubes and ovaries.\\nAfter amputation of the uterus, two methods of treating the\\nstump are available.\\nBy the extraperitoneal method the stump is transfixed by\\nlong needles and retained in the lower angle of the wound.\\nBy the intraperitoneal method the stump is sewed over in\\nsuch a manner as to cover it completely with peritoneum,\\nafter which it is dropped into the abdominal cavity.\\nThe advantages of the Porro operation are that it renders\\nsubsequent uterine hemorrhage or conception impossible, and\\ndecreases the risk of puerperal infection, while it adds nothing\\nto the danger of the operation.", "height": "3712", "width": "2696", "jp2-path": "obstetricsmanual00evan_0420.jp2"}, "409": {"fulltext": "SELECTION OF OBSTETRIC OPERATIONS. 409\\nIndicatioHs Coeliohystercctomy, or Porro-Csesarean section,\\nis indicated when labor has been prolonged and manipulations\\nhave been attempted to secure delivery, but have failed and\\nsepsis is probable when the uterus or its appendages are so\\ndiseased as to require a subsequent operation for their removal\\nand when any condition is present which will make it impos-\\nsible for a child to be delivered subsequently by the natural\\npassages.\\nThe preparations are the same as for Csesarean section,\\nexcept that the following instruments should be added to the\\nlist given previously 1 large pedicle-scissors 4 curved\\nlarge pedicle-clamps 2 large volsellum forceps 2 right and 2\\nleft aneurism-needles and 1 right and 1 left sharp-pointed\\npedicle-needles.\\nOperation The abdominal incision should extend from two\\ninches above the umbilicus to just above the symphysis. The\\nuterus is draw^n up out of the abdomen, and a sterile towel is\\npacked into the peritoneal cavity to prevent the escape of the\\nintestines. The assistant then draws the edges of the abdomi-\\nnal incision close about the cervix, which he grasps firmly\\nwith both hands so as to control hemorrhage when the uterine\\nincision is made.\\nThe uterus is then incised and the child and placenta\\nremoved as quickly as possible. The ovarian arteries are\\nthen sought and tied, as also the arteries of the round liga-\\nments. The broad ligaments are then clamped and cut;\\nperitoneal flaps for covering over the stump are then pre-\\npared, the uterus amputated, and the uterine arteries tied.\\nThe stump is then oversewn and dropped, the peritoneal\\ncavity is washed out, and the abdominal wall closed.\\nGENERAL RULES GOVERNING THE SELECTION OF OB-\\nSTETRIC OPERATIONS IN CASES OF OBSTRUCTED\\nLABOR.\\nConjugate of 9.5 cm. or less The best method is to induce\\nlabor at or about four weeks before the expected termination\\nof pregnancy. If the condition of the pelvis is only discov-\\nered after labor has begun, the labor may be allowed to go on\\nfor twenty-four hours. Attention should be paid to the", "height": "3712", "width": "2480", "jp2-path": "obstetricsmanual00evan_0421.jp2"}, "410": {"fulltext": "410 OBSTETRIC OPERATIONS.\\nwoman s general condition and the distention of the lower\\nuterine segment. The choice of operation then lies between\\nforceps, version, symphysiotomy, and Csesarean section.\\nForceps may be applied and the patient placed in the\\nWalcher position if after twenty minutes the head does not\\nbecome engaged, they should be discarded. Version may suc-\\nceed where the forceps have failed, but the risk for the child\\nis considerable. If the danger of version is considered too\\ngreat to risk, then symphysiotomy should be done. If after\\nthe pubis has been divided the head descends to the brim, the\\ndelivery may be completed by forceps. Should the head\\nremain high after separation of the pubes, then version offers\\na more favorable result to the child.\\nThe most important conditions affecting the choice of opera-\\ntion are the size and compressibility of the foetal head. A\\ncompressible head may pass through a pelvis that would prove\\nan insuperable obstacle to an incompressible head of the same\\nsize.\\nThe relative size of the head and pelvis may be approxi-\\nmately determined, by grasping the head firmly with the ex-\\ntended fingers placed on the abdominal wall, and pressing it\\ndown upon the pelvic brim for some time. The pressure\\nthus exerted should be in the axis of the pelvic inlet. If the\\nhead can thus be forced within the brim, the natural forces\\nwill certainly secure the engagement.\\nConjugate of 7 cm. or less If at the thirty-sixth week the\\nhead can be forced into the brim by steady pressure from\\nabove, labor should be induced. The risk to the child of in-\\nducing labor before the thirty-sixth week is too great to afford\\nmuch chance of its surviving its birth. If at this time the\\nhead is too large to engage, the case should be left till about\\nterm and Csesarean section performed. Embryotomy should\\nnever be performed upon a living child if it possibly can be\\navoided. (3n the other hand, Csesarean section should not\\nbe rashly undertaken by an operator unskilled and inex-\\nperienced in abdominal surgery. As before said, the final\\ndecision should be left to the patient or her nearest rela-\\ntions.\\nWhen the pelvic canal is obstructed by a tumor which can-\\nnot be dislodged or which would be subjected to dangerous", "height": "3712", "width": "2692", "jp2-path": "obstetricsmanual00evan_0422.jp2"}, "411": {"fulltext": "EMBRYOTOMY. 411\\npressure during the passage of the child, the safest method\\nof delivery would be Csesarean section or the Porro operation.\\nEMBRYOTOMY.\\nDefinition Embryotomy is a generic term which includes\\nall the destructive operations by which the volume of the\\nfoetus is reduced to permit of its extraction through the natu-\\nral passages. The term thus includes craniotomy, decapita-\\ntion, evisceration, and amputation of the extremities.