Osteopathy Complete
Elmer D. Barber, D. O.
1898
OBSTETRICS - MIDWIFERY
MALE GENERATIVE ORGANS
The male generative organs consist of the Prostate
Gland, Cowper's Glands, the Penis, the Testes, and the Vesiculae Seminales.
Prostate Gland. - The Prostate Gland is a
muscular, glandular body, and is placed around the commencement of the
urethra and immediately in front of the neck of the bladder. It is
situated in the pelvic cavity behind and below the symphysis pubis, posterior
to the deep perineal fascia, resting upon the rectum, When enlarged, it
may be distinctly felt through the rectum. It resembles, in size
and shape, a horse-chestnut. It measures about 1 1/2 by 1 inch by
3/4 inch, and weighs about three-fourths of an ounce.
It is perforated by the urethra and ejaculatory
ducts. The ejaculatory ducts pass forward obliquely between the middle
and each lateral lobe of the prostate, and open into the prostatic portion
of the urethra.
The
arteries which supply the prostate are
derived from the internal pudic, vesical, and hemorrhoidal.
The
veins form a plexus around the sides
and base of the prostate; receiving in front the dorsal vein of the penis,
and, terminating in the internal iliac vein.
The
nerves are derived from the pelvic plexus.
Cowper's Glands. - Cowper's glands are situated
between two layers of the deep perineal fascia, one on each side of the
membranous portion of the urethra, close above the bulb. They are
about the size of peas, and gradually diminish as age advances. They
consist of several lobules, held together by a fibrous investment.
Their excretory ducts are nearly an inch in length, and pass obliquely
forward beneath the mucous membrane, opening by a minute orifice on the
floor of the bulbous portion of the urethra.
Penis. - The penis is composed of a mass
of erectile tissue arranged in three compartments of cylindrical shape,
each surrounded by a fibrous sheath, forming numerous bands which divide
the compartments into a number of spaces.
The compartments are called the Corpora Cavernosa,
and the Corpus Spongiosum.
The penis is the organ of copulation, consisting
of a root, body, and extremity, or glans penis.
The corpora cavernosa consist of two fibrous cylindrical
tubes placed side b side and intimately connected alone, the median line
for their anterior three-fourths, forming the chief part of the body of
the penis. A median groove on the upper part of the body of the penis.
A median groove on the upper surface contains the dorsal vein of the penis,
while the groove on the under surface receives the corpus spongiosum.
The whole of the structure of the corpora cavernosa contained within the
fibrous sheath consists of a sponge-like tissue of areolar spaces freely
communicating wit h each other and filled with venous blood.
The
arteries, on entering the cavernous structure,
divide into branches, which are supported and enclosed by the trabeculae.
Some of these terminate in a capillary network, the branches opening directly
into the cavernous spaces. They are bound down in spaces by fine
fabrous processes, and are more abundant in the back part of the corpora
cavernosa.
The blood is returned by a series of vessels, some
of which emerge from the base of the glans penis, and converge on the dorsum,
to form the dorsal vein. Others pass out on the upper surface, and
join the dorsal vein. The greater number pass out at the root of
the penis and join the prostatic plexus.
The corpus spongiosum is an erectile tube lying
in the inferior groove between the two corpora cavernosa, enclosing the
urethra. It forms a rounded enlargement, the bulb, and terminates
anteriorly in another expansion, the glans penis, which overlaps the anterior
rounded extremity of the corpora cavernosa.
The erectile tissue consists of an intricate venous
plexus, supplied by afferent arteries and emptied by efferent veins.
The
nerves are derived from the internal
pudic nerve and the pelvic plexus.
The glans penis is of the form of an obtuse comb,
flattened from above downward; at its summit is a vertical fissure, the
meatus urinarius. The base of the gland forms a rounded projecting
border, and behind the corona is a deep constriction, the cervix.
Upon both of these parts numerous small glands are found, which secrete
a sebaceous matter of peculiar odor.
Testes. - The testes, or testicles, are glandular
organs, suspended obliquely in the scrotum by the spermatic cords.
They secrete a seminal fluid. The testicles measure each about an
inch in diameter, and weigh three-fourths to one ounce. They descend
before birth to the inguinal canal, alone, which their pass with the spermatic
cord, emerging at the external abdominal ring, and descending into the
scrotum.
The scrotum is a cutaneous pouch which contains
the testes and part of the spermatic cord. Its external aspect varies
under different circumstances: Under the influence of warmth and in old
and debilitated persons it becomes elongated and flaccid, but under the
influence of cold and in the young and robust it is short, corrugated,
and closely applied to the testes.
The spermatic cord is composed of arteries, veins,
lymphatics, nerves, the excretory ducts of the testicle, and a thin fibrous
cord. These structures are connected together by an areolar tissue,
and invested by fascia brought down in the descent of the testicle.
The
arteries of the cord are the spermatic
from the aorta, the artery of the vas deferens from the superior vesical,
and the cremasteric from the deep epigastric.
