Dr. (Alfred) Auvard.

A system of obstetrics online

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A SYSTEM OF



OBSTETRICS



WITH FIVE HUNDRED AND THIRTY-SEVEN ILLUSTRATIONS;
BASED UPON A TRANSLATION FROM THE FRENCH

OF AWARD



REVISED BY

CURTIS M. BEEBE, M. D.

CHICAGO. ILL.



1892
J. B. FLINT & COMPANY

NEW YORK



Ou






Copyright,

1892,

J. BENTON FLINT.



hWUfrtT ft f ««B?Mah



mEStVBSt



THE MERSHON COMPANY PRESS,
RAHWAV, N. J.



CONTENTS.



PAGE.

I. Menstruation and Fecundation, 17

II. Development and Description of the Human ovum. . 27

III. Modification of the Maternal Organism. . . 64

IV. The Parturient Canal 84

V. Presentations and Positions. ... . . . 97

VI. Symptomatology of Pregnancy, 127

VII. The Diagnosis of Pregnancy 158

VIII. Progress and Duration of Pregnancy. — Prognosis.—

Hygiene, 164

IX. Accouchement.— Maternal Phenomena. . . . 170

Phenomena of the Appendages 188

X. Mechanism of Accouchejient.— Fetal Phenomena. . 194
XI. Influence of Accouchement on the Mother and on

the Child, 214

XII. Management of the Accouchement 224

XIII. Accouchement.— Delivery of the Appendages, . 234

XIV. Post-Partum, 240

XV. Puerperal Pathology. — General Disease. — Eclampsia. 250

XVI. Puerperal Septicemia, 257

XVII. Puerperal Pathology. — Extra Genital Localized

Diseases. 269

XVIII. Diseases of the Bony Pelvis 277

XIX. Diseases of the Genital System and its Dependen-
cies.— Genital Dystocia. 307

XX. Diseases and Anomalies of the Placenta. . . 324

XXI. Diseases of the Ovuline Envelopes, .... 335

XXII. Diseases and Death of the Fetus.— Fetal Dystocia, 338

XXIII. Multiple Pregnancy, 348

XXIV. Premature Expulsion 359

XXV. Accidents of Accouchement, 368

XXVI. Accidents of the Delivery of Appendages. . . 376

XXVII. Accidents of Post-Partum. 389

XXVIII. The Vectis or the Lever 391

XXIX. Versions 302

XXX. Forceps 402

XXXI. Manual Extraction, 416

XXXII. Induced Expulsion, 420

XXXIII. Embryotomy 423

XXXIV. Hysterotomy. — Cesariax Section 432



TREATISE ON OBSTETRICS.



CHAPTER I.



MENSTRUATION AND FECUNDATION.

Woman's life is divided into three great periods : one, prsegenital ;
another, genital; the third, post-genital. The first extends from
birth to the first menstruation ; the second, from puberty to the
menopause, and the last, from the menopause to the close of life.

Only the genital period interests the obstetrician, for it is that
portion of woman's life that is consecrated to procreation. In im-
posing this role upon woman, nature has established in her a pre-
ponderance of the genital system, an idea that Michelet has so well
expressed in the words, "Woman is a matrix supplied with organs."

This genital system, which dominates the feminine organism,
imposes three different states, that successively divide the genital
period. For a time there is repose, calm, an intermittent and a
regular truce accorded to the economy. Then there is the prepa-
ration for fecundation, the period of emission of the ovule, the
menstrual state. Sometimes, finally, after the meeting and the
union of the two elements, male and female, a being developes in
the interior of the uterus, and causes in the gestating woman a
series of changes necessary to ensure this new life ; this epoch is
designated as the puerperal state. Thus, a state of repose, a men-
strual state and a puerperal state occur during the genital life of
woman. It is the puerperal state that especially interests the
obstetrician. Obstetrics is the study of the puerperal state, pro-
vided this term is used to designate the period which extends from
impregnation to the end of lactation, or to the end of the third
month after delivery when the mother does not nurse her child.

Before entering upon the study of pregnancy it will be necessary
to consider briefly menstruation and fecundation, which are its pre-
liminaries to pregnancy. The term menstruation is applied to the
flow of blood, which occurs periodically from the female genital
organs. Menstruation comprises two essential phenomena, ovu-
lation and a sanguineous flow. Each demands a special study.