\\nIndications Embryotomy should never be performed on a\\nliving child when any other obstetric operation offers a reason-\\nable chance of saving its life.\\nThe patient and her friends may decline any conservative\\noperation and insist on embryotomy. In such case, if the\\nphysician is of opinion that a conservative operation would\\noffer a reasonable chance of saving the child, he is at liberty\\nto transfer the case to some one else should he so desire.\\nWhen such a course is not open to him, the physician must\\nunder protest yield to the desire of the patient and her friends,\\nas he has no legal right to compel them to follow his judg-\\nment.\\nProvided the foetus is dead, the following conditions may\\nbe mentioned as constituting the ordinary indications for\\nembryotomy\\n1. Deformity of the pelvis where forceps or version is\\nimpossible, or would expose the mother to unnecessary risk.\\n2. Obstruction of the parturient canal by tumors uterine,\\novarian, malignant, or osseous.\\n3. Impaction of the presenting part face presentations,\\noccipitoposterior positions, locked twins.\\n4. Eclampsia, or other causes demanding rapid delivery\\nwhere forceps or version would be difficult or prolonged.\\n5. Monstrosities hydrocephalus the latter constitutes an\\nindication for embryotomy on the living child, for if the\\ncondition is so marked as to prevent delivery there is no\\nprobability of the child surviving should conservative opera-\\ntion be performed.\\nEmbryotomy-instruments The object of embryotomy being\\nto reduce the bulk of the foetus, the presenting part has first", "height": "3712", "width": "2496", "jp2-path": "obstetricsmanual00evan_0423.jp2"}, "412": {"fulltext": "412\\nOBSTETRIC OPERATIONS,\\nto be perforated and its contents evacuated. If this proced-\\nure fails to reduce the bulk of the foetus sufficiently, it is\\nSmellie s scissors.\\nnecessary then to crush the presenting part by means of a\\npowerful instrument, so that delivery may be accomplished.\\nPerforators The best instruments for perforating the head\\nFig. 144.\\nBlot s perforator.\\nare Smellie^s scissors and Blot s perforator (Figs. 143 and 144),\\nthough a pair of scissors with a long handle answers the pur-\\nFiG. 145.\\nBraun s cranioclast.\\npose admirably. The Germans prefer to perforate the skull\\nby means of a trephine with a long handle.\\nCranioclast This is a powerful instrument for seizing the", "height": "3732", "width": "2668", "jp2-path": "obstetricsmanual00evan_0424.jp2"}, "413": {"fulltext": "EMBRYOTOMY.\\n413\\nFig. 14G.\\nhead after it has been perforated (Fig. 1 45). It consists of\\ntwo blades, one for insertion inside and the other outside the\\nskull. At the ends of the handles there is a powerful com-\\npression screw which enables the operator to obtain a firm\\ngrip of the head.\\nCephalotribe This instrument is simply a heavy forceps\\nspecially modified for compressing the head after it has been\\nperforated (Fig. 146). The blades are applied on either side\\nof the head, which is then crushed by\\ntightening a screw attached to the ends\\nof the handles.\\nThe most perfect instrument for reduc-\\ning the bulk of the foetal head is Tar-\\nnier s basiotribe, which is at once a per-\\nforator, a cranioclast, and a cephalotribe\\n(Fig. 147). This instrument is composed\\nof a perforator, two heavy fenestrated\\nblades of unequal length, and is provided\\nwith a pow^erful compression screw.\\nMethod of use After disarticulating\\nthe instrument the perforator is pushed\\nthrough a suture or fontanelle, the short\\nblade is then applied on the outside of\\nthe head like an ordinary forceps blade,\\nand is then articulated with the perfora-\\ntor, when the compression screw is tight-\\nened until the blade is forced close to the\\nperforator, thus crushing one side of the\\nhead.\\nAfter loosening the compression screw\\nthe long blade is applied to the opposite\\nside of the head and its handle articu-\\nlated to the handle of the short blade,\\nwhen the screw is again tightened, thus\\ncompletely crushing the head. Thus the\\nbase as well as the vault of the skull can\\nbe crushed and flattened to a little less\\nthan two inches (Fig. 148).\\nHook and crotchet This instrument consists of a curved\\nmetal bar terminating at one end in a blunt hook, at the other\\nLusk s cephalotribe.", "height": "3712", "width": "2472", "jp2-path": "obstetricsmanual00evan_0425.jp2"}, "414": {"fulltext": "414\\nOBSTETRIC OPERATIONS.\\nin a crotchet tip (Fig. 149). The crotchet-tip end may be in-\\nserted into the skull after perforation and hooked into the\\nforamen magnum, thus permitting the instrument to be used\\nFig. 148.\\nTarnier s basiotribe.\\nBasiotripsy accomplished.\\nas an extractor. The hook may be used to pull down the\\nneck.\\nBraun^s hook, which consists of a steel rod with a strong\\ntransverse handle at one end and a sharply bent hook, tipped", "height": "3732", "width": "2676", "jp2-path": "obstetricsmanual00evan_0426.jp2"}, "415": {"fulltext": "EMBRYOTOMY. 415\\nwith a rounded button, at the other, is employed as a decapi-\\ntator.\\nZweifel has devised a decapitator which consists practically\\nof two Braun s hooks so arranged that by separating the\\nhandles the tips can be moved in opposite directions.\\nIn America, where extreme degrees of pelvic contraction\\nare rarely to be met with, embryotomy can usually be carried\\nout with comparatively little risk to the mother, provided the\\noperator is careful and moderately skilful, by means of a pair\\nof blunt-pointed scissors with short blades and a long handle\\nand an old-fashioned hook and crotchet. The writer has per-\\nformed seven embryotomies with these two instruments, and\\nFig. 149.