The
nerves are the spermatic plexus from
the sympathetic, and filaments from the pelvic plexus.
Vesiculae Seminales. - The seminal vesicles
are two lobulated membranous pouches between the rectum and base of the
bladder, serving as reservoirs for the semen, also secreting a fluid to
be added to the secretion of the testicles. They measure about two
and one-half inches in length, about five lines in breadth, and two or
three lines in thickness. They vary in size in different individuals
and also in the same individual on the two sides. Their upper surface
is in contact with the base of the bladder, extending from near the termination
of the ureters to the base of the prostate gland. Their under surface
rests upon the rectum, from which they are separated by the recto-vesical
fascia.
The ejaculatory ducts, one on each side, are formed by the junction
of the ducts of the vesiculae seminales with the vasa deferentia.
Each duct is about three-fourths of an inch in length, commencing at the
base of the prostate and running forward and downward between the middle
and lateral lobes and along the sides of the sinus pocularis.
FEMALE GENERATIVE ORGANS
The female generative organs are divided into the
external and internal.
External. - The external are divided into
the Mons Veneris, the Labia Majora and Minora, the Clitoris, the Meatus
Urinarius, and the Orifice of the Vagina. The term "vulva," as generally
applied, includes all these parts.
Mons Veneris. - The mons veneris is a round
eminence in front of the pubic symphysis, formed by a collection of fatty
tissue beneath the integument.
Labia Majora. - The labia majora are two
prominent longitudinal cutaneous folds extending downward from the mons
veneris to the anterior boundary of the perineum.
Labia Minora. - The labia minora, or nymphae,
are two folds of mucous membrane, hidden posteriorly in the labia majora,
but anteriorly they embrace the clitoris , forming its prepuce.
Clitoris. - The clitoris is an erectile structure
analogous to the corpora cavernosa of the penis. It is situated beneath
the anterior commissure, partially hidden between the anterior extremities
of the labia minora. The body is short, concealed beneath the labia.
The free extremity, or glans clitoridis, is a small rounded tubercle, consisting
of spongy erectile tissue, and highly sensitive. It might be called
a diminutive penis, like it, being provided with a body, two crura, a glans,
prepuce, a suspensory ligament, and with two small muscles, the erectoris
clitoridis, inserted into the crura.
The clitoris consists of two corpora cavernosa,
composed of erectile tissue invested by a layer of dense fibrous membrane,
uniting along their adjacent surfaces by means of an incomplete fibrous
pectiniform septum.
The triangular smooth surface between the entrance
of the vagina and the clitoris is the vestibule.
Meatus Urinarius. - The meatus urinarius
is the orifice of the urethra, and is situated near the margin of the vagina,
about an inch below the clitoris, at the back part of the vestibule.
Orifice of the Vagina. - The orifice of the
vagina is below the meatus urinarius, surrounded by the sphincter vaginee
muscle, and, as a rule, partly closed in the virgin by the hymen.
Other parts comprised in the vulva are the Hymen,
Glands of Bartholin, and the Bulbi Vestibuli.
The hymen is a membranous fold which closes, to
a greater or less extent, the opening of the vagina. It varies much
in shape. Its commonest form is that of a ring broadest posteriorly.
It is sometimes represented by a semilunar fold with its concave margin
turned toward the pubes. It may persist after copulation, so that
its presence cannot be depended upon as a sure test of virginity.
The glands of Bartholin, one on each side of the
vaginal orifice, are analogous to Cowper's glands in the male, present
a slightly oblong body about the size of a horse-bean, are of a reddish-yellow
color, and the duct of each gland opens on the inner side of the labia
minora external to the hymen.
The bulbi vestibule are two large oblong masses,
about an inch long, consisting of a venous plexus invested by fibrous membrane,
and extend along the sides of the vestibule, from the clitoris. They
are considered analogous to the bulb of the corpus spongiosum in the male.
Internal. - The internal organs of generation
are the Vagina, the Uterus and its appendages: the Fallopian Tubes, the
Ovaries and their Ligaments, and the Round Ligaments.
Vagina. - The vagina is situated in the cavity
of the pelvis, in front of the rectum, behind the bladder, and extends
from. the vulva to the uterus. It is curved upward and backward,
at first, in the line of the outlet, and afterward in that of the axis
of the cavity of the pelvis. Its walls are usually in contact.
Its length is about two and one-half inches along its anterior wall, and
three and one-half inches along its posterior wall.
The vagina consists of an internal mucous lining,
of a muscular coat, and between the two a layer of erectile tissue.
Uterus. - The uterus is a hollow, pear-shaped,
muscular organ, about three inches long, two inches broad, and one inch
thick, flattened from before backward, placed base upward, and forming
an angle with the vagina, which partially receives its cervix. It
is the organ of gestation, receiving the fecundated ovum in its cavity,
supporting and retaining it during the development of the fetus, and becoming
the principal agent in its expulsion at the time of parturition.
