The principles and practice of obstetricy, as at present taught, by James Blundell ... To which are added, notes and illustrations. By Thomas Castle ..

Front matter

TRANSFERRED TO YALE MEDICAL LIBRARY

Open Knowledge Commons and Yale University, Cushing/Whitney Medical Library

THE

Preface

To speak of the value of Dr. Blundell's Obstetric Instructions I deem unnecessary, his name alone is sufficient to give importance and authority to any publication ; I have, therefore, only to premise that this volume is written from the Lectures which were delivered by the learned Professor, at Guy's Hospital, in 1830-31. But as the Lectures in question did not exactly accord with the plan I had myself in view, and, more especially, as Dr. Blundell has somewhat varied his later instructions, I have, in my capacity of Editor, used the text of the " Lancet," to a certain extent, as the foundation of the treatise, rearranged and subdivided the subjects, and introduced such fresh matter as my own notes would supply. To Dr. Blundell I am indebted for correcting some of the sheets, as they were proceeding through the press ; and, in particular, I may observe, the alterations connected with Transfusion. The essay on the disease which he has named Hidrosis, or Hidrotic Fever, is also new, and well deserves the at tention of the practitioner.

T. C.

Trinity College. Cambridge, March 15th, 1834

Section I

Of the Structure and Obstetric Properties of the Pelvis, S$c.

Bones of the Pelvis, 19 ; Ligaments of the Pelvis, 21 ; Joints of the Pelvi3, 22 ; Obstetric properties of the Pelvis, 22 ; Standard Pelvis, 23 ; Distorted Pelvis, 25 ; Contracted Pelvis, 26 ; Small Pelvis, 27 ; Large Pelvis, 2S ; Means of ascertaining the kinds of Pelves, 28 ; Comparison between the Male and Female Pelvis, 30 j The Axis of the Pelvis, 30 ; The Obstetric properties of the Child's Head, 31 ; Standard Head, 32; Deviations from the Standard Head, 33.

SECTION II. On the External Parts of Generation

Mons Veneris, 34 ; Labia Pudendi, 34 ; Clitoris, 35 ; Nymphte, 35 ; Meatus Urinarius, 35 ; Orifice of the Vagina, 36 ; Hymen, or Circulus Membranosus, 36 ; Perinaeum, 37 ; Blood-vessels, &c. 38.

SECTION I. On the Menses

On the Menses, 46 ; Nature of the Menstrual Discharge, 47 ; Appearance of the Menses, 47; Symptoms attending Menstruation, 48 ; Source of the Menses, 49 ; Probable use of Menstruation, 49 , Relative Questions, 50 ; Casual effects of Obstructed or Perverted Menstruation, 50.

SECTION II. On Conception and Impregnation

Commonly two Genital Structures, 51 ; Different Theories of Conception, 51 ; Two Substances necessary, 53; Contact of the two Substances necessary, 53 ; Experiments proving Contact necessary, 54; Inferences to be drawn from these Experiments, 56; Death from Impregnation, 56 ; Where do the Rudiments and Fecundating Fluid meet ? 56 ; Very little Semen Impregnates, 57 ; Anomalous Impregnation, 58 ; Different Degress of Fecundity, 59 ; Impregnation not Periodical, 59 ; Sexual Instinct, 60 ; Superfcetation, 61 ; Double Uterus, 62.

SECTION IV. On the Gravid Uterus

Size of the Gravid Uterus, 64 ; Situation of, 64 ; Intumescence of, 64 ; Fluctuation, 65 ; Structures of, 65 ; Nerves and Absorbents of, 65 ; Substance of the Uterus is Muscular, 66; Thickness of the Uterus, 67; Of the Uterus during the Progress of Pregnancy, 68.

SECTION v. Contents of the Womb

Foetus and Appendages, 72 ; Peculiarities of the Foetus, 72 ; Position of the Child in Utero, 78 ; Of the Placenta, 79; Funis Umbilicalis, 81; Involucra or Membranes, 84; Tunica Decidua, 84 ; Chorion, 85 ; Amnion, 86 ; Formation of the Placenta, 86 ; Tunica decidua reflexa, 87 ; Liquor Amnii, 88.