\\nCrotchet.\\nin no case was there laceration or injury of the maternal soft\\nparts, and the mothers all made uneventful recoveries.\\nThe time for operation is at the conclusion of the first stage\\nof labor.\\nPreparations The patient after being anaesthetized is placed\\nin the lithotomy position with her hips at the edge of the bed\\nor table on which she lies. The vulva, vagina, and inner\\nsurfaces of her thighs are then scrubbed with spirits of green\\nsoap and hot water, to be followed with a douche of formalin\\nor bichloride solution. The bladder is then catheterized. The\\ndouche-bag should be filled Avith sterile water and hung in a\\nposition to secure a good, forceful stream.\\nThe instruments to be used in the operation are then placed\\nin a convenient position after being sterilized.\\nOperation.\\nThe operator, suitably prepared, first makes a careful inter-\\nnal examination, to ascertain the exact conditions present. If\\npossible, the hand should be passed into the uterus till the\\ncord can be reached, to make certain the foetus has perished.\\nWhen the head is found presenting at the brim it should be\\nsteadied from above by an assistant when possible.", "height": "3712", "width": "2484", "jp2-path": "obstetricsmanual00evan_0427.jp2"}, "416": {"fulltext": "416 OBSTETRIC OPERATIONS.\\nThe perforator: The operator then locates the suture or\\nfontanelle with the tips of the index and middle fingers of his\\nleft hand placed in the vagina. The perforator held in his\\nright hand is then guided into position between the fingers of\\nthe left hand placed on the head. The head is perforated\\nbv steady upward pressure of the instrument held in the right\\nhand. Having penetrated the skull, the perforator is swept in\\nevery direction to break up the brain, and the opening is\\nenlarged in every direction. The douc^he nozzle is in-\\nserted into the opening in the skull, and, a return flow\\nhaving been provided for, a stream of water is let into the\\ncavity to wash away the broken-up brain-substance.\\nIf a cranioclast or cephalotribe is at hand, it should now be\\napplied and the head carefully extracted, care being taken to\\nguard the sharp edges of the cranial bones from cutting the\\nmaternal tissues.\\nWhen the crotchet hook is used, it is to be thrust into the\\nskull and hooked into the base about the forearm magnum.\\nAfter obtaining a firui hold the head is drawn down.\\nWhen long scissors are employed to open the skull-cavity\\nthe tips of the blades should be kept between the two fingers\\nof the operator s left hand which are in contact with the\\nhead. The cutting is done by little snips, separating the\\nblades as little as possible. Having cut through to the skull,\\nthe tip of the scissors with the blades closed is thrust through\\na fontanelle or suture. The blades are then separated as\\nwidely as possible and swept about to break up the brain-\\nsubstance. The cerebral cavity is washed out and the crotchet\\nused as described.\\nSometimes after the cranial contents have been removed\\nthe child is expelled by natural efforts.\\nIn most cases in which the pelvis will permit of their proper\\napplication, the ordinary forceps may be used as extractors of\\nthe perforated head.\\nPerforation of the after-coming head When it is necessary\\nto perforate the after-coming head, the perforator may be in-\\nserted through the quadrilateral fontanelle behind the ear,\\nor into the foramen magnum through the mouth of the child.\\nDecapitation: In impacted shoulder presentation it may be", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0428.jp2"}, "417": {"fulltext": "EMBRYOTOMY, 417\\nnecessary to sever the head from the trunk in order to effect\\ndelivery.\\nThis may be performed by passing the hook end of the\\nhook and crotchet over the neck to draw it down as far as\\npossible, where it is held by an assistant. By means of a\\npair of long-handled scissors the operator can then cut through\\nthe neck, being careful to guard the blades between the two\\nfingers of the left hand held in the vagina.\\nEvisceration This is rarely indicated. When necessary it\\nmay be done with a pair of long-handled scissors.\\nIn all cases after the separation of the placenta, the uterine\\ncavity should be douched with hot salt solution. Lacerations\\nof the soft tissues should then be sought, and if found sutured\\nat once.\\nDangers of embryotomy The chief dangers of embryotomy\\nai*e, lacerations of the maternal tissues by spicules of bone or\\nby instruments and sepsis.\\nAs the mother has been exhausted by prolonged and in-\\neffectual efforts to complete labor, before embryotomy is\\nperformed, she has but little resisting power should septic\\ninfection take place while the bruised and lacerated condi-\\ntion of the soft parts favors the development of sepsis.\\n27\u00e2\u0080\u0094 Obst.", "height": "3684", "width": "2480", "jp2-path": "obstetricsmanual00evan_0429.jp2"}, "418": {"fulltext": "", "height": "3712", "width": "2692", "jp2-path": "obstetricsmanual00evan_0430.jp2"}, "419": {"fulltext": "INDEX.\\nAbortion, 194\\ncomplete, 198\\ndefinition, 194\\ndiagnosis, 197\\netiology, 196\\norigin, foetal, 197\\nmaternal, 196\\npaternal, 196\\nfrequency, 195\\ninduction of (see Induction of abor-\\ntion), 371\\ninevitable, 197\\nmissed, 201\\nlabor, 201\\npartial, 198\\npatliologT. 