Fallopian Tubes. - The Fallopian tubes, or
oviducts, are really the ducts of the ovaries. They consist of a
serous, muscular (an external longitudinal and an internal circular) layer
of non-striped muscle, and a mucous layer, lined by a single layer of ciliated
columnar epithelium, but no glands.
They convey the ova from the ovaries to the cavity of the uterus.
They are two in number, one on each side, situated in the upper margin
of the broad ligament, extending from each superior angle of the uterus
to the sides of the pelvis; each tube is about four inches in length.
The general direction of the Fallopian tubes is outward, backward, and
downward. The uterine opening is minute, and will only admit a fine
bristle; the abdominal opening is comparatively much larger.
Ovaries. - The ovaries are oval-shaped bodies,
flattened from above downward, situated one on each side of the uterus
in the posterior part of the broad ligament, behind and below the Fallopian
tubes. Each ovary is connected by its anterior straight margin to
the broad ligament, by its inner extremity to the uterus by a proper ligament,
the ligament of the ovary, and by its outer end to the fimbriated extremity
of the Fallopian tube. The ovaries are about an inch and a half in
length, three-quarters of an inch in width, and about a third of an inch
in thickness.
The ovaries are analogous to the testes in the male.
Their exact position has been the subject of considerable difference of
opinion, and writers differ much as to what is to be regarded as their
normal position. They appear to be differently placed in different
individuals.
Kolliker asserts that the ovary is placed obliquely
in the pelvis, its long axis lying parallel to the external iliac vessels,
with its surface directed inward and outward and its convex free border
upward. He has made some important observations on the subject and
his views are largely accepted. He teaches that the uterus rarely
lies symmetrically in the middle of the pelvic cavity, but is generally
inclined to one side or the other, most frequently to the left. The
position of the two ovaries varies according to the inclination of the
uterus. In whichever position the ovary is placed, the Fallopian
tube forms a loop around it, the uterine half ascending obliquely over
it, and the outer half, including the dilated extremity, descending and
bulging freely behind it.
Ligaments of the Ovaries. - The ligament
of the ovary is a round fibrous cord extending from the superior angles
of the uterus to the ovary at its lower extremity.
Round Ligaments. - The round ligaments are
two cords, composed of muscular fibrous, and areolar tissue, nerves, and
blood vessels, extending from the fundus uteri to the labla majora.
They are said to be analogous to the peritoneal pouch in the male.
The Graafian follicles, or ovisacs, contain the
ova. Immediately beneath the superficial covering is a layer of stroma
in which are a large number of minute vesicles of uniform size; these are
the Graafian vesicles or follicles in their earliest condition,
and the layer where they have been found has been termed the cortical
layer; they are especially numerous in the ovary of the young, child.
After puberty and during the whole of the childbearing period large and
mature, or almost mature, Graafian vesicles are also found in the cortical
layer in small numbers and also "corpora lutea," the remains of vesicles
which have burst and are undergoing atrophy and absorption. Beneath
this superficial stratum other large and more mature Graafian vesicles
are found imbedded in the ovarian stroma. These increase in size
as they recede from the surface toward a highly vascular stroma in the
center of the organ, termed the Medullary substance; this stroma
forms the tissue of the hium by which the ovary is attached, and through
which the blood vessels enter. It does not contain any Graafian vesicles.
The larger Graafian follicles consist of
an external fibro-vascular coat connected with the surrounding stroma of
the ovary by a network of blood vessels; and an internal coat, which is
lined by a layer of nucleated cells, called the membrana granulosa.
The fluid contained in the interior of the vesicles is transparent and
albuminous. In it is suspended the ovum. In that part of the
mature Graafian vesicle which is nearest the surface of the ovary the cells
of the membrana granuloma are collected into a mass which projects into
the cavity of the vesicle. This is termed the discus proligerus,
and in this the ovum is imbedded.
The development and maturation of the Graafian vesicles
and ova continue uninterruptedly from puberty to the end of the fruitful
period of woman's life, while their formation commences before birth.
Before puberty the ovaries are small, and the Graafian vesicles contained
in them are disposed in a comparatively thin layer in the cortical substance.
At puberty the ovaries enlarge, are more vascular, the Graafian vesicles
are developed in greater abundance, and their ova are capable of fecundation.
The discharge of the ovum is produced by the bursting
of the Graafian vesicles after having gradually approached the surface
of the ovary. The ovum and fluid contents are liberated and escape
on the exterior of the ovary, passing thence into the Fallopian tube.
Puberty. - This term "puberty" is applied
to the period at which a human being becomes capable of procreating, which
occurs from the thirteenth to the fifteenth year in the female, and the
fourteenth to the sixteenth in the male. In warm climates, puberty
often occurs in girls even at eight years of age. Toward the fortieth
or fiftieth year, the procreative faculty ceases in the female, with the
cessation of the menses; this constitutes the menopause, whilst in man
the formation of seminal fluid has been observed up to old age. From
the period of puberty onward the sexual appetite occurs, and the ripe ova
are discharged from the ovary.