SECTION I. Signs of Pregnancy

The most certain Indications, 108 ; The more common Indications, 108 ; ffideraa of the Lower Limbs, 109 ; Vomiting and Retchings, 109 ; Movement of the Foetus, 109 ; Enlargement of the Abdomen, 110; State of the Breasts, 111 ; Value of the Areolar Sign, 113 ; Suspension of the Menses, 114 ; Accidental or Anomalous Indications, 115 ; Signs furnished by an examination, 116.

SECTION II. Of the Progress of Pregnancy

Means of ascertaining, Manual Examination, 119 ; Reckoning, 120.

SECTION III. Of some of the Diseases of Pregnancy

Nausea and Diarrhoea, 121 ; Effusions of Water, 126 ; Syphilis, 128 ; Dyspepsia, 131 ; Cardialgia, 132 ; Fastidious Taste, 132 ; Constipation, 133 ; Prolapsus Uteri, 133 ; Micturition, 134 ; Calculus in the Bladder, 134 ; Icterus or Jaundice, 134 ; Dyspnoea and Cough,135 ; Convulsions, 135 ; Odontalgia, 136 ; Ptyalism, 136 ; Mastodynia, 137 ; Dropsy of the Ovum, 137 ; Rigidity and Laxity of the Abdomen, 137 ; False Pains, 138 ; Foetal Turbulency, 139.

SECTION I. On Delivery

General Remarks, 140 ; Three Stages in Parturition, 140 ; Five Classes, 141 ; Early Attend-

CONTENTS.

ance necessary, 142 ; Instruments sometimes required, 142 ; Preliminary Inquiries, 143 ; State of the Room, 144 ; Position in the Early Stage, 144 ; Position in the Advanced Stage, 144 ; Guarding the Bed, 145,

SECTION II. On Natural Parturition

Precursory Symptoms, 145 ; Symptoms during the First Stage, 146 ; Descent of the Child's Head, 147 ; Effects on the Os Uteri and Vagina, 147 ; Eruption of the Liquor Amnii, 148 ; Position of the Child's head, 148 ; Pains during Parturition, 150 ; Birth of the Head, 150 ; Duration of the Process of Parturition, 151 ; Morbid Effects of Parturition, 151.

SECTION III. Duties of the Obstetrician

Decision in Dubious Cases, 152 ; Symptoms during the Early Stage, 153 ; On Rupturing the Membranes, 154 ; Early Knowledge of the Presentation, 155 ; Position of the Woman, 155 ; Situation of the different parts, 156 ; In Natural Labor do not interfere, 157 ; Attention to the state of the Bladder, 157 ; The Protection of the Perinaeum, 158 ; Birth of the Shoulders, 158 ; The Funis round the Child's Neck, 158 ; Cutting the Funis, 159 ; Examine for a Second Foetus, 160; Recapitulation, 161 ; Birth of Still-born Children, 161.

SECTION IV. Birth and Management of the Secundines

Natural Expulsion of the Placenta, 164 ; Effects of Uterine Contraction, 164 ; State of the Uterus after Delivery, 165 ; Means to secure Uterine Contraction, 166 ; Injudicious removal of the Placenta, 167; Manner of removing the Placenta, 169; Necessary Cautions, 170 ; Errors in managing the Placenta, 171 ; Conclusion, 173.

section v. Effects produced on the Genitals by Parturition

Dilatation of the Parts, 173 ; Lacerations and Contusions, 173 ; Inflammations and Suppurations, 174; Sloughings, 175 ; Micturition, 175 ; Incontinence of Urine, 175 ; Compression of the Nerves, 176 ; Tenesmus, 176.

SECTION VI. Transmission of the Child through the Pelvis

Vertex Presentation, 177; Face Presentation, 181; Forehead and Ear Presentation, 183; Foot or Crural Presentation, 184 ; Breech Presentation, 187 ; Transverse Presentation, 192.

SECTION VIII. On Flooding Cases

Commencement, 197 ; Source of the Hemorrhage, 198 ; Why a larger or smaller quantity discharged, 198 ; Causes of the cessation of Hemorrhage, 199 ; Uterine Hemorrhage sometimes rapidly fatal, 202 ; The less alarming symptoms, 202 ; The immediate precursors of dissolution, 202 ; The Hemorrhage may occur in gushes or drainings, 203.

