Copyright
Henry J. (Henry Jacques) Garrigues.

A text-book of the science and art of obstetrics online

. (page 12 of 80)
Online LibraryHenry J. (Henry Jacques) GarriguesA text-book of the science and art of obstetrics → online text (page 12 of 80)
Font size
QR-code for this ebook


the pelvic organs and interferes with the free circulation in the lower
extremities. The longer time she spends in the open air the better.
It is also advisable to leave the windows of her bedroom wide open
in summer-time, and not to close them entirely even in the cold sea-
son. The pregnant woman should take long walks every day, even
in bad weather. She may also ride in street-cars and on railroads,
but she should avoid being jolted in a carriage going over bad roads.
She should not ride on horseback, wheel, dance, jump up and down
stairs, climb mountains, play tennis, skate, or swim. Light gymnastic
movements, giving the arms a similar chance to be used to that which
the legs have in walking, are to be encouraged. There is no reason
why she should not make a bed or prepare a meal if she is wont to
do so.

She should have a movement of the bowels at least once a day.
As there is a tendency to constipation, often special measures have
to be taken to obtain this. Nearly all fruits and vegetables have an
aperient effect and should, therefore, form part of the diet. Espe-
cially grapes and oranges taken before breakfast are useful. If any
medicines are prescribed, they should be of the mildest, such as mag-
nesia, rhubarb, cascara, or senna. But the writer has found that
some of the worst cases of constipation yield to the regular use of
distilled water, of which a cjuart is drunk on an empty stomach
every morning, a tumblerful every quarter of an hour. Salines are
said to have an injurious influence on the development of the child,
especially on that of the bones. If the woman has not had a move-
ment in the course of the day, she should take an enema of a quart
of soapsuds before retiring.

In the choice of clothing, the leading ideas should be to secure
sufficiently warm wearing apparel, avoiding pressure and heavy weight
on the abdomen. The decollete dress of society leaving half the chest
unprotected is out of the question. The pregnant woman should be
covered with woollen underwear all over her body up to the neck.
Then she will not need many articles of dress. Her petticoats are
loosely buttoned or bound around the waist. The common corset,
exercising great pressure in the direction of the pelvis, should be pro-
scribed. The woman should either go without any or have one of
those especially made for the purpose without steels or whalebones.



128 NORMAL PREGNANCY.

On the other hand, an abdominal supporter, preferably made of flan-
nel, is recommendable, especially in repeated pregnancies. It pre-
vents too great a distention of the abdominal wall and is thus service-
able in helping the woman to regain her shape after delivery, and not
look as if she were always pregnant or suff'ering from an abdomi-
nal tumor. Round garters should be replaced by side garters.

The woman should take a lukewarm bath, about 95° F., once a
week, and, as there usually is some increase of vaginal secretion, she
should wash the perineum daily with lukewarm water. If the secre-
tion constitutes a discharge that irritates the skin, there is no objection
to vaginal injections medicated with mild astringents, such as borax
or alum, of lukewarm temperature, and in small quantities (3! to
Oi), once or twice a day. Surf bathing should be forbidden, but
there is no objection to still water baths of short duration, — maxi-
mum, a quarter of an hour.

The nipples should be washed and kept free from crusts. If they
are short, they may be pulled upon several times daily in order to
elongate them and render them more fit for lactation. If there are
none, they cannot be formed, and the woman cannot nurse her child.
Their skin may be mollified by daily inunction with albolene, lanolin,
cold-cream, or other greasy substances, and it may be hardened by
washing it with brandy or cologne or painting it with a solution of
tannic acid, — e.g.^ glycerite of tannin (si to si). It is doubtful if these
measures prevent sore nipples during lactation, which seem to be an
unavoidable accompaniment of its earlier stage ; but the patient likes
to do something to prepare herself, and might take her physician to
task if he had not advised any preventive. The nipples should be
protected against pressure from the clothing.

The mental condition should not be neglected. It is much better
for the pregnant woman to have pleasant company than to brood in
idle solitude over her coming confinement. Friends should carefully
abstain from all grewsome stories and preserve her from anxiety and
worry. Perusal of light literature, interest in what is going on in the
world, and attention to daily duties are all valuable elements of a
healthy mental atmosphere.

Under ordinary circumstances connection can hardly be totally
avoided, but any excess in this direction should be deprecated. In
women who, on account of anteflexion of the uterus, conceive with
difficulty and easily lose the foetus, the writer forbids intercourse in
the third and the sixth months, periods at which abortion is particu-
larly liable to occur.