Menstruation. - At regular intervals of time,
twenty eight days in the adult female, there is a rupture of one or more
ripe Graafian follicles, and at the same time there is a discharge of blood
from the external genitals. This process is known as "menstruation,"
"menses," or "periods." Most women menstruate during the first quarter
of the moon, and only a few at full and new moon.
At the onset of menstruation there is usually an
increased feeling of congestion in the internal generative organs, pain
in the back and loins, tension in the region of the uterus and ovaries,
which are sensitive to pressure, fatigue in the limbs, alternate feeling
of heat and cold, and a slight increase in the temperature of the skin.
The process of digestion may be retarded, and there may be variations in
the evacuation of the feces and urine. The discharge is at first
slimy, afterwards becoming bloody, and lasting three to four days.
After cessation of the discharge of blood, there is a small quantity of
mucus given off.
The uterine mucous membrane is the chief source,
of the blood. The ciliated epithelium of the swollen, congested,
and folded, soft, thick mucous membrane is shed. The orifices of
the numerous mucous glands of the mucous membrane are distinct, the glands
enlarge, and the cells undergo fatty degeneration, as do also the tissue
and the blood vessels lying between the glands. This degeneration
and excretion of the degenerated tissue occurs only in the superficial
layers of the mucosa, whose blood vessels, when torn, yield the blood.
The deeper layers remain intact, and from them, after menstruation is over,
the new mucous membrane is formed.
Erection. - Erection is due to the overfilling
of the penis with blood, whereby the volume of the organ is increased
four or file times, while, at the same time, there is also a higher temperature,
increased blood pressure, with at first a pulsatile movement, increased
consistence, and erection of the organ.
The arteries are controlled by the nervi
erigentes, which arise chiefly from the second sacral nerves.
As these nerves contain vaso-dilator fibers,
they can be excited reflexly from the sensory nerves of the penis, the
transference center being in the center for erection in the spinal cord.
This reflex can also be discharged by sensory impressions produced by voluntary
movements of the genitals; a tendency to induce erection is followed by
the thought of sexual impulses.
The center for erection in the spinal card is, however,
controlled by the dominating vaso-dilator center in the medulla oblongata,
and the two centers are connected by fibers within the cord.
Stimulation of the upper part of the cord as by asphyxiated blood, may
also be followed by erection. The seminal fluid is frequently found
discharged in persons who have been hanged.
The activity of the cerebrum has a decided
influence on the genital vaso-dilator nerves; as anger or shame is followed
by dilatation of the blood vessels of the head, owing to stimulation of
the vaso-dilator fibers, so when the attention is directed to the sexual
centers there is an action upon the nervi erigentes.
When the impulse to erection is obtained by the
increased supply of arterial blood, the "full completion" of the act is
brought about by the activity of the following transversely striped muscles:
the ischio-cavernosus, the deep transversus perinei, and the bulbo-cavernosus.
The contraction of these muscles is partially under control of the will,
whereby the erection may be increased; normally, however, their contraction
is excited reflexly by stimulation of the sensory nerves of the
penis.
The imperfect erection which occurs in the female
is confined to the corpora cavernosa clitoridis and the bulbi vestibuli.
During erection, the passage from the urethra to the bladder is closed
by the swelling of the caput gallinaginis, and partly by the action of
the sphincter urethra, which is connected with the deep transverus perinei,
that the spermatozoa can traverse the whole length of the vagina and pass
into the uterus.
The sticky surface of the ovum enables the spermatozoon
to adhere to it. At the place where the head of the sperm, touches
the yelk, there is formed opposite to it an elevation of the yelk.
After the spermatozoon has penetrated into the yelk, the other spermatozoa
are prevented from entering the ovum by the formation of a membrane on
the surface of the yelk.
Fertilization occurs either in the ovary or in the
Fallopian tube.
THE FETUS
Nourishment. - The impregnated ovum, during
its passage through the oviduct, receives nourishment, first, from the
discus-proligerus; afterward, by a liquid derived from the mucous membrane
of the oviduct. It receives nourishment after reaching the uterus,
from the villi of the chorion and a liquid secretion from the uterine mucous
membrane; later, from the umbilical vesicle, the nutrient materials of
which are carried to the embryo, through the omphalo-mesenteric veins;
finally, the placenta is the chief source of nourishment.
Circulation. - The heart, at this period
of embryonic life, consists of a single cavity. The first aortic
arches are given off from its upper end; at its lower, the omphalo-mesenteric
veins. The blood passes into the body of the embryo, propelled by
the heart through the aortic arches, and is then distributed to the vascular
area of the umbilical vesicle by the omphalo-mesenteric arteries.
It is returned to the heart from the venous sinuses by the omphalo-mesenteric
veins. The blood is carried to the fetus from the placenta, rich
with nutritive material and oxygen by the umbilical vein.