Section IX

Management of Simple Flooding Cases in the Earlier Months.

Commencement, 203 ; Regimen and Position, 203 ; Mild Aperients, 201 ; Febricula, or Slight Fever, 204 ; Turpentine, 205 ; Abstraction of Blood, 205 ; Proper Nourishment, 206 ; Gastric Astringents, 207 ; Of Faintness, 207.

SECTION X. Management of the More Copious Floodings

Commencement, 207 ; Rest and Nourishment, 208 ; Turpentine, 208 ; Stimulants, 208 ; Acetate of Lead, 209 ; Cold Applications, 210 ; Plugging the Vagina, 211 ; Deobstruents, 211 ; Discharging the Liquor Amnii, 212 ; Manually emptying the Uterus, 213.

Section XI

Management of the More Copious Floodings in the latter Months especially.

Commencement, 214 ; Removal of the Child, 214 ; Circumstances under which these Hemorrhages occur, 215 ; Has the Bleeding been arrested ? 215 ; Is the System on the rally, or on the decline ? 215 ; Change of Position, 216.

SECTION XII. Management of Floodings in the Asphyxial State

Empty the Uterus, 217 ; Cold Applications some times advisable, 218 ; Plugging the Vagina not generally necessary, 219 ; Nourishment, 219 ; Opium against Restlessness, 219 ; Stimulants, 220 ; Death after cessation of Floodings, 221 ; Transfusion in these Cases, 222 ; Evacuating the Uterus, 224; On the propriety of Delivery, 224 ; Rules regulating Manual Interference, 226.

SECTION XIII. Preternatural Labors

Foot or Crural Presentations, 228 ; Method of giving Assistance, 230 ; The Child's Head in front of the Pelvis, 231 ; Errors in the management of Crural Presentations, 232 ; Breech Presentations, 232 ; On Manual Interference, 233 ; The Abdomen situated anteriorly, 233 ; Manual Assistance, 234 ; Errors in the management of Breech Presentations, 235.

SECTION xv. Extraordinary Difficulties in Preternatural Cases

Enlargement of the Abdomen, 236 ; The Position of the Arms, 236 ; Abstraction of the Head, 237 ; Laying open the Head, 239 ; Decapitation of the Foetus, 240 ; Transverse Presentations, 241 ; Escape of the Child from the Uterus, 241 ; Indications for relying on the natural efforts, 242 ; Evolution of the Child, 242 ; Ordinary method of Delivery, 243 ; Caesarian Operation may be sometimes necessary, 244 ; On the propriety of Embryotomy, 244 ; Probable Effects of Non-delivery, 245.

SECTION XVI. On Turning

Different Indications, 246; Attention to the state of the Bladder, &c. 247; Position of the 2

Patient and yourself, 247 ; Position of the Uterus and Foetus, 248 ; Ascertain the position of the Feet, 248 ; Division of Turning Cases, 249.

SECTION xx. After Management of Floodings

Do not hastily leave your Patient, 257 ; On making the Patient comfortable, 258 ; Beware of Secret Bleedings, 258 ; Pressure on the Abdomen, 259 ; Apply Napkins to the Genitals, 259 ; Nourishment, 259 ; Head ache and Diarrhoea from profuse Hemorrhage, 260 ; Weakness, 261 ; Aqueous Effusions, 261 ; Errors to be avoided, 261.

SECTION XXI. On Transfusion

Progress of Transfusion, 263 ; The blood of one animal may be substituted for the blood of another of the same species, 264 ; The blood of animals of different species unsuccessful, 264 ; Blood may be transmitted through a syringe without much deterioration, 265 ; Experiments, 265 ; Mode of performing Transfusion, 266 ; Transfusion not without its dangers, 268.

Section XXII

Of the different Substances which escape from the Uterus in the Earlier and Middle Months.

Modes in which the Ovum is expelled, 269 ; Sometimes more than one Ovum, 270 ; Ambiguous traces of the Embryo, 271 ; Conclusion, 272.

SECTION XXIII. Of Floodings in the Earlier Months

Commencement, 272 : Rapid and tardy Miscarriages, 273 ; Partial Evacuations of the Uterus, 273 ; Continued Hemorrhage after Expulsion, 274 ; Management of the Earlier Floodings, 275 ; Errors in Management, 276.