The physician should examine the urine for albumin, even in
apparently healthy women, at least once a month.



PART III.— NORMAL LABOR.



CHAPTER I.
CAUSES OF LABOR.

In a general way one may say that labor begins when the time
has come. Why this period in woman and the cow should be about
nine months, in the elephant about twenty months, and in dogs about
two months cannot be told any more than why morphine makes one
sleep and coffee keeps one awake. As the great German poet-philos-
opher Goethe says, "Care has been taken that trees do not grow into
heaven" ("Es ist dafiir gesorgt class die Biiume nicht in den Himmel
wachsen''). There is a regulating power that has bound natural
processes within certain limits of time and space. But we may per-
haps find what means are employed to determine the transition from
pregnancy to labor. In all probability there are several causes oper-
ating in combination with one another. Fatty degeneration of the
decidua makes a foreign body of the ovum, which irritates the nerves
of the uterus and produces muscular contraction, in a way similar to
that in which a bougie works which we introduce into the cavity of
the uterus when we want to induce premature labor or strengthen
ineffective labor pains. When this theory is impugned on the
ground that uterine contraction sets in even in cases of extra-uterine
pregnancy, it must be remembered that even in ectopic gestation a
decidua is formed and has to be expelled.

In the placenta a change gradually takes place, the intervillous
spaces becoming reduced in size by an invasion of giant cells,
which begin to appear among the decidual cells as early as the third
month, and gradually cause a thrombosis of the sinuses. The effect
of this process is to render the blood — both that of the mother and
that of the foetus — more venous in character, and a surplus of
carbonic acid in the blood makes the uterus contract. When under
Louis Philippe the French army was warring in Algeria, a tribe of
Kabyles sought refuge in a large cave. The French general built a
fire at the entrance. Those in the cave were suffocated, and it was
found that all pregnant women in the trilDe had aborted.

In consequence of the growth of the child the trnsion in the
wall of the uterus becomes greater and greater, and there must come
a moment when the expansion can go no further. This tension,
combined with the weight of the foetus, presses the latter against the

9 129



130 NORMAL LABOR.

internal os, and, on the other hand, the cervix, gradually opening
both from below and above, offers less resistance to the pressure from
above.

Perhaps the congestion to the uterus that out of pregnancy takes
place every four weeks, and induces the menstrual flow, continues in
the pregnant woman, and at the end of the tenth lunar month results
in labor.

The exciting cause that, finally, makes the uterus contract suf-
ficiently to dilate the cervix and expel the foetus is doubtless irritation
of the large cervical ganglion, which in the pregnant condition attains
such enormous dimensions, be the stimulus mere mechanical pressure
or be it of a chemical nature. So much is sure, that the beginning
of labor may be hastened by physical exertion and retarded by rest.
Often it is brought about by strong mental emotions, — fright or joy.
Opium retards it and aperient medicines further it. A busy down-
town practitioner of the writer's acquaintance manages sometimes
to attend personally to five confinements in one day by a judicious
use of hypodermic injections of morphine in some cases and the
admmistration of a dose of castor oil in others. Ambitious house-
surgeons in Maternity Hospital, wanting to have as many cases as
possible when their term of service was drawing to an end, used to
give castor oil to all the women in the waiting ward who were at the
end of pregnancy.



CHAPTER II.

THE AXATOMY OF THE PARTURIENT CAXAL.

The parturient canal — that is, the parts through which the foetus
passes in a normal birth — is composed of hard and soft parts. The
hard part is formed by the bony pelvis ; the soft by the muscles that
line it, the uterus, the vag'ina, and the vulva.

A. The Pelvis.

§ 1. Bones of the Pelvis. — The reader is, of course, supposed to
have studied anatomy, so that it will be necessary only briefly to refresh
his memory and then to examine the pelvis from the obstetrician's
stand-pomt.

The pelvis is the large bony structure intervening between the
vertebral column and the lower extremities. IL is composed of four
bones, two — the sacrum and the coccyx — situated in the median line
and behind, and two — the hip-bones — placed laterally, on either side
and in front.



THE ANATOMY OF THE PARTURIENT CANAL.



131



The SACRUM of the adult woman is a strong, somewhat pyramidal
?jone, on which we distinguish a base, an apex, an anterior and a
posterior surface, and two lateral edges. The central part of the base
is, by means of a fibrocartilaginous disk, like that connecting the
vertebree, joined to the fifth lumbar vertebra. Laterally it is expanded
into the so-called afe, or wings. Behind the central fibrocartilage is
a triangular opening leading into the sacral canal, on either side of
which is an articular process articulating with the corresponding pro-
cess of the fifth lumbar vertebra. The apex is very much smaller
than the base, and has the shape of a transverse narrow oval articu-
lating with the coccyx.