It is divided into two currents, after entering
at the umbilicus, the larger current passing into the inferior vena cava,
while the smaller one enters the liver, and is carried to the vena cava
by the hepatic veins. The blood in the inferior vena cava, composed
chiefly of pure blood from the placenta, goes to the right auricle, but
the Eustachian valve turns the current through the foramen ovale into the
left auricle, from which it passes into the left ventricle. The blood
from the head and upper extremities passes into the right auricle through
the superior vena cava, from which it enters the right ventricle.
The blood from the left ventricle supplies the head and upper extremities;
the heart, contracting, forces the blood from the left ventricle into the
aorta, and from the right ventricle into the pulmonary artery. That
which enters the pulmonary artery from the right ventricle passes into
the aorta through the ductus arteriosus, somewhat below the point at which
the arteries of the head and upper extremities are given off. The
impure blood from the right ventricle, after entering the aorta, supplies
the trunk, lower extremities, and placenta; passing from the aorta into
the internal iliacs, it enters the hypogastric arteries, and thus is returned
to the placenta.
Secretory Organs. - A short time before the
fifth month the sebaceous glands begin to develop, and their secretion
is seen about two weeks later. The liver is developed about the fifth
month, and forms bile which passes into the large and small intestine.
The kidneys secrete during the latter half of intrauterine life, and it
is probable that the fetus voids its urine into the liquor amnii.
Movements. - The movements of the fetus are
recognized by the mother at about four and one-half months. It is
probable that it moves its upper and lower extremities as easily as the
twelfth or sixteenth week. The fetus cannot see, hear, or smell.
Taste is the first sense developed, and has been shown to exist
in a child born at seven months.
Changes after Birth. - After respiration
is established, the ductus arteriosus begins immediately to contract, and
is completely closed in from two to ten days. By the tenth day the
foramen ovale is closed. It occasionally remains permanently open.
This condition is known as cyanosis neonatorum. In from two to five
days the umbilical veins and ductus venosus are obliterated, the former
becoming the round ligament of the liver.
SIGNS OF PREGNANCY
Absence of the menses.
Nausea and vomiting.
Enlargement and tingling sensations in the breast.
Nervous disorders.
Salivation.
Irritability of the bladder.
Leucorrhea.
Abnormal temperature.
Quickening.
Changes in the vagina.
Changes in the cervix and os uteri.
Change of shape and size of the uterus.
Intermittent contractions of the uterus.
Uterine fluctuations.
Movements of the fetus.
LABOR
(Labor is the process by which the fetus and its appendages are separated
from the mother,
and is the physiological end of pregnancy.)
SYMPTOMS
Descent of the Uterus. - Descent of the uterus
usually occurs front one to two weeks prior to labor;. in some instances
only one or two days, and in others one month prior to confinement.
The waist of the patient becomes smaller, respiration less difficult, and
the pressure upon the stomach is relieved as the fetal head, enclosed by
the lower portion of the uterus, descends into the cavity of the pelvis.
The bladder and rectum become irritable after the sinking of the uterus,
and there is difficulty in locomotion, while the edema of the lower limbs
is increased.
Secretions. - There is a glairy secretion
from the glands of the cervix, which becomes mixed with blood as labor
approaches. A profuse discharge indicates that the cervix will dilate
rapidly.
Changes in the Organs. - The vagina and external
genitals are swollen and covered by a copious secretion, and the vagina
becomes moist and relaxed, while the labia majora are separated.
Contractions. - Painful uterine contractions
occur, causing little or no discomfort in the primiparae, while in the
multiparae they often become painful several days before labor.
Indications. - The conditions which indicate
that labor has begun are effacement and dilatation of the cervix with uterine
contractions regularly recurring.
Stages. - Labor is divided into three stages.
The first stage ends with the complete dilatation of the cervix.
The second stage begins after the cervix is dilated, ending with the expulsion
of the child. The third stage includes the detachment and the expulsion
of the placenta.
First Stage. - In the first stage the pains
are "acute," "grinding," or "cutting," beginning in the lumbo-sacral
region, and extending to the pubes, radiating down the thighs. The
contractions of the uterus, the compression of the uterine nerves, and
dilatation of the cervix are the causes of the pain.
Second Stage. - In the second stage there
is a sensation of tearing and stretching. They are spoken of as "bearingdown"
pains. The abdominal muscles are now brought into play, increasing
by their contractions, the suffering of the patient. Cramps occur
in the legs; there is a sense of tearing apart of the perineum and the
vulvo-vaginal canal; there is also a sensation of tenesmus in the rectum.
The causes of these pains are obviously the pressure exerted by the fetus
upon the nerves and organs of the pelvis, and the stretching of the pelvic
soft parts.
Dilatation of the Cervix. - The uterine cavity
decreases in size as the os dilates, and the action of the muscular fibers
of the body of the uterus draws the cervix up over the advancing part of
the fetus. At the commencement of the uterine contraction the cervix
becomes irregular, as if puckered, thicker, and the os decreases in size.