Ovulation is the liberation by the ovary of a cell, having an
important future and to which has been given the name ovule.



18



Menstruation and Fecundation.



A word on the ovary and its contents. The ovary, situated in
the posterior wing of the broad ligament, is a small gland resembling
an almond in form. It measures four centimetres in length, two in
height ami one centimetre and a half in its antero-posterior thick-
no- : it- weight is eight grammes. Its two surfaces and its
superior border being free it floats in the peritoneal cavity. Its
inferior border is attached by a ligament to the uterus and to the
pavilion of the tube by one of its fimbriae. I shall return to the
anatomical relations of the ovary in connection with the subject of
fecundation.



r^'^P^^ 1 ^^^,




FlG. i. — Section of a fragment of the cvary. S S, ovarian stroma: e, epithelium ;
I I, Graafian follicles highly developed ; 2 2, non-developed follicles; 3, very small
follicles; O, ovule in the Graafian follicle; vv, bloodvessels; 9, cells of the granular
membrane.

On section, the structure of the ovary is found of a reddish color,
rose colored in some parts, a deeper red in others. This is the
bulbus portion, a mixture of non-striated mucular fibres, con-
nective tissue fibres, arteries, veins, lymphatics and some nerve
filaments. This bulbus portion forms almost the whole of the
ovary. It is covered by a thin envelope, which scarcely measures
a millimetre in thickness.

The peripheral portion, called the fibrous tunic by the older
writers, is distinguished from the subjacent portion by its pale
color, its apparent homogeneousness and by its firmness. This
envelope is the fundamental portion of the ovary. It is formed by
the accumulation "f <>\ i-;t <•.-., also called ovarian vesicles or Graafian
follicles. It i- in the interior of these vesicles that the ovule is found.

I lontrary to what is observed in all the other glands of the organ-
i-m, the ovary has its cavity at the surface and it is there that the
phenomenon of ovulation takes place. To comprehend the phe-
nomenon a complete description of the ovisac and its contents is



Menstruation and Fecundation.



19



indispensable. The follicle contains an accumulation of other cells,
among them one of particular character, the ovule. The ovule is
the female primordial element, just as the spermatozoid is the pri-
mordial element of the male. The ovule is constituted by the
germinative spot, the germinative vesicle, the vitellus and vitelline
membrane. The ovule is contained in the interior of the ovarian
vesicle surrounded by cells, the whole being enveloped in a common
membrane. Altogether these structures form the ovisac. In its
conformation the ovule does not differ from ordinary cells. Each
ovisac contains an ovule, and each ovary contains, as M. Sappey
has demonstrated, approximately 300,000 ovisac, or 600,000 to each
woman.




Fig. 2. — Schematic representation of the Graafian follicle or ovisac
and of its contents, the ovule.

Let us follow an ovisac in its menstrual evolution. In its interior
the cells assume proliferation and at one point a cavity is formed,
that fills with liquid, perhaps the result of the cellular activity.
The vesicle enlarges markedly under the influence of the cell pro-
liferation and of the accumulation of liquid. It takes on a size
that becomes visible to the naked eye at the surface of the ovary.



20



Menstruation and Fecundation.



This swelling continues and the vesicle, instead of remaining
spherical, takes an ovular form, with the small extremity corre-
sponding to the free surface of the ovary. At the moment when
the distention hecomes too great, rupture occurs at the most pro-
jecting point. This rupture, prepared for by the modifications in
the ovisac, is provoked by the congestion of the bulbus portion of
the ovary. This congestion occurs under the influence of menstru-
ation or any genital excitation, such as that produced by coitus.




Fig. 3. — Ovisac preparing to rupture and liberate the ovule.

At the moment of dehiscence the ovule is thrown outward.
The ovisac, abandoned by the ovary, becomes henceforth useless.
Its role is completed. Blood and plastic lymph are effused into its
interior. The place of rupture which has given passage to the
ovule cicatrizes. The vesicle becomes folded on itself. From the
transformations of its contents it takes on the appearance of the
corpus liitcinn, disappearing by degrees until reduced to a linear or
radiate cicatrix that is more or less depressed. The corpus luteum
of menstruation differs from that of pregnancy only by the fact
that the iatter, under the influence of the activity impressed on all
the genital zone by fecundation, instead of diminishing, enlarges
for two or three months and does not undergo regression until after
delivery. Thus we understand the phenomena of ovulation, there



Menstruation and Fecundation. 21

now remains to be studied the other condition of menstruation, that
is, the flow of blood.

