severe and troublesome pain is often experienced in the right
hypochondrium during the latter period of pregnancy; and this suffering
is, almost always, sought to be mitigated or removed by blood-letting.
When decided evidences of plethora accompany this painful affection,
bleeding will occasionally procure considerable relief; but in the
majority of instances, no mitigation whatever is obtained from this
measure. The relief which is sometimes procured by bleeding is always of
short duration, the pain usually returning in the course of two or three
days; and if the bleeding is thus frequently repeated, as is sometimes
done, much mischief is apt to be produced by the general debility and
languor which it tends to occasion. When the symptoms of vascular
turgescence throughout the system are conspicuous in connection with
this pain in the side, it will certainly be proper to diminish the mass
of the circulating fluid by venesection; but when no indications of this
kind are present, blood ought not to be abstracted, merely on account of
this affection, for it will most assuredly fail of procuring the desired
relief, and may, when not particularly called for, operate unfavorably
on the general health of the patient. Moderation in diet, together with
a proper attention to the state of the bowels, and the use of gentle
exercise by walking, will, in general, do much more toward the removal
of this source of uneasiness and suffering, than will result from
blood-letting, when this evacuation is not specially indicated by the
fullness and firmness of the pulse, or by other manifestations of
general vascular plethora.”
But in these cases, when so careful a practitioner as Dr. Eberle even,
would think it best to resort to the lancet, it is a well-attested fact,
that fasting and prudent abstemiousness are far better, more effectual,
and more permanent in their action upon the system than blood-letting.
The _hunger-cure_, which I have so often for years past recommended, is
a most valuable remedy in all plethora or over-fullness of the system,
and in all kinds and degrees of pain arising from such fullness. See,
too, how reasonable it looks; for the body, as you know, is always
wasting itself, so that if we stop off the supply, the over-fullness
must by a natural process very soon become cured; hence I say, do not be
bled in pregnancy; and when you have need FAST.
LETTER XXI.
STERILITY OR BARRENNESS.
Their Causes—The Catamenial Discharge as affecting it—Fluor
Albus—Corpulency—The Treatment appropriate in these Cases.
When a woman is not able to conceive, the defect must depend upon a
malformation, a diseased state, or a diseased action of the generative
organs.
_Causes._—Organic barrenness happens in those cases where there is some
structural hindrance or defect, either natural or accidental. The vagina
may be imperforate, so as wholly to preclude the intermission of the
seminal fluid; the ovaria may be either wholly wanting or too small; or
the Fallopian tubes imperforate; or the uterus so small as not to be
capable of its proper functions. The hymen may also be so hard and
resisting as to prevent the natural measures for conception.
In most cases of barrenness, however, the organs of generation appear to
be properly formed, but their action is imperfect or disordered.
If the menses have not appeared, or if the discharge is scanty, and
occurs at irregular periods, the woman rarely conceives.
So also when the menstrual flux is more frequently repeated than it is
in its natural course, or when it occurs even after the proper time, in
too great profusion, and, as is generally the case, intermixed with
genuine blood, there is little prospect of conception taking place. In
such cases there often appears to be as little desire for cohabitation
as there is power of fecundity.
Pregnancy seldom happens when the catamenial discharge is attended with
great and spasmodic pain, particularly if the discharge is small in
amount, and of deteriorated quality. If, under such circumstances,
conception does take place, the next periodical flow is very apt to
cause the uterus to discharge the germ, thus bringing on an early
miscarriage.
The state of weakness and debility of the uterine system occasioned by
too frequent sexual intercourse, is a common cause of sterility. Those
unfortunate creatures who follow a life of prostitution seldom bear
children.
Bad cases of fluor albus often indicate a state of the uterus and
ovaries which does not admit of conception.
There is also to be mentioned, among the causes of barrenness, what has
been called by medical writers _copulative incongruity_. “Every one,”
observes Dr. Good, “must have noticed occasional instances in which a
husband and wife, apparently in sound health and vigor of life, have no
increase while together, either of whom, nevertheless, upon the death of
the other, has become the parent of a numerous family; and both of whom,
in one or two curious instances of divorce, upon a second marriage. In
various instances, indeed, the latent cause of sterility, whatever it
consists in, seems gradually to diminish, and the pair that was years
childless is at length endowed with a progeny.”