A little later, however, the os increases in size and the cervix becomes
thin. As dilatation of the cervix advances the decrease in the size
of the os does not take place at the beginning of a contraction.
The dilatation is more rapid as the second stage
advances; the cervix no longer points posteriorly and toward the left,
but assumes a more central position. The longitudinal muscular fibers
of the body and the fundus of the uterus overcome the action of the circular
fibers of the cervix, and tend to pull it open.
Water-Bag. - The water-bag encloses the liquor
amnii, projecting through the os uteri. It is first shaped like the
crystal of a watch. but becomes hemispherical later. The size and
form of the bag of water depends upon the presentation of the fetus and
upon the extent of the dilatation of the os. The bag usually ruptures
at the time the dilatation of the cervix is complete.
Abdominal Muscles. - The muscles of the abdomen
assist the uterus in the expulsion of the, fetus during the second stage
of labor. Their action is voluntary, until the head is being expelled
from the vulva, when the patient loses all control, and reflex action takes
place.
Dilatation of the Vagina. - The vagina is
dilated by the descent of the presenting part, offering but little resistance,
except at its orifice, where the head may be delayed. At each contraction
the head advances, but recedes again in the interval of the utero-abdominal
effort. This process is continued until the parietal protuberances
escape from the vulva, when it becomes fixed. Almost immediately
a strong contraction follows, and the head is born. A short interval
of rest usually follows, and the body is expelled by a renewal of the contractions.
The birth of the child is followed by a discharge of liquor amnii mixed
with blood.
Third Stage - Detachment of the Placenta.
- The placenta is usually expelled in from ten to twenty minutes.
The blood becoming clotted in the mouths of the vessels, and chiefly through
uterine retraction, prevents hemorrhage, the muscular fibers of the uterus
acting as living ligatures. Its detachment is accomplished by uterine
retraction. The placenta is expelled by contraction of the uterus,
assisted by voluntary efforts, and is detached almost simultaneously in
all parts.
Effects of Labor on the Mother. - The arterial
pressure is increased during the uterine contractions, and the pulse becomes
more rapid, declining again in the interval of pain. The respirations
become slower during the pains, and more rapid in the intervals.
The temperature rises as labor advances. During the first stage vomiting
may occur, but has no significance. If, during the second stage,
weak uterine contractions and exhaustion is accompanied by vomiting, immediate
delivery is indicated.
The duration of labor averages about seventeen hours
in primiparae; in multiparae, about twelve hours.
Arrangement of Bed. - The bed should be so
placed as to allow access from both sides. Upon it should be placed
a mattress made of some firm material. Over the lower portion of
the mattress spread a rubber cloth, to protect it, and over this spread
a comforter or blanket. Over the comforter place a folded sheet,
and over the upper part of the mattress place another sheet folded once
upon itself. Remove the rubber cloth and everything upon it after
labor, and bring down over the lower half of the mattress the lower half
of the upper sheet.
The clothing of the patient should be raised upon
the hips, and a sheet folded once secured to it by means of safety pins.
After delivery, remove the sheet and bring the clothing down over the hips
and limbs.
MANAGEMENT
First Stage. - The urine should be passed
frequently, and the catheter used should there be retention. If the
rectum is found to contain feces, it should be emptied at once by an injection
of soap and water. If the membranes do not rupture as soon as the
cervix is fully dilated, they should be ruptured; this may be readily accomplished
with the end of a hairpin pressed against the amniotic pouch during a contraction
of the uterus, or the membrane may be broken with the nail of the index
finger during a pain. The dilatation of the cervix should not be
artificially interfered with, but left to Nature in normal labor.
TREATMENT
As the dilatation of the cervix and descent of the
head into the pelvis are favored by a sitting or upright posture, the patient
should not be permitted to lie down, until the pain has become rather severe,
when the operator should place the hand just above the pubes, pressing
the muscles gently downward, and placing the index and second finger upon
either side of and against the clitoris. A pressure at this point
causes the circular fibers around the os uteri to relax without pain.
This pressure should be continued until the cervix is fully dilated and
the head of the fetus has reached the floor of the pelvis. If the
fingers are removed for an instant, the patient will suffer intense pain,
while instant relief is the result of a continuation of the pressure.
Second Stage. - As soon as the cervix is
fully dilated, remove the fingers from the clitoris, and apply a strong
pressure upon either side and very close to the spinous processes of the
three lower lumbar vertebra. As long as this pressure is continued
the labor will proceed very rapidly, and with scarcely any pain, comparatively,
up to the time of delivery, when two or three very severe pains may be
expected. At this time the patient should assume the left lateral
position. This position lessens the danger of rupturing the perineum,
and enables the operator to make such manipulations as may be needed.
If the perineum is not sufficiently relaxed to allow the escape of the
head without producing a laceration, it should be retarded by direct pressure;
the knees of the patient should be drawn toward the abdomen, and a folded
pillow placed between them. Place the left hand over the right thigh
of the patient, and with the thumb on the occiput, and the fingers on the
anterior part of the fetal head, hold it back during contraction.