196\\nblood-mole, 196\\ncast-off decidua, 196\\neffusion of blood, 196\\nprognosis, 198\\nsymptoms, 195\\nexpulsion of the ovum, 195\\nhemorrhage, 195\\npain, 195\\nthreatened, 197\\ntreatment, 198\\nactive, 200\\nafter-, 201\\nexpectant, 199\\nof inevitable, 199\\nprophylactic, 199\\nof threatened, 199\\ntubal, 203\\nAccidental hemorrhage, 263\\napparent, 263\\nconcealed, 263\\netiology, 264\\nsymptoms, 264\\ntreatment, 265\\nAlbuminuria in pregnancy, 181\\nAlimentary system, changes of, in\\npregnancv, 43\\nAllantois, 30\\nAmnion, 29, 35\\nliquor amnii, 35\\nfunction, 35\\npathology, 156\\ndropsy, 156\\nhydramnios, 156\\noligohydramnios, 156\\npremature rupture, 159\\nsac, 30\\nAmniotic bands, 158\\nAnasarca of foetus, 166\\nAnatomy, obstetric (see Obstetric anat-\\nomy), 56-96\\nApoplexy of placenta, 162\\nArea pellucida, 28\\nAreolae, abscess of, 331\\nArrest of lactation, 331\\nindications, 331\\nmethod, 331\\nAtresia of vagina, 302\\nAxis of bony outlet, 76\\nof brim, 76\\nparturient, 76\\nof plane of the vulvovaginal ring,\\n76\\nrelation of uterine to foetal, 90\\nB.\\nBallottement, 50\\nBladder, calculus, 303\\ncystocele, 303\\ndistended, 303\\nBlastodermic vesicle, 26\\nBlood-mole, 196\\nBloodvessels in pregnancy, 184\\nBreasts, abscess {see Mammary abscess),\\n329\\nabsence, 320\\nchanges in pregnancy, 41\\ndiseases of, 172\\nabscess, 172\\neczema of the nipples, 172\\nexcessive secretion, 172\\nengorgement of, 322\\n419", "height": "3700", "width": "2472", "jp2-path": "obstetricsmanual00evan_0431.jp2"}, "420": {"fulltext": "420\\nINDEX.\\nBreasts, engorgement of, treatment,\\n322\\nbreast-bandage, 324\\nbreast-pump, 322\\nmassage, 323\\nMurphy binder, 324\\nnursing, 322\\nhypertrophy, 320\\ninflammation of (see Mastitis), 326\\nmastitis (see Mastitis), 326\\nsupernumerary, 320\\nCsesarean section, 404\\nhistory, 404\\nindications, 404\\noperation, 406\\nPorro, 408\\nCalculus of bladder, 303\\nCaput succedaneum, 115\\nCarcinoma of cervix, 303\\nCardiac diseases in pregnancy, 184\\nCerebral hemorrhage in puerperium,\\n338\\nCervical lacerations, repair, 370\\noperation, 370\\nCervix, atresia, 298\\ncarcinoma, 303\\ncicatricial contraction, 298\\nimpaction of anterior lip, 299\\npolypi, 305\\nrigidity, 298\\ntreatment, 298\\nsoftening of, 41, 46\\nviolet discoloration, 41, 47\\nChorion, 30, 31, 34\\nhydatidiform degeneration, 159\\npathologv, 159\\nvilli, 31, 32\\nCirculatory system, changes of, in\\npregnancy, 43\\nClimacteric, 18\\nCcelum, 29\\nColostrum, 149\\nConception, 21\\nConstipation in pregnancy, 174\\nCord (see Umbilical cord), 30, 34\\nCorpus luteum, 20\\nof pregnancy, 20\\nCough in pregnancy, 183\\nCutaneous system, changes of, in\\npregnancy, 44\\nCystitis in puerperium, 336\\nCystocele, 303\\nI\\nDecidua, 23, 34\\nDecidua, cells, 25\\ncoalescence, 23\\ndevelopment of, 23\\nlayers, 23\\npathology, 154\\natrophy, 156\\ndecidual endometritis, 154, 155\\nacute, 154\\netiology, 154\\ntreatment, 154\\nchronic, 155\\ncatarrhal, 155\\ndiflTuse, 155\\noccurrence, 155\\ntreatment, 155\\nreflexa, 23\\nserotina, 23\\nvera, 23\\nDental caries in pregnancy, 173\\nDevelopment, 23\\ndecidua (see Decidua), 23\\nfoetus (see Foetus), 25\\nplacenta (see Placenta), 3\\nDiagnosis of pregnancy, 45-51\\nDiarrhoea in pregnancy, 174\\nDiphtheria in puerperium, 333\\nDuctus arteriosus, 38\\nvenosus, 36\\nDyspnoea in pregnancy, 183\\nDystocia, 209\\ndue to abnormalities of the foetal\\nappendages, 253\\naccidental hemorrhage,\\n263\\nadherent placenta, 266\\ncoiling of cord about\\nneck, 258\\nplacenta prsevia (see Pla-\\ncenta prxvia), 258\\nprolapse of cord, 254\\nretained placenta, 266\\nshort cord, 253\\nanomalies of foetal development,\\n248\\nencephalocele, 252\\nhydrencephalus, 252\\nhydrocephalus, 250\\nmeningocele, 252\\nmonstrosities, 253\\novergrowth of foetus, 248\\npremature ossification of\\nskull, 249\\ntumors of foetal trunk,\\n252\\nmalpositions of the foetus, 209\\nbreech presentations, 221-\\n237\\nbrow pi-esentations, 221", "height": "3708", "width": "2692", "jp2-path": "obstetricsmanual00evan_0432.jp2"}, "421": {"fulltext": "INDEX.\\n421\\nDystocia, due to malpositions of the\\nfoetus, face presentations,\\n215-221\\noccipitoposterior cases, 209-\\n214\\nplural births, 245\\nprolapse of the foetal limbs,\\n244\\ntransverse presentations,\\n237-244\\ntriplets, 248\\ntwin labors, 245\\nmaternal, 268-312\\nanomalies in forces of labor, 268-\\n272\\nof tlie maternal soft structures\\n(see Uterus, Vagina, etc.), 297-\\n312\\nof the pelvis (see Pelvis), 272-\\n297\\nE.\\nEclampsia, 188\\ncourse, 190\\ndefinition, 188\\ndiagnosis, 192\\neclamptic fit, 189\\nduration, 189\\netiology, 190\\ntoxaemia, 190\\nfrequency, 188\\npathological anatomy, 191\\nkiduevs, 191\\nliver, \\\\92\\nlungs, 192\\nspleen, 192\\nprognosis, 192\\nsymptoms, 188\\npremonitory, 188\\ntermination, 190\\ntreatment, 192\\nduring attack, 193\\nmedical, 193\\nobstetrical, 194\\nprophylactic, 192\\nurine, 188\\nEctoderm, 28\\nEctopic gestation, 202\\ndefinition, 202\\ndiagnosis, 206\\netiology, 204\\nfrequency, 202\\npathology, 204\\nprimary, 202\\nsecondary, 202\\ntubal, infundibular, 202\\ninterstitial, 202\\nEctopic gestation, secondary tubal,\\ntrue, 202\\ntubo-ovariau, 202\\nsymptoms, 205\\nterminations, 202,203\\ntreatment, 207\\nvarieties, 202\\nabdominal, 202\\novarian, 202\\ntubal, 202\\nEczema of nipples, 172\\nElephantiasis of foetus, 165\\nEmbryology, 21\\nEmbryonic area, 28\\nEmbryotomy, 411\\ndangers of, 417\\ndefinition, 411\\nevisceration, 417\\nindications, 411\\ninstruments, 411\\nbasiotribe, 413\\nblunt-pointed scissors, 415, 416\\nBraun s hook, 414\\ncephalotribe, 413, 416\\ncranioclast, 412, 416\\nhook and crotchet, 413, 416\\nperforators, 412, 416\\noperation, 415\\nperforation of after-coming head,\\n416\\nEncephalocele, 252\\nEndocervicitis, 172\\nEndometritis, decidual, acute, 154\\nchronic, 155\\nin puerperal septic infection, 347, 350\\nEntoderm, 28\\nEpiblast, 26, 28\\npermanent, 28\\nprimitive, 28\\nEpisiotomy, 361\\nadvantage of, 362\\ndefinition, 361\\nindications, 361\\noperation, 362\\nErysipelas in puerperium, 333\\nErythema in nuerperium, 333\\nEutocia, 96, 209\\nF.