Fig. 165.



Fig. 166.




The anterior surfaces of the sacrum and coc-
cyx. A, ala, or wing ; B, articular process ; C,
first anterior sacral foramen ; D, articular sur-
face connected with the body of the fifth lum-
bar vertebra ; E, line of coalition between first
and second sacral vertebra ; F, promontory ; O,
articular surface connected with the coccyx.




The posterior surfaces of the sacrum and
coccyx. /, sacrum : A, sacral crest ; B, first pos-
terior sacral foramen ; C, articular surface con-
nected with the body of the fifth lumbar verte-
bra ; D, articular process in contact with the
corresponding process of the fifth lumbar ver-
tebra ; E, eminences representing the articular
processes of the sacral vertebra3 ; F, eminences
representing the transverse processes ; <?, apex ;
H, cornua ; /, auricular surface. II, coccyx :
A, cornua ; B, apex ; C, transverse process.



The anterior surface (Fig. 165) is strongly concave from above
downward and slightly so from side to side. On either side are four
openings, anterior sacral foramina^ leading into the sacral canal. Out-
ward these holes are continued as furrows for the sacral nerves.
Transverse bony ridges extend between each two holes across the
median line, marking the places where the bodies of the five vertebrEe
of which the sacrum is originally composed have grown together.
Where the anterior surface joins the central articular surface of the
base is a projecting, strongly convex line, called i\\Qp7'omontory^ which



132



^'ORMAL LABOR.



behind merges in the ala. Outside of the promontory is a smooth,
thick, rounded-oif edge, separatmg the anterior surface from the ala.

The posterior surface (Fig. 166) is strongly convex from above
downward and somewhat so from side to side. It is narrower than
the anterior surface, and very rough, serving for the attachment of
the powerful erector spinse muscle. In the median line are three or
four small eminences, the sjjinoKs processes, usually more or less con-
nected with one another, so as to form a ridge, the sacral crest. Be-
low this ridge is a triangular openmg, the lower end of the sacral
canal, the sides of which end in small processes, the sacral cornua,
which articulate with the cornua of the coccyx. Outside of the



Fig. 167.



Fig. 168.




Emr^^




Lateral edge of the sacrum. A. surface ar-
ticulating with the body of the fifth lumbar
vertebra ; B, superficies auricularls ; C, articu-
lar process ; D, tubercles and hollows for the
attachment of the sacro-iliac ligaments; E,
sacral crest ; F, coccyx.



The sacral canal. A, promontory ; B, apex
of sacrum ; C, apex of coccyx. 27 indicates the
depth of the sacral hollow, — 27 millimetres, or
a little over an inch.



central ridge is a shallow groove formed by the united laininpe of the
original sacral vertebrae. Outside of this, agam, are found four jjos-
terior sacral foramina, correspondmg to, but smaller than, the anterior,
and leading into the sacral canal. Inside of each hole is a small
eminence representing the articular process, and outside a larger one,
corresponding to a transverse process.

The side edges (Fig. 167) have above a large S-shaped surface,
superficies auricularis, wliich articulates with the hip-bone. Behind
this are deep depressions for the attachment of ligaments. Tlie
middle part of the side edge is concave and rough and serves for the
attachment of the sacrosciatic ligaments. The lowest part forms
together with the coccyx a notch for the fifth sacral nerve.



THE ANATOMY OF THE PARTURIENT CANAL.



The sacral canal (Fig. 168) is carved like the bone, and contains
the Cauda equina.

The COCCYX (Fig-s. 1G5, 166) is a small triangular bony mass, com-
posed of four rudimentary vertebra?, wliich in middle life usually
grow together ^\'ith one another, and in advanced age also with tlie
sacrum. In tlie middle of the base is an oval surface articulating with
the apex of the sacrum. Laterally and behind are two small articular
processes, called cornua, which articulate with the cornua of the
sacrum. On the lateral edge of the first coccygeal vertebra is a trans-
verse process, forming together with the lower part of the side edge of
the sacrum a notch for the fifth sacral nerve. The three other
vertebrae are smaller than the first and are only rudimentary bodies.

The HIP-BONE, OS cox^, or os innominatum, an irregular, large, and
strong bone, has a shape that somewhat suggests a figure 8. It is
originally composed of three bones, the ilium above, the ischium below,
and ihe piibes, or os pubis, in front, meeting in the acetabulum, or coty-
loid cavity, a deep hollow, forming the articulation with the thigh-bone.

