MANUAL fe
OF
2% » +
“ | Obstetrics, Gynecology and Pediatrics,
i
BY
KENNETH N. FENWICK, M.A., M.D.
Prof: Obstetrics and Diseases of Women and Children, Royal Colleye of Physicians and Surgeons in affiliation with Queen’s University, oe Kingston ; Member of the Royal College of Surgeons, England ; coca Fellow of the Obstetrical Society, Edinburgh; and ote 2g
Surgeon to the Kingston General Hospital. ) . a
KINGSTON, ONTARIO : JOHN HENDERSON & CO,, 1889,
Entered according to Act of the Parliament of Canada, in the year one thousand { , eight hundred and eighty-eight, by Kenner N, Fenwick, M.A., M.D., Kingston, Ontario, in the Office of the Minister of Agriculture.
Jel i se ar Oe
The object of this little book is to furnish an outline of the
main facts in Obstetrics and the Diseases of Women and
Children, and includes a synopsis of the physical signs of Diseases of the Chest and Diseases of the Skin.
1t is really a syllabus of my sessional lectures with such
®@ additions and alterations as I thought would make it more
| valuable for reference in emergencies. thousand =|
Kingston, . 4 , ‘ While seeking to meet the wants of the medical student in
® general, and my own class in particular, the work does not pretend to originality, nor does it aim at supplanting the larger text books on the subject which are not always within the reach of every medical student.
Elegance of expression has often been sacrificed to con- iciseness, for obvious reasons.
In conclusion, I wish to acknowledge my indebtedness to Mr. J. R. Shannon, B.A., for valuable assistance in revising © proofs.
—
|@ 141 Kine Sr. W., KINGSTON.
146756
CONTENTS.
eee () omer
OBSTETRICS, PAGE,
i 3A. THE FEMALE ORGANS OF GENERATION, - - - : - |
I. Hexternal 1. The pudenda,
Mons veneris, labia Majora and minora, Clitoris, vestibule, hymen - - - : 2 Curuncule myrtiformes, and
% Fossa navicularis
P| 2, The Vagina.
> =I. Internal. : : : : al ER rh Sea ao Ae ay 3G
1, The Uterus.
2. The fallopian tubes.. - : : : : : : Graaffian follicle. : : : - - : - 6 Parovarium, ovum,
y IIL. Periodical Ovulation - + + - i oe 7 38 1. The discharge of the ovum.
On
2. Menstruation. : : : : - : - - 8 3. The Corpus luteum. - : : : : - : 10 4 False and true. = si1V. *Fecundation of the Ovum. UATE COU cas se Re eg | 7 V. Development of the Ovum. - + += + © + 12 E 1. Formation of nucleus of vitellus, : : : - 13 : 2. Segmentation of vitellus. 3. Formation of the membranes, - - : : : 14 Amnion, allantois, chorion, Umbilical Vesicle. - : : : - : - 15 4, Preparation of the Uterus to receive it. - - - 16 is Decidua vera, retlexa, and serotina.
a 4 5. Formation of the Placenta, a the umbilical cord. - : : : - : - 18
vi. CONTENTS.
VI. Development of the Embryo. . . . - 1, Of its various parts. 4 2, As a whole. - - AGE . - - 20 @
B. PREGNANCY.
I. Changes occurring in the mother. - - - - - 22 1, In the sexual apparatus. 2. In the system at large. - - . - . - 23 Il. The signs of pregnancy. : - : : : 24 1, Cessation of the Menses, 2. Mammary sympathies 3. Abdominal enlargement. - - - - - 25 4, Ballottement. - . ; - . . ° - 26 5. Quickening. 6. Auscultation. is fe A's - oot le
(a). Pulsation of foetal heart. (6). Uterine souffle. 7. Jacquemier’s Test, - - - - . - - 28 8. Intermittent Uterine Contractions. 9. Kyestine in the Urine. 10. Morning Sickness. 11. Salivation.
III. The Disorders of Pregnancy. - - . - - - 29 1. Local. (a) (Edema of Labia. a (b) Pruritus of Vulva. Pd (c) Metritis. 2. Reflex.
(a) Neuralgia. (6) Salivation. (c) Vomiting. (d) Constipation.
(e) Syncope. a C. (f) Insomnia, s 3. Mechanical, abi - - . . . . 30 Hygiene of Pregnancy. IV. Abnormal Pregnancy. - - - - - . - 30 1, Due to peculiar conditions of uteru:
(a) Double. (6) Displacements, a 2. Due to peculiar conditions of decidua. a
CONTEETS. vii. 19 a 3 3. Due to peculiar conditions of placenta. Reyes eB 4 As to form, position, development, and nutrition. - 20 & 4, Due to peculiar conditions of amnion and its fluid.
be (a) Excess—hydramnion. : (6) Deficient,
a8 5. Due to peculiar conditions of the cord, 93 6. Due to peculiar conditions of the chorion. Hydatidi- form mole, - V. Premature expulsion of the ovum. Abortion. <> 78. ae Causes— 1, Maternal. (a) Predisposing. - - - - . 34 - 2 @& (b) Exciting. - 8 & 2, Footal. L Diagnosis, prognosis, - - - - «+ = « 35 > 27 : Treatment. - - - - - - - . 36 4 1. The prevention of habitual abortion, 2. The arrest of threatened abortion. 2 3, The management of inevitable abortion. (a) Where the sac is not ~uptured. (6) Where the sac is ruptured. 4, The management of neglected abortion - - 37 & 5. The management of premature labors. - 29 a VI. Retrauterine pregnancy, or ectopic gestation. - . e 38 a 1, Tubal pregnancy. 2. Ovarian pregnancy, 3. Abdominal pregnancy. : Symptoms, termination, diagnosis, i? Treatment, ee CAVA Oh ht ee i i I, eR 1. Cases of early gestation. = 2, Cases of advanced gestation. (a) Footus living. (6) Fostus dead. 3 C. Lazor, hee 4 I. Duration of pregnancy. Saas A AN a See emery 1 II. Cause of onset of labor. - 30 a III, Symptoms, - : - - - - - : - 42 Ei Premonitory. Ist stage. 2nd stage. - : - - - 43
Srd stage. - - - . . ge ae
Vill. CONTENTS.
IV. Duration of labor.
V. The eupellent forces. - ° ° . . 1. The uterine contractions. The nervous mechanism of labour. 2. The accessory forces. -
VI. The mechanism of labour, 1, The female pelvis. Its planes and axes. - - - . - 2. The fcetal head. : - Its sutures, fontanelles, and icinabaue,
VII. Zutocia or normal labor.
The position of vertex, Ist Position. 1. Descent and flexion. - - - . : 2, Rotation. : : : - : : 3. Extension. 4, Restitution. 5. Expulsion of the trunk. 2nd Position. - : : - . ; ; ‘ 8rd Position, 1, May be converted into 2nd. 2, Persistent 3rd. 4th Position. : : - - - ‘ * Management of labour, : . ° , ‘ é Of Ist stage. . - . . - “7 Of 2nd stage. - - - - - . P Of perineum. - - - - ‘ ;: Of 3rd stage. - - - - ‘ A 4 Use of anesthetics.
VILI. Dystocia or extraordinary labor, - + = «© «
1, From imperfect uterine efforts.
(a) Irregular action.
(b) Inertia. : : : : :
Use of ergot—its indications and contra- tndiowitua
2. From impeded uterine efforts.
(a) Connected with the foetus.
(2) From abnormal position.
(i) Face presentation.
58
59 59 61 61 62 63
64
65 66
CONTENTS. ix,
(ii) Breech presentation. - : - 68 455 Management. A ae - 70 Treatment of aftercoming head. - 46 (iii) Shoulder presentation. : : 71 48 Terminations and treatment. - - 72 (8) Size and form. - 50 & . (i) Large heads. § (ii) Deformities. 51 (vy) Number. - 53 Multiple pregnancy. if 54 Twins. - : : : : : 73 (6) Connected with the passages. 55 (a) Pelvis, - - - - - - - 74 (i) Contracted pelvis proper. 56 Ist. Pelvis Aquabiliter Justo-minor. _ 57 2nd. The flattened pelvis. - : 75 3rd. The flattened generally con- ; tracted pelvis. (ii) Irregular forms. oi Ist. The Negele Oblique. 2nd, The Kyphotic. - 8rd. The Scolio-Rachitic. Measurement. - - - 76 - 59 I, Internal pelvimetry. é 59 fo II, External pelvimetry. gt Influence of contracted pelvis. ge 1, During pregnancy. -~— - 77 . 62 2. During labor. ; 63 Treatment. - : - 78 ae (B) Os uteri. 4 (a0, an cr a at mE RR, {1 - 64 q (ii) Rigidity. x (iii) Induration. . & (y) Vagina. - 65 a (i) Atresia. 66 g (ii) ‘Tumors. a (c) Connected with the secundines. - - - 81 P| (a) Liquor amnii. (i) Abundant,
(ii) Deficient.
1V. Craniotomy.
V. Embryotomy. 1, Exenteration. : 2. Decapitation.
VI, Caesarean Section,
K. Diseases oF CHILDBED, I. Convalesence and its disorders.
CONTENTS,
(8) The membraes. (y) The cord,
(i) Short.
(ii) Entangled. (iii) Presenting. (6) Placenta. (i) Adhesion. - lst. Simple retention. 2nd. Hour-glass contraction. 3rd. Morbid adhesion. (ii) Preevia. 3. Complications of labor. (a) Hemorrhage. (a) Accidental, (8) Unavoidable. (y) Post partum. Treatment.. Secondary uterine hemorrhage. (b) Eclampsia or puerperal convulsions, (ec) Syncope. -_. : (d) Inversion of the uterus, . (e) Rupture of the uterus,
D, OBsTETRIC OPERATIONS.
I. The induction of premature labor. iI. The forceps. III. Version or turning.
VII. Ovaro-hysterectomy. VII. Laparo-Hlytrotomy,
81
CONTENTS. xi.
4 sl | i Dinesot Mae 2 oe re 12 1. Sore nipples. 4 2. Mastitis. - at - . , - ‘ - lll 4g 3. Defective secretion of milk, - - . . - 112 a 4. Galactorrhea. - - - - : : - - 113 3 III. Puerperal fever. - 8 Treatment. a AR a ye coagigle g uy tS | | IV. Puerperal venous thrombosis and embolism. - - - 120 eT 1. Pulmonary obstruction. Seaivapne : oc RR - 83 é 2. Phlegmasia alba dolens. - - - . : - 122 . 86 ae V. Puerperal insanity. : - - . . oe), wo ot RBS - 87 GYNAECOLOGY. . 88 | Hg - 90 Diagnosis. - : . - P - 128. q A. Non-INSTRUMENTAL EXAMINATION. - - - : . - 130 / : a. 1. Eeternal abdominal.
; 1. Inspection.
ic 4 2. Palpation. - ~- : fa Fee : : - 181 a 3. Percussion.
4, Auscultation.
: : oe II, Inspection of the external genitals. - 101 4 Ill. Digital examination. : : 5 - : : - 132 * 1. Vaginal. | 2. Rectal. Ce a ee ee a 4 3. Vesical, © ae : IV. Bimanual. - 104 | ) 3B. lnsTRUMENTAL EXAMINATION. - 105 a I. The speculum. ' § iia fe Re ee - 16 & 2. Bivalve. - 107 4 8. Duckbill. Il. The uterine sound. Uses and contra-indications. - - - - 135
Other instruments.
xii, CONTENTS.
SPECIAL DISEASES.
A, DISASES OF THE VULVA, = + - += += = = - 137 I, Malformations. 3 II, Inflammation. a We RE TMC see My Rel 4
SII, New Growths, -
IV. Rupture of Perineum. Causes, 1, Owing to the mother. 2. Owing to the child.
3. Owing to the physician. - - - - : - 139 Its nature and effects. Treatment.
1, The immediate or primary operation. - - - 140°
2. The secondary operation. (a) Partial rupture, (b) Complete rupture,
B, DISEASES OF THE VAGINA. - . . : . shi a a ’ I, Malformations. II. Vaginismus.
III. Inflammation. - - - : - - - - 142 IV. New Growths. V. Fistule. Vesico-vaginal fistula. Causes, 1. Traumatic. : : : 5 - - - 143
2. Pathological. Symptoms, operation.
C, DISEASES oF THE UTERUS,
I, Disorders of menstruation. ; 4 | 1, Amenorrhea, - : - - cae : - 144 (a) Delayed menstruation.
(2) From congenital malformation. § 8) Functional,
CONTENTS. xiii,
(b) Suppressed menstruation. - . : - 145 Causes, symptoms, treatme..t. 2, Dysmenorrhea.
- 137 4a (a) Neuralgic. - (b) Congestive. 138 4 (c) Obstructive. - - = - + 146 . & (d) Membranous. (e) Ovarian. 3, Menorrhagia. - : : : - : 147 Symptoms, pathology, treatment. - - - 148 Leucorrhea, - 139 1. Vaginal,—(a) acute, (b) chronic. 2. Uterine. - - : . » 149 Sterility. Causes. - : : : : - : - 150 “ Treatment. - : . : . - 15) Il. Malformations. III. Stenosis of 08 wteri.\- : - - . - - «+ We a Iv aaa st - - 153 - M41 ss 1, Endometritis. a (a) Acute, (b) chronic. : Pathology, causes, symptoms, and treatment. - 154 142 2. Acute Metritis. 3, Chronic Metritis : - : : : : - 155 Subinvolution. Symptoms and treatment. - . : - - 156 V. Dislocations or displacements. . . - + - 157 3 Causes. - : : © - : - - 158 Peta! - 1. Anteversion. - : é ; ' . , - 159 4 2, Anteflexion. " Symptoms. a 3. Retroversion. ps Me es a a eee - 162 4 5. Prolapsus. - - . : ; - - : 163 144 : 6. Inversion. - : - - : - - - 165 VI. New Formations. Sao ee rE ee Ue ag } — 1. Fibro-myoma. | : 2, Fibro-cystic. Stic aN de Baa ee : 3. Uterine polypi. - - : . - - - 170 |
xiv. CONTENTS.
4. Carcinoma. Cancer of cervix. do ofbody. - ,
VII. Laceration of the Cervia. - - -
‘D. DisEasEs or PELVIC CONNECTIVE TISSUE, - I, Parametritis. (I. Perimetritis. - - - - - III. Pelvic hematocele.
E. DISEASES OF THE TUBES AND OVARIES. -
I. Of the tubes. II. Of the ovaries, 1. Prolapse, 2. Odphoritis. - 3. Ovarian tumors. -
F. DrIskasEs OF THE BLADDER.
I. Malformations. II. Cystitis, III. Caleuli and foreign bodies. - VI. Functional diseases. 1. Irritability, 2. Incontinence. — - - - 3. Retention. 4, Dysuria. V. New growths. VI. Diseases of the urethra. 1. Urethritis. : . ‘ * 2. Fissure.
3. Prolapse of mucous membrane. 4, Caruncle,
“G. NEUROSES. - : . . Z i I. Hysteria,
Il, Hystero-epilepsy, - - - .-
III. Newrasthenia,
172 172
175
176 177
179
180 18]
184
185
186
187
187
190
CONTENTS. xv. PEDIATRICS. . 172 - 172 General examination of children, - 162 é 175 Treatment of the new born infant. - 197 Asphyxia. - : : - 198 Selection of wet-nurse. - : - 199 176 Hand-feeding, ; 177 I, Diseasis of Intestinal tract. 1, Dentition, - - : 201 - 179 2. Thrush, - - : - - - 202 3. Stomatitis. - - 203 (a) Aphthous. (b) Ulcerative. s 180 (c) Gangrenous. - 204 - 181 4, Marasmus. 5. Gastric catarrh. - - 205 184 6. Diarrhea, He vecan sony - 206 (a} Simple. (b) Inflammatory. 207 . (c) Choleraic. ; - 185 7. Dysenteory. : - - - 208 8. Constipation. 9. Intestinal obstruction. 209 : 186 10. Intestinal worms, . Diseases of the Nervous System. | 1, General symptoms. : - 210 2. Convulsions. oie, Ma 211 - 3. Hydrocephalus. : : - - 212 4 4, Tubercular meningitis. ete 213 - lrg 5. Acute infantile spinal paralysis. : - 214 q 6. Pseudo-hypertrophic paralysis. - - - - 215 5 III. Diseases of the respiratory system. - . a “ - 216 1. Examination of the chest. Physical signs. 187 2. Laryngismus Stridulus. - : - - - 222 3 3. Diphtheria. : : : - : : - - 223 - 190 (a) Pharyngeal.
(b) Laryngeal, —Croup.
CONTENTS.
4, Bronchitis, -
5. Pneumonia. - (a) Croupous. (b) Catarrhal.
6. Pleurisy. : Empyema,
IV. Diathetic diseases. 1. Scrofula. 2. Infantile syphilis. -
V. Diseases of the liver. i. Jaundice, (a) Icterus neonatorum. (a) Benign. (8) Grave. - (b) Icterus of childhood. 2. Amyloid liver. 3. Fatty liver. - VI. Acute infectious diseases. 1. Mumps. 2. Measles. 3. Rétheln. - 4, Scarlet fever. 5. Varicella. - 6. Whoopingcough. VII. Diseases of the skin.
4%
a Mi *
Dae Sea
OBSTETRICS,
" GGYNMCOLOGY AND PEDIATRICS.
—_o——-
OBSTETRICS. A.—TuHe FemMALe OrGANS OF GENERATION. L EXTHRNAL. | 1. The Pudenda include all those parts which are visible
externally, viz. :—Mons Veneris, labia majora, labia minora, | clitoris, vestibule, hymen, caruncule myrtiformes, and fossa > navicularis.
a. The Mons Veneris, or “ mount of love,” is an irregular tri-
P angular prominence, situated in front of the symphysis pubis. ® After puberty it is covered with a thick growth of coarse hair
and is sharply defined above by a line at the lower part of the
shypogastric region.
_ 6. The Labia Majora are two cutaneous folds beginning
at the lower part of the mons veneris, co.stituting the Manterior commissure ; and extending downwards on each side of
the vulvar cleft, terminate by blending with the integument of
3 he perineum. Unless the thighs are abducted the inner sides
of the labia are always in contact. ce. The Labia Minora, or nymphe, are two muco-cutaneous
@folds springing from the inner surfaces of the labia majora, and
have been compared to a cock’s comb. They begin just beloy, the anterior commissure as double folds which meet above and
9 OBSTETRICS.
below the clitoris, forming the preprce and frenulum of the clitoris ; and descending on each side of the vestibule and on the inner side of the labium bond with its middle part. They however unite again by a muco-cutaneous commis- sure below known as the fourchette.
d. The Clitoris is a small curved oblong organ, analogous to the penis in the male, situated just below the anterior commis- sure. It appears as a small pear-shaped projection, the glans, covered above by the prepuce, and attached by its body to a point immediately under the anterior edge of the arch of the pubis where it divides into two crura. It consists of cavernous or erectile tissue, surrounded by a firm fibrous coat over which is an extremely sensitive tissue.
e. The Vestibule is a triangular space bounded on each side by the labia minora, below by the vaginal orifice, with its apex immediately below the clitoris. In the median line of this space, three quarters of an inch below the clitoris, is the meatus urimareus or urethral orifice, which appears as a dimple or pucker in the mucous membrane and serves as a guide in intro- ducing the catheter.
J. The Hymen is a circular or crescentic fold of connective tissue, covered by mucous membrane, which immediately sur- rounds the orifice of the vagina,
g. The Caruncule Myrtiformes are fleshy eminences found at the mouth of the vagina, the result of sloughing and cicatriza- tion after childbirth, and are not, as formerly supposed, the remains of a ruptured hymen.
h. The Fossa Navicularis is a depression formed between the hymen and fourchette, when the labia majora are drawn apart.
2. The Vagina is a musculo- membranous canal situated between the rectum and bladder, and connects the pudenda with
the uterus, It runs obliquely upwards and backwards, its
e glans, by to a
of the AVernous er which
each side
its apex , of this 1e meatus limple or yin intro-
onnective ely sur-
found at cicatriza- osed, the
ween the vn apart.
situated nda with ards, its
of the le and middle ommis-
ogous to commis-
OBSTETRICS. 3
anterior and posterior wal\s being in contact with one another. Its length is anteriuciy 24 in. and posteriorly 34 in.
The fornix or upper part encircles the cervix uteri, extending
higher on its posterior than its anterior aspect. It has three coats, mucous, muscular (consisting of circular and longitudinal
fibres) and fibrous. A circular bundle of muscular fibres sur- rounds the lower part and is called the sphincter cunne.