\\nFibromyoma of uterus, 304\\nFoetal circulation, 36\\nhead, flexion of. 85, 108, 109\\nmoulding of. 86\\nheart-sounds, 132\\nmovements, 96\\ntrunk, 88\\ndiameters, 88", "height": "3688", "width": "2488", "jp2-path": "obstetricsmanual00evan_0433.jp2"}, "422": {"fulltext": "422\\nINDEX.\\nFoetal trunk, mobility, 88, 89\\nFcEtus, anasarca, 166\\nanomalies, 165\\ncentre of gravity, 96\\ncirculation (see Feetal circulation), 36\\ncontagious diseases, 168\\ndeath of, 168\\ncauses, 168\\nsequelae, 169\\ndevelopment, 25\\nelephantiasis, 165\\nhead of, 77\\nbase, 77\\ndiameters, 82-84\\nflexion of, 85\\nglabella, 81\\nmobility of, 88, 89\\nmoulding of, 86\\nocciput, 81\\nplanes, 85\\ncircumferences, 85\\nprotuberances, 81\\nfrontal, 82\\noccipital, 81\\nsinciput, 81\\nvault, 77\\nfontanelles, 78\\nfalse, 80\\nsutures, 78\\nvertex, 80\\nichthyosis, 166\\nmature, 76\\nmonstrosities, 165\\nmortality of, 165\\nossification of skull, 249\\novergrowth, 248\\ntreatment, 249\\npositions (see Positions), 93\\nposture, 89\\nnormal, 89\\npresentations (see Presentations), 91\\nrachitis, 166\\nshape relative to uterus, 96\\nsyphilis, 167\\ndiagnosis, 167\\ninfection, 167\\nmanifestations, 167\\ntreatment, 168\\ntuberculosis, 168\\ntumors of trunk, 252\\nFontanelles. 78\\nfalse, 80\\nForceps, axis-traction, 377\\ndescription, 375\\noperation, 374\\nin breech cases, 390\\ndangers of, 391\\nin dorsal position, 381\\nForceps operation in dorsal position,\\naxis-traction, 377, 383\\nwith ordinary forceps, 386\\ndistention of perineum, 383\\nextraction, 382\\nintroduction of blades, 381\\nsupport of limbs, 381\\nin face presentations, 390\\nhigh, 376, 381\\nhistory, 374\\nindications for, 378\\nin left lateral position, extraction,\\n388\\ninsertion of blades, 386\\nlow, 376, 381\\nmedium, 381\\nmethods, 380\\nContinental, 380\\nEnglish, 380\\nin occipitoposterior cases, 389\\nposture of patient, 380\\npreparations for, 379\\nFunic souffle, 133\\nG.\\nGalactocele, 331\\nGalactorrhoea, 322\\nGingivitis in pregnancy, 173\\nGraafian follicle, 18\\nmembrana granulosa, 18\\nnumber, 18\\novum (see Ovum), 18, 19\\ntunica fibrosa, 18\\npropria, 18\\nH.\\nHsematoma of vagina, 302\\nHsematuria in pregnancy, 180\\nin puerperium, 337\\nHeart murmurs in pregnancy, 184\\nHegar s sign, 48\\nHemorrhage, accidental (see Accidental\\nhemorrhage), 263\\nhaematoma, 317\\npost-partum, 312\\ndefinition, 312\\ndiagnosis, 313\\netiology, 312\\nsymptoms, 313\\ntreatment, 314-316\\npuerperal, 317\\nsecondary, 315\\nHemorrhoids in pregnancy, 180\\nin puerperium, 335\\nHernia into umbilical cord, 165\\nHerpes in pregnancy, 187", "height": "3712", "width": "2660", "jp2-path": "obstetricsmanual00evan_0434.jp2"}, "423": {"fulltext": "INDEX.\\n423\\nHydramnios, 156\\ndiaguosis, 157\\netiology, 156\\nsymptoms, 157\\ntreatment, 158\\nHydrocephalus, 250, 252\\nHvmeu, unruptured, 302\\nHypoblast, 26, 28\\ncleavage, 28\\npermanent, 29\\nIchthyosis of foetus, 166\\nIcterus in pregnancy, 179\\nImpetigo in pregnancy, 187\\nImpregnation, 21\\nIndigestion in pregnancy, 174\\nInduction of abortion, 371\\ndefinition, 371\\nindications, 371\\nmethods, 372\\ndilatation and curetting, 372\\ndrugs, 372\\nof premature labor, 373\\nindications, 373\\nmethods, 374\\nKrause s, 374\\nTarnier s, 374\\nInfectious diseases in pregnancy, 187\\nInsanity in puerperium, 338-341\\nInversion of uterus, 310-312\\nK.\\nKidney of pregnancy, 181\\nLabor, delayed, 270\\ncauses, 270\\ndiagnosis, 270\\ntreatment, 271\\nmissed, 201\\nnormal (see Normal labor), 96\\npathology (see Dystocia), 209-212\\nprecipitate, 268\\netiology, 268\\ntreatment, 269\\npremature, induction of (see Induc-\\ntion of premature labor). 373\\nLacerations of cervix (see Cervical\\nlacerations). 370\\nof perineum see Perineal lacerations),\\n362\\nLactation, 148\\narrest of (see Arrest of lactation) 331\\ncolostrum (see Colostrum), 149\\nLactation, establishment of, 150, 151\\nmammarv glands, 149\\nmilk (see Milk), 149\\nLeucorrhcea of vagina, 169\\nLiquor amnii, alterations in character,\\n159\\nLochia, 146\\nalba, 146\\ncharacter, 146\\ncomposition, 146\\nodor, 146\\nquantity, 146\\nrubra, 146\\nserosa, 146\\nM.\\nMalaria in puerperium, 334\\nMammae (see Breasts), 320\\nMammary abscess, 329\\nof areolae, 331\\nlocation, 329\\nsymptoms, 329\\ntreatment, 329\\nincision, 330\\nMastitis, 326\\netiology, 327\\nsymptoms, 327\\ntreatment, 328\\nabortive, 328\\nvarieties, 326\\nglandular, 326\\nparenchymatous, 326\\npost-mammary, 326\\nsubcutaneous, 326\\nMeasles in puerperium, 332\\nMembranes, 29\\nrupture of, 136\\nat term, 33\\nMeningocele, 252\\nMenopause, 18\\nMenstruation, 17, 20\\ncause, 17\\ncessation, 18\\ncharacter of flow, 17\\nduration, 18\\nonset, 17\\nand ovulation, 20\\nquantity, 18\\nstructural changes, 17\\nsuppression, 45\\nMesoblast, 29\\ncleavage, 29\\nMesoderm, 29\\nMilk, 149\\nchemical composition, 149\\nquality, 150\\nquantity, 150", "height": "3712", "width": "2488", "jp2-path": "obstetricsmanual00evan_0435.jp2"}, "424": {"fulltext": "424\\nINDEX.\\nMilk, secretion of, 150\\ndeficient, 320\\nexcessive, 321\\ngalactorrhoea, 322\\npolygalactia, 321\\nMiscarriage (see Abortion), 194, 195,\\n201\\nMole, blood-, 196\\nfleshy, 155, 196\\ntubal, 203\\nvesicular, 159\\nsymptoms, 159\\ntreatment, 161\\nMonstrosities, 253\\nMultipara, 97\\nMyelitis in puerperium, 337\\nN.