Fig. 169.




The hip-bone, outer surface. A, acetabulum ; B, ilium ; C, ischium ; 1>, pubes ; E, crest of ilium ;
F, anterior superior spine of ilium ; G, posterior superior spine of ilium ; //, anterior inferior spine
of ilium ; /, posterior inferior spine of ilium ; ./, great sciatic notch ; K. spine of the ischium ; 7.,
tuberosity of the ischium ; M, obturator foramen ; X, spine of the pubcs ; O, iliopectineal eminence.

The ilium (Fig. 169) has a shovel-like shape and extends upward
and to the side. Its upper border is thick and somewhat S-shaped
and is called the cre-sf. At its ends it runs out into small pointed



134



NORMAL LABOR.



processes, the anterior superior and the posterior superior spine. Under
each of them is found another process, the anterior inferior and tlie
p)osterior inferior spAne. The outer surface serves for the attachment
of tlie massy gluteal muscles (Fig. 170). The inner forms a large flat
hollow, cahed the iliac fossa, where often the head of the foetus finds
a resting-place. Behind the iliac fossa is the large auricular surface,
articulating with the corresponding surface of the sacrum. Inside from
the iliac fossa is a smooth thick line, the iliac pjortion of theiliopjectineal
line. Behind the articular surface are rough surfaces for the attach-
ment of the iliosacral ligaments and the erector spinas muscle.

Fig. 170.




The hip-bone, inner surface. A, iliac fossa ; B, auricular surface ; C, iliac portion of iliopecti-
neal line ; i>, tuberositj- of the ischium ; E, spine of the ischium ; F, ascending branch of ischium ;
(?, body of pubes ; H, symphj-sis pubis ; I, descending ramus of pubes ; J, ascending ramus of pubes ;
K, iliopectineal eminence ; L, obturator foramen ; .V, anterior superior spine of ilium ; ^V, anterior
inferior spine of ilium ; 0, posterior superior spine of ilium ; P, posterior inferior spine of ilium.

On the ischium we remark the large tuberosity that serves as support
for the body in the sitting posture, and behind that a small, flat, tri-
angular projection, the spine of the ischium, which is of great obstetric
importance, both as a landmark and as a point that influences the
movement of the head of the foetus during labor. The ischium has a
smooth concave inner surface, a continuation of that of the ilium, and
joins the os pubis by means of its ascending branch.

The p)ubic bone, or os pubis, has inward a quadrangular body, the
posterior surface of which is smooth, slightly concave from side to
side, and slightly convex from above downward. The anterior sur-
face is roudi and serves for the attachment of muscles going down to



THE ANATOMY OF THE PARTURIENT CANAL.



135



the thigh. On its inner border it articulates with the corresponding
surface of the other pubic bone, forming the symjjhysis pubis. Below
the body the descending ramus merges in the ascending ramus of the
ischium. Above the body extends the ascending ramus., near the
outer end of which is situated the low iliopedineal eminence. Outside
of the upper end of tlie sympliysis is a rough surface, called the crest.,
and terminating outward in the pointed spine^ from which a sharp
edge, the pubic portion of the iliopectineal line, extends to the iliopec-
tineal eminence. Between the ischium and the pubis is a large oval
opening, called the obturator foramen.

§ 2. The Lig-aments of the Pelvis. — The pelvic bones are bound
together by strong ligaments. Between the sacrum and the ilium there
is the so-called synchondrosis, which in reality is a joint with a synovial
membrane (Fig. 171). On the iliac side is a central prominence be-

FiG. 171.




Horizontal section througla the left sacro-iliac articulation. Actual size. (Luschka.)

tween two hollows, and on the sacral side a corresponding central
concavity between two convexities. By this arrangement a kind of
screw is formed, which permits a limited movement. Independently
of pregnancy and in both sexes the sacrum is slightly movable, the
promontory tipping forward and the apex backward during defecation.
During pregnancy, when the parts composing the joint are softened,
this motility is much increased, which allows the promontory to recede
during the beginning of labor, and the apex to be pushed back when



136



NORMAL LABOR.



Fig. 1^



the head is passing through the lower part of the pelvis (Fig. 172). The
sacro-iliac articulation is strengthened by the anterior sac ro-iUae ligament

in front, and the particularly strong
posterior sacro-iliac ligament behind,
which prevents the sacrum from
falling into the pelvic cavity.