SECTION XXIV. Of Floodings in the Latter Months

Three species of Floodings, 277 ; Floodings in which the Placenta is over the Os Uteri, 277 ; Cause of the Hemorrhage in this instance, 278 ; Mode of ascertaining the situation of the Placenta, 279 ; General rules for Delivery, 279 ; Mode of Turning in these cases, 280 ; Errors likely to be committed, 282.

Section XXV

Floodings in which the Placenta is not over the Os Uteri.

Commencement, 2S2 ; Immediate Death from Flooding, 283 ; Flooding during Labor, 283 ; Flooding before Labor, 284 ; The Waters discharged, and the Hemorrhage continues, 285 ; Errors to be avoided in managing these cases, 285.

Section XXVI

Floodings after the Expulsion of the Child, called After -Floodings.

Floodings from retention of a portion of the Placenta, or from a clot of blood, 286 ; Flooding with vomiting, 286 ; Internal and concealed Hemorrhage, 287 ; External Hemorrhage, 287.

SECTION XXVII. Treatment of After- Floodings

Copious After-Floodings, 288 ; Necessity of Uterine contractions, 288 ; Condition of the Uterus after Delivery, 289 ; Flooding after the Placenta is removed, 289 ; Flooding from a portion of the Placenta remaining, 290 ; Inversion of the Uterus, 290 ; Flooding before the Placenta is removed, 290 ; The employment of Refrigerants, 291 ; Faintness and Asphyxia, 292 ; Plugging the Vagina, 293 ; Recapitulation, 293 ; After-management of the Patient, 293 ; Treatment of spare After-Floodings, 294 ; Errors to be avoided in managing After-Floodings, 294 ; Some women peculiarly liable to Floodings, 295.

SECTION XXVIII. On Laborious Labor

Accidents, or effects, which occur, more especially during Laborious Labors, 295 ; Rupture of the Trachia or Bronchii, 296 ; Vascular and Cardiac Lacerations, 296 ; Rupture of the Genitals, 296 ; Laceration of the Perinaeum, 297 ; Large accumulations of Urine, 298 ; Contusions and Mortifications, 299 ; Inflammation of the Cervix Uteri and Vagina, 301 ; Excitement in the patient, 301 ; Contusions and Death, 301 ; Convulsions, 301 ; After-flooding, 302 ; Child still-born, 302 ; Swelling of the Labia Pudendi, &c. 302.

SECTION XXIX. Effects following Laborious Parturition

Swelling and Sloughings, 303 ; Suppuration with Hectic Fever, 303 ; Collapse, 304 ; Inflammation of the Abdominal Viscera, 304 ; Puerperal Irritability, 305 ; Rigors, Wastings, Sweatings, &c, 305 ; Retention of Urine, 306 ; Weakness of the Bladder, 306 ; Rupture of the Bladder, 306 ; Sloughings of the Vagina, &c, 307 ; Pressure on the Nerves, 307.

section xxx. On the Use of Instruments

Instruments in common use, 308 ; Examine what is the state o'f the Patient, 309 ; State of the Softer Parts, 309; Empty the Bladder, 310; Ascertain distinctly the Position of the Head, 310; Position of the Patient, &c. 311 ; Recapitulation, 311.

SECTION XXXI. Of the Long Forceps

Cases most frequently requiring the Long Forceps, 312 ; Introduction of the Instrument, 313 ; Co-operate with the Natural Efforts, 314 ; Imitate Nature, 314 ; Abstracting the head, 315 ; The grand Error is using force, 317.

SECTION XXXII. Of the Lever

Variety of Levers, 317 ; Cases in which employed, 318 ; Management of the Instrument, 318 ; Errors liable to be committed, 321.

SECTION XXXIII. Of the Short Forceps

Different kinds of Short Forceps, 322 ; Curved Short Forceps, 322 ; Straight Short Forceps, 323 ; Three Cases principally requiring the Short Forceps, 324 ; Management in the First Case, 324; Management in the Second Case, 325; Management in the Third Case, 326.