Corpulency is also to be mentioned among the causes of barrenness. Women
who are very fat are often sterile, from the fact that obesity is in
reality a state of disease.
It is supposed by many that barrenness is almost always the fault of the
female. But this is not necessarily so; the husband, as well as the
wife, may be feeble in the procreative function; and men who have lived
a debauched or dissipated life are very apt to be so. Hence it is that
women are often blamed when they ought not to be.
_Treatment._—In regard to the therapeutic management suitable to be
adopted in such cases, it is to be remarked, that if organic disease is
the cause of the difficulty, we cannot, as a general thing, expect by
any means to effect a cure. But in a large majority of cases the
difficulty is only a functional one; in many of these, therefore, a cure
may be brought about.
The sum total of the therapeutic management proper to be adopted in such
cases is, invigorating the general health. That which will best tend to
fortify and strengthen the system generally is also best for the local
weakness. Nor is a cure to be effected in a short period of time in most
cases of sterility. It may require many months, and even years, to
accomplish the object.
“Abstinence by consent for many months,” observes Dr. Good, “has proved
a more frequent remedy than any other, and especially when the
intercourse has been so incessantly repeated as to break down the
staminal strength; and hence the separation produced by a voyage to
India has often proved successful.”
Some years ago I wrote in my note-book the following paragraphs on this
subject:
“A few months since, one of my patients, a gentleman of this city,
informed me that a lady relative of his, with whom also I am acquainted,
had been married about eight years, remaining, much to her sorrow,
childless. She experienced frequent miscarriages, accompanied with much
general debility. About two years since the subject of water-treatment
came under her observation. She at once commenced a course of bathing,
with due attention to regimen, etc. She became much improved, and, in
due time, bore a healthy, well-formed child. She attributed this most
desirable result to the effects of water in restoring her general
health.
“Another lady remained without offspring for fifteen years after
marriage. Her husband, in building a new house since the introduction of
Croton water into this city, erected also convenient bathing fixtures.
The lady practiced perseveringly a course of bathing, and became much
improved in her bodily health. She, too, was at length blessed with an
offspring, and, as she believed, in consequence of the course she had
pursued in restoring her general health.
“I have known and heard of numbers of cases in which, by a prudent
course of bathing, exercise, etc., the use of a plain and unstimulating
diet, and the observing of proper temperance in the marital privileges,
persons have borne children when most earnestly, and by a great variety
of means, that object had been sought in vain. Yet be it ever
remembered, that little is to be expected from either water or diet
without _strict temperance in all things_.”
The vegetable diet, so called, is very favorable to reproduction in the
human species. See how Ireland, a small island comparatively, sends its
inhabitants all over Great Britain and the wide extent of the United
States. Yet the mass of Irish people, as every one knows, subsist, while
in their own country, mainly on potatoes and sour milk, or a diet
equally simple. The celebrated Dr. Cheyne remarked, from much
experience, that the total milk and seed diet (meaning by seed,
farinaceous substances generally), persevered in for two years, was in
almost all cases sufficient to enable the barren to become pregnant by
the appropriate means.
Fortify and invigorate the general health, observing at the same time
the strictest “temperance in all things.” These are the means by which
to overcome that, to many, unfortunate state, barrenness.
You, then, who may be in the condition we have been considering, if you
wish to be cured of it, leave none of the tonic means, none of the good
rules of health untried. If you are faithful in every thing, so may you
expect to succeed. But if it should be found that it is not possible for
you to conceive, you will yet have the satisfaction of knowing that your
toils have not been in vain; your health will become so much improved as
to reward you a thousand-fold for every good thing you do.
I ought to remark also, before closing, that when a woman who has been
for a time barren becomes again pregnant, she must be very careful of
herself during this period, as with a little imprudence abortion is very
likely to occur.
LETTER XXII.
THE PELVIS AND ITS ORGANS.