The periodical hemorrhage that occurs during the genital life of
woman generally begins, in France, at fifteen years of wj^ and

inates at forty-live. Thus it may be said that the genital life
continues about thirty years. But there are observed frequent

variations in the period of appearance and of cessation of the
menses, variations which depend upon the constitution, upon the
temperament, upon the geographical latitude of the country, upon
the education, upon the habitual diet, upon the race and upon the
social condition of the woman. Various facts of precocious and of
late menstruation have been cited. The menstrual flow is repro-
duced in general every solar month (thirty to thirty-one days),
sometimes oftener ; every lunar month (twenty-eight days), and
some women menstruate even every three weeks, others only every
five weeks. Finally, there are some in whom the appearance of the
flow is capricious and irregular. The duration of the flow is com-
monly from three to six days. Some women only menstruate a few
hours, others from ten to twelve days. I only give the extreme
figures. It is difficult to appreciate the quantity of blood lost at each
menstrual period, but a quantity less than fifty grammes or greater
than five hundred grammes may be considered as pathological.

The blood which flows during the menstrual period has its source
in the tubes and in the body of the uterus, rarely in some other
portion of the genital organs. Exceptionally the flow may occur
from another region, in such cases as have been called menstrual
deviation, where the periodical haemorrhage takes place from the
lungs, from the intestine, from the mouth, from the nose, from the
surface of a wound, from an erectile tumor or from the nipple.

I return to the uterus. At each menstruation the uterine mucosa
is folded on itself in such a way as to recall the cerebral convolutions.
This tumefaction, the consequence of the genital congestion, favors
the implantation of the fecundated ovule, which thus becomes
grafted on the folds of the mucosa. The mucosa also undergoes
other modifications, about which there are so many different
opinions that it is impossible to judge of their true nature.

Having sufficiently discussed the two essential phenomena of
menstruation, there remains the study of their relations. Does the
flow of blood depend upon ovulation? Or, on the contrary, does
ovulation depend upon the blood-flow? Or, a third hypothesis, are
these two factors independent ? Each of these theories has its
partisans. Without wishing to enter here into a complete discussion
of this difficult question, I shall say that I believe in a certain de- '
gree of independence of ovulation and menstruation. I also believe '
that they are subordinate, one to the other, in such a way that they
most often occur together. It is the union of ovulation and of



22 Menstruation and Fecundation.

istruation that constitutes menstruation, as the current of air
and the contraction of the vocal cords forms the voice. Now there
is the same union and the same independence existing between the
current of air and the contraction of the vocal cords, as between
ovulation and the ilow of blood. Ovulation is the essential phe-
nomenon of menstruation and the sanguineous flow the accessory
element. One assures fecundation, the other preparation for it.
Their union place the woman in the most favorable condition for
conception. From this study of menstruation we pass to that of
fecundation or conception.

Fecundation is the union of two elements, male and female, in
the aim of procreation of a new being. Conception is the synonym
of fecundation, and only differs from it by a simple shade of
meaning; fecundation indicating the union of the two procreative
elements, and conception applying better to the state of the woman
who has just been fecundated. We have spoken of one element,
the ovule. We shall now turn to the spermatozoid.

The spermatozoid, wrongly called spermatozoon at the time it
was considered animalcule, is composed of a head of ovular form,
measuring 5 mm. in its long axis, of a small cylindrical body of-
fering almost the same length, and finally an undulating tail which
grows successively thinner toward its extremity, and has a length
of 45 mm. From the recent studies on the development and
the nature of the spermatozoid, it has been proven that it is only
a cell of a particular form, the nucleus being represented by the
head and the protoplasm by the intermediate segment. The tail is
only a simple cilium analogous to that met in other cells of the
economy. Under the microscope, in a drop of fresh spermatic fluid,
spermatozoids are seen in great number, moving with great rapidity.
These displacements are due to a corkscrew movement of the cilium
which constitutes the tail of the anatomical element. In a second
a spermatozoid covers its length ; it moves at the rate of two to
three millimetres a minute. These movements quickly cease as
soon as the spermatozoid is placed in an acid medium instead of
tin- alkaline fluid in which it normally occurs. The uterine fluid
being alkaline, and likewise that of the tube, the spermatozoid pre-
serves its n.ovements therein for a certain length of time, to fifteen
days, according to Schroeder, and perhaps even more. But if there
is endometritis, the uterine secretion becomes acid and the sperma-
tozoid is quickly killed.