The mucous membrane is thrown into folds or transverse ridges which are well marked in virgins, especially on the anterior wall, but become obliterated in multipare and in old age.
II. INTERNAL.
1. The Uterus is a pear-shaped, thick-walled, hollow organ, flattened antero-posteriorly, convex behind, and plain in front.
® Tt differs in the virgin and in multipare. It consists of fundus,
body and neck ; measures 3 in. in length, 2 in. in breadth, and one inch in thickness. It weighs 1 oz. Its cavity is triangular and opens laterally into the fallopian tubes by orifices 1-25 in. in size.
The lower extremity or cervix projects into the vagina, and presents a transverse aperture called the os tincee, from its fancied resemblance to a tench’s mouth. The os is bounded by two thick lips, of which the anterior is longer than the posterior, The cavity of the cervix extends from the external to the inter- nal os, and its mucous membrane presents folds called the arbor
| vite, and contains a large number of giands called the follicles
of Naboth.
The peritoneum is reflected over the uterus, covering it anteriorly and posteriorly, meeting at the lateral borders and spreading to the ilia of each side, dividing the pelvis into two halves, and constituting the ligamenta lata, or broad ligaments. The round ligaments are two bands of smooth, muscular and elastic fibres, which extend first into the broad ligament, then |
4 OBSTETRICS.
pass outwards and forwards, enter the inguinal canal with the 2. epigastric artery, and are attached to the tissue of the labia the u majora. They were the former inguinal ligaments of the folds Wolffian bodies,
ting ¢
On the posterior surface the peritoneum descends over the ity 0 supra-vaginal portion of the uterus, and over that portion of the large vagina which covers the posterior lip of the intra-vaginal por- af
tion, then becoming continuous with the peritoneal investment One,
of the rectum, This forms a deep excavation between the uterus angl and the rectum, called the cul-de-sac of Douglas. eg The uterus possesses a large degree of mobility, and its posi- oe tion is largely influenced by neighboring organs: thus, a full tot bladder pushes the fundus backwards ; a full rectum pushes the 3 cervix forwards, etc. on € The muscular fibres of the uterus are arranged in three layers pro The superficial covers the back and front like a hood, leaving ant the sides free; the median layer forms the great bulk of the bor walls, the fibres being longitudinal and transverse ; while the of 1 ) inner layer is circular and insignificant. The mucous membrane one 4 measures 1-25 in. in thickness, is covered with an alkaline r i mucous and when slightly magnified presents the orifices of the ay : uterine glands which extend through the whole thickness of the Ve mucous membrane. The mucous membrane of the body of the | ‘e uterus is covered with ciliated epithelium producing a current bi | i towards the fallopian tubes. | a ; Hi The mucous membrane of the cervix is of a yellowish red ay color, firm, and presents ruge. It is covered with columnar ai \ epithelium, and tubular glands are present in large numbers, nm r the Nabothian follicles, ‘3 Hi The blood vessels to the uterus are the uterine from the la hypogastric and aorta, which pass over to the cervix and ascend of
to the uterus.
h the labia f the
r the of the 1 por- tment terus
posi- a full es the
ayers aving f the e the: brane caline of the f the f the rrent
1 red mnar bers,
the cend
OBSTETRICS. 5
2. The Fallopian Tubes pass outwards from the fundus of the uterus laterally. They are 3 to 4 in. long, contained in the folds of the broad ligament, and consist of the isthmus, admit- ting a bristle, the ampula admitting a sound, and a free extrem- ity or pavilion communicating with the abdominal cavity and large enough to admit a small goose quill. The free extremity is surrounded by 10 to 15 fimbrie all of which are free but one, which is larger than the others, and is attached to the outer angle of the ovary presenting a little gutter or furrow from the ovary to the opening of the tube. The fallopian tubes consist of a peritoneal, fibrous, muscular and mucous coat, the last arranged in folds and covered with ciliated epithelium, the direc- tion of the current being from the ovary to the uterus.
3. The Ovaries are two flattened, nearly ovoid bodies which lie on each side of the uterus, attached to the broad ligameut, and project from its posterior surface. They are about the size of an almond, 1} in. long, in. broad, and } in. thick. Their outer border next the broad ligament presents a hilum for the passage of vessels. The outer extremity is rounded and attached to one of the fimbriz of the fallopian tube.
The inner extremity is pointed and attached to the side of the uterus by the ovarian ligament.
Each ovary weighs 75 grains. The surface is marked by rounded translucent elevations produced by distended Graaffian follicles and often cicatrices and corpora lutea in various stages of atrophy.
Externally the ovary is surrounded by a fibrous coating called the tunica albuginea which is internally adherent to the subjacent tissues. Beneath this the parenchyma of the ovary is divided into a cortical and medullary substance. The medul- lary substance is reddish and spongy and contains an abundance of blood vessels.
The cortical portion is of a grayish color and consists of lay-
6 OBSTETRICS,
ers of connective tissue continuous with the medullary portion,
and imbedded in this layer is a multitude of Graaffian follicles.
The Graafian Follicles contain the ova, and at certain periods they enlarge, approach the surface of the ovary, and finally rvp- ture, discharging their contents, which are carried by the vortex into the fimbriated extremity of the fallopian tube. These fol- licles exist only in the cortical substance of the ovary where they number several thousands, some of which never reach maturity. Though they exist from the earliest period of childhood, and even before birth, yet it is only at the age of puberty that the important stage in their development is noticed. Then from 12 to 30 of them enlarge, so that at that period we have all sizes between the smallest primordial follicle 1-800 in. and the largest nearly } in. in size. In the fully sized follicles we have fully developed ova, one or very rarely two, of the pretty uniform diameter of 1-125th of an inch.
In the largest follicles then we have an outer layer of connec- tive tissue called the tunica propria, which islined with epithelial cells called the membrana granulosa, and at a certain point in this membrane is a mass of cells called the discus or cumulus proligerus in which the ovum is embedded.
The follicle also contains a liquid which is alkaline, slightly yello. 1, not viscid, and containing a small quantity of album- inoid matter coagulable by heat.
The Parovarium or organ of Rosenmiiller is the remains of the Wolffian body tying in the folds of the broad ligament between the ovary and the fallopian tube. It consists of from 12 to 15 tubes of fibrous tissue lined by ciliated epithelium and is often the seat of so-called Parovarian cysts.
The Germ Cell or Ovum when ripe is 1-125 in. in size, glob- ular in shape and consists of :—
(a). Zona Pellucida, or external membrane, clear, structure- less, strong and resisting, 1-2,500 in. in thickness. This with
connec- vithelial int in umulus
slightly album-
ains of yament of from m and
glob-
cture- 3 with
OBSTETRICS. 7
radiating striations becomes the vitelline membrane. — In fishes and molluscs there exists a micropyle or porus for the passage of the spermatozoa, and though this has not been demonstrated in the mammalia or in man, it probably exists.
(6). The Vitellus, c lled tne principal or formative yolk, contains the elements which are to undergo development into the embryo. It is a semi-fluid mass containing besides the ger- minal ve-%cie, numerous granules which are large strongly- refracti::. .‘obular bodies, very bright ; and between these are
smaller and not so distinct albuminous granules.
(c). The Germinal Vesicle is the enlarged nucleus of the primordial ovum, and is clear, globular, 1-700 in. in size, em- bedded in the vitellus, its position varying. In its interior are a number of fine granules and a large dark spot,
(d). The Germinal Spot, which is 1-3,000 in. in size.
ITI. PERIODICAL OVULATION.
1. The Discharge of the Ovum. A ripe Graaffian fcl- licle about 2 5 in. in size presents a rounded elevation with en- larged blood vessels upon the surface of the ovary, and at the most prominent portion is an ovoid spot which is entirely free from blood vessels, called the macula folliculi, where for a time before rupture a process of fatty degeneration is going on. At
' the same time at other portions of the follicle there is a growth
of cells which projects into the interior, as well as an extension of blood vessels in the form of loops. These changes, together with the increase in pressure of the liquid contained in the fol- licle, causes the latter to burst, and with the liquid the discus proligerus and ovum are expelled.
The periodical ripening of the ova and their discharge consti- tutes “ovulation ” and may be considered as the primary act of reproduction. It is necessary to bear in mind then tl it the ova exist originally in the ovaries as part of their natural struc-
8 OBSTETRICS.
ture ; that they only become fully developed at a certain age,
viz: that of puberty, when the generative function is about to be established ; that successive crops of these ova ripen and are discharged in the adult female independently of sexual inter- course. Furthermore the ripening and discharge of the ovum are acconipanied by a peculiar condition of the general system known in the lower animals as “rutting” and in the human female as menstruation.
2. Menstruation. During infancy and childhood the sex- ual system is inactive, but at the age of 14 or 15 the human female undergoes a remarkable change and arrives at what is termed the age of puberty. There is then a marked increase in the
general development of the body ; the limbs become fuller and more rounded ; a growth of hair appears upon the mons veneris ; the mammary glands increase in size and take on a new stage of development ; Graaffian follicles enlarge and appear ready to rupture. At this time is also noticed a change in the moral as welPas the physical attributes of the female ; a seeming consci- ousness of a capacity for new functions and a change in feeling towards the opposite sex which gives rise to that modesty so becoming and lovely in the true woman.
The female now becomes capable of impregnation and con- tinues so, in the absence of pathological conditions, until the final cessation of the menses, known as the menopause or climac- teric which usually occurs at 45 years of age. Puberty occurs earlier in warm than cold climates, and its onset is SREY in some girls than in others.
Together with these changes then in the female at puberty a discharge or flow from-the genital organs is established, and this recurs every 28 days, corresponding to the period of dis- charge of the ovum. Each period begins with a feeling of gen- eral malaise, a sense of fulness and weight in the pelvic organs, and an increase of vaginal mucus, which has a peculiar fishy
im odour
whic an avé ally l¢
mem|
smeal 1-51 enlar: mem Exce true tion
tain age, §
bout to and are al inter- e ovum 1 system e human
the sex- n female s termed e in the ller and veneris ; bw Stage ready to moral as g consci- n feeling lesty so
nd con- ntil the ‘ climac- y occurs rlier in
puberty ied, and of dis- of gen- organs, r fishy
® lation.
| time impregnation is most apt to, take place.
= menstruation and usually removes sexual desire. when disvharged from the ovary enters the fimbriated extremity
OBSTETRICS. 9
odour. These feelings are soon relieved by a discharge of blood which is usually kept fluid by the acid vaginal mucus. It lasts on anaverage four days, and measures about 6 oz., becoming gradu- ally less in amount, and lighter in color until it stops. The mucous membrane of the uterus at this .ime is thicker and softer and smeared with blood. From the 1-25 in. in thickness it becomes
1-5in. thick, loosely attached, tirown into folds, and its glands
enlarge. A fatty degeneration of the surface of the mucous membrane and of its blood vessels gives rise to the hemorrhage. Except a considerable desquamation of epithelium there is no true exfoliation of the mucous membrane in normal menstrua- tion although there is in membranous dysmenorrhea.
The process of menstruation may be thus explained: An ovum ripens; the swelling of the Graaffian follicle irritates
# the nerve termini in the ovary, which irritation is propagated
to the central organs. Through reflexes by vaso-motor pro- cesses an arterial congestion of the internal female sexual organs
is set up. This in turn increases the liquor folliculi, so that the theca folliculi bursts and allows the ovum to escape,—ovu-
At the same time the uterine mucosa becomes so hyper- emic that there occurs a bursting of the peripheral vessels, hemorrhage occurs upon the surface of the uterine mucous mem- brane, constituting menstruation. It is immediately after the menses that sexual desire is decidedly marked and at this As we should naturally expect removal of the ovaries prevents ovulation and The ovum
of the fallopian tube, the fimbrie being covered with vibratile ciliated epithelium, inciting a kind of vortex in the peritoneal
§ fluid which carries toward and into the tube everything lying
near it. Thisis seen experimentally in the lower animals with coloring matter which is even drawn from one side to the other
;when the opposite tube is occluded. The ovum then passes
10 OBSTETRICS.
along the tube to the uterus by the movement of the ciliated epithelium. Accidental causes may arrest it at the surface of the ovary, and if impregnated, give rise to ‘ovarian preg- nancy ;” if it drops into the abdominal cavity, we have “abdominal pregnancy,” or i. arrested in the fallopian tube, “ tubal pregnancy.”
If sexual intercourse do not take place the ovum passes down §
to the uterus unimpregnated, loses its vitality after a short time
and is carried away with the uterine discharges. The menstrual § flow is therefore only the external manifestation of a more §
important process taking place within. Its disorders constitute amenorrhea, dysmenorrhea. and menorrhagia.
3. The Corpus Luteum. Let us see now what takes place
in the Graaffian follicle after the expulsion of the ovum. Its § office of providing for the formation and growth of the ovam is §
now over and it passes through a process of oblitccation. The
bloody cavity left becomes converted into a peculiar svulid spher- oidal body called the corpus luteum, the growth and retroces- sion of which are modified by pregnancy, 30 that we have two varieties, that of menstruation and that of pregnancy.
(a). The Corpus Luteum of Menstruation, often called the false corpus luteum. After rupture, blood fills the cavity of the Graaffian follicle and soon coagulates. This begins to con- tract and the serum separates from the clot and is absorbed, while the clot becomes smaller and denser, and its coloring mat- ter becomes partially absorbed. At the same time the vesicular membrane becomes thickened and convoluted, beginning at the deeper part of the follicle. This hypertrophy reaches its maxi- mum at the end of three weeks, and the ruptured follicle has now become completely solidified, showing a prominence upon the ovary and a minute cicatrix. After -this it diminishes in size, its central coagulum continues to be absorbed, loses still .its coloring matter, and the whole goes on atrophying. The
| lute
deve uter men
he ciliated surface of rian preg- we have bian tube,
sses down §
short time
menstrual § bf a more &
constitute
akes place
vum. Its § le OVam is §
ion. The vlid spher- d retroces-
have two
called the cavity of ns to con- absorbed, ring mat- > vesicular ing at the its maxi- ollicle has ence upon nishes in loses still ing. The
OBSTETRICS. ll
convoluted wall assumes a more decidedly yellow color, under- goes fatty degeneration and at the end of eight or nine weeks the whole is reduced to an insignificant yellowish cicatricial mark, and finally all traces of it disappear. At a post mortem several of these may be seen in various stages of growth and atrophy. |
Such then is the process that takes place independently of sexual intercourse or impregnation.
(b). The Corpus Luteum of Pregnancy. The true corpus luteum presents a difference in the rapidity and degree of its development, due to the sympathy which exists between the uterus @ .’ the ovaries. As soon as pregnancy takes place menstruation is arrested, no “ore ova come to maturity and no more Graaffian follicles are ruptured during the whole period of gestation. Hence we might expect that the corpus luteum would be affected by an influence which affects the system in general so profoundly.
During the first three weeks its growth is the same as the false variety, but during the fourth week instead of retrograd- ing it continues developing, the external wall growing thicker and more convoluted. This growth goes on until by the third and fourth month it reaches its maximum, about the sixth month it begins to retrograde, and after delivery atrophy goes on rapidly, and after lactation has come to an end the ovaries
resume their ordinary function as before. \
IV. FACUNDATION OF THE OVUM.
The last change and one which indicates its complete maturity, is, that the germinal vesicle comes to the surface and disappears from view, as also the germinal spot. In place of the germinal vesicle a spindlc-shaped body appears. The granular elements
| of the vitellus arrange themselves around each of the two poles
of the spindle in the form of astar. When this takes place the
peripheral pole of the nucleus or altered germinal vesicle, along
12 OBSTETRICS.
with some of the cellular substance of the ovum, protrude upon Th the surface of the vitellus, where they are nipped off from the §@ or not ovum in the form of small corpuscles jus; like an excretory pro- # tain { duct. These bodies, which are not made use of in the further #§ and o development and growth of the ovum, are called polar or direct- 1. ing globules. The remaining part of the germinal vesicle stays 7 j,; the within the vitellus and travels back towards the centre of the & ,itell. ovum to form the female pronucleus. As a rule only one sper- & the c: matozoon penetrates the ovum and as it does so it moves @ 4 Jars towards the female pronucleus while its head becomes surroun- and i ded with a star; it then loses its head and tail, the latter only J ance, serving as a motor organ while the remaining middle piece MH dence swells up to form a second new nucleus, the male protonucleus. 2. The union of these two elements forms the first embryonic seg- @ ., gm mentation sphere or blasto-sphere. (Landois). 32, Should union of the sexes have taken place by the fusion of polys the germ cell and sperm cell, a new stimulus is imparted to the & being
growth of the former, and the fecundated ovum starts on a peculiar course of development by which it is rae converted into the body of the young animal.
covel vitel
T
Many questions of great interest arise in connection with fj #bou fecundation such as hereditary influence ; maternal influence; J 20°
the Ba CCl
determination of sex, and effect of previous pregnancies,
V. DEVELOPMENT OF THE OVUM.
It is probable then that the ovum is fecundated either in the fallopian tube or in the pavilion near the ovary. The ovum as it passes down the fallopian tube becomes covered with an albuminous secretion which in birds is very abundant and con- stitutes the “ white of egg.” This serves to protect and nourish the ovum for a short time, and if the spermatozoa have not pene- trated the vitelline membrane near the ovary, it prevents their doing so now.
ide upon @ from the §
ory pro- p further br direct- cle stays re of the one sper- it moves surroun - tter only dle piece pnucleus. onic seg-
fusion of ed to the arts on a converted
ion with influence ; 8,
her in the 2 ovum as
with an ; and con- id nourish not pene- ents their
OBSTETRICS. 13
The next thing noticed, whether the ovum has been fecuncdated or not, is that the vitellus gradually withdraws itself from cer- tain portions of the vitelline membrane or becomes deformed and often rotates upon itself by amceboid motion.
1. We have said the sign of complete maturity of the ovum is the disappearance of the germinative vesicle. The deformed vitellus resumes its original rounded appearance and again fills the cavity of the vitelline membrane. The granules collect in a large zone around the centre of a clear spot in the vitellus and in the centre itself a clear rounded body makes its appear- ance, called the nucleus of the vitellus. This is positive evi- dence of fecundation:and appears at from 15 to 30 hours.
2. Segmentation ofthe Vitellus. Almost immediately, segmentation takes place, the vitellus dividing into 2, 4, 8, 16, 32, 64, etc., until the whole forms an external membrane of polygonal cells containing a small quantity of fluid, the former being called the blastodermic membrane. The albuminous covering of the ovum gradually liquifies and is absorbed by the vitelline membrane for the nourishment of the vitellus.
The ovum now passes from the fallopian tube into the uterus about the eighth day after fecundation, having increased in size about 5 times, and being now composed of an external covering, the vitelline membrane, then the blastodermic membrane, and
| a certain amount of fluid in its interior.
Soon after the formation of the blastodermic membrane, at a certain point on its surface appears a rounded elevation or heap of cells called the embryonic spot which soon becomes elongated or oval, is then surrounded by a clear oval area called the area pellucida, with a dark line in its centre called the primitive trace. The latter afterwards becomes the headfold and groove for the neural canal.
Next the blastodermic membrane separates into two layers, an external or .serous called the epiblast, and an internal or
14 OBSTETRICS.
mucous called the hypoblast. The layers thicken at the prim- itive groove and by elevation of ridges and their union posteri- orly canal for the spinal cord is formed. th Sees
At. » same time another layer is fox med from the inner sur- face of the 6xternal layer, and the adjoining surface of the inter- nal layer, called the mesoblast. From the epiblast are devel- oped the epidermis and its appendages, the great nerve centres, the principal parts of the eye, ear, nose aud one layer of the |
amnion.
From the hypoblast are formed the epithelial lining of the whole alimentary canal and of the lungs, and one layer of the allantois. From the mesoblast are formed the bones, muscles, § fascie, peripheral nerves, vascular system, connective tissue, muscular coat of the alimentary canal, the outer layer of the amnion, and the other layer of the allantois.
3. The Formation of the Membranes. As the ovum is received into the uterus the vitelline membrane developes upon its surface little villosities formed of amorphous matter with granules, but non-vascular, and not permanent, merely | assisting in fixing the ovum to the uterine cavity.