Support the perineum with the right hand, placed in such a position that
the fold between the thumb and index finger is in relation with the anterior
edge; press gently in the direction of the symphysis, during a pain.
It is sometimes advisable to introduce one or two fingers into the rectum,
and draw the perineum forward toward the symphysis, at the same instant
retarding the progress of the head by a pressure of the thumb. After
the head is delivered, it should be held in the right hand, while the left
placed upon the abdomen follows the uterus as it descends, and forces out
the body.
Enlarge the loop, if the cord is coiled around the
neck, and draw carefully over the child's head, or deliver the shoulders
and body through the loop, or, failing in this ligate each end, and divide
the cord. Always support the perineum during the deliver of the shoulders.
The most common delay is caused by an arrest of the anterior shoulder beneath
the symphysis. Under such circumstances, make traction directly downward
with the hands placed on the sides of the head. To assist in the
expulsion of the posterior shoulder, it may be necessary to direct the
head toward' the symphysis, at the same time making slight traction.
After the shoulders are delivered, the body is rapidly expelled.
In all obstetrical cases in which Osteopathy has been applied the results
have been something remarkable, the hours of confinement being reduced
about two thirds, while if the treatment is applied correctly, the pain
is reduced to a minimum.
It appears that a pressure upon the sides of
the clitoris in the first stage of labor, and a strong pressure
upon the lower lumbar region in the second stage, cause the parts to
relax in such a manner as to obviate, with proper attention, all danger
of laceration, in all instances, except those in which a malformation in
the pelvis or an abnormally large head in the fetus would necessitate the
use of surgical instruments.
MANAGEMENT
The Child. - The child should be placed away
from the in other's discharges, near the side of the bed, care being exercised
not to pull upon the cord. Clear the mucus from the throat and mouth
with the finger, and if respiration does not occur, place the child in
a basin of hot water, leaving the chest exposed after which, dash cold
water upon it, until breathing is established. Under osteopathic
treatment it is seldom necessary to resort either to the above or to artificial
respiration
Tying the Cord. - Tie the cord about three
finger breadths from the umbilicus with one ligature, the other at a distance
of two inches from the first toward the placenta. The cord should
not be tied until after the child breathes freely and the pulsations have
decreased in force. Always examine the cut surface of the cord to
see if the ligature has been applied correctly before handing the child
to the nurse. Under certain circumstances it is advisable not to
ligate the cord until the pulsations have entirely ceased. The advantages
of this plan are that the child receive more blood and loses less weight
during the first week following birth, and is especially indicated in children
who are poorly nourished or who are born prematurely.
Third Stage. - After delivery of the child,
the mother should be placed upon the back, while the nurse, immediately
after the birth, should place her hand over the uterus and keep it in that
position until the operator is ready to attend to the delivery of the placenta.
TREATMENT
Immediately after tying and severing the cord, and
before the delivery of the placenta, the operator should flex the patient's
limbs, one at a time, upon the abdomen; while in this position, place the
chin over the patient's knee, one hand upon the great trochanter, the other
grasping the ankle; with the chin give gentle but strong abduction to the
knee, press hard with the hand upon the trochanter, and with the other
hand adduct the foot as the limb is gently extended. Treat the opposite
limb in a similar manner.
This treatment will not occupy over one minute,
and should never be omitted, as patients treated in this manner never suffer
with pain in the hips and thighs, and are able walk with comfort at a much
earlier period.
To Deliver the Placenta. - Make very gentle
but rather strong friction over the body and fundus of the uterus, through
the wall of the abdomen. The placenta is usually expelled from the
uterus after three or four uterine contractions. During this period
an assistant should make gentle bat rather strong pressure upon the two
or three lower vertebra, as this pressure reduces the pain without in the
least affecting the strength of the uterine contractions. After the
placenta has been expelled into the vagina, traction may be made upon the
cord, and extraction slowly accomplished, at the same time keeping up a
pressure upon the fundus of the uterus. If the placenta is gradually
removed, there is no danger of any part of the membrane being torn.
It is advisable, however, that the placenta should be removed with two
or three revolutions, so as to twist the membranes into a rope.
MANAGEMENT
Binder. - The binder should extend from the
ensiform cartilage to the trochanters, and be pinned securely with
safety pins. Unbleached muslin makes a good bandage. Should
it become necessary to use compression over the uterus, three firm rolls
should be made of as man towels rather thicker than the wrist; place one
of them transversely just above the uterus, and the other two at the sides
of the uterus, pinning the bandage firmly over them.
Washing the Child. - The vernix caseosa should
be softened with the yelk of an egg and some oily substance, and removed.
The temperature of the bath should be about 98 degrees. A very fine
soap should be used to cleanse the child, as the common article is apt
to irritate the skin. The child should be carefully dried and the
belly-band applied after bathing.