The two elements, male and female, now being understood, we
may essay the solution of the problem of fecundation, and to this
end we shall note successively : The place of the meeting of these
two elements; the approach of these elements, one toward the
other ; the difficulties that they must overcome before union.



Menstruation and Fecundation.



28



At the moment of ovular dehiscence tin* ovule becomes free at
the surface of the ovary, the spermatozoid, for the other part, ia de-
posited at the external orifice of the uterus as a consequence of
coitus. To meet, the ovule and the spermatozoid must travel
through the uterus and the tube. But the approach of these elements
toward each other can only he comprehended by a previous study
of the parts through which they must pass. We turn, then, to the
cavities of the uterus and of the tubes.




Head.



Intermediate
Segment.



.Tail.




Fig. 4. — Spermatozoid.



Fig. 5. — Uterus:
body; isthmus; cer-



The uterine cavity is subdivided into that of the body and that of
the cervix, which are separated by a short canal, the isthmus (Fig.
5). Each of these cavities measure about two and one-half cen-
timetres vertically, though in the nulliparous woman the cavity of
the cervix exceeds that of the body, and, on the contrary, in the
muciparous woman that of the body is relatively greater. The
cavity of the body has a triangular aspect, the superior angles being
continuous with the tubes, and the inferior with the isthmus. The
surfaces are plane and applied one to the other in such a way that
the space is virtual or is filled in the normal state with a small
quantity of mucus.

The cavity of the cervix is fusiform, slightly flattened from before
backward. The mucosa that lines its walls is uplifted by the
arbor vita, two in number. Each one of these structures is composed
of a longitudinal axis, from which arise transverve and ascending
branches. The anterior axis begins at the external orifice and is
directed obliquely above and to the right ; the posterior axis, placed
symmetrically to the origin of the former, followes an oblique path
in an analogous direction, that is to the left and toward the internal
orifice. The two axes terminate by gradual diminution toward



24 Menstruation and Fecundation.

the isthmus, no branches existing at that place. The utility of the
arbor vita' is unknown, but it is supposed that they favor the passage
of the spermatozoids.

The uterine cavity is lined by a mucosa, of one to two millimetres
in thickness, continuous above with that of the tube and below with
that of the cervix. In the cervical cavity the epithelium is calci-
form, and is continued into the interior of the numerous racemose
glands of this region. At the summit of the projections of the
arbor vitae the epithelium becomes cylindrical and possesses cilia.
In the isthmus and in the cavity of the body of the uterus, there is
found cylindrical epithelium w r ith cilia, that is prolonged into the
interior of the tubular glands (with the exclusion of the cilia), the
only variety contained in this region.

The tube or oviduct is the canal that establishes communication
between the surface of the ovary and the uterine cavity. When the
abdominal cavity is opened, and the intestines are removed, there
will be seen on each side of the uterus two transverse folds. These
are the broad ligaments, the free or the superior border of which is
divided into three wings. The anterior contains the round ligament,
the median contains the tube, and the posterior is reserved for the
ovary and its ligaments, to the number of two, one attaching it to the
uterus (ligament of the ovary), the other to the tube (ligament of
the tube).

The tube presents an average length of twelve centimetres. De-
parting from the supero-lateral angle of the uterus it takes a slightly
tortuous course toward the lateral wall of the pelvis, terminating a
short distance from this wall by expanding into a fringed and
mobile pavilion. In the vicinity of the uterus the diameter of the
tube is about one millimetre, and this increases more and more
toward the pavilion. Its structure comprises a superficial, incom-
plete, serous envelope ; a non-striated muscular tunic, composed of
a superficial longitudinal layer and a deep circular; finally, the
mucosa, which presents numerous longitudinal folds (Fig. 6). The
epithelium which lines its cavity has cilia, as in the uterus, and
at the free border of the tube it becomes directly continuous with
the flattened epithelium of the peritonaeum. This description is
sufficient to give us a succinct idea of the canal, which extends from
the ovary to the external orifice of the uterus, and which the two
elements, male and female, follow in their approach toward each
other.