At this time a fold of the external layer makes its appearance, most prominent at the cephalic and caudal extremity of the neural canal, which gradually increases, passing over the dorsal surface of the embryo, and finally meets so as to completely enclose the embryo ; and this is called the amnion. When it has been completely formed, the vitelline membrane has been encroached upon by the external amniotic membrane and 4is- appears, leaving this layer of the amnion as the external cover- ing of the ovum which still possesses non-vascular villosities,
Soon after the development of the amnion, the allantois is formed, before the two layers of the amnion have fused, It appears as a small pear-shaped vesicle which springs from the mucous layer near the caudal extremity of the embryo, It rap-
the prim- bn posteri-
inner sur- the inter- are devel- e centres, yer of the
ng of the yer of the
8, muscles, §
ve tissue, yer of the
3 the ovum developes us matter
at, merely |
ppearance, ity of the the dorsal sompletely When it ) has been e and dis- nal cover- losities. Jlantois is fused, It | from the
. Tt rap-
# suspended the embryo.
speci BP, 9
OBSTETRICS. 15
idly increases until it forms a membrane of two layers situated between the two layers of the amnion. It becomes vascular and very soon encloses the internal layer of the amnion and the embryo. Then the two layers of the allantois blend into one, invade, and supercede the external layer of the amnion, becoming now the external layer of the ovum and called the chorion. That portion of the allantois included in the embryo forms the bladder and is connected for a time with the rest of the allantois
@ by the urachus.
The allantois is a vascular membrane, at first containing two arteries and two veins. The arteries persist and form the two arteries of the umbilical cord, but the right vein becomes oblit- erated, the left remaining as the umbilical vein. These vessels are connected with the permanent vascular tufts of the chorion.
While this is going on the blastodermic vesicle becomes divided into .wo parts, the lower being embryonic, the layer above forming the wmbilical vesicle which is cut off as it were from the abdominal cavity, but still communicates freely with the intestine. It gradually diminishes as the embryo increases and becomes farther removed from the embryo by elongation of its pedicle and finally becomes compressed between the amnion and chorion.
The chorion now becomes marked by a multitude of compound villi over its whole surface which gives it a shaggy appearance. The amnion is separated from the chorion by a gelatinous layer in which is embedded the umbilical vesicle, but the former gradually disappears until about the fourth month the amnion comes in contact with the internal surface of the chorion, when. it forms a lining for the chorion and secretes a fluid in which is The amniotic fluid consists of water, albumen, urea and various salts, and has great power of resisting putrefaction. The uses of the liquor amnii are to facilitate the
devalopment and maintain the form of the ovum and uterus; to protect the embryo from pressure aud lessen thks influence of
ee
ee eee IDES Sg SO
16 OBSTETRICS.
falls, blows, and other accidents to the mother ; to facilitate the growth of the foetus and allow of its active motions ; to aid the dilatation of the os uteri during labor, and after the membranes are ruptured to favor relaxation of the vagina and perineum, thus facilitating the passage of the child and the easier perfor- mance of obstetric operations.
The amnion then gradually becomes distended by increase in the quantity of amniotic fluid and reaches the internal surface of the chorion about the end of the fourth month, and extends § over the umbilical cord to form its external covering.
4. Preparation ofthe Uterus to receive the Ovum. As the fecundated ovum enters the uterus, being shaggy with the villosities of the chorion, it becomes engaged in one of the furrows of the hypertrophied mucous membrane of the uterus. The hypertrophied mucous membrane lining the uterus is called § the decidua vera, and the new growth springing from the border of the furrow in which the ovum is received is called the decidua reflexa, because it folds over and finally envelopes completely | the ovum. That part of the decidua vera which afterwards becomes the placenta is called decidua serotina.
These changes do not take place in the mucous membrane of the cervix uteri, the glands there secreting a semi-solid trans- parent viscid mucus, which closes the os and is called the uterine
plug.
Afterwards both decidua vera and reflexa diminish in activity of growth, and lose their importance as 2 means ot nourishment for the embryo, while that part in contact with the vascular tufts of the chorion continues to grow and finally takes part in the formation of the placenta. |
5. Formation of the Placenta. Our knowledge of the development and structure of the placenta is derived largely from its study in the lower animals.
litate the
to aid the embranes perineum, ier perfor-
y increase nal surface
e Ovum. aggy with ne of the he uterus,
the border he decidua
completely }
afterwards
mbrane of olid trans- the uterine
in activity urishment > vascular 68 part in
wledye of ed largely
d extends §
s is called &
OBSTETRICS. 17
The villi of the chorion all atrophy except at that part which is to become the placenta. These villi penetrate into the fol- licles of the uterine mucous membrane and become developed into a tufted capillary loop. At the same time the uterine fol- licle into which the villus has penetrated enlarges, sending out branching diverticuli corresponding to the ramifications of the villus, Every uterine follicle is soon covered with a network of dilated capillaries, which enlarge, and encroaching upon the spaces between them, fuse and become dilated into sinuses which communicate with the arteries in the muscular wall of the uterus, the sinuses extending through its whole thickness. The vascular tufts of the chorion still grow outwards and extend through the entire thickness of the placenta. By and bye the four membranes fuse into one, viz: the membrane of the fetal villus, that of the uterine follicle, the wall of the foetal blood- vessel and the wall of the uterine sinus. So that the tufts of the foetal blood-vessels are bathed in the blood of the maternal sinuses, by which means both absorption and exhalation go on, but there is no direct communication.
At the end of the third month the limits of the placenta hecome distinct and the organ soon becomes fully developed. At the full period it occupies nearly one third of the uterine mucous membrane, is round or ovoid with thin edges, measures 7 to 9 in. in diameter and weighs from 15 to 30 oz.
Its foetal surface is covered with smooth amniotic membrane and its uterine surface is rough and divided into irregular lobes
or cotyledons separated by dissepiments.
The uterine arteries enter the maternal sinuses obliquely, so that when the uterus contracts after delivery and expulsion of the placenta these vessels are more completely closed by the muscular contraction.
The functions of the placenta are :—es a respiratory organ
it provides for the interchange of gases between the fcetal and 3
18 OBSTETRICS.
maternal blood ; as an organ of nutrition the epithelial cells of the foetal villi possess a selective power and absorb nutri- ment, and it is in this way that medicines are absorbed and zymotic diseases communicated; while as an excretory organ, urea is eliminated so that it discharges the function of the kidneys, and lastly it possesses a glycogenic function until the liver is sufficiently developed to undertake that work.
. Lhe Umbilical Cord. The attachment of the embryo to the investing membranes of the ovum is at first a short and wide funnel-shaped connection, consisting of the .commencement of the chorion, part of the amnion, and between the two a gela- tinous material containing the stem of the umbilical vesicle. As the amniotic cavity enlarges the embryo recedes and its connecting part elongates, beginning to present the appearance of a cord, and as it emerges from the embryo at a point where the abdominal walls afterwards close round it to form the umbilicus it is called the umbilical cord. The fully developed cord is about the thickness of the finger, about 20 in. long, its external covering being the amnion, beneath it a gelatinous layer, the gelatine of Whorton, which surrounds the two arteries and vein protecting them from compression or obliteration. The arteries are twisted round the vein, and the cord itself is often twisted. The cord also contains the relic of the umbilical vesicle and the urachus, which is the connection between the allantois and bladder.
The decidua reflexa is being constantly distended by the growth of the ovum, and is finally pressed against the opposing surface of the decidua vera, so that by the end of the seventh month they are in contact and soon blend so as to form a single thin friable semi-opaque layer in which no trace of glandular structure can be discovered.
During the process of development then the product of fecun- dation is nourished, first as an ovum by the albuminous secre-
tion ¢
by th
1. calle calle place a foe!
TI taine inal
ial cells D nutri- bed and y organ, of the ntil the
p to the nd wide ment of ba gela- vesicle.
and its pearance t where brm the pveloped long, its latinous arteries eration. itself is mbilical een the
by the pposing seventh a single andular
f fecun- 8 secre-
OBSTETRICS. 19
tion on its surface, then by the ‘umbilical vesicle ; as an embryo by the villi of the chorion, and as a foetus by the placenta.
VI. DEVELOPMENT OF THE EMBRYO.
1. Of its Various Parts. The product of fecundation is called an ovum until some form becomes apparent, and then it is called an embryo, and after the third month, at the time the placenta has formed and quickening is about to occur, it is called a foetus and retains that name until delivery.
The bladder is formed from that portion of the allantois con- tained in the abdominal cavity after the closure of the abdom- inal plates. |
The intestine is at first « straight tube and becomes convelu- ted. The anus is at first closed. The liver buds from the intestine.
The front of the upper part of the body is open and develops by four arches, the first forming the face and bones of the ear, the second and third forming the hyoid bone and parts adjacent, while the fourth forms the larynx. At first the face is open as far back as the ears, and cleft palate is thus caused by a defici- ency in the union of the lamelle which form the palatine arch.
The genital and urinary organs are preceded by two large symmetrical structures called the Wolffian bodies, which at about the 30th day develop rapidly at each side of the spinal column and are as large as to almost fill the cavity of the abdomen. Very soon two ovoid bodies appear at their side, the testes in the male, the ovaries in the female. At the external border are two ducts, one of which in the male becomes the vas defer- ens and in the female the fallopian tube. The kidmeys are behind and until they are fully developed their office is under- taken by the Wolffian bodies. The scrotum corresponds to the
v
labia and hence inguinal shernia in the female passes down into the labia.
20 OBSTETRICS
2. Asa Whole.—V/irst Month (4th week). Its length is 4 lines, weighs 20 grains, size of a maggot or barley corn, and the form of a serpent coiled. The mouth on the cephalic extremity appears as a cleft, and the eyes as two black points. Nipple-like protuberances mark the position of the extremities.
The heart can be seen and the liver is disproportionately large.
Second Month (8th week). It measures 15 to 18 lines and weighs from 2 to 5 drachms. Is the size of a kidney-bean. The head is disproportionately large. The nose, lips and exter- nal parts of generation are visible, The anus appears as a dark point. The abdomen encloses the internal organs. The extrem- ities project slightly from the trunk. Ossification occurs in the clavicle and lower jaw about the end of the seventh week ; in the frontal bone and ribs, towards the end of the eighth week.
Third Month (12th week). It measures 2 to 4 inches and weighs 1 to 2 ounces. The eyes and mouth are closed, the fingers well separated, the nails recognizable, the sex can be detected by the aid of a lens, the supra-renal capsules and thy- mus gland are formed, the cavities of the heart and divisions of the hrain are distinct, the placenta is isolated, the umbilical vesicle, allantois, etc., have disappeared, and the membranes are larger than a goose egg.
Fourth Month (16th week). It measures 5 to 6 inches and weighs from 2} to 3 ounces. The skin is rosy and tolerably
dense, the sex is seen without the aid of a lens, the mouth is |
large and open, the umbilicus is near the pubis, the large intes- tine contains a greyish white meconium, and the muscles pos- sess contractility.
Fifth Month (20th week). It measures 10 to 11 inches and weighs from 6 to 10 ounces. From the fifth month on the length of the foetus is approximately exactly double the number of lunar months. ‘The nails are distinct, the head, liver, heart
hod Sis ae RD PAO ee a, Tees A\ ine eee.
ngth is rn, and ephalic points. emities. ionately
nes and ey-bean. d exter- is a dark b extrem- rs in the eek ; in th week. ches and sed, the kK can be and thy- risions of umbilical ‘anes are
ches and
tolerabl} mouth
ge intes- cles pos-
ches and . on the
number er, heart
OBSTETRICS.
and kidneys are disproportionately large. Hair appears as a light down, meconium is of a yellowish-green color, and points of ossification appear in the pubis and os calcis.
Siath Month (24th week). It measures 12 inches and weighs 1 to 2 pounds. Down and sebaceous matter cover the skin, the skin is of a cinnabar red color and the umbilicus is further from the pubis, the meconium is of a darker color, the scrotum is empty, the testes being close to the kidneys, the pupillary mem- brane is still present and the prepuce has appeared.
Seventh Month (28th week). It measures 14 inches and
weighs 3 to 4 pounds. The skin is of a dirty red color, the hair is half an inch long and plentiful, the pupillary membrane is disappoaring, the eyelids are non-adherent, meconium is of a dark olive-green, the fontane’ies are distinctly felt, the liver is still large, and the foetus is now ‘ viable,” j. e., capable of main- taining a distinct existence from the mother.
Eighth Month (32nd week). It measures 16 inches and weighs 4 to 5 pounds. The skin is more of a rosy flesh color and is covered with soft hair, the pupillary membrane has dis- appeared and the testes have descended into the scrotum. The open vulva disclose the clitoris to view. The nails almost reach the tips of the fingers, the eyelids are open and the cornea is transparent.
Ninth Month (36th week). It measures 18 inches and weighs 6 pounds. The head is covered with hair, the down on the body is disappearing, the scrotum is corrugated and the vulva closing.
Tenth Month (40th week), nine calendar months. It measures 20 inches and weighs from 7 to10 pounds. The skin is firm, not wrinkled, the fontanelles are large, hair on head, the nails are hard and reach the tips of the fingers, and the cartil- ages of the ears feel elastic. The true sign of complete maturity is the appearance of a centre of ossification in the inferior
22 OBSTETRICS.
extremity of the femur; this may be of use in medico-legal rule cases to determine the maturity of a dead child. To find it si. make a horizontal incision through the knee joint, remove the the patella and make thin slices until a colored point is found, and inte still carefully slice, until a red spot is noticed. This osseous mel nucleus measures from # to 3 lines in diameter. atte J
B.—PREGNANCY. ss
I. CHANGES OCCURRING IN THE MOTHER. [§ 2" 1. Inthe Sexual Apparatus. The wterws increases in Si vascularity, the arteries increasing in size and becoming tor- me tuous. The veins dilate and become intimately united with the ‘hie
_ walls of the uterns. The mucous membrane becomes soft and thickened, and the muscular fibres increase in size and amount. The uterus increases in weight from 1 ounce to 2 pounds. At first this increase is %t due to expansion of the ovum, for the same change occurs duriny the first four months in extra-uterine pregnancy ; later on, however, it is due to expansion from pres- | sure of its contents. In the early months of pregnancy the | increase of the size of the uterus is in the antero-posterior and lateral, rather than in the longitudinal diameter, so that it is not until the fourth month that the fundus can be felt through the abdominal wall above the symphysis pubis. At the fifth month it fills the hypogastric region, and at the ninth month it reaches the epigastrium. During the lart two weeks it sinks in the pelvis.
The cervix also hypertrophies, but its development is com- | pleted by the fourth month and is the result rather of loosening of its structure and swelling from serous infiltration due to hyperemia. An apparent shortening of the cervix takes place, which was thought to be due to a gradual unfolding from above downwards, as the uterine cavity enlarged ; but no real shorten- ing takes place, however, for the internal os remains closed, as a
osseous
amount. ds. At , for the a-uterine om pres- ancy the rior and that it is through the fifth month it it sinks
is com- posening due to 28 place, m above shorten- ed, as a
OBSTETRICS. 23
rule, up to the last two weeks of pregnancy, and the apparent siortening of the cervix is due to a spindle-shaped dilatation of the cervical canal causing an approximation of the external and internal orifices, and also to the swelling of the vaginal mucous membrane, and of the loose tissue surrounding the vaginal attachment of the cervix.
In the vagina, the muscular fibres hypertrophy, the veins increase and give it a blue color, the mucous membrane thickens and secretes more mucus, and there is thus often a pouting or protusion of the anterior vaginal wall between the vulva.
The vulva are turgid and the labia gape, the abdominal walls stretch, the navel protrudes, the linea albicantes appear and these are also often seen on the thighs.
The mammary glands increase in size, the nipple elongates, and changes occur in the areola. The capacity of the bladder is diminished from pressure and there is increased freouency of urination. Constipation is common, cramps in the legs are fre- quent from pressure on the sacral nerves, and cedema of the legs and varicose veins are common.
2. In the System at Large. There is an increase in the total quantity of blood. The red blood corpuscles, albumen, iron and salts are diminished, while the white blood corpusctes, the elements of fibrin, and the water of the blood are increased. As the amount of blood is increased the balance of the circulation would require either increased frequency of the heart-beat or increased capacity of the ventricles. Now as freque.-vy is not increased the dilatation of the cavities is necessary. So also arterial tension is increased and the pulse is fuller. As the heart then has to do more work, eccentric hyertrophy of the left ventricle takes place.
Then the thyroid gland enlarges, there is an increased amount of © O, discharged by the lungs, the thorax is increased in breadth and diminished in depth, the breathing is often oppressed, indigestion is frequent, especially nausea and vomit-
94 OBSTETRICS.
ing, due to spasmodic contraction of the stomach and diaphragm ; the appetite is capricious. Besides pigmentation of the areola, often dirty brown looking spots or patches appear on the face, especially the eyelids, root of nose and upper lip.
Increased blood pressure causes abundant and watery urine.
The nervous system is very impressionable ; the whole character |
is changed, neuralgic affections are common, the special senses are otuun disordered, and there is often dizziness and syncope.
IIl.—_THH SIGNS OF PREGNANCY.
In the ear'y periods of pregnancy no decided diagnosis can be made, but as it advances it is not long before certain phenora- ena clearly show the presence of theembryo. The signs of prez- nancy then become a part of every physician’s outfit to be used as a means of differential diagnosis for the satisfaction of him- self and his patients; for there are several diseases of the uterus and its appendages, and of contiguous abdominal organs which it is essontial to distinguish from pregnancy.
1. Cessation of the Menses. In married women, if pre- viously healthy, this is a positive sign. In newly married versons menstruation is often very irregular, so that they may miss a period and yet not be pregnant. Cases again occur rarely where menstruation goes on during pregnancy, but it is scanty,
‘comes from the cervix and is likely to be hemorrhagic and fre-
quently results in abortion.
When conception occurs immediately before the menses it
frequently does not arrest the discharge though it usually diminishes the amount.
All the causes of amenorrhcea must be borne in mind.
2. Mammary Sympathies. Ata very early period of pregnancy the breasts become full and sensitive and tender. The superficial veins become larger, and visible under the skin,
sand p
Toward from th plasemé
Then shert a inent, 4 develoy darken
becomé¢
3. the cor ment ¢ the hy womal and oO clothe: any 8'
Suk ment the w ulatio
ragm ; reola, face,
urine,
racter |
senses pe.
can be enoya- f p res- e used f him- uterus which
if pre- larried y may rarely canty, ad fre.
ses it sually
OBSTETRICS. 25
Towards the seventh month a serous or milky discharge exudes from the nipples. These changes, however, may occur in dis- placements and uterine tumors.
Then after fecundation, the nipple, which in the virgin is shert and the areola pink, becomes turgid, enlarged, and prom- inent, and its colorv deepens owing to increased vascularity and development of the lactiferous tubes. The areola enlarges, darkens from deposit of pigment, and becomes elevated, soft
j and puffy. The sebaceous follicles of the areola also enlarge and
become prominent.
3. Abdominal Enlargement. After conception and the consequent uterine development there is a gradual enlarge- ment of the whole of the lower part of the body, not merely of the hypogastric region, but also of the sides and nates. The woman is conscious of a sense of fullness, weight and pressure, and often. perceives an increase in the size of the waist, her clothes become too tight and oppressive even before she notices any swelling in the abdomen.
Subsequently the distension is proportionate to the develop ment of the uterus, much depending on the size and height of the woman, her degree of emaciation or obesity, gaseous accum- ulations in the bowe!s, diseases of liver or spleen, tumors, dropsy, deformity, quantity of liquor amnii, size of child, or multiple pregnancy. sa
The enlargement of the abdomen from pregnancy might be mistaken for other conditions :—
(a). Distension from retained Menses. Here the previous his- tory an‘ the presence of imperforate hymen or atresia of vagina or uterus would show what it was. The existence of a pelvic tumor in a girl who has never menstruated will of itself give rise to suspicion, as pregnancy under such circumstances is of extreme rarity. ‘lhen general symptoms will be found to have existed for a longer period than if pregnancy were
26 OBSTETRICS.
present, such as periodic attacks of pain at the menstrual periods. There will also be absence of mammary changes and other signs of pregnancy.
(b). Uterine and Ovarian Tumors. Menstruation does not cease in ovarian disease and is usually increased in fibroids. Then the character of the tumor, fluctuation in ovarian tumor, and the hard nodular masses in fibroid, the history of the case, the length of time, the absence of cervical softening and auscultation. There is great difficulty when these growths are complicated with pregnancy.
(c). Tympanitis, or “ Phantom Tumor,” is recognised by the percussion-note and the absence of uterine tumor, as demons- trated by placing the hand on the abdomen and directing the patient to make alternate deep inspirations and prolonged expi- rations. During each expiration press the hand more firmly, until by and bye the hand feels the spinal column and no intervening body. ) ,
In some cases it is of advantage to put the patient under chloroform.
4. Ballottement. Is a manipulation by which the foetus may be felt floating in the fluid contents of the uterus.
The patient lying upon her back, introduce one or two fing- ers of one hand up to the anterior fornix of the vagina, at the same time steadying the uterus outside by the other hand. Then by a sudden impulse of the fingers against the anterior part of the uterus above the cervix the foetus is felt like a ball floating loosely in a bag of water. When distinctly felt this is a positive sign of pregnancy.