Between the sacrum and the
ischium we have the great sacra-
sciatic ligament, or the ligamentum
tuber oso-sacrale, and in front of
that the lesser sacrosciatic ligament,
or ligamenfirn spinoso-sacrale. By
these two ligaments the sacrosciatic
notches are converted into two fo-
ramina, the superior or great sacro-
sciatic foramen and the inferior or
lesser sacrosciatic foramen (Fig. 17-3).
Between the sacrum and the
coccyx is found a fibrous disk, and in it sometimes a sjmo^ial mem-
brane. Between the cornua are interarticular ligaments. The union

Fig. 173.




Diagram .showing the oscillatory move-
ments of the sacrum. (Duncan.) ab, sym-
physis pubis ; c, c, promontory ; d, d, apex of
coccyx.




The ligaments of the pelvis. A. iliolumbar ligament ; B, anterior .sacro-iliac ligament ; C, sacro-
iliac articulation ; D, great sacrosciatic ligament ; E, lesser sacrosciatic ligament ; F. great sacro-
sciatic foramen ; G, lesser sacrosciatic foramen ; H, sacrococcygeal articulation ; /, symphysis
pubis; J, obturator membrane; K. Poupart's ligament; L, Gimbernat's ligament.

between the two bones is strengthened by the anterior, the posterior.,
and the lateral sacrococcygeal ligaments.



THE ANATOMY OF THE PARTURIENT CANAL.



137



The two pubic bones are bound together by a disk of cartilage and
fibrocartilage, the symphysis pubis (Fig. 174), which is much thicker
in front than behind and contains a small cavity with an imperfect
synovial membrane. The synchondrosis is strengthened by the an-
terior, the posterior, and the superior pubic ligament and the subpubic
ligament. The last is a thick triangular arch of sinewy, arched fibres,
forming the upper limit of the pubic arch. During pregnancy the joint
of the symphysis becomes softened and admits some degree of sliding.

The obturator foramen is closed by a thin fibrous membrane, the
obturator membrane, from which spring the obturator internus and 06-
turator externus muscles.

In the perineum we have two strong ligaments, the transverse liga-
ment of the pelvis and the ischioperineal ligament. The transverse liga-
ment of the perineum is a strong ligament lying immediately behind and
below the subpubic ligament, together with which it strengthens the

Fig. 174.




Horizontal section of symphysis pubis. (Luschka.)



symphysis pubis. The ischioperineal ligament is a strong fibrous band
inserted on the ischium just in front of the tuberosity. It goes trans-
versely through the pelvic outlet, at the posterior margin of the trans-
versus periuEei muscle, and, being connected with the fasciae of the
perineum, it constitutes the chief support of the pelvic floor.

§ 3. The Pelvis as a "Whole. — The pelvis (Fig. 175) has its name
from its supposed likeness to a barber's basin, — in Latin called pelvis.
By the iliopectineal line, its continuation on the ala of the sacrum,
and the promontory — a line which as a whole is sometimes designated
liaea terminalis — it is divided into a larger upper and a smaller lower
part, respectively called the large or false pelvis and the small or true
pelvis. The cavity of the false pelvis forms part of the abdominal
cavity, while that of the true pelvis is specifically called the pelvic
cavity. The cavity of the false pelvis is closed in front by the ab-
dominal wall. It is of obstetrical interest only in so far as in pluri-
parse the head during gestation often is found in one of the iliac



138



iVORMAL LABOR.



fossae, and because by measuring the false pelvis, Avhich is much more
accessible, we are enabled to form an idea of the dimensions of the
true.

Measurements of the dry bony pelvis are needed in describing and
comparing it with others. They are, of course, smaller than the cor-
responding measurements taken during life, all the soft parts having
been removed. The ciistances measured on the false pelvis are that
between the anterior superior spines of the ilium (Sp. II.), which is
9 inches (twenty-three centimetres), and that between the most di-
vergent points of the crests (Cr. II.), which is 10 inches (twenty-five
centimetres). Pelves differ in size in different individuals, and these

Fig. 175.




The normal female pelvis. A, sacrum ; B, coccyx ; C, crest of the ilium ; D, acetabulum ; E,
spine of the ischium ; F, symphysis pubis ; G, spine of the pubes ; H, obturator foramen ; I, tuber-
osity of the ischium ; J J J, linea terminalis.



figures, as well as the others that follow, represent only the average
found by measuring a large number of pelves, and they give the aver-
age only approximately, leaving out of consideration small fractions,
that would embarrass the memory without being of practical value.

The true pelvis is of much greater importance, and an accurate



Online LibraryHenry J. (Henry Jacques) GarriguesA text-book of the science and art of obstetrics → online text (page 12 of 80)