SECTION XXXIV. Rules for using the Embryospastic Instruments

On their Abuse and Neglect, 327 ; Knowledge of Cases requiring them, 327 ; Circumstances under which sometimes allowable, 328 ; Measurements of the Pelvis, 328 ; Appearance of dangerous Symptoms, 329; Prolongation of the Labor, 329 ; Conclusion, 330.

section xxxv. Of Craniotomy Instruments

Instruments, 331 ; Perforator, 331 ; Craniotomy Forceps, 332 ; Crotchet, 333 ; Blunt Hook, 333.

section xxxvi. Craniotomy in Cases of slight Contraction

Introduction of the Perforator, 333 ; Immediately demolish the Brain, 334; Abstracting the Fetus, 334 ; Abstraction by the Crochet, 336 ; Abstraction by the Finger, 336 ; Of Cases of difficult Abstraction, 337; Obstruction to the Passage of the Shoulders, 337.

SECTION XXXVII. Craniotomy in Cases of considerable Contraction

Open the Head freely, 338 ; Position of the Foetal Head, 338 ; Recapitulation, 339.

Section Xxxviii

Of the Signs which Indicate the Need of Craniotomy.

Peremptory necessity should be clearly established, 339 ; Failure of the Forceps, 340 ; In Full-sized and Contracted Pelvis, 340 ; Previous Operations no Rule, 341 ; State of the Foetus, 341 ; Rules for using the Perforator, 342.

SECTION xxxix

Of the Indications of the Death of the Foetus.

Desquamation of the Cuticle, 343 ; Disruption of the Cranial bones, 343 ; Condition of the Funis, 343 ; Want of motion in the Child, 344 ; Want of Cerebral Pulsation, 344 ; Foetid Discharges, &c. 345 ; State of the Head, &c. 346 ; Coldness of the Abdomen, &c. 346.

SECTION XL. Induction of Premature Delivery

Difficulties attending the Induction, 348.

SECTION XLI. On the Ccesarian Operation

Steps of the Operation, 349 ; Extensive Abdominal Incisions not necessarily fatal, 350 ; Direction of the Incisions, 350 ; Application of the Sutures, 351 ; Sterility should be ensured, 352 ; Success and Fatality of the Operation, 352 ; British Rule of Obstetricy, 353; Nature of the attending Dangers, 354 ; On Peritonitis, as the cause of Death after Csesarian Delivery, 356 ; On the entire removal of the Uterus, 358.

On Particular Laborious Labors.

Section XLV

Laborious Labors from an Unfavorable Position of the Cranium.

Varieties in these Cases, 364 ; Means of alleviating the Difficulties. 364 ; Turning, as a rule, improper, 365 ; Adjustment of the Head, 365 ; Reliance on the Natural Efforts, &c. 366 ; Rectification of Face and Forehead Presentations, 366.

Section XLVI

Laborious Labors from Distortion and Contraction of the Pelvis.

Angular and Elliptical Contractions, 366 ; Means of ascertaining the Contraction, 367 ; Division of these Labors, 368 ; Labors with the highest degree of Contraction, 368 ; Locked Head, 369; Labors with slight Contraction, 371.

SECTION XLVII. Laborious Labors from Rigidity

Symptoms and Effects of Rigidity, 372 ; Means of obtaining relaxation, 373 ; Reliance on the Natural Efforts, 374 ; Be cautious of the Perinaeum, 374 ; Instrumental Assistance, 375 ; Cautions, 375.

SECTION XLVIII. Laborious Labors from different Causes

Thickness of the Membranes, 376 ; Length of the Funis, 377 ; Anchylosed Sacrococcygeal Joint, 377 ; Rigidity from Age, 37S; Bulk of the Foetus, 378 ; Hydrocephalic Head, 378 ; Descent of the Head and Cord together, 379 ; Descent of the Arm with the Cord, 379 ; Conclusion, 380.

SECTION XLIX. Retention of the Placenta

Effects of a Retained Placenta, 380 ; Liability to Hemorrhage, 380 ; Foetid Discharges, 381 ; Constitutional Irritation, 381 ; Treatment, 382 ; Pressure of the Abdomen, 382; Purgatives, 382 ; Ergot of Rye, 383 ; Manual Assistance, 383 ; Rules regulating Manual Assistance, 384.