5. Quickening. This sign, which simply means the move-
ment of the foetus as felt by the mother, is the first satisfactory § proof that she is pregnant with a living child. It usually |
occurs at four and a half months, but may be earlier or as late
as the fifth month. The first sensation is trifling and is often
S describ
liar, su the ha motions pation, The wo tions O gastric muscle: those o
(a).
detect
o child is
groin 0 the firs not de ing pr tation
(d). or bel mothe as for is belli erecti of bl Hence vous, uteru wher
nstrual ges and
oes not fibroids, tumor, of the ing and ths are
l by the emons- ing the pd expi- firmly, and no
wt under ie foetus
wo fing- , at the r hand. interior © a ball t this is
e move- sfactory § usually | as late | is often |
OBSTETRICS. 27
= described as like flatulence, but more frequently as being pecu- liar, sudden, vibrating or like the fluttering of a bird held in
the hand. As pregnancy advances the intervals of these motions become shorter, and the sensations more decided. Pal- pation, especially with a cold hand, often detects motion. The woman may be deceived by flatulence, corpulency, pulsa- tions of abdominal aorta, impulse of the heart felt in the epi- gastric region, aneurism, or irregular action of the abdominal muscles ; so it is better to trust to your own senses rather than those of the patient.
6. Auscultation. This may be direct or indirect and by it we may detect :— .
(a). Pulsations of the Fetal Heart. We can in this way detect the rhythm, strength and frequency. The average beat is ra per minute, and it is best heard when the dorsum of the child is anterior, and is most frequently heard bes+ ~ ar the left groin of the mother about midway toward the um. :18, bec wse the first position of the vertex is most common. ~*ould you not detect the foetal heart sounds, do not be too hasty in deny- ing pregnancy, nor rashly suppose the child is dead. Auscul- tation also assists in detecting twins.
(b). Uterine Souffle. This is a murmuring, cooing, hissing, or bellows-like sound, and corresponds to the pulsations of the mother’s vessels; hence it is really dependent, not on the placenta as formerly supposed, but on the blood-vessels of the uterus. It is believed that duringgpregnancy the uterus is analogous to an erectile tissue, and that the sound depends on the rapid passage of blood from the arterial into the distended venous sinuses. Hence when the circulation is excited, or the mother very ner- vous, the sound can be detected over the whole body of the uterus, but it is generally confined to that portion of the uterus where the placenta is located, and the circulation is most active.
a ee
—
28 OBSTETRICS.
This sound may not be detected at all in some cases, or it may appear and disappear. As an auxilliary sign it is one of importance.
7. Jacquemier’s Test. The violet color of the vulva and vagina is due to the pressure of the uterus on the large veins of the pelvis. It can often be seen early in pregnancy upon the cervix, but this may also arise from a tumor.
8. Intermittent Uterine Contractions. These pain- less contractions of the uterus, followed by regular periods of relaxation, occur during pregnancy, and are owing to periodic discharges of nerve force. They may be increased by manipu- lation and often serve as a valuable means of diagnosis.
9. Kyestine in the Urine. This is a gelatino-albumin- ous pellicle which forms on the surface of uvine of pregnant
women after it is allowed to stand a few hours. It is seldom |
seen before the second month and is most marked between the third and seventh months.
These signs which we have thus far described are sometimes known as sensible or positive signs, but there are others not infrequent which are not peculiar to pregnancy as they may be found in other states. If, however, they are noticed in healthy married women, when there is no evident disease, they would render it very probable that pregnancy had occurred. They have hence been called rational or probable signs. They may be trifling, or they may be distressing and severe, and they gradu- ally merge into the diseases peculiar to pregnancy.
10. Morning Sickness. This is usually a feeling of nausea or sinking at the epigastrium, dr vertigo, felt on rising in the morning. It may beslight or goon to violent vomiting. It usually occurs early in pregnancy and lasts three months. It may occur in the evening, or it may be absent altogether.
11. Salivation or increased flow of saliva is a common indication in pregnancy.
Besi: pruriti
It is the disc mal,
augmel in dist blood-v the non and th
Lie sure U uterus are sv sists 1 and ba
(0). by acr
To
(c).
confi
it may ne of
va and eins of on the
e pain- iods of eriodic anipu-
bumin- regnant
seldom |
een the
metimes lers not may be healthy y would ey have may be ' gradu.
ling of n rising miting. hs. It
OBSTETRICS. 29 Pi
Besides these we may have frequent desire to micturate, pruritis vulvae, nervous irritability, etc. ;
It is impossible to draw a iine between the rational signs and i the disorders of pregnancy, between the normal and the abnor- + : mal. Thus the simple nervousness of pregnancy may be so augmented as to result in convulsions ; the nausea may result in distressing and dangerous vomiting; the fullness of the blood-vessels may lead to general plethora or local congestion ; the normal merges into the abnormal ; the healthy into disease, A and this brings us naturally to a consideration of :— i
II. THE DISORDERS OF PREGNANCY.
1. Local.—(a). @dema of Labia. This is caused by pres. sure upon the veins, and especially if the pelvis is large, the uterus sinking lower and pressing upon the veins. The labia are swollen and there is stiffness in walking. Treatment con- sists in rest in the recumbent position, attention to the bowels, and bathing with warm water and acetate of lead lotion. (6). Pruritus of Vulva. This is intollerable itching caused . ("* by acrid discharges or uncleanliness, or by diabetes. To be treated similarly to the last. (c). Metritis. Is usually caused by cold or violence and is confined to the muscular coat. The pain is severe, continuous, and increased by pressure. It often gives rise to adhesion of the placenta. It is treated by hot fomentations with turpentine, by morphia and rest. 2. Reflex.—(a). Newralgia. nine. (6). Salivation. When excessive, treated by atropia., Co” fir (c). Vomiting. Often becomes distressing and in some cases even dangerous. It is best treated first by simple remedies as bismuth, oxalate of cerium, ingluvin, hydrocyanic acid. This
ea ee MAB:
Treated by tonics and quin-
30 OBSTETRICS.
failing, chloral, or tincture of iodine in drop doses may succeed. If not, paint the os with solution of cocaine 4 p. c., or with nitrate of silver, or use the spinal ice bag. Failing with this dilate the os with steel dilator, and in rare cases it may be necessary to induce abortion.
(d), Constipation. (e). Syncope. (/). Insomnia.
3 Mechanical. Ventral hernia, prolapse of rectum and piles, eneuresis and dysuria, cramps, varicose veins, anasarca, and albumenuria.
Hygiene of Pregnancy. As the respiratory activity is
increased and more C O , eliminated, pure air is essential. |
Country air is better than town, and close confinement is to be avoided. The diet should be nutritious and easily digested, and a large appetite should be restrained.
The dress should be loose and easy, garters and tight corsets should be avoided, but flannel drawers should be worn. Gentle exercise should be encouraged, such as quiet walks and drives. Special care should be taken to avoid over-exertion at the men- strual periods. Railway journeys should be interdicted, and the marital relations should be infrequent, as this in newly married persons is a frequent cause of abortion. Frequent bathing is beneficial as it relieves the kidneys of a portion of their work. The genitals should be frequently washed.
_ The friends should be instructed to exercise forbearance and gentleness on account of the increased irritability of pregnancy.
IV. ABNORMAL PREGNANCY.
1. Due to Peculiar Conditions of Uterus.—(a). Double Uterus. There are various forms, such as uterus and cervix double and vagina single ; uterus double and cervix and | vagina single ; uterus double, cervix single and vagina double ;
or the u forms pe sides sir sufficien decidua end of p (b). J nancy t it becon tion of | a few m sary to 2. L ometret chronic This before ovum ;
or adhe 3. I (a). shape, (0). tuting utering (c). hydrar to defe
(d). calcar¢
4. its
cceed, r with h this hay be
m and asarca,
vity is
sential. .
s to be gested,
corsets Gentle
drives. |
16 men- ed, and newly requent rtion of
ice and
znancy.
.—(a).
us and |
7ix and
louble ; |
OBSTETRICS, 31
or the uterus, cervix and vagina double throughout. All these forms permit of normal utero-gestation on either side or on both sides simultaneously, provided each half of the genital canal be sufficiently developed. If pregnancy occur on one side only, a
B decidua vera is developed on the other side and expelled at the
end of pregnancy.
(b). Displacements. During the first few months of preg- nancy the uterus may be retroverted and this may go on until it becomes incarcerated behind the sacrum, resulting in reten- tion of urine or abortion. It should be replaced and held up for a few months by a pessary or in some rare cases it may be neces- sary to induce abortion. ;
2. Due to Peculiar Conditions of Decidua. End- ometretis deciduae may be acute, resembling Asiatic cholera, or chronic, and give rise to hydrorrhea gravidarum.
This may be the result of previous endometritis existing before pregnancy ; the result of syphilis ; irritation of diseased ovum ; or retention of a dead foetus. It may result in abortion or adherent placenta.
3. Due to Peculiar Conditions of the Placenta.—
(a). Asto Form. Instead of being round it may be horse-shoe shape, or like a battledore.
(b). As to Position. It may be attached over the os, consti- tuting placenta preevia ; over the fallopian tubes ; or in extra- uterine pregnancy at various points in the abdominal cavity.
(c). Asto Development. It may be abnormally large, due to hydramnion or hyperplasia ; and if too small it may give rise to defective development of the fcetus.
(d). As to its own Nutrition. It may have undergone fatty, calcareous or pigmentary degeneration.
4. Due to Peculiar Conditions of the Amnion and its Fluid.—(a). Hacess of Amniotic Fluid or Hydramnion.
32 OBSTETRICS.
Causes. Usually results on the foetal side from mechanical of the disturbance of the placenta and umbilical circulation. the mc
Symptoms. It impedes locomotion and produces discomfort @ the vil and pain from distension, The lungs and heart are pressed ™ cratior upon causing dyspnoea and palpitation. There are also neu-@ disinte
ralgic pains and cedema of labia and legs. amnio'
It usually results in premature expulsion with slow and pro- It is longed first stage and mal-presentations ; in precipitate second § matert stage ; and inertia in the third stage, leading often to post- Syn partum hemorrhage. enlarg
Diagnosis. It may be mistaken for twins, but the tenseness# dough of the uterine and abdominal walls, the feebleness or absence § abnor of foetal heart sounds, and the difficulty in perceiving the foetus sound:
on palpation will assist in distinguishing it. the si2 Treatment. The abdomen should be supported, and active Tre exercise prevented. If symptoms should be urgent premature °@refu
labor should be induced. great
i‘ ° ° ° ° e t ts
(5). Defective Amount of Amniotic Fluid. This is apt to poe 1: limit the movements of the fetus and so cause discomfort to the fin mother. It isalso apt to cause abnormal foldings of the amnion d i ge
and adhesions between it and the foetus, which give rise to various deformities, to intrauterine amputation, etc. | Vv.
5. Due to Peculiar Conditions of Cord. May have
twisting, knots, or coiling of the cord
6. Due to Peculiar Conditions of the Chorion.— Hydatitiform Mole. Is produced by a proliferative degenera- tion of the villi of the chorion, a hypertrophy of their investing epithellum and connective tissue cells, which undergo mucoid degeneration. This gives them the appearance of cysts with translucent semi-fluid contents, varying in size from a millet seed to that of a walnut, and forming in mass a growth which may attain the size of a child’s head or even larger. The fluid™
OBSTETRICS. 33
hanical @ of the cysts is albuminous closely resembling liquor amnii. If the mole is found, as it usually is, during the first month, while
omfort @ the villi are equally developed on its entire surface, the degen-
pressed @ cration will involve its whole surface. The foetus then dies,
so neu-@ disintegrates and may undergo complete absorption, leaving the amniotic cavity empty.
nd pro- It is more frequent in multipara, probably owing to a morbid
second # maternal condition such as cancerous or syphilitic dyscrasia.
to post- Symptoms. Failure of correspondence between the uterine enlargement and the computed period of utero-gestation ; the enseness ™@ doughy feel of the uterus; the lower segment of the uterus is absence @ abnormally tense; absence of ballottement and fetal cardiac he foetus sounds ; the passage of cysts; abortion usually occurs before the sixth month. acre” a ss d active Treatment. If the diagnosis is doubtful, non-interferen. ‘ut ‘emature @ careful watching would be best, but if certain, there is always great danger of hemorrhage and the sooner the uterine con- tents are removed the better. The tampon and ergot should be employed, and in some cases the os may be dilated and the fingers used to scoop out the cysts. Bear in mind the great danger of hemorrhage and meet it actively and promptly.
is apt to ort to the & e amnion e rise to
V. PREMATURE EXPULSION OF THE OVUM.
lay have An interruption of pregnancy any time before the sixth month is spoken of as an abortion or miscarriage, after that as ©
rion.—Y 2 premature delivery.
legenera- There is little hope of the foetus living before the end of the
investing twenty-eighth week, or seventh lunar month, or 196 days.
o mucoid Abortion is very frequent and is said to occur as often as one
sts with B to every 10 labors. The number of fetal lives lost is therefore
a millet # enormous. They occur more frequently in multipara, and many
th which j cases of early abortion are mistaken for dysmenorrhea and
The fluid unrecognised. Their influence on the future health of the 4
34 OBSTETRICS.
patient is important ; they are rarely fatal, but from loss of blood often lead to great debility and are one of the most fruitful sources of uterine disease, probably because the patient is more careless during convalescence and thus involution of the uterus is interfered with.
Up to the end of the third month the ovum is cast off in mass, the decidua afterwards coming away in shreds or in one mein- brane, After that, the placenta being formed, the amnion is first ruptured, the foetus is expelled and the. membranes are shed as in natural labor. Often, however, the placental adhe- sions are firm and the secundines being retained give rise to hem- orrhage or septic poisoning, so that abortion is more dangerous than natural labor.
Causes. The premature expulsion of the ovum is affected by contraction of the uterine fibres ; the causes of abortion therefore are all those which produce this effect.
1. Maternal.—(a). Predisposing. Over-heated and _ill- ventilated rooms ; over-fatigue and excessive indulgence in the pleasures of society ; alcoholic indulgence ; over-frequent coitus ; fevers; zymotic diseases ; bronchitis; pneumonia; syphilis ; lead-poisoning ; in short, all those circumstances that increase the susceptibility. or irritability of the cerebro-spinal nervous
system. (6). Ho Anything that directly or, indirectly excites the ut » contract and expel its contents, such as fright,
anxiety, sudden shock, over-suckling, excessive vomiting, falls, accidents, presence of a fibroid tumor in the uterus, old peri- toneal adhesions, and displacements of the uterus, especially retroversion or flexion.
2. Foetal. Death of the foetus, which may occur from effusions of blood into the structure of the placenta, from degenerations of its structure, or from atrophy, rupture, twisting or knotting of the cord. |
Sym After such as mictur dischar a threa amoun three | the co vestige among abnorn of thes
m cases, ¢
and th the ret cervix This g abortic with ¢ freque the wo rarely exhaug no mo abortic
Dia descen called once @e for tre
P. TO — cated, cages
* blood ruitful 3 more uterus
1 mass,
mein- hion is
es are 1 adhe- (0 hem- gerous
ted by
erefore
nd ill-
in the coitus ; philis ; nerease lervous
excites fright, y, falls, d peri- vecially
r from 1, from upture,
OBSTETRICS. 35
Symptoms.—The two symptoms are hemorrhage and pain. After the third month there are often premonitory symptoms such as fulness, and weight in the pelvis, sacral pains, frequent micturition, periodic labor-like pains, and a mucous or watery discharge. These symptoms, followed by hemorrhage, indicate a threatened abortion, the hemorrhage and pain increasing in amount until the ovum is finally expelled. During the first three months, if the death of the fcetus has occurred before the completion »f the abortion, it often happens that every vestige of the e:ibryo may disappear and you cannot find it among the clots or secundines. In cases where there are abnormal adhesions to the walls of the uterus, retained portions of the secundines may remain after theovum is expelled, In other cases, especially after the third month, the membranes rupture and the embryo escapes with the liquor amnii. While usually the retained portions quickly follow, it often happens that the cervix contracts upon the contents and a period of rest follows, This gives rise to what is commonly known as an incomplete abortion. The hemorrhage may cease for a time, and then recur with expulsive pains and force out the contents; or more frequently there is putrid decomposition of tue retained portions, the woman being thus exposed to septiceemia which, although rarely fatal, gives rise to continuous fever, recurrent and exhaustive hemorrhages or perimetritis. There is, perhaps, no more fruitful source of uterine disease than a mis-managed abortion.
Diagnosis. Hemorrhage, pain, dilatation of cervix, and descent of the ovum, are sure signs of an abortion. When called to a case of hemorrhage occurring during pregnancy, at once examine the clots, even breaking them up under water, for traces of the ovum.
Prognosis. “All cases of spontaneous abortion, if uncompli-
= cated, are, under proper treatment, devoid of danger, and fatal
cages are usually due to the ignorance, imprudence or wilfulness
36 OBSTETRICS
of the patient, or else to malpractice on the part of the physician.
Treatment.—1. The Prevention of Habitual Abor- tion. If it is due to syphilis, mercury or potass. iodid. are indicated. If to retroflexion, use a pessary after replacing the uterus ; this should always be removed after the third month.
In the newly married, if «bortion accidentally occurs, it fre- quently recurs, being kept up by a morbid condition of the endo- metrium used by the shortness of the interval between the
+ ~ggnancies, which does not allow the restoravion of the mucous |
membrane to a normal condition. A six weeks rest from coitus will often cure such cases. In many cases of so-called habitual abortion, fluid extract of viburnum prunifolium (black haw) in dr. ss—i doses 4 times a day is very beneficial.
2. The Arrest of Threatened Abortion. This may be affected where the death of the ovum has not taken place, and where the hem rrhage arises from a slight detachment only of
the decidua or placenta.
Pain in the hack during pregnancy should always be a warn- ing to rest. If ever so slight a hemorrhage should occur the patient should lie down and keep perfectly still on her back. Restlessness, pain and anxiety should be allayed by a full dose of opium or a hypodermic of morphia. Then the black haw may
~~
be given and the patient should be kept in bed a full week after |
the final disappearance of all threatening symptoms.
3. The Management of Ixevitable Abortion,— (a.) Where the Sac is not Ruptured. In these cases the hemorrhage is rarely profuse. The ovum is forced into the
cervix by the uterine contractions and acts as a plug, the effused :
blood-coagulating between the ovum and the uterine wall.
In such a case, interference with the finger or tampon is |
unner the p hemo then | (d). escap' The and t the la finger pressi with | is not prope 4. patie1 comp
of the
Abor- id. are
ing the onth.
, it fre- e endo- een the mucous
coitus abitual haw) in
his may ace, and only of
@ warn- secur the ar back. full dose law may ek after
tion,— ases the into the
2 effused |
ll.
npon is |
OBSTETRICS. 37
unnecessary and does harm, unless you are at a distance from the patient and fear to leave her on account of the dread of hemorrhage coming on, or if it is long retained in the cervix ; then you may dilate with the finger and hasten its exit.
(b). Where the Suc is Ruptured. Here the liquor amnii escapes and. removal of pressure allows profuse hemorrhage. The indication is t+ check hemorrhage and empty the uterus, and the most effectual method to stop the former is to further the lucter. If possible, remove the ovum by introducing the finger, sweep the cavity of the uterus and withdraw its contents, pressing on the outside with the left hand. Then wash it out with a stream of warin bichloride solution (1-5,000). If the os is not sufficiently dilated use a steel dilator, which can only be properly done with a speculum.
4. The Management of Neglected Abortion. Ifa patient comes to you two or three weeks after the supposed completion of an abortion, with-a history of recurrent hemorr- hages, you may be sure the ovum is there yet and the fetid dis- charge and absorption of septic matter may lead to chills, fever, and uterine or perimetric inflammation. In such cases the hemorrhage, septicemia or perimetritis may terminate fatally.
You should at once empty the uterus and wash it out, and in some cases it may be necessary to use a dull wire curette.
5. Management of Premature Labors. Here the tampon may be usually discarded, and after rupture of the membranes and expulsion of the foetus, hemorrhage may be con- trolled by grasping the fundus and compressing the uterine walls. You may introduce the fingers and remove the placenta assisted by compression with the left hand.
In any of these manipulations the physician’s hands should be scrupulously clean and then washed in bichloride solution (1-1,000) and smeared with carbolized vaseline or salicylic cream (vaseline 8 parts, acid salicyl. 1 part).