General Description—Differences between the Male and Female Pelvis—The
Bladder and Urethra—The Vagina—The Uterus and its Appendages.
Before entering upon the subject of labor and its phenomena, it is
proper that I should give you some idea of the parts more immediately
concerned in parturition. In doing this, I propose for the most part to
adopt the plain and concise description of these structures given by Mr.
Erasmus Wilson, of London, whose work on anatomy stands as high as any
other that has ever been written.
THE PELVIS.
The pelvis, considered as a whole, is divisible into a _false_ and
_true_ pelvis; the former is the expanded portion, bounded on each side
by the ossa ilii, and separated from the true pelvis by the linea
iliopectinea. The true pelvis is all that portion which is situated
beneath the iliopectinea. This line forms the margin or _brim_ of the
true pelvis, while the included area is called the _inlet_. The form of
the inlet is heart-shaped, obtusely pointed in front at the symphysis
pubis, expanded on each side, and encroached upon behind by a projection
of the upper part of the sacrum, which is named the promontory. The
cavity is somewhat encroached upon at each side by a smooth quadrangular
plane of bone, corresponding with the internal surface of the
acetabulum, and leading to the spine of the ischium. In front are two
fossæ around the obturator foramina, for lodging the obturator internus
muscle, at each side. The inferior termination of the pelvis is very
irregular, and is termed the _outlet_. It is bounded in front by the
convergence of the rami of the ischium and pubes, which constitute the
arch of the pubes; on each side by the tuberosity of the ischium, and by
two irregular fissures formed by the greater and lesser sacro-ischiatic
notches; and behind by the lateral borders of the sacrum, and by the
coccyx.
[Illustration:
A FEMALE PELVIS.
1. The last lumbar vertebra. 2, 2. The intervertebral substance
connecting the last lumbar vertebra with the fourth and sacrum. 3.
The promontory of the sacrum. 4. The anterior surface of the sacrum,
on which its transverse lines and foramina are seen. 5. The tip of
the coccyx. 6, 6. The iliac fossæ, forming the lateral boundaries of
the false pelvis. 7. The anterior superior spinous process of the
ilium; left side. 8. The anterior inferior spinous process. 9. The
acetabulum. _a._ The notch of the acetabulum. _b._ The body of the
ischium. _c._ Its tuberosity. _d._ The spine of the ischium seen
through the obturator foramen. _e._ The os pubis. _f._ The symphysis
pubis. _g._ The arch of the pubes. _h._ The angle of the os pubis.
_i._ The spine of the pubes; the prominent ridge between _h_ and _i_
is the crest of the pubes. _k_, _k_. The pectineal line of the
pubes. _l_, _l_. The ilio-pectineal line; _m_, _m_. The prolongation
of this line to the promontory of the sacrum. The line represented
by _h_, _i_, _k_, _k_, _l_, _l_, and _m_, _m_, is the brim of the
true pelvis. _n._ The ilio-pectineal eminence. _o._ The smooth
surface which supports the femoral vessels. _p_, _p_. The great
sacro-ischiatic notch.
]
The pelvis is placed obliquely with regard to the trunk of the body, so
that the inner surface of the ossa pubis is directed upward, and would
support the superincumbent weight of the viscera. The base of the sacrum
rises nearly four inches above the level of the upper border of the
symphysis pubis and the apex of the coccyx, somewhat more than half an
inch above its lower border. If a line were carried through the central
axis of the inlet, it would impinge by one extremity against the
umbilicus, and by the other against the middle of the coccyx. The _axis
of the inlet_ is therefore directed _downward and backward_, while that
of the _outlet_ points _downward and forward_, and corresponds with a
line drawn from the upper part of the sacrum, through the center of the
outlet. The axis of the cavity represents a curve, which corresponds
very nearly with the curve of the sacrum, the extremities being
indicated by the central points of the inlet and outlet. A knowledge of
the direction of these axes is most important to the surgeon, as
indicating the line in which instruments should be used in operations
upon the viscera of the pelvis, and the direction of force in the
removal of calculi from the bladder; and to the accoucher, as explaining
the course taken by the fetus during parturition.