\\nNephritis in pregnancy, 182\\nNervous system, changes of, in preg-\\nnancy, 43\\nNeuralgia in pregnancy, 185\\nNeuritis in puerperium, 337\\nNeuroses in pregnancy, 185, 186\\nNipples, anomalies, 320\\ninversion, 320\\nsore, 325\\ntreatment, 325\\nsupernumerary, 320\\nNormal labor, 96\\nanaesthetics, use of, 126, 127\\nantisepsis, 119\\nagents, 120\\nnurse, 122\\nobstetrician, 121\\npatient, 123\\nblood lost in, 118\\nduration, 97\\nfirst stage, 102\\nanatomy of soft parts, 107\\nclinical phenomena, 106\\ninitial labor-pains, 106\\nreflex vomiting, 107\\ndry labors, 105\\nmanagement, 128\\nexamination, 129\\nauscultation, 132\\npalpation, 129\\nvaginal, 134\\npreliminary conduct of phy-\\nsician, 128\\nsucceeding the examina-\\ntion, 136\\nmechanism, 103\\naction of uterine fibres, 104\\ndilatation of cervix, 103\\nhydrostatic pressure, 103\\nNormal labor, first stage, os uteri, 106\\nrupture of membranes, 105\\nsigns and symptoms, 102, 103\\ncharacteristic, 103\\npremonitory, 102\\nforces of, 99\\ncontractions of abdominal mus-\\ncles, 101\\nof uterus, 99\\nduration, 99\\nefiiect of, 100\\nintermittent, 99\\ninvoluntary, 99\\npainful, 99\\nperistaltic, 99\\nof vaginal and pelvic mus-\\ncles, 99, 101\\ngravity, 102\\npolarity, 100\\nretraction of uterus, 100\\nmanagement of, 119\\nonset, causes of, 97, 98\\npreparation for, 124\\nnurse, 126\\npatient, 125\\nlabor-room, 125\\nphysician, 124\\nobstetric bag, 124\\nsecond stage, 107\\nanatomy, 115\\nclinical phenomena, 113\\nmoulding of head, 114\\nmanagement, 137\\nlaceration of perineum, 138\\nperineal stage, 137\\nposition, 137\\nrapid cases, 137\\nmechanism, 107\\ndelivery of trunk, 113\\nhead movements, 108\\ndescent, 108\\nextension, 112\\nexternal rotation, 112\\nflexion, 108, 109\\ninternal rotation, 110\\nrestitution, 112\\nstages, 97\\nthird stage, 116\\nmanagement, 141\\nCrede s method of expres-\\nsion, 141\\nfinal measures, 142\\nlacei-ations, 141\\nretraction of uterus, 142\\nmechanism, 116\\nexpulsion of placenta, 117\\nseparation of placenta, 116\\nof membranes, 117", "height": "3712", "width": "2668", "jp2-path": "obstetricsmanual00evan_0436.jp2"}, "425": {"fulltext": "INDEX.\\n425\\nO.\\nObstetric anatomy, 56-96\\noperations, 361-417\\nCaesarean section, 404-409\\nembryotomy, 411-417\\nepisiotomv, 361\\nforceps, 374-391\\ngeneral rules governing selection\\nof, 409-411\\ninduction of abortion, 371\\nof premature labor, 373\\nrepair of cervical lacerations, 370\\ncomplete tear, 368\\nexternal superficial tear, 363\\ninternal tear, 364\\nvaginal and perineal lacera-\\ntions, 362\\nsymphysiotomy, 398-404\\nversions, 391-398\\n(Edema of placenta, 164\\nof vagina, 169\\nof vulva, 169\\nOligohydramnois, 156\\nOvarian cysts, 306\\nOvulation, 18, 20\\nand menstruation, 20\\nOvum, 18, 19\\nat different periods of pregnancy,\\n35, 36\\ndiscus proligerus, 18\\nfertilization, 22\\ngerminal spot, 19\\nvesicle, 19\\nimmature, 19\\nimpregnated, 25\\nmaturity, 19\\nnucleolus, 19, 26\\nnucleus, 19, 25\\npolar bodies, 19\\npronucleus, 19, 26\\nsegmentation, 26\\nyolk, 19, 25\\nzona pellucida, 19\\nParametritis in puerperal septic in-\\nfection, 350\\nParotitis in pregnancy, 173\\nParturient axis, 76\\nParturition, 57\\nPathology of amnion (see Amnion), 156\\nof breasts (sec Breasts), 172\\nof chorion (see Chorion), 159\\nof decidua (see Decidua), 154\\nof foetus (see Foetus), 165\\nof placenta (see Placenta), 161\\nof pregnancy, 154\\nPathology of the pregnant woman,\\n169\\nabortion (see Abortion), 194\\nalbuminuria, 181\\nbloodvessels, 184\\ncardiac diseases, 184\\nconstipation, 174\\ncough, 183\\ndental caries, 173\\ndiarrhoea, 174\\ndyspncea, 183\\neclampsia (see Eclampsia), 188\\nectopic gestation (see Ectopic\\ngestation), 202\\ngingivitis, 173\\nhsematuria, 180\\nheart murmurs, 184\\nhemorrhoids, 180\\nherpes, 187\\nicterus, 179\\nimpetigo, 187\\nindigestion, 174\\ninfectious diseases, 187\\nkidney of pregnancy, 181\\nnephritis, 182\\nacute, 182\\nchronic, 182\\ndifferential diagnosis, 182\\ntreatment, 182\\nneuralgia, 185\\nneuroses, 185, 186\\nparotitis, 173\\nphthisis pulmonalis, 183\\npigmentation, 187\\npneumonia, 183\\npremature labor (see Premature\\nlabor), 194\\nptyalism, 173\\nsalivation, 173\\nscanty urine, 180\\nthyroid gland, 185\\ntoxaemia (see Toxsemia), 188\\nvomiting, 174\\npernicious (see Pernicious vom-\\niting), 175\\nsimple, 175\\nof umbilical cord (see Umbilical\\ncord), 164\\nof uterus (see Uterus), 170\\nof vagina (see Vagina), 169\\nof vulva (see Vulva), 169\\nPelvic canal, soft parts, 71-76\\nmuscles, 71-74\\nfloor, 72\\nfascia, 74\\nmeasurement, 72\\nmuscles, 71-74\\nsegments, 72", "height": "3708", "width": "2472", "jp2-path": "obstetricsmanual00evan_0437.jp2"}, "426": {"fulltext": "426\\nINDEX.\\nPelvic floor, segments, pubio, 72\\nsacral, 72\\nPelvi-genital canal, 57, 61\\nPelvimetry, 275\\nmeasurements, 275-279\\nexternal, 275\\ninternal, 277\\nPelvis, 61\\nanomalies of, 272-297\\nclassification, 273\\ndeep, 282\\ndiagnosis, 274\\ndue to injuries, tumors, or dis-\\nease, 294\\nspinal curvature, 296\\nkyphoscoliosis, 297\\nkyphosis, 296\\nlordosis, 296\\nscoliosis, 297\\nflat, 283\\nmechanism of labor, 287\\nnon-rachitic, 283\\nrachitic, 285\\ntreatment of labor, 288\\nfrequency, 272\\nfunnel-shaped, 282\\njustomajor, 279\\njustominor, 279\\nmalacosteon, 291\\nmasculine, 282\\nobliquely contracted, 289\\npseudomalacosteon, 292\\nshallow, 282\\nspondylolisthetic pelves, 293\\ntransversely contracted, 291\\ndiameters, 67-70\\nof the brim, 67-70\\nconjugate, 68\\nmeasurements, 70\\noblique, 70\\ntransverse, 70\\nfalse, 63\\ninclination, 71\\njoints of, 62\\nmobility, 63\\nlateral grooves, 65, 66\\nplanes, 66\\nthe brim, 66\\nthe cavity, 67\\nthe outlet, 67\\ntrue, 63\\ncavity, 64\\nboundaries, 64-66\\ninferior strait, 64\\ninlet, 63\\noutlet, 64\\nsuperior