38 OBSTETRICS.
VI. EXTRAUTERINE PREGNANC™” OR ECTO- surrowl PIC GESTATION. with tl As the spermatozoa travel along the fallopian tube towards tines, 1 the ovary to meet the ovum, the latter after fecundation may Syn be arrested and undergo development at some point outside of resemb the uterus, and so we may have tubal, ovarian, or abdominal ceases. pregnancy. in the 1. Tubal Pregnancy. This is the most frequent of the conver three varieties. Then t Causes. Catarrhal affections of the tube attended with loss like 1] of ciliated epithelium ; dilatation of the tube ; anything which of por causes obstruction, such as flexions, constrictions, presence of are th polypi, ete. languc As the ovum developes, the mucous membrane of the tube pull thickens like the decidua and receives the club-shaped extremi- Ter ties of the villi; a decidua reflexa is rare; the placenta is the ra purely a foetal organ. As the ovum developes, the tube bonus stretches. If allowed to progress, at any early period, usually foots within the first three months, rupture of the sac occurs at the ruptut
point of least resistance and usually at the site of the placenta, pc death occurring from hemorrhage or acute peritonitis. So the Tubal pregnancy has been produced artificially in a bitch by 1. exposing and ligating the fallopian tube. te " 2. Ovarian Pregnancy. Cases are on record where hanna fecundation and development take place in the Graaffian follicle, 3 the walls of which, together with the ovarian stroma, furnishing ihe - a membranous envelope like an ovarian cyst. 2 Rupture of the sac usually occurs within three or four pe months. tala 3. Abdominal Pregnancy. In those rare cases where fostiia the ovum |. ; been fecundated and dropped into the abdominal. of the cavity, whenever the ovum comes into contact with the Di
peritoneum, a connective tissue proliferation is set ‘up which presen
TO-
wards may ide of
minal
f the
h loss which
nee of
e tube tremi- nta is
tube isually at the centa,
ich by
where llicle, ishing
- four
where minal: 1 the which
OBSTETRICS. 39
surrounds it with a vascular sac. The walls of this keep pace with the growth of the ovum, and form adhesions to the intes- tines, mesentery and omentum.
Symptoms of Ketrauterine Pregnancy. The earlier stages resemble those of the intrauterine form. Menstruation usually ceases. Up to a certain point the hypertrophic changes occur in the uterus in the same manner, the mucous membrane being converte. into a decidua and a mucous plug fills the cervix. Then there are . .voxysmal pains in the sac and uterine pains like those of labor which are often followed by the expulsion of portions of decidua. When rupture occurs the symptoms are those of internal hemorrhage, and shock, viz.:—yawning, languor, pallor, fainting, clammy perspiration, rapid feeble pulse, intermittent vomiting, collapse and acute anemia.
Termination. Although the usual ending of these cases is the rupture of the sac causing death from hemorrhage - or peri- tonitis, sometimes they terminate in recovery. Thus a dead fetus may be retained for years, or when it dies previous to rupture the ovum may degenerate into a mole, or the fetus may undergo mumification and be converted into a lithopeedion. So that we may thus have :
1. The death of the foetus and its becoming encysted in its own membranes.
2. The rupture of the sac, and the death of the mother from hemorrhage, shock or inflammation.
3. The rupture of the sac and the encysting of the foetus in the cavity of the abdomen.
4, The occurrence of inflammation and abscess which may destroy the patient, or result in w fistulous communication between the sac and intestines or bladder, through which the foetus may be evacuated in pieces, and subsequent obliteration of the sac’ and complete recovery of the patient.
Diaynosis. The existence of the signs of pregnancy ; the
presence of a tunior external to the uterus ; the occurrence of & .
4
40 OBSTETRICS.
paroxysmal pains; and the exclusion of an ovum from the uterine cavity as determined by the sound.
Treatment. Varies with the stage of pregnancy and the condition of the foetus.
1. Cases of Early Gestation. The indication is to imitate nature, for spontaneous recovery commonly follows the accidental death of the embryo. This may be accomplished in various ways, such as puncturing the sac with a trocar or Pacquelin’s cautery, to inject the sac with atropia or morphia ; or, best of all, and the only method which should always be resorted to in these cases, is by means of electricity. The faradic current is applied for five to ten minutes daily for one or two weeks Some recommend laparotomy. !
2. Cases of Advanced Gestation.—(a). Fatus Living. In many cases extrauterine pregnancy escapes detection until too late to employ a fceticidal method, and she may have gone nearly or quite to her full time before the diagnosis is made. Now although it may be very desirable to endeavor to save both mother and child by laparotomy, the history of the primary operation shows that there is only one chance in nine of saving the mother, and one out of two in saving the child. The elements of danger are the functionally active condition of the placenta up to the moment of separating it from the foetus; the abnormal characteristics of the placenta itself; the vas- cularity of the cyst wall; and the peculiar position and non- contractile vasis on which the placenta is attached.
(b). Foetus Dead. It is found by experience that if the woman passes through the period of danger, viz., pseudo-labor, without rupture of the sac, and the child dies, a longer delay of ten weeks, on the average, will enable a secondary laparotomy to be performed with a prospect of saving the woman in over 70 per cent of the cases.
The reason is that after foetal death the placental functions
cease, the vessels of the cord gradually close, as well as those |
directl: blvod ; coming which calibre if the s!owly or nec be left above, and th
Is t extruc sufferi travai
Ts ¢ 280 d been and 4 beyo estab.
A labor strua
tion of foetus ; e@ vas- d non-
if the labor, slay of otomy n Over
ctions
those |
OBSTETRICS. 4)
directly concerned in the oxygenating process of the child’s blood ; the placenta undergoes a process of carnification, be- coming more solid and tough and less vascular, and the vessels which enter it from the mother are only of a number and calibre sufficient to keep its tissue from decomposition. Hence, if the foetus be now removed by laparotomy, exfoliation may s:owly take place without opening any important blood-vessel or necessarily favoring septic absorption. The placenta should be left to come away spontaneously, the wound being closed above, and left open below for the passage of the umbilical cord, and the introduction of antiseptic injections.
C.—LABorR
Is the process by means of which the fully developed foetus is extruded from the mother’s body, and as it is accompanied by suffering and muscular exertion it has been termed labor, travail or child-birth.
_.L THE DURATION OF PREGNANCY.
Is often a moral and a legal question. The average period is 280 days or 40 weeks or nine calendar months. Cases have been prolonged to 10 months. The laws of France, Scotland and Austria allow a possible limit of 300 days, and no case beyond this from a single coitus has been scientifically established.
A simplerule to determine the period of expected onset of labor is to count back three calendar months fromthe last men- strual period and add seven days.
Il. 1HE CAUSE OF THE ONSET OF LABOR.
During the first three months the growth of the uterus is more rapid than that of the ovum, which is freely movable within the uterine cavity except at its placental attachment. In the fourth month the decidua reflexa becomes so far adherent to the chorion that it can only be separated by some degree of force, and the amnion is in contact with the chorion.
42 OBSTETRICS.
After the fourth month the amnion and chorion become agglutinated, though even at the end of pregnancy they may be with care separated from one another. After the fifth month the agglutination of decidua vera and reflexa takes place. In the last half of pregnancy the rapid development of the ovum causes a corresponding expansion of the uterine cavity, the uterine walls become thinned, so that by the end of gestation they do not exceed two or three lines in thickness. The great extension of the uterine cavity is not owing simply to over- stretching, as is proved by the fact that the uterus toward the close of gestation is increased nearly twenty fold in weight, and by the histories of extrauterine gestation in which up to a cer- tain period the uterus enlarges progressively in spite of the absence of the ovum. The increase in weight is due to increase in size and amount of muscular fibre cells, blood-vessels and connective tissue.
At the same time that these changes in the uterus are being completed there is increased irritability of the uterine tissue, and finally a fatty degeneration takes place in the decidua ser- otina which soon gives rise to separation of the membranes, the contents of the uterus then acting as a foreign body, contrac- tion takes place, and all being ready labor sets in. Another element in the causation may be a periodicity inherent in some way that we cannot yet explain in the nerve centres, like the menstrual periodicity of 28 days.
Ill. SYMPTOMS OF LABOR. Premonitory. Subsidence of the abdominal tumor takes place
a few hours or a few days before labor sets in, followed by a sense of relief about the heart and lungs.
Then a relaxation of the soft parts: takes place, followed by increased secretion, and a discharge of a small amount of bloody mucus, known as a “show.” “False pains” are frequent, and there is tenesmus of the rectum, increased fulness of the mamme, and frequent micturition,
The | and is ¢ For « three 8s!
Ist | intermi or botl good.”
greatly
On e dant, t soon th
As t os is pl As the At the of the openin waters uterus the cir
The front ¢ retaing cervix canal. stretc know
2n first s stage, frequeé more
OBSTETRICS. 43
come The nervous system is often affected and she has tremors, ay be and is anxious, depressed and fretful.
onth For clinical convenience actual labor has been divided into In three stages :—
ovum § Ist Stage.— Dilatation of the Cervix. The pains become
» the intermittent and regular, and are felt in the back or abdomen
ation great
or both, and the patient expresses a feeling that they “do no
good.” There is often nausea, vomiting, perspiration and over-
d the t, and a cer- f the rease
and
greatly increased secretion.
On examination the secretion of the vagina is felt to be abun- dant, the os is felt enlarging, the membranes protruding and soon the presenting part can be felt.
As the pains increase in intensity and frequency the external os is put upon the stretch, its edge becoming thin and sharp. As the pain subsides the os relaxes and the membranes retreat. At the same time the softening, relaxation and hypersecretion of the soft parts increase. There are three elements in the opening of the oc: 1. The mechanical stretching by the bag of waters ; 2. Zhe contraction of the longitudinal fibres of the uterus, which draw the cervix open, and 3. The relaxation of the circular fibres.
being issue, a ser- 8, the atrac-
lot her ses The membranes then rupture and that part of the fluid in
ba the front of the presenting part escapes, while the rest may be retained for a while. The head then presses down into the cervix so that finally this and the vagina become one continuous canal. Should the membranes be late in rupturing, and be
place stretched over the child’s head’ and face when born, this is bya known. as a “ Caul.”
2nd Stage.—Lapulsion of the Child. The symptoms of the
ed by first stage gradually and insensibly glide into those of the second
nt of
stage, the contractions of the uterus rapidly becoming more }) z
are frequent, returning every two or three minutes and becoming Iness more pr'longed The uterine pains are now reinforced by
)
44 OBSTETRICS.
the abdominal muscles and the woman feels that they are easier borne because she can help herself. The glottis serves as asort of safety-valve action, for if the pains are weak she holds ‘her breath and bears down, and if they are excessive she cries out, the glo'tis opens and the muscles do not have the same purchase. The head now makes progress, the perineum bulges, the labia gape, the head recedes during the interval and then advances during the pain, the pressure on the rectum leads to evacuation of the bowel, the perineum thus stretches over the head and finally the head is born with great agony, a gush of amniotic fluid and usually more or less laceration of the four- chette, especially in primipara. There is usually an edematous swelling on one or other parietal bone caused by pressure of the circle of contact, which is known as the caput succedaneum.
The second stage is one of danger to mother and child ; to the mother from all those accidents which may arise from dis- turbance of the vascular and nervous systems, to irritation of uterus, vagina and perineum, and most of those complications which give rise to tedious and difficult or impracticable labors.
The child’s life may be endangered or destroyed by pressure on its body or on the cord or placenta.
Srd Stage.—Hapulsion of Placenta. After the birth of the child there is a short respite from pain, seldom longer than 10 or 15 minutes when the pain and bearing down recurs. <A hard and tense tumor is felt through the abdomen, a finger in the vagina feels the placenta at the os or in the vagina.
The placenta then usually presents its foetal surface or edge, and is scon expelled with the membranes and more or less
blood. IV. DURATION OF LABOR.
The average time for a primipara is 17 hours, for a multipara, 12 hours.
The first stage occupies 10 out of the 12 hours. Although
longer mothe this ti and tl distur in con t10.18
The two | streng consti
Th may t from hage. this s
De excit often ofte anxi¢ weak ther full ; refre
y are ves as holds cries same ulges, then ads to r the ush of four- atous
ure of
neum. Id; to m dis- tion of cations labors.
ressure irth of r than 5s A ger in r edge, r less
ipara,
hough
OBSTETRICS. 45
longer and more tedious it is generally a safe stage for the mother as well as the child, the mother not being usually at this time liable to any of the accidental complications of labor, and the child, if the membranes are unruptured, is very slightly disturbed by the contractions of the uterus which have no effect in compressing its tissues or injuring the attachments or func- tiuas of the placenta.
The second stage is short compared with the first, occupying two hours or less in a labor of 12 hours, depending on the strength of the woman, the relaxation of her tissues, her age, constitution, etc.
The third stage is short, usually only 10 or 15 minutes, but may take half an hour. It is a stage of danger to the mother from exhaustion, syncope, collapse, but especially from hemorr- hage. Hysteria, puerperal convulsions, etc., may complicate this stage.
Delivery being now accomplished the nervous and vascular excitement rapidly disappear, and the mother feels weak, and often faint and exhausted. She also feels cold and chilly and often has a tremor or rigor, accompanied by depression and anxiety of mind. The pulse becomes less frequent, small and weak, hands and feet are often cold. In less than half an hour there is a reaction, the surface becomes warmer and the pulse full and natural, and she has a tendency to sleep which will refresh her exhausted system.
V. THE BXPELLENT FORCES.
These are the essential and the accessory.
1. The Uterine Contractions (essential). That the uterus is a contractile organ, is proved by its hardness and rigidity and its alteration of form ; the sensations of twisting, grinding and contraction ; the rigidity and alteration of the size of the os ; the tension and protrusion of the membranes ; the
46 OBSTETRICS.
descent of the child; the pressure of the uterus on the hand when introduced in version ; and by the rapid diminution and obliteration of its cavity after evacuation of its contents.
Sometimes there is a general and uniform contraction of the uterine muscular fibres by which the walls are rendered more firm and tense, and its contents compressed. It is this tonic rigidity or contraction of the uterus which compresses the placenta after tle birth of the child, and when this is expelle: the walls regularly condense and obliterate its cavity, so pre- venting hemorrhage. This‘tonic contraction is usually painless and is dependent entirely on the sympathetic nervous system.
Nervous Mechanism of Labor. The uterus is independent of .
direct volition, for its rythmic contractions go on in insensibility from apoplexy, coma, anesthesia, etc. It is, however, under the influence of emotions, as is seen when the pains leave by the excitement of the physician’s presence, and come back when he retires. It is in this manner that encouragement and hope tend to help the progress of labor.
The causes of uterine contractions are :—
1. Periodic Centric Discharges of Energy. This is seen during pregnancy in the alternate contraction and relaxa- tion of the uterus, and in the contractions induced by ergot, by excess of CO,, and zymotic diseases.
2. Reflex Stimulus. —(a) Through the Cerebro-spinal Nerves. Examples of this are the contractions of the uterus caused by suckling, cold to the body, the pressure of ‘the head on the perineum, or the hand drawing back the perineum.
(6) Through the Sympathetic. Examples of this are whe.e a dead ovum acts as a foreign body ; the beginning of ordinary labor ; the use of the bougie to induce premature labor ; and the dilating pressure of the bag of membranes or the foetal head.
or
Ner cord, or there a
The the cer action govern cord fr emotio the ut the sp hence
Whe more di at first vigorol
more O
In © twistin The p: a pain. less a1 the elc is dire is espe accour uterus that tl the pe finger. dilatec when
slow, |
hand and
under ve by when
hope
‘his is elaxa- ot, by
spinal iterus
| head
1.6 a inary
OBSTETRICS, 47
Nerve Centres and Nerves. There are two centres in the cord, one in the medulla and one in the lumbar region, and there are also nerve centres situated in the uterus itself.
The centre in the medulla is for reflex stimuli, transmitted by the cerebo-spinal nerves of the upper part of the body; from the action of CO,, etc. The centre in the lumbar region immediately governs the uterus. Stimuli are transmicced to it throu :h the cord from the centre in the medulla, and also indirectly, as by emotions, from the brain. The nerves carrying the stimuli from the uterus are the sympathetic, but these have filaments from the spinal cord through the lumbar and sacral nerves, and hence the pains of labor.
When labor has fully commenced the uterus takes on a more decided action ; the alternate contractions and relaxations at first at long intervals become more and more rapid and vigorous, and the intervals shorter. As these contractions are more or less painful they are known as “ pains.”
In the first stage they are said to be cutting, gri ding,
twisting, but in the second stage pressing, bearing down, forcing. The pain is experienced in every part of the uterus during a pain, While the tonic contractions of the uterus are pain- less and resemble those of the heart and other hollow viscera ; the clonic contractions of labor are painful, because the uterus is directly or indirectly connected with the spinal cord. This is especially the case with the nerves of the cervix, thus accounting for the greater sensibility of this portion of the uterus. The first effect noticed of these clonic contractions is that the os becomes rigid, then thinner and slightly open ; after the pain it becomes soft, relaxed and yields more ‘readily to the finger. This process goes on until in a few hours the os is dilated, quicker in multipara than in primipara. As a rule when the edges are thin and knife-like, the dilation will be
slow, epecially if. considerable density remains after the con-
Se ae
.— SS eee
48 OBSTETRICS,
traction has subsided. When the edges are thicker and softer the os enlarges more rapidly.
Should the liquor amnii have escaped prematurely there is often great retardation of the ~rocess, especially in primipara, and it is know as a “ dry labor.”
Dilatation of the os is effected mostly by the longitudinal fibres, by which the length of the uterus is shortened, there is descent of the fundus and elevation of the os, and while the cir- cular fibres of the os also contract, the action of the longitudinal fibres is more powerful, so that the circular ones yield and the os becomes dilated. Then the bag of waters, or the presenting prt of the child, may be regarded as a mould upon which the cervix expands. The membranes now usually rupture as the os becomes completely dilated and the expulsive stage begins. The descent and delivery of the child are accomplished by a continuation and increase of the contractions of the longitudinal and circular fibres of the uterus by which its cavity is dimin- ished in every direction, and the child, greatly compressed, is expelled through the only opening which exists at its inferior extremity. The pains increase in severity as labor advances owing to the fundamental law that the contractions of the uterus are inversely as the size of the organ. -
The more the longitudinal and circular fibres are shortened, the more efficient is their action. Hence, when the membranes
are ruptured and the liquor amnii evacuated the pains become |
more severe and prolonged. So, as the child descends they increase, and finally the most severe contractions are felt at the termination of labor, when the last portions of the infant escape from the uterus. The placenta then being detached acts as a foreign body and is expelled by the same forces.
2. Contractions of Abdominal Muscles and Dia- phragm (accessory). Some have gone so far as to think that the expulsive stage of labor is mainly performed by this means,
but th in par volun or arr
The as an of th can b sneezi
Bef strain gainec nervo 08 is ¢ pelvis and o the m increa conta its fle
Th¢ tions equal to its pressi so thg upon forces eum ¢ ment expel
In the w
ssedl, is nferior vances of the
rtened, branes 9ecome 3 they at the escape gs as a
| Dia- k that means,
OBSTETRICS. 49
but the fact that labor may be completed under anesthesia, or in paraplegia, and that in inertia of the uterus no amount of voluntary action of the abdominal muscles will expel the child or arrest hemorrhage is sufficient proof that it is not.
The action of these muscles is of great importance, however, as an accessory force, for by their combined action the viscera of the abdomen can be compressed and a particular direction can be given to this force as required, just as in the acts of sneezing, coughing, vomiting, and defecation.
Before the os is dilated there is not much disposition to strain, and it ought not to be encouraged, for nothing can be gained at this time, but it rather delays dilatation by increasing nervous excitement and rigidity of the os. When, however, the os is dilated, the sense of fulness, weight and pressure in the pelvis causes a disposition to strain which cannot be resisted and ought to be now indulged. The first efiect is rupture of the membranes, then the tonic contractions of the uterus are increased, so that the walls of the uterus are brought into close contact with the Body of the child increasing at the same time its flexion.
Their next effect is to strengthen and increase the contrac- tions of the uterus by fixing and supporting it and making equable pressure upon its surface, and giving a proper direction to its axis. The uterus being fixed by its attachments and pressing against the brim of the pelvis cannot descend lower, so that the abdominal muscles act through its walls directly upon the child forcing it downward through the pelvis. These forces also facilitate the distension and elongation of the perin- eum and enlargement of the vagina; they aid in the detach- ment and expulsion of the placenta and clots, and finally in expelling them from the vagina. |
In breech cases it is this force which expels the head and the woman can thus effectually help herself.
OBSTETRICS.