There are certain striking differences between the male and female
pelvis. In the male the bones are thicker, stronger, and more solid, and
the cavity deeper and narrower. In the female the bones are lighter and
more delicate, the iliac fossæ are large, and the ilia expanded; the
inlet, the outlet, and the cavity, are large, and the acetabula farther
removed from each other; the cavity is shallow, the tuberosities widely
separated, the obturator foramina triangular, and the span of the pubic
arch greater. The precise diameter of the inlet and outlet, and the
depth of the cavity, are important considerations to the accoucher.
The contents of the pelvis are, the bladder, vagina, uterus with its
appendages, and the rectum. Some portion of the small intestines also
occupies the upper part of its cavity.
THE BLADDER.
This is in relation with the os pubis in front, with the uterus behind,
from which it is usually separated by a convolution of small intestine,
and with the neck of the uterus and vagina beneath. The form of the
female bladder corresponds with that of the pelvis, being broad from
side to side, and often bulging more on one side than on the other. This
is particularly evident after frequent parturition. The _coats_ of the
bladder are the same as those of the male.
THE URETHRA.
This is about an inch and a half in length, and is lodged in the upper
wall of the vagina in its course downward and forward, beneath the arch
of the os pubis, to the meatus urinarius. It is lined by mucous
membrane, which is disposed in longitudinal folds, and is continuous
internally with that of the bladder, and externally with the vulva; the
mucous membrane is surrounded by a proper coat of elastic tissue, to
which the muscular fibres of the detrusor urinæ are attached. It is to
the elastic tissue that is due the remarkable dilatability of the female
urethra, and its speedy return to its original diameter. The meatus is
encircled by a ring of fibrous tissue, which prevents it from distending
with the same facility as the rest of the canal; hence it is sometimes
advantageous in performing this operation, to divide the margin of the
meatus slightly with the knife.
THE VAGINA.
This is a membranous canal, leading from the vulva to the uterus, and
corresponding in direction with the axis of the outlet of the pelvis. It
is constricted at its commencement, but near the uterus becomes dilated,
and is closed by the contact of the anterior with the posterior wall.
Its length is variable; but it is always longer upon the posterior than
upon the anterior wall, the former being usually about five or six
inches in length, and the latter four or five. It is attached to the
cervix of the uterus, which latter projects into the upper extremity of
the canal.
In structure, the vagina is composed of a _mucous lining_, a layer of
_erectile tissue_, and an external tunic of _contractile fibrous
tissue_, resembling the dartos of the scrotum. The upper fourth of the
posterior wall is covered, on its pelvic surface, by the peritoneum,
while in front the peritoneum is reflected from the upper part of the
cervix of the uterus to the posterior surface of the bladder. On each
side it gives attachment, superiorly to the broad ligaments of the
uterus, and inferiorly to the pelvic fascia and levatores ani.
The mucous membrane presents a number of _transverse papillæ_ or _rugæ_,
upon its upper and lower surfaces, which extend outward on each side
from a middle raphé. The transverse papillæ and raphé are more apparent
upon the upper than upon the lower surface, and the two raphé are called
the _columns of the vagina_. The mucous membrane is covered by a thin
cuticular epithelium, which is continued from the labia, and terminates
by a fringed border at about the middle of the cervix uteri.
The middle, or _erectile layer_, consists of erectile tissue enclosed
between two layers of fibrous membrane; this layer is thickest near the
commencement of the vagina, and becomes gradually thinner as it
approaches the uterus.
The external, or _dartoid layer_ of the vagina, serves to connect it to
the surrounding viscera. Thus it is very closely adherent to the under
surface of the bladder, and drags that organ down with it in prolapsus
uteri. To the rectum it is less closely connected, and that intestine is
therefore less frequently affected in prolapsus.