But a preliminary question occurs here, that of knowing at what
place the meeting of the spermatozoid and ovule usually takesplace.
If it is possible to determine this point, we know in advance the
path taken by each of these elements. It has been shown from the
experiments of Bisehoff and of Nuck, on bitches, that the meeting
- place in the external third of the tube. Coste admits the same



Menstruation and Fecundation. l~>

for the human female; he also believes thai if the meeting takes
place aearer the uterus fecundation i- nol possible, for is pene-
trating thus far the ovule becomes bo coated with albumen as to
become impermeable.

Lei us take the ovule at the Burface of the ovary and the Bperma-
tozoid at the entrance of the uterus, and follow these elements to
tht' point of meeting, in the external third of the tube, studying
their mode of progression.

We havefour theories : One, of the progression of the spermatozoid
by capillary action (Coste, hoiegeois) ; on< , as to the action of the
vibratile cilia (Muller) ; another, as to the movement of aspiration
made hy the uterus at the end of coition (Biolan, Morgan), and a
fourth, a supposition that the sperrnatozoids are capable of inde-
pendent migration by virtue of the rapid progression revealed
under the microscope. Thus we are in the presence of four theories
that render quite plain the progress of the spermatozoid. It has
been objected that ciliated cells do not exist in the whole extent of
the genital organs ; that aspiration cannot be exerted in a cancerous
uterus ; that in certain animals fecundation is possible although
the sperrnatozoids are not mobile. These are simple objections of
detail which show us that one of these causes may be deficient or
absent without impeding fecundation. It appears rational to admit
that capillary action, the vibratile cilia, uterine aspiration and
the movements of the sperrnatozoids are conjoined in aiding the
progress of the male element in the interior of the female genital
organs. All these theories are true in part, but no one of them
should be admitted to the exclusion of the rest.

"With regard to the ovule, the problem to be solved is the manner
in which it passes from the surface of the ovary to the external
third of the tube. The distance is short and yet the difficulty is
great, for the route is not continuous. The surface of the ovary,
like the pavilion of the tube, floats in the great peritoneal cavity.
The ovule then passes from one to the other, much as a projectile
is thrown from one point to another in the atmosphere. Attempts
have been made to explain this migration in five different way- :

1. Heller and Rouget believe that, at the moment of dehiscence of
an ovisac, the pavilion of the tube, free in the usual state, applies
itself on the ovary and exactly encloses it. The ovule is thus en-
grossed and gathered into the tube at its issue from the ovisac.

2. Kehrer advances the theory of the projection of the ovule into
the pavilion of the tube by an impulse given it from the bursting
of the Graaffian follicle. I do not believe in this fantastic theory.

3. The ligament which unites the ovary to the pavilion is slightly
hollowed out on its upper surface in the form of a trough ; Henle
interprets this anatomical disposition by giving us the opinion that
the ovule follows tins from the ovary to the tube. 4. But little



26



Menstruation and Fecundation.



satisfied with the explanations given, and discouraged in his vain
researches, Kiwisch has advanced the idea that the migration of
the ovale is accidental. The peritonaeum thus becomes the tomb
of useless ovules. 5. I arrive at the theory of the menstrual lake,
that I have reserved for the end, as it appears the most adapted to
explain the migration of the ovule.




Fig. 6.— Uterus. Tube. Ovary.




Fig. 7. — Posterior round ligament. I, ligament of the ovary; 2, ligament of the
tube; 3, posterior round ligament, with the three branches external, median, internal.

According to Becker, at the moment of dehicence there occurs
around the ovary an accumulation- of serum and liquid blood which
constitutes a veritable lake. When the ovule leaves the ovisac it
floats on this fluid, which, being diverted by the tube into the uterus
draws the ovaule with it into the genital canal. But an objection
arises at once. If this current draws the ovule from the ovary
toward the vulva, how can the spermatozoid, placed under the same
influence, pursue a contrary direction? 1 shall remark that the
spermatozoid is generally deposited in the feminine genital organs
before or after the flow, and that it gains the external third of the
tube without undergoing the influence of this current. I know that



Online LibraryDr. (Alfred) AuvardA system of obstetrics → online text (page 1 of 28)