50 VI. MECHANISM OF LABOR.
This comprehends the movements of adjustment by which the foetus accommodates itself to the dimensions of the bony pelvis, and to the variations in the direction of the parturient canal. To thoroughly understand the process it will be necessary to study the pelvis and the foetal head :—
1. The Female Pelvis. The bony pelvis is formed by the union of the sacrum, coccyx and the two ossa innominata.
The savrum is shaped like a wedge and consists of a vertebra] portion with twoale or wings. In early life it consists of five vertebrae but afterwards they amalgamate into one single piece. Its base articulates with the last lumbar vertebra with which it forms a projecting angle known as the promontory of the sacrum. The sacrum measures 4} in. long by 44 in. wide, and has two curves, a lateral and a longitudinal.
The coccyx is composed of four rudimentary vertebre. It is attached by a hinge joint to the sacrum, and is pushed back during defecation and child birth. When gnchylosed it is a hindrance to labor.
The ossa innominata up to the age of puberty cunsist of three bones, the ilium, ischium, and pubis, and although they are afterwards amalgamated, they still retain the same names.
The articulations are the symphysis pubis, and the sacro-iliac synchondroses. During pregnancy the fibres of the pubic fibro- cartilage become infiltrated with serum and the ligaments elong- ate, so that at full time the distance between the pubic bones is doubled, and, at the same time, a slight degree of mobility exists atthe sacro-iliac joint. This arrangement facilitates labor; thus at the beginning of labor as the head enters the brim the woman naturally chooses to sit up, to walk about, or if in bed to recline with the legs extended, positions which favor the rotation backward of the upper portion of the sacrum, and con- sequently increase of the antero-posterior diameter of the superior
strait
pelvis body musc! pressi the s¢ the p
Th obtur. ments formi.
The two p basin-
EXCH f
Tn |
sions
axes,
Pla simpl ness, the u cav it
The bound with prom¢ meas diame te the
Th
iliac ¢
h the elvis, anal. ry to
d by lata. bra] f five piece. which f the
3, and
It is back tis a
three y are
o-iliac fibro- plong- pnes is exists labor; m the n bed or the d con- perior
OBSTETRICS. 51
strait. As the head, however, descends to the floor of the pelvis, the patient instinctively draws up her knees, throws the body forward, and during a pain contracts the abdominal muscles. In this way she succeeds in tilting up the pubis, in pressing the promontory forwards, and in rotating the point of the sacrum backward, thus increasing the conjugate diameter at the pelvic outlet.
The ligaments are the obturator membrane closing che obturator foramen, and the greater or lesser sacro-sciatic liga- ments which convert the notches into ‘oramina and assist ir. forming the inclined planes of the pelvis.
The complete pelvis is divided by the ileo-pectineal line into two parts, the false above, and the true below. ‘The latter is a basin-like cavity, closed in by soft parts below, and called the excas ation. .
Tn order to understand the changes in the shape and dimen- sions of this bony canal it is usual to describe certain planes and axes.
Planes and Axes of the Pelvis. By a plane is meant simply a superficial surface without reference to depth or thick- ness. The upper and lower openings are termed respectively the upper and lower straits, while the space between is the cavity of the pelvis.
The plane of the superior strait or brim of the pelvis is bounded by the linea pectin:a and has an elliptical contour with a depression behind produced by the projection of the promontory of the sacrum. Its dimensions are determined by measuring its diameters. The antero-posterior or conjugate diameter extends from the upper border of the symphysis pubis te the promontory, and meas™™ss 44 inches.
The oblique diameter extends, the right from the right sacro- iliag synchondrosis forward, the left from the left sacro-iliac
52 OBSTETRICS,
synchondrosis forward to the acetabulum, and measures 5 inches. '
The transverse diameter is the widest distance between the ilia, and measures 54 inches.
The axis of the superior strait is a line perpendicular to the centre of its plane, and extends from the umbilicus to the coccyXx.
The plane of the inferior strait, or the outlet, is bounded by the subpubic ligament, the pubic rami, the rami and tuberosities of the ischia, the sciatic ligaments and the coccyx.
The conjugate diameter of the outlet extends from the lower borde: of the symphysis to the extremity of the coccyx and measures 3} inches, but when the coccyx is pushed backward it measures 44 inches.
The oblique diameters of the outlet are unimportant owing to the elasticity of the sciatic ligaments,
The transverse diameters of the outlet extend between the inner borders of the tuberosities, and measure 4 inches,
The axis of the outlet, when the coccyx is undisturbed, touches the promontory; if it is pushed backward it touches the lower border of the first sacral vertebra.
The pelvic cavity has an irregular cylindrical shape, its diameters being increased by the concavity of the sacrum, its anterior depth being 14 inches, its posterior being 4} toe 5 inches.
The axis of the pelvic cavity may be represented by a line drawn perpendicular to a series of intersecting planes radiating from the symphysis as a centre, the upper being somewhat parallel to the plane of the superior strait, and the lower some- what parallel to the plane of the outlet. The axis resembles an ellipse.
The Inclined Planes. ‘The ischiatic spines divide the pelvic
cavit: sectic ward: inclin in th plane and i of no
Th from of an 4,90 |
In
‘ dimin
it bec filled muse Th whic ani a ineal and
ye, its 1m, its te 5
a line liating ewhat - gome- bles an
pelvic
OBSTETRICS. 53
cavity into two unequal sections; in the anterior and larger section the lateral walls slope downwards, inwards, and for- wards towards the pubic arch, and are know as the anterior inclined planes upon which rotation of the occiput takes place in the mechanism of normal labor. The posterior inclined planes are smaller and slope downwards, inwards and backwards, and it is upon these that the sinciput rotates in the mechanism of normal labor.
The diagonal conjugate or sacro-sub-pubic diameter reaches from the pubic arch to the promontory of the sacrum and is 3 of an inch longer than the true conjugate and hence it measures 4.90 inches.
Influence of the Soft Parts. The psoas and iJiacus muscles
‘ diminish the transverse diameter nearly half an inch, so that
it becomes the same as the ovlique. The sciatic notches are filled by the pyramidelis and the tendon of the obturator
~ Jat RAG muscle. ty s
The outlet of the pelvis is closed by a succession of layers which form the perineal or pelvic floor and include the levator ani and coccygeus muscle, the pelvic fascia, the superficial per- ineal muscles, including the constrictor vagine, ischio-cavernosi, and transversus perinei.
By the bulging of the perineum during labor, both the length and degree of curvature of the pelvic canal are increased, the soft parts posterior to the vulva forming a gutter-like exten- sion, the axis of which is continuous with that of the pelvis.
2. The Foetal Head. This part presents the greatest mechanical difficulty to the passage of the child. The vault or compressible portion is composed of the frontal and parietal bones and the squamous portion of the temporal, and occipital. The posterior part of this is spoken of as the occiput while the opposite extremity of the ellipse is called the s:nciput. The base or incompressible portion is formed by the union of the
a: a <r es
ee oe
SS SSS
ee
oS Ne ee
54 OBSTETRICS.
ethmoid, sphenoid, petrous portion of the temporal, and the basilar portion of the occipital.
The Sutures and Fontanelles. The flat bones of the vault are held loosely in position by periosteum and dura mater, The sutures are the frontal, coronal, sagittal, and lambdoidal.
The anterior fontanelle or bregma is rhomboidal, the pos- terior fontanelle is smaller and triangular. The Diameters of the Head.
1. Antero-posterior :
a. Occipito-mental............ 54 inches b. Occipito-frontal............. 4,“ c. Sub-occipito-bregmatic........ 3% “
2. Transverse :
.a. Bi-parietal...........0. 06% 3% inches
b. Bi-temporal................. oi.
Ch MASTOID, oo dace EF es 3 a 3. Vertical :
a. Fronto-mental.............. 3} inches
b. Cervico-bregmatic........... 3g.
The articulation of the head with the spinal column at a point nearer the occiput than the sinciput. is of importance in the mechanism of labor. It converts the head into a lever, consisting of two unequal portions. As the child’s head passes through the pelvis the resistance to i's passage causes flexion of the chin upon the thorax.
VII. EUTOCIA OR NORMAL LABOR...
Vertex presentations alone are to be regarded as normal, as they only realize the ...echanical conditions compatible with the highest degree of safety to both mother and child. Perfect acquaintance with all the details of thi. natural process is neces- sary to a scientific knowledge of midwifery. ‘The physician
Th
anter
terio1
Th descr rotati
Le cribij differ
1si left a able dia and redu¢ child
cave
the
ault ater, al.
pos-
at a ice in lever, ASSES ion of
al, as h the erfect
heces -
sician
OBSTETRICS. 55
who is well acquainted with the mechanism of labor, can by various measures facilitate such changes as to shorten the progress of labor and thus diminish the anxieties, sufferings and dangers of the lying-in woman, and also greatly increase the chances for the safety of her child.
By presentation is meant that portion of the foetal ellipse which is felt toward the centre of the canal of the pelvis or vagina.
By position is meant the relation of the presenting part to the pelvic cavity.
There are four positions of the vertex. 1. Left occipito- anterior. 2. Right occipito-anterior. 3. Right occipito-pos- terior, and 4. Left occipito-posterior.
The mechanism of labor in vertex presentations is usually described as consisting of several acts, viz: Descent, flexion, rotation, extension, restitution and expulsion of the trunk.
Let us now study the mechanism of the first position, des- cribing each act, and then we can see how the other positions differ afterwards.
lst Position, Left Occipito-anterior, L. O. A. Occiput is to left acetabulum. ‘This is the most frequent and the most favor- able of all the positions of the vertex. The reason the long diameter of the head generally enters the pelvis in the oblique and not in the transverse diameter, is that the psoas and iliacus reduce the latter to the same length as the former, and as the child lies usually with its back forward to accommodate its con- cave anterior surface to the convexity of the mother’s spine, so the head more naturally then enters the oblique than by twisting as it would if it engaged in the transverse diam- eter. Then as the left oblique diameter is partially occu- pied by the rectum and sigmoid flexure of the colon ; as the pregnant uterus generally has a natural obliquity to the right
56 OBSTETRICS.
and is rotated on its axis so that its front looks towards the right and its left is foremost and most dependent, the foetus is most readily accommodated to the shape of the uterus when its antero-posterior nearly corresponds with the transverse or great- est diameter of the uterine cavity, and hence the first position is most common.
On a ee the finger comes in contact with the pos-
t \-or angle of the parietal bone, and detects the right branch of the lambdaidal structure. Following this downwards and backwards you come to the overlapping edges of the pos- terior fontanelle.
1, Descent and Flexion. These movements are usually associated, descent taking place owing to the essential and accessory forces, flexion being due to the vertex meeting some resistance in the parturient canal, the force transmitted through the spine causing the descent of the occiput and flexion of the head on the chest. The head enters the pelvis in the axis of the brim, with the biparietal diameter parallel with the plane of the superior strait. It is a. passive movement, and takes place as soon as the occiput has met with sufficient resistance to arrest its further progress, the end being the substitution of a shorter diameter for a previously longer one. Thus the average length of the sub-occipito-bregmatic diameter of the flexed head, 3% in, is #in. less than the occipito-frontal or maximum diameter of the head when midway between extension and flexion.
Another cause of flexion, independent of the bony pressure, depends upon the relation between the shape of the head’ and the pressure exercised upon it at the girdle of contact either with the os or the imperfectly expanded soft parts, the propel- ling force being the general fluid pressure transmitted to the foetus through the liquor amnii. The head forms an unequal wedge, the slope at the occipital end being steeper than at the
impings pubic a
frontal in flex:
2. I ‘incline the pu ‘im ping wards, The ob diamet
3. ‘FE against upon t thorax. sacrum coccyx vulva, ¢ the per
head e
4.
the pe
quarter same pd pelvis.
5. H
and the
2nd occiput the left
The except
the 1s 18 n its reat- tion
pos- ‘ight ards pos-
lally and Ome ough ’ the is of lane wakes ance on. of
the f the al or nsion
sure, » and ither ‘opel- o the equal t the
OBSTETRICS. 57
frontal, so that the force and resistance just explained result in flexion of the head upon the chest.
2. Rotation. The occiput now impinges on the left anterior ‘inclined plane, gliding downwards, inwards, and forwards, under the pubic arch where it becomes fixed, while the sinciput impinges on the right posterior inclined plane, gliding down- ‘wards, inwards, and backwards into the hollow of the sacrum. The object of rotation is to change the head from the oblique diameter of the brim to the conjugate diameter of the outlet.
3. Extension. The lower part of the occiput resting against the under surface of the pubis, the propulsive force acts upon the sinciput causing separation of the chin from the thorax. As soon as the forehead has swept the hollow of the sacrum and passes the apex of the sacrum, the recoil of the coccyx and elastic perineum drives the head forward to the vulva, and as the biparietal diameter passes the vaginal orifice
the perineum rapidly retracts, gliding over the face and the
head emerges.
4. Restitution. The head now, not being supported by the perineum, falls toward the anal orifice, and performs a quarter rotation, the occiput turning toward the left thigh, the same position it occupied at the brim before it engaged in the pelvis. This movement is due to the rotation of the shoulders.
_ 5. Expulsion of the Trunk. The right shoulder impinges on the right anterior inclined plane, fixes under the ‘pubic arch, the left shoulder sweeps the hollow of the sacrum and the body emerges. ,
2nd Position, Right Occipito-anterior, &. O. A. Here the occiput is towards the right acetabulum, and the head occupies the left oblique diameter.
The mechanism is precisely the same as in the first position except that the occiput impinges on the right anterior inclined
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58 OBSTETRICS.
plane, and the left shoulder on the left: anterior inclined plane increa: while the right shoulder sweeps the hollow of the sacrum. owing 3rd Position, Right Occipito-posterior, Rk. O. P. Here the Cases oceiput is towards the right sacro-iliac synchondrosis, and the perine head occupies the right oblique diameter. This is the reverse The of the first position. incline The chief cause of occipito-posterior positions is a partial oe extension of the head during the early stages of labor, the fore- 4th
| head being thrown anteriorly in accordance with the law that put is | the most dependent portion of the presenting part is moved to pies tl _ the front. owing Now one of two things will occur: either it will be converted the rec into the 2nd position, or will become persistent 3rd It m 1. Itmay be Converted into a 2nd Position. One ne '
iat Oo
cause is the prominence of the promontory of the sacrum which has a tendency to throw the head on to the anterior inclined plane.
Wer
Another cause is the spine of the ischium and the greater te iii length of the anterior than the posterior inclined plane. Hence eee when the head descends in the 3rd position, if the occiput aubciibe
strikes on the spine of the ischium or extreme boundary of the B oacog ;
anterior inclined plane, it will be reflected forwards, and imping- J og, pre ing on the anterior inclined plane be converted into the 2nd rantae position. forest, ? If, however, the point of the occiput should strike posteriorly § forth
restore speedil somew the diff as the i
The the ph
to the spine of the ischium, it will be reflected backward into the hollow of the sacrum, and we have :—
2. Persistent 3rd Position. Here descent and flexion take place just as in the 2nd position, but there is no extension movement, extreme flexion taking its place. Restitution occurs as in the 2nd position. The difficulties arise from loss of power from the peculiar position of the child, from the §
plane
re the d the everse
partial e fore- vy that ved to
verted
One . which
clined
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eriorly §
rd into
flexion tension itution e from
‘om the 8
OBSTETRICS. 59
increase.l resistance met with by the head during its descent, owing to extreme flexion instead of extension. Hence these cases are tedious and there is more danger of rupturing the perineum. ree
The left shoulder usually impinges on the Wairierior
inclined plane while the right sweeps the hollow of the sacrum.
4th Position, Left Occipito-posterior, L.O. P. Here the ocei- put is to the left sacro-iliac synchondrosis, and the head occu- pies the left oblique diameter. This position is less frequent owing to the presence of the sigmoid flexure of the colon and the rectum.
It may be converted into the 1st position or become persis- tent 4th, the cause and mechanism being precisely similar to that of 3rd position, but reversing the planes.
MANAGEMENT OF LABOR.
Were labor always the natural physiological process it ought to be, no treatment whatever would be demanded. Thus throughout the world thousands of children are daily born with- out the least supervision by an instructed. physician, in many cases in secresy and retirement, and often delivery is safely effected even in opposition to superstitious practices and igno- rant interference. The savage woman retires, it may be to the forest, and secluded even from her female companions brings forth her child, and perhaps in a few hours is sufficiently restored to attend to her own and her infant’s necessities, and speedily returns to her usual laborious occupation. While somewhat similar cases rarely occur in civilized society, stil] the difficulties and dangers of labor are exceedingly augmented as the indulgences and luxuries of life are wultiplied.
The diminution of physical power, the nervous excitability, the physical alterations from tight lacing, and the mental and
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[SS Se Se
ee a Se ee ee ee oe
Sar
a
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60 OBSTETRICS.
moral development cf the educated lady all predispose to vari- ous complications, while at the same time the natural processes are more imperfectly and less efficiently executed.
Now while meddlesome midwifery is bad, it is necessary to know when to interfere as well as when to abstain. It is therefore your business to carefully watch the whole process of labor, to ascertain whether it is perfectly regular, and to detect the least deviation from the natural process, and thus you may often render timely assistance. You should sustain the mind and spirits of the mother and explain to her what sensations she should encourage and what she should resist, and in what manner she can most effectually promote her safe delivery.
Preparatory Treatment. When called to a case you should go at once, for it is better to be a few hours too soon than one minute too late. If it is in the country or any distance from your office go prepared for every emergency, and take your pocket case, enema syringe, hypodermic syringe, the very best fluid extract of ergot, chloroform, perchloride of iron, chloral, your obstetric forceps, and a solution of bichloride of mercury in alcohol (dr. 1—oz. 1).
At the house see that they have brandy, and plenty of hot See yourself that the bed is properly made After the patient has become at ease with you, suggest an examination to “ see if all is right.” By the finger in the vagina you will recognise not only the presentation but the condition of the vulva and perineum, the state of the rectum and bladder, the length of the vagina, the
and cold water. and the patient arranged.
degree of dilatation and softening of the cervix, the amount of
cervical and vaginal secretion, the hardness of the child’s head, and if the membranes are not ruptured the quantity of the amniotic fluid.
It is best to examine the patient while lying on her left side, but in some cases she may best be upon her back, and you
should see the
You
the abc
auseullt
Whi such as nancy, 5 now uy and sit as to d
Befo should bichlor’
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rupture since t
You is unsd or back advante tions,
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of hot made pme at right.” ily the m, the na, the ount of s head, of the
ft side, nd you
OBSTETRICS, 61
should wait for a pain, but afterwards keep the finger theve to see the effect during the interval.
You should*also try to map out the position of the foetus on the abdomen by palpation and if the foetal movements are absent auscultate.
While this is going on enquire into the history of the case, such as the length of previous labors, her health during preg- nancy, the number of previous pregnancies and whether she is now up to full time, when the pains began, as to their frequency and situxtion and if the membranes have ruptured. If asked as to duration of labor be guarded and possibly ambiguous,
MANAGEMENT OF FIRST STAGE.
Before making any vaginal examination the hands and nails should be scrupulously clean, and then washed in a solution of bichloride (1 to 1000), and the finger smeared with vaseline.
During the first stage, you should make occasional, but not
too frequent, vaginal examinations to see if dilatation is going on.
Caution her to pass urine frequently and occasionally retire from the room to allow her to doso. If the rectum is felt to be full use an enema. She should be encouraged to sit up and walk about, but never to bear down during this stage. Warm drinks may be employed. When the os is dilated you may rupture the membranes if that has not occurred spontaneously, since they have finished their work and now only retard labor.
MANAGEMENT OF SECOND STAGE.
You should now insist on the recumbent posture, as the erect is unsafe for both mother and child. The position on the side or back is a matter of indifference, but may be varied with advantage, and now you should make more frequent examina- tions. So long as the advance is regular do not interfere, but
et ~~ a a ee
OBSTETRICS,
should.the pains slacken you should not let the duration of the second stage exceed the physiological limits. A very rapid second stage is not natural as it endangers the integrity of the vagina and perineum and predisposes to postpartum hemorrhage.
Every adjuvant should be used during this stage to assist the process, such as change of posture, pressure upon the abdo- men, drawing up the knees, pressing on a foot board, holding the hands or sheet. In occipito-posterior positions, failure of rotation is always due to insufficient flexion, hence you should try to promote this by pressing on the forehead by the fingers during the pain, try to assist rotation, and during the interval of a pain hook two fingers over the occiput and draw it down- wards and forwards.
ATTENTION TO THE PERINEUM.
Direct pressure on the perineum should be avoided by trying to check the two rapid advance of the head and by pressing the head forward to the pubic arch so as to equalize pressure on the ring of the vulval outlet, and by favoring the expulsion of the head during the interval of a-pain.