strait, 63\\nPerineal body, 75\\nPerineal lacerations, complete tear,\\n368\\nconditions, 368\\noperation, 368-370\\nexternal tear, 363\\ninternal tear, 364\\nconditions, 364\\nmethod of repair, 365-368\\nrepair, 362\\nPerineum, 75\\nrigidity, 302\\nPeritonitis in puerperal septic infec-\\ntion, 351\\nPernicious vomiting, 175\\nduration, 175\\netiology, 176\\nphysiological uterine contrac-\\ntions, 176\\npredisposing causes, 176\\nsymptoms, 175\\ntreatment, 178\\ndietetic, 178\\ndigital dilatation of cervix, 179\\ndrugs, 179\\nhygienic, 178\\ninduction of abortion, 179\\nrectal alimentation, 178\\nPhlegmasia alba dolens, 351\\nPhthisis pulmonalis in pregnancy, 183\\nPigmentation in pregnancy, 50, 187\\nPlacenta, 31\\nadherent, 164, 266\\ncauses, 267\\ntreatment, 268\\nanomalies, 161\\nof position, 161\\nof shape, 161\\nof size, 161\\nof weight, 161\\napoplexy, 162\\ncauses, 163\\ndefinition, 162\\nforms, 162\\nresults, 163\\nsymptoms, 163\\ntreatment, 163\\naspects, 33\\nbattledore, 161\\ncircular sinus, 34\\ncotyledons, 33\\ndegeneration, calcareous, 162\\nfatty, 162\\nfunctions, 34\\nhorse-shoe, 161\\ninflammation (see Placentitis), 163\\nintervillous spaces, 32\\nmaternal blood, 33\\nmembranacea, 161", "height": "3728", "width": "2716", "jp2-path": "obstetricsmanual00evan_0438.jp2"}, "427": {"fulltext": "INDEX.\\n427\\nPlacenta, oedema of, 164\\npolypi, 196\\npraevia, 258\\ncentralis, 258\\netiology, 259\\nlateralis, 258\\nmargiualis, 258\\nsymptoms, 260\\ntreatment, 261\\npremature separation of (see Acci-\\ndental hemorrhage), 263\\nretained, 266\\nsinuses, 32\\nsite, 34\\nstructure, 31\\nsuccenturiata, 161\\nsypliilis of, 164\\nat term, 33\\ntumors of, 164\\nwhite infarctions, 162\\nPlacentitis, 163\\npathological changes, 163\\nPlural births, 245\\nPneumonia in pregnancy, 183\\nin puerperium, 333\\nPolygalactia, 321\\nPolypi of cervix, 305\\nof placenta, 196\\nPorro operation, 408\\nPosition, 92\\nPositions, 93-96\\nbreech, 95\\nface, 94\\noccipitoposterior, 209\\ndiagnosis, 209\\nmanagement of labor, 212\\nat the pelvic inlet, 213\\nin the pelvic cavity, 214\\nmechanism, 210\\nabnormal, 211\\nprognosis, 214\\nsomatic, 95\\nvertex, 94\\nPregnancy, ballottement, 50\\nchanges in alimentary system, 43\\ncirculatory system, 43\\ncutaneous system, 44\\nmaternal organism, 38\\nuterus, 38\\nnervous system. 43\\nrespiratory system, 43\\nurinary system, 44\\ncorpus luteum of, 20\\ndiagnosis, 45-51\\ndifferential, 52, 53\\nof life or death of child, 54\\nof nulliparity, 53\\nof parity, 53\\nPregnancy, diagnosis, summary of, 51\\ntrimesters, 45-51\\nfirst, 45-48\\nobjective signs, 46\\nHegar s sign, 48\\nsoftening of cervix, 46\\nviolet discoloration, 47\\nsymptoms, 45\\nmammary changes, 46\\nnausea, 46\\nsuppression of menstrua-\\ntion, 45\\nvomiting, 46\\nsecond, 48\\nobjective signs, 49\\nsymptoms, 48\\nthird, 50\\nobjective signs, 51\\nsymptoms, 50\\nduration, 44\\ncommon rule, 44\\ndate of quickening, 45\\ntable, 45\\nfoetal heart-sounds, 49\\nmovements, 49, 51\\nHegar s sign, 48\\nhygiene of, 54-56\\nlikely to occur, 22\\nlinese albicantes, 44, 51\\nmanagement of, 54-56\\nnormal, 21\\npathology of (see Pathology of preg-\\nnancy), 154\\npigmentation, 42, 44, 50\\npressure-symptoms, 51\\nquickening, 49\\nsettling, 51\\nuterine contractions, 49\\nsouffle, 49\\nvomiting of, 43\\nPremature labor (see Abortion), 194,\\n201\\nPresentation, 90\\nI Presentations, 91\\nbreech, 221\\ncauses, 222\\ndiagnosis, 223\\nfrequency, 222\\nmanagement, 226\\narms delivered, head retained,\\n234\\narrest at brim, 228\\ndelivery of after-coming head,\\n233\\nimpaction in pelvis, 230\\nrapid extraction of trunk, 230\\nmechanism, 224\\nabnormal, 225", "height": "3712", "width": "2484", "jp2-path": "obstetricsmanual00evan_0439.jp2"}, "428": {"fulltext": "428\\nINDEX.\\nPresentations, cephalic, 91, 92, 96\\nface, 95, 215\\ncauses, 215\\ndiagnosis, 215\\nmanagement, 219\\nmechanism, 217\\noccurrence, 215\\npositions, 215\\npelvic. 91, 93\\nshoulder, 95\\nsomatic, 91, 93\\ntransverse, 92, 237\\ncauses, 237\\ndiagnosis, 238\\nfrequency, 237\\nmechanism, 239\\nspontaneous evolution, 240\\nversion, 239\\nwith body doubled up, 240\\npositions, 237\\ndorso-anterior, 237\\ndorsoposterior, 237\\nPrimigravida, 97\\nPrimipara, 97\\nPrimitive groove, 28\\nstreak, 28\\nProlapse of cord, 254\\nof foetal limbs, 244, 245\\nof uterus, 172, 300\\nPruritus of vagina, 169\\nof vulva, 1H9\\nPtyalism, 173\\nin pregnancy, 173\\nPuerperal period (see Puerperal state),\\n143\\npathology of (see Uterus, Breasts,\\nHemorrhage), 312\\nstate, 143\\nanatomy of parts, 143\\nbladder, 144\\nbroad ligaments, 144\\nperitoneum, 144\\nuterus, 143\\nvagina, 144\\nvulva, 144\\nbeginning, 143\\nduration, 143\\nmanagement of, 150\\nafter-pains, 153\\ncare of breasts, 151\\nof genitalia, 151\\ncontraindications to suckling,\\n152\\nlying-in room, 150\\nnourishment, 152\\nrest, 152\\nphysiological phenomena, 143\\nphysiology of, 145\\nPuerperal state, physiology of, invo-\\nlution, 145\\nabdominal walls, 147\\ncirculatory system, 147\\ndigestive apparatus, 148\\nlactation (see Lactation), 148\\novaries, 147\\npelvic joints, 147\\nskin, 148\\ntubes, 147\\nurinary system, 147\\nuterus, 145\\nlochia (see Lochia), 146\\nmucosa, 146\\nmuscle-cells, 145\\nvessels and nerves, 145\\nvagina, 147\\nvulva, 147\\nseptic infection, 345-361\\nbacteriology, 345\\ncervix, 346\\nsaprsemia, 346\\nvagina, 346\\ndefinition, 345\\ndiagnosis, 354\\nculture from uterus, 355\\nlochia, 354\\nfrequency, 345\\npathology, 347\\nauto-infection, 352\\nendometritis, 347\\nmodes of infection, 351\\nparametritis, 350\\nperitonitis, 351\\nphlegmasia alba dolens, 351\\npyaemia, 351\\nsalpingitis, 350\\nulcer, 347\\nvaginitis, 347\\nsymptomatology, 352\\nonset, 352\\nparametritis, 353\\nperitonitis, 353\\npyaemia, 353\\nsepticaemia, 354\\ntreatment, 357\\ngeneral, 359\\nserum-therapy, 360\\nlocal, 357\\nprophylaxis, 357\\nPuerperiura (see Puerperal state), 143\\nfever other than septic, 343, 344\\nintercurrent diseases, 332-361\\nanaemia, 334\\ncerebral hemorrhage, 338\\ncystitis, 336\\ndiphtheria, 333\\nerysipelas, 333", "height": "3728", "width": "2676", "jp2-path": "obstetricsmanual00evan_0440.jp2"}, "429": {"fulltext": "INDEX.