The uterus is a flattened organ, of a pyriform shape, having the base
directed upward and forward, and the apex downward and backward in the
line of the axis of the inlet of the pelvis, and forming a considerable
angle with the course of the vagina. It is convex on its posterior
surface, and somewhat flattened upon its anterior aspect. In the
unimpregnated state it is about three inches in length, two in breadth
across its broadest part, and one in thickness, and is divided into
fundus, body, cervix, and os uteri. At the period of puberty, the uterus
weighs about one ounce and a half: after parturition, from two to three
ounces; and at the ninth month of utero-gestation, from two to four
pounds.
The _fundus_ and _body_ are inclosed in a duplicature of peritoneum,
which is connected with the two sides of the pelvis, and forms a
transverse septum between the bladder and rectum. The folds formed by
this duplicature of peritoneum on either side of the organ are the
_broad ligaments_ of the uterus. The cervix is the lower portion of the
organ; it is distinguished from the body by a well-marked constriction;
to its upper part is attached the upper extremity of the vagina, and at
its extremity is an opening, which is nearly round in the virgin, and
transverse after parturition; the _os uteri_, bounded before and behind
by two labia, the anterior labium being the most thick, and the
posterior somewhat the longest. The opening of the os uteri is of
considerable size, and is named the orificium uteri externum; the canal
then becomes narrowed, and at the upper end of the cervix is constricted
into a smaller opening, the orificium internum. At this point the canal
of the cervix expands into the shallow triangular cavity of the uterus,
the inferior angle corresponding with the orificium internum, and the
two superior angles, which are funnel-shaped, and represent the original
bicornute condition of the organ, with the commencement of the Fallopian
tubes. In the canal of the cervix uteri are two or three longitudinal
folds, to which numerous oblique folds converge, so as to give the idea
of branches from the stem of a tree; hence this appearance has been
denominated the _arbor vitæ uterina_. Between these folds, and around
the os uteri, are numerous mucous follicles. It is the closure of the
mouth of one of these follicles, and the subsequent distention of the
follicle, with its proper secretion, that occasion those vesicular
appearances so often noticed within the mouth and cervix of the uterus,
called the _ovula of Naboth_.
_Structure._—The uterus is composed of three tunices: of an _external_,
or _serous coat_, derived from the peritoneum, which constitutes the
duplicatures on each side of the organ, called the broad ligaments; of a
_middle_, or _muscular coat_, which gives thickness and bulk to the
uterus; and of an _internal_, or _mucous membrane_, which lines its
interior, and is continuous, on the other hand, with the mucous lining
of the Fallopian tubes, and on the other with that of the vagina. In the
unimpregnated state, the muscular coat is exceedingly condensed in
texture, offers considerable resistance to section with the scalpel, and
appears to be composed of whitish fibers, inextricably interlaced and
intermingled with blood-vessels. In the impregnated uterus the fibers
are of large size, and distinct, and are disposed in two layers,
superficial and deep. The _superficial layer_ consists of fibers, which
pursue a vertical direction, some being longitudinal and others oblique.
The longitudinal fibers are found principally upon the middle line,
forming a thin plane upon the anterior and posterior face of the organ,
and upon its fundus. The oblique fibers occupy chiefly the sides and
fundus. At the angles of the uterus, the fibers of the superficial layer
are continued outward upon the Fallopian tubes, and into the round
ligaments and ligaments of the ovaries. The _deep layer_ consists of two
hollow cones of circular fibers, having their apex at the openings of
the Fallopian tubes, and by their bases intermingling with each other on
the body of the organ. These fibers are continuous with the deep
muscular layer of the Fallopian tubes, and indicate the primitive
formation of the uterus by the blending of these two canals. Around the
cervix uteri the muscular fibers assume a circular form, interlacing
with and crossing each other at acute angles. The _mucous membrane_ is
provided with a columnar ciliated epithelium, which extends from the
middle of the cervix uteri to the extremities of the Fallopian tubes.
_Vessels and Nerves._—The _arteries_ of the uterus are the uterine, from
the internal iliac, and the spermatic, from the aorta. The _veins_ are
very large and remarkable; in the impregnated uterus they are called
sinuses, and consist of canals, channeled through the substance of the
organ, being merely lined by the internal membrane of the veins. They
terminate on each side of the uterus in the uterine plexuses. The
_lymphatics_ terminate in the lumbar glands.