If the pains are very severe at this time the woman should be encouraged to cry out and not to bear down, and if these means are not likely to avoid atear you should use chloroform. In rare cases episiotomy may be resorted to.
When the head is born wipe the mucus from its mouth and nose, and see that the cord if round its neck is untwisted. Sup- port the child and lift it upwards, being careful not to hurry matters as the shoulders often tear a perineum unscathed by the head.
You should now give the mother a dose of ergot. cord has ceased to pulsate tie it about two inches from the navel and again an inch further off for the sake of cleanliness,
When the
cut it b now at uterus
that yo go of tl
You from 1& on the « your ob; uterine
Shoul method apply at the ute grasp t downwa
the place This hage, anc dangers It is v see that The c ones sub in maint gestion, abdomen Use of labor, an hypertro which leg
OBSTETRICS. 63 | {
f the cut it between, and hand the child to the nurse. You should ‘ rapid now at once place your left hand upon the abdomen over the i): f the uterus relieving the nurse who has attended to this all the time | | hage. that you have been tying and cutting the cord, and never let | ‘ sli go of the uterus until the third stage has been fully completed. | lf il MANAGEMENT OF THIRD STAGE. : in Bi re vy You should keep your left hand upon the uterus and wait I { 10uld from 15 to 20 minutes for a contraction, not making traction hi ngers on the cord but simply holding it tense with your other hand, i erval your object now being to guard against hemorrhage, to promote ‘ lown- uterine contractions and to secure the expulsion of the placenta. ; Should the placenta not be expelled in 20 minutes, Crede’s | method or a modification of it should be resorted to, viz: apply at first light and then stronger friction to the fundus of rying the uterus until an energetic contraction is obtained, then g the grasp the uterus in the palm of the hand and by compressing it ee downward in the axis of the uterus and repeating this process Lh dae the placenta is eapressed from the uterus and vagina. This method by maintaining contraction prevents hemorr- hage, and by promoting speedy pa cad guards against the dangers of retention. a It is well to retain the hand on the uterus for a short time to see that it contracts firmly and that clots are not retained. The cloths with discharges are now removed and warm dry 4 and ones substituted, and a bandage is applied. A bandage assists a Sup Fin maintaining uterine contraction, in preventing passive con- Ht perry gestion, supporting the parts and preventing pendulous | | ed by ; abdomen.
en the § labor, and is safer at this time than any other owing to the m the §{ hypertrophy of the heart and increased aortic blood pressure, liness, § which lessens the danger of sudden anemia of the brain.
Use of Anesthetics. Chloroform is preferable to ether in | | } !
4 OBSTETRICS.
In ordinary labor, when called for, it need only be given during the pain, unless some obstetric operation is undertaken, and then the patient should be put thorougnly under it. If the pains are weak or there is any tendency to hemorrhage chloroform should be avoided.
After the patient has been bathed about the labia, a piece of
gsuze or clean rag soaked in bichloride sclution (1-2000) should |
be applied and over this a pad made of gauze filled with absorbent cofton or tow. These pads are cheaper than napkins and cleaner because they can be burned after being used for a few hours, forra napkin can never be washed so as to be thor-
oughly aseptic. VIII. DYSTOCIA OR EXTRAORDINARY LABOR.
1. From Imperfect Uterine Efforts.—(a). Irregular Action. To understand how this impedes labor it is necessary to bear in mind the principal features of normal labor, viz: regular contractions of the uterus followed by relaxation and distinct periods of repose ; stretching and thinning of the mus- cular fibres of the lower part of the uterus and retraction of the uterus above that point ; softening and dilatation of the cervix ; fixat?on of the uterus in the axis of the pelvis and the addition of the accessory to the essential forces.
in the first stage of labor the pains are most frequently |
defective from their short duration, or exhausting from being too rapid. Premature rupture of the membranes and loss of liquor amnii is apt to cause a “ dry labor.”
Treatment, Always try to iind the cause and then regulate th» pains and resiore then to their normal character. * See that the bladder and rectum are evacuated ; secure abdominal support if there is faulty position of the uterus ; in hydiamnion
rupture the membranes ; if pains are exhausting use chloroform ;
if os is rigid the hot vaginal douche or chloral may assist ; qui- nine in gr. v doses will often strengthen the pains.
In irregt have |
may | causes (6). uterin erful — tissue tion ° Tre to eith broken then th irritati Duri obstrue ciple th organ, down. the fore
Durit
_ cause o
The by Dr. ¢ contract intermis become
Indicd or linge
2. To cncangel
accidentd 6
iven ‘ken, melt
‘hage
ce of hould with pkins for a thor-
OR.
ogular essary iy VIZ: mn and b mus- of the ervix ; dition
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‘ qui-
bform ; F
OBSTETHICS. 65
In the second stage, if a deformed pelvis is not the cause of irregular action, ergot or forceps may be indicated. You may have spasm of the os around the neck or body of the child, and may have to use forceps. In the third stage irregular action causes hour-glass contraction.
(6). Inertia, Is a diminution or temporary suspension of uterine action. It may arise from deficient nerve force ; pow- erful emotions ; plethora; weakness of the uterine muscular tissue ; exhausting disease ; constitutional debility ; malnutri- tion’ plural births ; hydramnion, and fatigue. .
Treatment. During the first stage there is very little danger to either mother or child especially if the membranes are not broken. The bladder and rectum should be evacuated, and then ths hot vaginal douche, gentle friction, hot drinks, digital irritation of cervix and mental encouragement will all assist.
During the second stage the danger is to the child from obstruction to delivery. Rupture the membranes on the prin- ciple that uterine contractions are inversely as the size of the organ. Change the posture and encourage the patient to bear down. If this i« not enough give ergot, use electricity or apply the forceps.
During the third stage inertia is most dangerous and is the cause of post partum hemorrhage.
The use of Ergot. It was introduced into obstetric practice by Dr. Stearns, in 1807. It excites very strong and powerful contractions of the useras which are very persistent and the intermissions are of comparatively short duration. The pains become of a tonic rather than of a clonic character.
Indications. 1. To increase the uterine pains in protracted or lingering iabors.
2. To hasten delivery when the ‘ife of the patient is endangered by some a... ‘ming symptoms, such as convulsions, accidental hemorrhage, ete.
8
66 OBSTETRICS,
3. To restrain uterine hemorrhage by causing firm contrac- tion of the uterus.
Munde’s pill for use in some cases after delivery, consists of ext. ergot gr. i, quinine gr. i, ext. nux. vom. gr. 4. Take one three times a day.
Contraindications. 1. During the first death of labor.
2. Rarely, if ever, in primipara. Ma ZA eed
3. In mal-presentations, or mal-positions of the fete
4, In rigidity of the os, vagina, or perineum.
5. In disproportion between the head of the child and the
pelvis. 4 6. In abortions. i Hssrer 9 a tnasrmred at: Leeaenlee
2. From Impeded Uterine Efforts.—(a). Connected with the Fotus. (a). From Abnormal Position.
(i). Face Presentation. dred cases.
It occurs once in three hun-
Symptoms. You notice the high position of the presenting part, and make out the forehead, nose, eyes, mouth, etc. Be careful not to mistake it for breech, and use the greatest gentle- ness if you suspect a face for fear of injuring the eyes.
Causes. The cause of face presentation is a furtherance of the slight extension in the early part of labor which is so apt to produce occipito-posterior, positions.
This extension movement may arise from congenital enlarge- ment of the thyroid gland which separates the chin from the chest ; from increased size of the chest, interfering with flexion ; from stricture of the cervix about the neck of the child, the uterine walls adding to the circumference of the thorax ; from mobility of the foetus due to small size or excess of amniotic fluid ; from oblique position of the child and uterus especially
*n cases of rapid escape of amniotic fluid ; or _ from coiling cf cord round neck of foetus,
Mechanism. In face presentations the chin cor responds to
the oce the tw sible fo
First Mento-. of the vy
(1). the san The chi put is p descent child’s r exceptio the thor
(2). J inclined arch, th sacrum.
(3). J the shor stretched chest, t brow, ve
(4). left sho
ond posi plane, a according
Second Here ex
except w At full delivery
of the ch
s of one
the
bd
acted
hun-
ting
Be
ntle- *
ce of t to
arge- hn the kion ; the from hiotic ially iling
Re $0
OBSTETRICS. 67
the occiput in vertex presentations, and there are four positions, the two first being possible, the third and fourth being impos- sible for d livery to take place.
First. Mento-antertor Position. (Possible). Left and Right- Mento-Iliac. The movements are s»mewhat varied from those of the vertex.
(1). Descent and Hxtension, Here extension occurs by the same rules that produce flexion in vertex presentations. The chin sinks deeper and deeper in the pelvis, while the occi- put is pushed backward against the dorsum of the child. The descent of the head is normally limited by the length of the child’s neck, as it is only in the case of a very small child, or exceptionally roomy pelvis, that the head and upper portion of the thorax can enter the pelvis simultaneously.
(2). Rotation. The chin now impinges on the anterior inclined plane, rotates forward and engages under the pubic arch, the vault of the cranium sweeping the hollow of the sacrum.
(3). Fleaion. The chin now emerges beneath the pubic arch, the shoulders press upon the base of the skull, the perineum is stretched by the cranial vault, ths head now flexes upon the chest, the chin rounds the symphysis while the mouth, nose, brow, vertex and occiput appear in succession.
(4). Restitution. The shoulders now engage ; in first position left shoulder impinges on right anterior inclined plane ; in sec- ond position right shoulder impinges on left anterior inclined plane, and the chin is thus directed to the left or right thigh according as it has been first or second position.
Second. Mento-posterior Positions, also called Mento-sacral. Here extreme extension takes place and delivery is impossible except with a small foetus, a dead foetus, or a very roomy pelvis. At full term, with a fully developed foetus and a normal pelvis, delivery is an impossiility owing.to the simultaneous entrance
of the chest and head. “70 t¢4«*'
68 OBSTETRICS.
Treatment. Be careful not to, rupture the membranes, for the face is ill adapted to dilate the cervical canal, and rupture of the membranes in these cases is apt to be followed by complete escape of the amniotic fluid which would endanger the life of the child.
Manipulations to push up the face and bring down the occi- put by pressure of the fingers usually fail. It is better to restore the normal attitude of the child by flexing the trunk and leaving the head to resume spontaneously its proper position as it sinks in the pelvis. It is performed by seizing the shoulder and breast with the hand through the abdominal walls, then lifting the chest upward and pressing it backward, at the same time steadying or raising the breech with the other hand applied near the fundus, so as to make the long axis of the child conform to that of the uterus, and finally pressing the breech directly downwards. As the child is raised the occiput is allowed to descend and then as the body is bent forward, flexion of the head is produced by the side walls of the pelvis.
After the membranes are ruptured exercise great care as to the eyes and admitting air intothe mouth. In mento-posterior positions the chin may sometimes be brought forwards by one blade of the forceps acting asa lever.
In these cases, however, if not eariy rectified craniotomy has usually to be resorted to.
(i). Breech Presentations. the head of dystocia, not because there is always necessity for interference, or any danger to the mother, but because there is danger to the child, and in primipara there is usually necessity for some intervention on the part of the physician, utherwise breech presentation might come under the head of natural labor as some have described it. We may have regular breech presentations where the legs are bent up in front of the body, or irregular giving rise to footling and knee presentations.
I have classed these under
The |
is as on
Caus presence foetus, | contract mature
Diag high up and the
Meche child’s t ing to th right an
lst Pe position slowly.
Desce impinges under th the sacrv
The de plane, wl The he in the ri anterior face swee of vertex 2nd P¢ lar to firs to second 3rd Po position 4
the a of lete
. of
ceci- * to and n as Ider chen ame and the the iput rar, lvis. AS to prior one
r has
nder y for re is ally ian, hd of rular
the ions.
OBSTETRICS. 69
The proportion of breech cases, (excluding premature births), is as one to sixty.
Causes. The absence of the conditions which determine the presence of the head, or which interfere with the fixation of the feetus, such as excess of amniotic fluid, lax uterine walls, and contractions of the pelvis. They occur very frequently in pre- mature labors, and when the child is dead.
Diagnosis, The bag of waters is apt to be very large and high up; the sacrum, coccyx, anus, and tuber ischii are felt ; and the presence of meconium is positive proof.
Mechanism. The position is defined by the direction of the child’s back or sacrum, and we have four positions corresp ond- ing to those of the vertex, viz: Left and right dorso-anterior, right and left dorso-posterior. ‘
lst Position, Left Dorso-anterior. This corresponds to first. position of vertex, and is the most common. The cervix dilates slowly.
Descent and rotation of the hips take place. The left hip impinges on the right anterior inclined plane and is directed under the pubic arch, while the right hip sweeps the hollow of the sacrum.
The /eft shoulder then impinges on the right anterior inclined plane, while the right shoulder sweeps the hollow of the sacrum.
The head now engages, the long diameter of the head being in the right oblique diameter, the occiput impinges on left anterior inclined plane, comes under the pubic arch, while the face sweeps the hollow of the sacrum precisely as in first position of vertex.
2nd Position, Right Sacro-anterior. The mechanism is simi- lav to first position, but reversing the planes, and corresponds to second position of vertex. ;
3rd Position, Right Sacro-posterior, This corresponds to 3rd position of vertex, is often converted into 2nd or Ist position
2 Ss
70 OBSTETRICS.
but it may persist and then the chief difficulties are from resist- ance of coccyx and perineum to flexion, the neck of the child being thus pushed so far forward that it is difficult for the fore- head or even for the face to get readily under the pubic arch.
4th Position. Left Sacro-posterior.
MANAGEMENT OF BreEEcH. ‘Try to preserve the membranes until the os is dilated by avoiding frequent examinations and cautioning the patient not to strain. After the membranes are ruptured expulsion of the body should be allowed to go on slowly, not dragging down a leg as it favors descent of the cord; the arms are apt to slip up by the side of the head, and the head is apt to become extended so that the maximum diameter of the head engages and may become locked. When the hips are at the vulva be ready to hasten delivery by telling the mother to strain downward. As the trunk emerges wrap it in warm flannel and raise it upwards. When the cord appears draw it down in one of the recesses of the pelvis and watch its pulsations. With one hand support the body of the child, with the other, or nurse, sustain a steady pressure on the fundus outside. The arms may be separately hooked down.
There are several ways of treating the after-coming head.
1. The Prague Method consists in raising the bédy of the child towards the abdomen of the mother and by placing your fingers on the face of the child, or in its mouth, make trac- tion forwards, This is the usual means resorted to.
2. Martin’s Method consists, besides the above, in making powerful pressure upon the child’s head externally and above with the other hand, thus expressing it as it were.
3. Deventer’s Method consists of a reversal of the Prague method, in that the body of the child is carried far backwards towards the perineum, with the view of turning the occiput out from under the pubes, the anterior surface of the
neck resting on the perineum.
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OBSTETRICS. 71
4. By the Application of Forceps. This is Crede’s. method and is highly spoken of by some authorities.
(i). Shoulder Presentations, or “cross births,” include elbow, hand and trunk presentations.
They occur 1; 260 cases. Their management is’ exceedingly important, for delivery by the natural process is impossible except under very unusual circumstances, and the safety of mother and child depend on their early recognition. Their treatment, easy at first, becomes difficult and dangerous if there . is much delay.
Causes. Prematurity, hydramnion, obliquity of the uterus, low attachment of the placenta, and falls duriug pregnancy. The tendency, however, is for such malpositions to be righted
either before labor sets in, or in its early part. «)¢ . 5 ¢e( gre!
Diagnosis. You will notice at once the high presentation and the absence of the head. You should then palpate the abdomen and you will feel the head in one fossa and the breech in the other. By a digital examination you feel high up the shoulder, and then the clavicle or axilla. The axilla will point to the feet and to one side, indicating that the head must lie in the opposite iliac fossa.
Again, the clavicle indicates the front and the scapula the back of the child, and so we know whether it is a dorso-anterior or dorso-posterior position. If you are still not satisfied of the exact position, and the membranes are already ruptured, you may bring down the arm, and see which one it is, and in which direction the palm points.
Positions. Dorso-pubic of right and left shoulder, and dorso- sacral of right and left shoulder. Thus in dorso-pubic positions , if the head lie in the left iliac fossa, the right shoulder presents, and vice-versa. So in dorso-sacral positions, if head lie in left iliac fossa, left shoulder presents and vice-versa.
Terminations. There are three possible terminetions which
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72 OBSTETRICS,
may occur naturally although we can never trust nature to accomplish them.
1. Spontaneous Rectification. Here the membrane§ are unbroken, and_it takes place by means of the circular fibres of the uterus; &gsisted by*the patient lying on the opposite side to which the breech is deflected. The head is made to present.
2. Spontaneous Version. Here the membranes have been ruptured, one side of the uterus contracts more vigorously than the other, so that the shoulder is pushed up and the breech brought down as the presenting part.
3. Spontaneous Evolution. The presenting arm and shoulder are tightly jammed down and the head is strongly flexed on the shoulder. As much of the body of the fcetus as the pelvis will contain becomes engaged, and then rotation occurs; this brings the body of the child into the antero- posterior diameter, The shoulder projects under the arch of the pubis, becomes fixed, and the body of the child becomes depressed and curved until it is expelled.
Treatment. This consists in turning, or if impacted may require decapitation, evisceration or embryulcia, for which, see obstetric operations.
(B). Size and Form. (7). Large Heaps. May give rise to dystocia and may require forceps, or turning. In these cases great care should be used in giving ergot.
4
~'\ (i). Derormities. These include hydrocephalus, encephalo- cele, spina bifida, ascites, and multiple foetuses like the Siamese cwins.
(y). Number. Muutiete Preenancy. Although the human female is said to be uniparous, there aré exceptions, and twins occur ouce in 85 cases, triplets once in 7,000, while quadru- plets and quintuplets occur still more infrequently.
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OBSTETRICS. 73
A condition closely connected with this subject is superfota- tion, by which is meant the fertilization of a second ovum belonging to another period of ovulation after the first has been developing for a month or more. Some doubt its possibility and most of these cases may be explained by a double uterus, by retention of one twin, by an interval between insemination and fructification of an ovum, by pre-existing extrauterine pregnancy and inaccurate information.
Twins. Are often hereditary, and this sometimes runs on the father’s side ; some races are more apt to have them than others ; and women married late in life are apt to have twins.
It may occur by two or more ova being fertilized at the same time, whether they have come from one or different ovaries, as is proved by the fact of two corpora lutea being found equally developed ; from the occasional occurrence of pregnancy on both sides of a double uterus, and from the occurrence of twin preg- nancy with one foetus in utero and the other extrauterine.
Again, twins may arise from an ovum having a double yolk, an embryo developing from each.
When twins develop from two ova each foetus is contained in its own chorion. If the ova are embedded in the decidua at sufficiently distant points the placente will be separate and each
ovum will have its distinct reflexa. Usually each foetus has its
own membrane and liquor amnii, an although the placentz are generally united in one mass yet each has its own independ- ent circulation.
Twins from the same ovum are always of the same sex.
The weight of each child in a case of twins is less than that of a single delivery, but the conjoined weight is greater. They usually average five or six pounds each.
It is almost impossible to diagnose twins before birth. The - abdomen is more distended and broader and you may hear two distinet foetal heart sounds.
74 ' OBSTETRICS,
Twin labors are usually easy, the first stage is apt to be tedious from inertia, the second stage is apt to be rapid, and inertia is apt to occur in the third stage so that post partum hemorrhage is to be dreaded. The interval ‘between the first and second child is usually from five to 30 minutes ;- sometimes both may present heads, but usually one is head and the other breech. Both placente usually follow the birth of the second child.
Management. Tie the cord after the birth of the first child and wait not more than half an hour; if pains do not return, rupture the membranes, and by external manipulation, the second child soon follows. The most serious complication is “locking” i. e., the interference of the second child with the delivery of the first one. Thus the first child presents a head but a foot or hand may be found presenting with it. Try aud determine if it belongs to the first or second child, but in all cases it should be pushed up as far as possible until the head has completely engaged in the pelvis.
In all cases of twins there is danger of inertia, and post- partum hemorrhage is to be anticipated and prevented or checked.
(6). Connected with the Passages.
(a). PELVIS.
A classification of contrtacted pelvis is difficult ; in the great proportion of cases, however, the diminution of space is usually at the brim and it is to these cases that the term “contracted pelvis” is usually applied, the others being irregular forms.