\\n429\\nPuerperium, intercurrent diseases,\\nerythema, 333\\nhsematuria, 337\\nhemorrhoids, 335\\nincontinence of urine, 336\\ninsanity, 338-341\\nmalaria, 334\\nmuscles, 332\\nmyelitis, 337\\nneuritis, 337\\npneumonia, 333\\npyelonephritis, 336\\nretention of urine, 335\\nrheumatism, 333\\nrotheln, 333\\nscarlet fever, 332\\nseptic infection (see Puerperal septic\\ninfection), 345\\nsudden death, 341\\nentrance of air into uterine si-\\nnuses, 343\\npulmonary embolism, 341\\nthrombosis, 341\\nPyaemia in puerperal septic infection.\\n351\\nPyelonephritis in puerperium, 336\\nQ.\\nQuickening of pregnancy, 49\\nEachitis of foetus, 166\\nEespiratory system, changes of, in\\npregnancy, 43\\nEetroversion of uterus, 170\\nEheumatism in puerperium, 333\\nEotheln in puerperium, 333\\nEupture of uterus, 306\\nSalivation, 173\\nSalpingitis in puerperal septic infec-\\ntion, 350\\nScarlet fever in puerperium, 332\\nSegmentation, 26\\nmorula stage, 26\\nSemen, 21\\nSomatopleure, 29\\nSpermatozoids, 21\\nmeeting-place with ovum, 22\\nSplanchnopleure, 29\\nSubinvolution, 318\\nSymphysiotomy, 398\\ndangers of, 403\\nSymphysiotomy, definition, 398\\nFrench method, 402\\nhistory, 398\\nindications, 399\\nItalian method, 400\\nrationale, 399\\nSyphilis of fcBtus, 167\\nof placenta, 164\\nThyroid gland in pregnancy, 185\\nToxaemia (see Eclampsia), 188\\nTreatment of abortion, 198\\nof accidental hemorrhage, 265\\nof adherent placenta, 268\\nof apoplexy of placenta, 163\\nof decidual endometritis, acute, 154\\nchronic, 155\\nof delayed labor, 271\\nof eclampsia, 192\\nof ectopic gestation, 207\\nof engorgement of breasts, 322\\nof mammary abscess, 329\\nof mastitis, 328\\nof nephritis in pregnancy, 182\\nof overgrowth of foetus, 249\\nof pernicious vomiting, 178\\nof post-partum hemorrhage, 314-316\\nof precipitate labor, 269\\nof prolapse of umbilical cord, 255\\nof puerperal septic infection, 357\\nof retroversion of uterus, 171\\nof rigidity of cervix, 298\\nof rupture of uterus, 309\\nof sore nipples, 325\\nof subinvolution of uterus, 319\\nof syphilis of foetus, 168\\nof vesicular mole, 161\\nTriplets, 248\\nTubal mole, 203\\nTuberculosis of foetus, 168\\nTumors of placenta, 164\\nof uterus, 172, 304-306\\nTwin labors, 245\\ncomplications, 247\\nu.\\nUlcer in puerperal septic infection,\\n347\\nUmbilical cord, 30, 34\\nanomalies, 164\\ncoils, 164\\nknots, 165\\nof length, 164\\ncoiling about foetal neck, 258\\nhernia into, 165", "height": "3696", "width": "2472", "jp2-path": "obstetricsmanual00evan_0441.jp2"}, "430": {"fulltext": "\u00e2\u0096\u00a06/^\\n430\\nINDEX.\\nUmbilical cord, prolapse of, 254\\ndiagnosis, 255\\ntreatment, 255\\nshort, 253\\nvein, 36\\nUracil us, 30\\nUrinary system, changes of, in preg-\\nnancy, 44\\nUrine, incontinence of, in puerperium,\\n336\\nretention of, in puerperium, 335\\nscanty, in pregnancy, 180\\nUterine bruit, 133\\ncontractions in pregnancy, 49\\ninertia, 270\\nsouffle of pregnancy, 49\\nUterus, arteries of, 39\\ncavity of, 57\\nchanges from pregnancy, 38\\ncontractions, 40, 99\\ndextro-rotation, 41\\ndiagnosis, 171\\ndisplacements of, 299-302\\ndouble, 297\\nendocervicitis, 172\\nfibromyoma, 304\\nfull-term, relation to contiguous\\nstructures, 60\\ninversion, 310-312\\nligaments, 59\\nlymphatics, 39\\nmuscle-fibres, 39, 57\\nlayers of, 57-59\\nnerves, 40\\nperitoneum, 60\\nprolapse, 172, 300\\nrelation to pelvis and abdomen,\\nfourth month, 40\\nninth month, 40\\nseventh montb, 40\\nsixth month, 40\\nthird month, 40\\nretroversion, 170\\nanatomical results, 170\\ncausation, 170\\ntreatment, 171\\nmild cases, 171\\nsevere cases, 171\\nrupture of, 306\\netiologv, 306\\nsite, 307\\nsymptoms, 308\\ntreatment, 309\\nsegments of, 59, 100\\nlower, 59\\nupper, 59\\nUterus, septate, 297\\nsubinvolution, 318\\ndiagnosis, 319\\netiology, 318\\ntreatment, 319\\ntumors, 172, 304-306\\nwalls of, 57\\nV.\\nVagina, atresia, 302\\nhsematoma, 302\\nlacerations of (see Perineal lacera-\\ntions), 362\\nleucorrhcea, 169\\noedema, 169\\npruritus, 169\\nsepta, 302\\nvarices, 469\\nviolet discoloration, 41, 47\\nVaginitis in puerperal septic infec-\\ntion, 347\\nVarices of vagina, 169\\nof vulva, 169\\nVegetations of vulva, 170\\nVersion, spontaneous, 239\\nVersions, 391\\ndefinition, 391\\nmethods, 392\\nbipolar, 393\\nindications, 394\\nmethod, 394\\nexternal, 392\\nindications, 392\\nmethod, 393\\ninternal, 395\\nindications, 395\\nmethod, 396\\nvarieties, 391\\ncephalic, 392\\npelvic, 392\\npodalic, 392\\nVesicular mole, 159\\nVitellus, 25\\nVomiting of pregnancy, 43, 46, 174, 175\\nVulva, oedema, 169\\npruritus, 169\\nvarices, 169\\nvegetations, 170\\nw.\\nWharton s jelly, 34\\nYolk-sac, 30\\n;.hbD?9", "height": "3712", "width": "2732", "jp2-path": "obstetricsmanual00evan_0442.jp2"}, "431": {"fulltext": "", "height": "3700", "width": "2484", "jp2-path": "obstetricsmanual00evan_0443.jp2"}, "432": {"fulltext": "", "height": "3704", "width": "2692", "jp2-path": "obstetricsmanual00evan_0444.jp2"}, "433": {"fulltext": "", "height": "3644", "width": "2304", "jp2-path": "obstetricsmanual00evan_0445.jp2"}, "434": {"fulltext": "LIBRARY OF CONGRESS\\n022 216 015 7", "height": "3847", "width": "2589", "jp2-path": "obstetricsmanual00evan_0446.jp2"}}