Bandage. - The bandage around the child's
body should be loose when first applied; otherwise, on account of the increase
of the pulmonary capacity, it may become too tight in the course of a few
hours.
REMARKS
We consider that the greatest triumph of Osteopathy
is in the treatment of diseases of women and in obstetrics.
Of the many obstetrical cases that have come under
our observation, we have never met with a single instance in which the
results were not entirely satisfactory.
We might mention in this connection the case of
a lady, who, in two previous confinements, had narrowly escaped death,
the labor being prolonged on each occasion over forty-eight hours, and
it being months before she had entirely recovered. Upon both of these
occasions the case was in charge of the best obstetricians that money could
procure. Under osteopathic treatment, in her third confinement, the
labor lasted but a little over two hours, and upon the seventh day she
was enjoying her usual health.
We might mention many other cases equally remarkable
and feel that we are justified in making the assertion that all cases,
where some malformation does not render it absolutely necessary to use
instruments, the above treatment, properly administered, will reduce the
time of labor and suffering of the patient at least three-fourths.
In case of delayed uterine contraction, before the placenta is expelled,
wring a towel out of cold water, fold it two or three times, and lay it
on the mother's abdomen, which will cause the uterus to immediately contract
and expel the placenta.
It is always advisable, immediately after the delivery
of the placenta, to inject a pint of cold water into the uterus, thus causing
the uterus to contract, and obviating the danger of hemorrhage.
The mother should have a hot vaginal douche daily
during the first twelve or fourteen days after confinement.
The mother should be permitted to lie in any position
she may desire after confinement; the old custom of keeping the patient
on the back for a number of days being a prolific source of "milk-leg."
"Milk-leg" usually occurs in the left leg, from
the fact that the right common iliac artery lies immediately over
the left common iliac vein, thereby acting as a ligature, obstructing
the return current of blood, when the patient is kept lying upon
the back. (See
cut 50.)
MASTITIS, OR GATHERED BREASTS
(Inflammation of the breasts; may terminate in suppuration.)
SYMPTOMS
When inflammation occurs in the tissues behind the
breast and on which it is placed, the pain is severe, throbbing, deep-seated,
and increased by moving the arm and shoulder; the breast becomes swollen,
red, and more prominent, being pushed forward by the abscess behind.
Sometimes, but less frequently, the breast itself is involved, when the
pain becomes very acute and cutting, the swelling very considerable, and
there is much constitutional disturbance - quick, full pulse, hot skin,
thirst, headache, sleeplessness, etc. This variety of gathered breasts
is preceded by rigors (shivering fits), followed by heat.
TREATMENT
1. Raise the arms high above the head, with
the knee between the shoulders, lowering the arms with a backward motion.
2. Move all the muscles near the breasts very
deeply.
3. Move the breasts gently in all directions,
raising them up and endeavoring to free all the glands, muscles, and circulation.
Treat every few hours. Immediate relief, and
a cure in a very short time, will be the result.
PHLEGMASIA ALBA DOLENS, OR "MILK-LEG"
(Acute edema from venous obstruction, usually in the left leg.)
SYMPTOMS
Swelling, pain, and general fever.
TREATMENT
1. Flex the limb gently but strongly against
the abdomen; giving strong abduction of the knee and adduction of the foot
as the limb is extended.
2. Grasping the limb close to the thigh, with
one hand on each side, move the flesh gently but deep the entire length
of the limb.
3. Flex the limb and cause the patient
to lie in such a position as to relieve the pressure on the left
common iliac vein (see
cut 50).
Treatment should be given each day. In acute
cases a speedy recovery may be expected. In chronic cases from four
to twelve weeks may be required.
PUERPERAL SEPTICEMEA,
PUERPERAL FEVER, OR "CHILD-BED FEVER"
(An acute febrile affections heterogenetic and contagious, peculiar
to women in childbirth.)
SYMPTOMS
Chill; fever; usually occurring about the third
day; lochia diminished or arrested; secretion of milk lessened; severe
pain on pressure; nausea and vomiting; constipation; urine becomes scanty
and high-colored; pulse varies from 100 to 150; jaundice may occur; temperature
often reaches 105; finally terminates in convalescence or typhoid fever.
Often mistaken for malarial fever.
TREATMENT
1. Place the patient on the side; beginning
at the upper cervicals, move the muscles upward and outward gently but
thoroughly the entire length of the spinal column.
2. Flex the limbs, one at a time, slowly but
strongly against the abdomen, abducting the knee and adducting the foot
as the limb is gently extended.
3. Place the bands on each side of the neck,
almost meeting over the upper cervicals; tip the head gently backward,
pressing quite strongly at the same time upon the vaso-motor.
4. Large injections of cool water should be
given each day to free the bowels; also give hot vaginal douches each day,
and oftener, if necessary.
PUERPERAL MANIA
(Delirium or madness, often following labor.)
TREATMENT
1. See
Puerperal Septicemia.
2. Thorough Treatment of the Neck.