(t). Con racted Pelvis Proper. 1st. Peivis AQUABILITER Justo-Minor. This is a symmetrically contracted pelvis charac- terized by a general diminution of all the diameters, but no devi- ation, or but little, from their relative proportion in the normal
pelvis. [tis simply below the standard size, and is due to a
premature arrest in the development of the bones so that the pelvis retains its infantile type. |
2nd. shorte: itic or burder to oste a shall: of the mainly presses the san of the ° the sac superio
3rd. combin the tra rachitic
(22). PELVISs. synchor
sacrum side. outside
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3rd. eral cur
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post- d or
OBSTETRICS, 75
2nd. Tue Fratrenep Petvis. Herethe conjugate diameter is shortened but the transverse remains normal. It may be rach- itic or non-rachitic, and is often due to lifting or carrying heavy burdens before the age of puberty, to arrest of development, or to osteomalacia, The result of these conditions is to produce a shallow pelvis with a contraction at the brim and a widening of the outlet. This deformity, when resulting from rickets, is mainly due to the weight of the super-imposed body, which presses the promontory forwards toward the median line, At the same time the sacrum is rendered more horizontal, the bodies of the vertebree sink between the ale so that the concavity of the sacrum from side to side is effaced, und the posterior superior spinous processes are approximated.
3rd. FLATTENED GENERALLY ContR\CTED Petvis. Thisis a combination of the other two varieties and there is narrowing in the transverse as well as the conjugate diameter. It may be rachitic or non-rachitic.
(ix). Irregular contracted Pelvis, st. THE N®GELE OBLIQUE Petvis. This consists in complete anchylosis of one sacrc-iliac synchondrosis, in destruction or defective development of the sacrum on that side, and displacement towards the anchylosed side. The cavity is obliquely ovate. You notice an inequality outside and the patient limps.
2nd. Tue Kypnoric Petvis. Is due to posterior spinal curva- ture or caries of the vertebree, and as a result of this an unnatu- ral direction is given to the weight of the superimposed trunk, which is communicated to the base of the sacrum, the promon- tory being thus thrust upwards and backwards, the symphysis is rendered prominent, the transverse diameters are diminished, and the conjugate increased.
3rd, Tue Scouio-Racuitic. This accompanies scoliosis or lat- eral curvature of the spine. There is expansion of the pubic arch, prominence and lowering of the promontory, widening and
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76 OBSTETRICS.
elongation of the sacrum and irregular kidney-shaped pelvic inlet, the pelvis being laterally tilted and asymmetrical.
DIAGNosIs OF ConTRACTED PeLvis. On enquiring into the his- tory vou usually find a previous occurrence of rickets indicated by late dentition, square head, pigeon breast, attacks of indiges- tion and profuse perspiration, tumefied abdomen, small stature, spinal curvature, enlarged joints, and bow-legs. Then an
‘enquiry into the }revious labors, if there have been such, will
throw light on the case.
MEASUREMENT.
1. Internal Pelvimetry. The patient is placed upon the back and the diameter which is now of importance is the diagonal conjugate or sacro-subpubic, and is the distance from the promontory of the sacrum to the lower border of the symphysis pubis. It may be measured by the pelvi- meter, but the fingers are best. While the point of the finger touches the promontory ot the sacrum, mark off on the back of hand the under border of symphysis and deduct half an inch, this will give the conjugate diameter,
2. External Pelvimetry. Measure with a pair of cal- lipers from the upper edge of the pubic symphysis to the depres- sion just below the spinous process of the last lumber vertebra. This is normally 7? inches and “educting 34 inches for the thick- ness of bone and soft parts, you have 4} inches as the conjugate diameter. Then the distance between the two anterior superior spinous processes should be normally 94 inches, and between the two most projecting points laterally on the crests of the ilia should normally measure 103 inches.
I append the c rresponding normal diameters and dimens- ions, as given by Carl Braun and Schroeder :
Distance between anterior superior spinous Inches. DODO iis i+ ed bus bine weenie ace brane 26 cm. or 10,2 Distance between iliac crests............ 29 cm. “ 11.4
retrove ceratior in norn pendulc
2. I high, a pains a tion is” ism in - compre shape o quity, | from ev
Trea tion of abdomi: operatic
befor enquire does th labor ; through living,
ic
OBSTETRICS. rhe 4
External conjugate diameter (Baudelocque) 20} cm. or 7.9 Distance from sacro-coccy geal joint to sub-
public joint (A. G. E. Breisky)...... 12.30m. “ 4.8 Distance between great trochanters...... 313 om. “ 12.3 Pelvic circumference (Kiwisch)........ 90 em. “ 35.4 Diagonal conjugate diameter............ 13 cm. “ 5,1 True conjugate diameter................ Ll cm. “ 4.3
INFLUENCE DURING PREGNANCY AND LABOR.
1. During Pregnancy. In the early months it favors retroversion and this gradually merges into flexion and incar- ceration. In the later months the uterus is elevated more than in normal cases and is more movable, and the abdomen is more pendulous.
2. During Labor. The presenting part is always very high, and faulty presentations are more apt to occur. The pains are apt to be strong and hence if the mechanical obstruc- tion is not removed the uterus is apt to rupture. The mechan- ism in these cases will depend on the size, form, position, and compressibility of the foetal head, as well as on the size and shape of the pelvic space. There is usually more lateral obli- quity, because the contracted pelvis prevents both parietal bones from entering at once.
Treatment. Our resources in contracted pelvis are the induc- tion of premature labor, forceps, version, craniotomy, and abdominal section, for an account of which, see obstetric operations.
before deciding the appropriate method it is important to enquire if pregnancy has advanced to the full term ; if not, does the case call for the induction of abortion or premature labor ; if the term has been reached, is it possible to deliver through the natural passage ; if the child is alive or dead; if living, do the interests of the mother require the sacrifice of
78 OBSTETRICS.
the child’s life ; and lastly, if the conditions are such as to ren- der it impossible for a living child to be born, what method would be best for the interests of both mother and child ?
To answer these questions it will assist if we divide contrac- ted pelvis into four degrees :—
First Degree. Where the conjvzate diameter is between 4 and 34 inches, the forceps are indicated.
It is assumed that the child may be born alive by the spon- taneous efforts of the mother, but it seems to be forgotten that a Jarge proportion of children will perish and the mothers suffer greatly, and their tissues be lacerated, unless assisted. The dangers to the child result from pressure obstructing the circulation, and the dangers to the :1nother from long continued pressure on the soft parts, causing inflammation and subsequent sloughing of the bladder, vagina or urethra. These results have been attributed to the forceps but are really due to neglect of their timely use.
Second Degree. Where the conjugate diameter is between 34 and 23 inches, version is indicated.
Here labor unassisted is hopeless for both mother and child. By turning you bring the narrow part of the head (the bi-tem- poral diameter, 34 inches) to engage first in the narrowed con- jugate, which the wider dome of the head could not do, and then after turning, manual abdominal pressure may be applied to the head and traction on the body from below.
If the child is dead it is always preferable in such a case to perforate and deliver.
Third Degree. Where the conjugate diameter is from 23 to 1? inches, here craniotomy is indicated, or if the child be alive and not injured by delay or futile attempts to deliver in other ways, and provided the general condition of the mother, her hygienic surroundings and capacity to secure skilled attendants
be such section, vided al
Fourt 1? inche and dan;
To rec
When
brit Bet
(2). O being m ontory c is notice hard to.
Treats with the or apply
Later: on the 0;
(i). I delay in of the lic and emo edges of
It ofte and who
OBSTETRICS. 79
be such as to give substantial hope of her surviving abdominal section, this operation would be justifiable and preferable, p o- vided also that she and her relatives consent.
Fourth Degree. When the conjugate diameter is less than 1? inches, abdominal section is, beyond all question, less difficult and dangerous than craniotomy.
To recapitulate :—
When conjugate diameter of
brim measures .
The proper mode of delivery is by : Between 4 and 34 inches............... Forceps. Ms Shand 2 “ 1. .......00.. Version. sh 2$and1¢ « . Craniotomy, or if child alive, by Abdominal Aboticn. Below 1? inches. . . Abdominal
Section and not C1 ening
(8). OS UTERI.
(z). OBLiquity. This may be lateral or anterior, the latter being more common ; the head is thrown toward the prom- ontory of the sacrum, and labor is thus impeded. The uterus is noticed to be thrown forward, the belly pendulous, and it is hard to find the os as it is so far back.
Treatment. Rupture the membranes, draw forward’ the os with the finger, and press on the abdomen with the other hand or apply a binder.
Lateral obliquity is often relieved by making the patient lie on the opposite side.
(i), Rigipity. This is one of the most common causes of delay in the first stage, and is often caused by premature escape of the liquor amnii. It is very often found in those of a nervous and emotional temperament, the pains becoming cramp-like, the edges of the os being thinly stretched over the head.
It often occurs in girls who have been brought up in luxury, and who bave had little physical exercise, the exciting causes
a ae
et
it ( ,
80 OBSTETRICS.
being powerful impressions on the mind, over-stimulating food or drinks, or too frequent examinations on the part of the physician. 7/?*&+-e agin
Treatment. If the membranes are intact, waiting and patience often succeed, but if the membranes are ruptured you may need to assist, for itis often in these cases that laceration of the cervix orcurs. Use first the hot vaginal douche, and if this is not sufficient give chloral hydrate in gr. XVdoses every half hour for three doses. It often acts well and does not interfere with the strength of the pains. In some cases, where due to severe continuous pains, chloroform is often more useful.
(iat). INpuRATION. This may be due to cicatricial hardening from former lacerations ; to hypertrophy of the cervix from dis- ease antecedent to pregnancy, or to aglutination and closure of the os.
Treatment. Try the same means as in rigidity, and if these fail, it may be necessary to make three or ‘our notches round the margin of the os with a blunt-pointed bistoury. Should these fail, especially in cancerous disease, craniotomy or Ceesarean section may be necessary.
(y). VAGINA.
(2). Arresia, This may be congenital or it may be acquired from lacerations, diphtheria, variola, enteric fever, cholera or syphilis. Persistent nymen comes under this head.
Treatment. The same as that of rigidity or induration of the os.
(iz). Tumors. These include cedema of the labia, sanguineous effusions, displacements of the bladder, scybala in the rectum, calculi in the bladder, encysted tumors of the vulva, fibroids, steatoma, polypi, scirrhus and ovarian tumors.
Treatment, This depends on their character and mobility. If they do not interfere with labor let them alone, if they obstruct
they by itse (C). (7). consids tensior T rec water | (27). premat (6). and git and rec Cy). child if separat (i), After where t hastene (v2). endange child wl
Cause insertio lapse of above al
Progr more se occurs a
Treat
maintain ,
DUS
OBSTETRICS. 81
they may need removal, but every case will have to be judged by itself.
(c). CONNECTED WITH THE SEcuNDINES. (a). Liquor AMNII.
(i). ABuNDANT. This is hydramnion. which has already been considered. It impedes labor in the first stage and by over-dis- tension paralyzes the uterus.
Treatment. Puncture the membranes high up and allow the water to escape slowly if possible. .
(aw). Dericient. This may delay labor for the same reason as premature rupture of the membranes.
(8). THe Mempranes. Thin membranes rupture prematurely and give rise to “ dry births,” and require to be punctured.
or if tough they may cause delay
(y). THe Corp. (2). SHort. Gives rise to danger to the child if it tears and bleeds, or to the mother from premature separation of the placenta and hemorrhage.
(%), Enranetup. It is often twisted round the child’s neck. After the head is born it may be slipped over its head, and
where this cannot be done it may be tied and cut, and delivery hastened
(iii). PRESENTING. ‘“‘ Prolapse of the funis,” although uct endangering the mother, is serious as regards the life of the child which is very apt to be sacrificed.
Causes. Unusual length of the cord, deep placental site, insertio velamentosa, 1 -ulder ana breech presentations, pro- lapse of the extremities, hydramnion, multiple pregnancies, and
_ above all contracted pelvis. —
Prognosis. More than one-half of the children die. It is more serious when it complicates head presentations. It occurs as 1; 300 cases.
Treatment. Ifthe membranes are not ruptured try and
maintain them so, for the expectant plan is best until dilatation " :
ROT SORE SLT EERE ELTON Oa ee a
- ———- x " rE penenon ~ — a a Re EIS
Ed
Pa. f ‘
82 OBSTETRICS.
is complete. After rupture of the membranes, if the presen- tation is still high, the cord should be replaced and held up until the child has engaged.
_/ This is best done by placing the patient in the genu-pectoral position ; introduce the hand and place the cord beyond the greatest circumference of the head, and if possible, to the back of the child’s neck; sustain the uterus externally by the other hand, and cease during the pains. If this is successful place the patient in the latero-prone position with the hips elevated by a pillow. If this should fail, put a piece of tape through the eye of a flex- ible catheter, and catching a loop of the cord with this push it into the uterus and leave the catheter there until the head engages so as to prevent prolapse again. If these means fail, especially in face presentations, version may be resorted to.
(5). Puacenta. (2). ADHESION. lst. SimpLeE RETENTION, May be caused by spasm of the os; from maluse of ergot ; large size of placenta ; or from dragging on cord so as to pull placenta against the pubic arch, or invert it so that it is like dragging on an umbrella; this has been sty'ed “ student’s placenta.” @%er 4% Ue. btn.
Treatment. There is always danger of hemorrhage while the placenta remains in the uterus, so if Crede’s method of removal, together with gentle traction, are not sufficent, introduce the hand, dilate the os, and remove the placenta.
2nd. Hour-eiass Contraction. Here portions of the uterus contract feebly, while the circular fibres are thrown into spasm and retain the placenta in the fundus. It may be caused by the maluse of ergot, or by premature dragging on the cord.
Treatment. Place the patient on her back, your left hand on the abdomen to steady the uterus, and with the right hand fol- low up the cord, gradually dilate the constricted part with two fingers, and seizing the placenta remove it.
3rd. Morsip ADHESION. May be uterine or placental. The
nlace! careot the pl it. T uterus and w have { no spe Tre placen the pl. moven the pl: Exe for he care sh the ut« employ (22). the ute segmen leaves 1 pours u vention natural hemorr! ment of on the hemorrl
Band different stretchii cervix.
OBSTETRICS. 83
nlacenta may be thickened, indurated, or have undergone cal- careous degeneratio . There may have been inflammation, and the placenta may be adherent in whole or in part as a result of it. Though it is rare it may be presumed to exist when the uterus is large, firmly contracted, the os sufficiently opened, and where suitable traction on the cord and external pressure have failed to remove it, and on digital examination you find no spasmodic stricture of the os or uterus.
Treatment. If the means for removing a simply retained placenta are not sufficient, insert your fingers carefully between the placenta and the uterine surface, and by slow and cautious movements of the fingers the adhesions ure bruken down and the placenta freed.
Exert no force and be careful not to injure the uterine tissue for hemorrhage, rupture, or inflammation may follow. Great care should be taken after these cases to use disinfectants, and the uterine douche with bichloride (1-5,000).should always be employed.
(iz). Pravia. Is where the placenta occupies that portion of the uterus subject to dilatation i. e., the internal os and lower segment of the uterus. The stretching of the lower segment leaves the mouths of the sinuses gaping, from which the blood pours until the stream is arrested either by art or by the super- vention of syncope. As the hemorrhage in such cases is the natural sequence of cervical dilatation, it is called “ unavoidable hemorrhage ” in contradistinction to hemorrhage from detach- ment of the placenta when situated normally at the fundus or on the side walls of the uterus, which is known as “ accidental hemorrhage.”
Bandl has shown that during labor the uterine body becomes differentiated into a retracting and ever thickening fundus, a stretching and ever-thinning “lower uterine segment,” and the cervix. It is not yet finally settled what is cervix and what is
3
—
Sapper
ee ee ee ray * a " “ = pe SAI AB RR RI CCT HER RI SEN NTL TAILS TERI RS MP . —
84 OBSTETRICS.
‘lower uterine segment.” After labor the lower uterine seg- ment and cervix can be felt at the lower part of the hard retracted uterus, hanging loosely like a flabby hose.
Placenta previa may be central or marginal, called also
partial. It occurs as 1: 1,000 cases.
Causes. It occurs more frequently in multipara than in primipara in the proportion of 6 to 1; more frequent in those who have had children rapidly, and in pregnancies shortly fol- lowing abortions. All these conditions favor relaxation of the uterine walls, dilatation of the uterine cavity, subinvolution of the uterus, and defective development of the decidua,
Symptoms. Sudden hemorrhage occurring during the last few weeks of pregnancy without any apparent cause, without warning or pain, often while urinating or asleep. The first out: pouring may lead to intense anemia, and if shortly repeated may cause death. It usually ceases when separation of the cotyledons is completed, and after rupture of the membranes, for then pressure of the presenting part bears upon the bleeding The hemorrhage is usually arrested during the height
surface. of the pains. :
Diagnosis. Itis not usually detected until the first hemor- rhage occurs. :
A sudden hemorrhage occurring during the last few weeks of pregnancy, without warning, cause, or pain, should always be regarded as suspicious of placenta previa. On making a digital examination the os ‘is felt to be soft and boggy, balotte- ment is obscure, the cervix is long, wide, soft, and you can often feel vessels pulsating in it, and you can usually feel the rough, spongy, granular texture of the placenta within the os.
Prognosis. Js unfavorable if left to nature or if not promptly assisted. No complication in midwifery is more apt to produce sudden and alarming effects, and none requires more prompt
and | to th case | from Tr. the w exists of suc and h quent ting, | promy doing chance We gress t This is it is n has be placent Simpsc placent placent not, ho accordi
If th septic p the co1 escapin, the tan
g- rd
sO
OBSTETRICS. 85
and scientific treatment. There are few cases more appalling to the young practitioner, and the successful management of a case of this kind at once distinguishes the educated accoucheur from the ignorant midwife.
Treatment. Always remember that there is no safety fi the mother as long as pregnancy continues if a placenta previ: exists. When, theref re, you have been summoned to a case of sudden hemorrhage during the latter months of pregnancy and have diagnosed placenta previa, delay is dangerous. Fre- quent recurrence of such hemorrhage may be seriously exhaus- ting, or one repetition may be fatal, and if we have not acted promptly, perhaps all we shall then have the opportunity of doing will be to regret that we did not act when we had the chance.
We must remember that a certain number of these cases pro- gress to a favorable termination and require no interference. This is more apt to occur in placenta previa marginalis, although it is not unknown in placenta previa centralis, where the child has been known to he born by strong contractions pushing the placenta out like a cap upon its head. It was on this fact that Simpson’s treatment, consisting in the previous removal of the placenta with the. hand, and Barnes’ method of detaching the placenta from the lower uterine segment, depend. We must not, however, leave it to nature, but each case must be treated according to its condition.
If the os is not dilated you must plug, using of course anti- septic precautions. The tampon strengthens the pains and by the compression it exerts, causes coagulation of the blood escaping from the uterine vessels. Having once introduced the tampon you should never leave the patient until labor is ended.
After at most fowr hours, the plug should be removed and the cervix examined. If the attachment of the placenta has
i H
86 OBSTETRICS,
only been slight to the lower zone, hemorrhage may now cease, the presenting part preventing any more, and the case may be allowed to proceed, or you may hasten delivery by ergot or forceps.
Barnes recommends separating at once that portion of the placenta Which is attached above the inner orifice of the cervix. By so doing he says “ we remove an obstacle to dilatation of the cervix, for the adherent placenta acts as an impediment.” ‘Pass one or two fingers as far as they will go through the os uteri, the hand being passed into the vagina if necessary ; feel- ing the placenta, insinuate the finger between it and the uterine wall, sweep the finger around in a circle so as to separate the placenta as far as the finger can reach. Commonly some amount of retraction of the cervix takes place and the hemor- rhage ceases.” :
Should these means not succeed you can rupture the mem- branes, give ergot and hasten the engagement of the foetus and its delivery. Should hemorrhage still persist, turn by Braxton Hicks’ method, bring down one leg and let the case go on natu- rally, as it is quite unnecessary to extract. In placenta previa centralis the hand should be passed through the least attached portion and the child turned, a leg brought down, ard then lett to nature.
In all these cases the most careful antiseptic precautions should be employed after delivery, as sepsis is apt to occur from the low placental site bringiny it nearer to the outer world, and nearer the accoucheur’s fingers, owing to laceration, and perhaps to imperfect retraction of the lower uterine segment.
3. Complications of Labor. (a). Hemorrwace. (a). ACCIDENTAL HEMORRHAGE.
This is hemorrhage occurring during pregnancy or labor owing to partial separation of the placenta when normally attached. : It is rare in primipara, and usually occurs in debilitated multipara.
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OBSTETRICS. 87
Causes. Slipping, straining, lifting heavy weights, stretch- ing, blows, congestion of the « terine vessels, causing the uterus to contract, and the partia. separation of the placenta, allowing the blood to escape between the membranes and the uterus,