SECTION L. Different Causes of Retention

Breaking the Funis, 3S5 ; Swelling of the Parts, Sec. 386 ; Irregular Uterine Contraction, 386 ; Scirrhous Adhesion, 388 ; Cohesion from Scirrhous, 3S9 ; Inertness of the Uterus, 390 ; Errors in Managing a Retained Placenta, 391.

SECTION LI. Labors with Monstrosity

Classes of Monsters, 392 ; Monsters in which Parts are Deficient, 392 ; Monsters with Redundancy, 393 ; Misshapen Monsters, &c. 393 ; Rules of Management, 393.

SECTION Hi.

Convulsions During Pregnancy and Labor.

Varieties of Convulsions, 394 ; Premonitory Symptoms, 395 ; Causes of Convulsions, 396 ; Convulsions during Gestation, 397 ; Convulsions during Pregnancy, &c. 398.

SECTION LIII. Treatment of Puerperal Convulsions

Abstraction of Blood, 398 ; Mode of Bleeding, 399 ; Remarks on Bleeding, 400 ; Evacuation of the Alimentary Canal, 400 ; Refrigeration of the Head, 401 ; On the Propriety of Delivery, 402 ; Rules for Delivery, 403 ; Subordinate Remedies, 404.

SECTION LIV. On the Prevention of Convulsions

Venesection, 405 ; Evacuation of the Alimentary Canal, 406 ; Warm Bath, 407 ; Nervous Medicines, 407; Acceleration of Delivery, 407

SECTION LV. Concluding Observations on Convulsions

Causes of Convulsions, 408 ; Prognosis, 409 ; Post-mortem Appearances, 409 ; Apoplexy and Sudden Death, 410.

SECTION LVI. Labors Complicated with Tumors, fyc

Exostosis, 411; Calculi in the Bladder, 411 ; Tumors on the Sacro-Sciatic Ligament, 412; Recto- Vaginal Tumors, 412 ; Rules of Practice in Cases of Recto- Vaginal Tumors, 413 ; Emptying the Tumor, 413 ; Practices of Dubious Utility, 413 ; Recapitulation, 414.

SECTION LVII. On Plurality of Children

Division of the Signs of Plurality, 415 ; Indications during Gestation, 416 ; Indications during Parturition, 417 ; Indications before a Second Birth, 417 ; Circumstances liable to mislead, 418.

SECTION LVIII. Management of Labors with Twins

Detention of the Twin, 419 ; Delivery of the Twin, 419 ; Delivery of the Placenta, 420 ; Conclusion, 421.

SECTION LIX. On Lingering Parturition

Ordinary Symptoms of Parturition, 421 ; On Manual Interference, 421 ; Position of the Patient, 422 ; Injections into the Rectum, 422 ; Cordials and Stimulants, 423 ; Evacuation of the Liquor Amnii, 423 ; On Stimulating the Uterus, 424 ; Effects of the Secale Cornutum, 424 ; On Turning, and the Use of Instruments, 425 ; After-Treatment of the Patient, 426; Errors to be avoided, 427.

CONTENTS.

SECTION LX. Inversion of the Uterus

Symptoms attending Inversion, 427; Diagnosis, 427 ; Prognosis, 428.

SECTION LXI. Treatment of Inversion of the Uterus

Chronic Inversions not Returnable, 428 ; Immediately reduce a recent Inversion, 429 ; Removal of the Placenta, 430 ; Two modes of Treatment, 430 ; Necessary Cautions in the Reduction, 431 ; Removal by Force not advisable, 431 ; Means of promoting an easy Reduction, 431 ; Palliative Remedies, 432 ; Causes of Inversion, 432 ; Errors liable to be Committed, 433.

SECTION LXII. Rupture of the Uterus

Symptoms attending, 434 ; The Causes, 435 ; Rules for Management, 436 ; Treatment when Delivery is Impracticable, 437; Termination of these Cases, 438.

SECTION LXIII. Delivery after the Death of the Mother

Duration of the Foetal Life, 438 ; Modes of Removing the Child, 440.

SECTION LXIV. Extra- Uterine Pregnancy

Ventral Pregnancy, 440 ; Ovarian Pregnancy, 441 ; Tubular Pregnane/, 441 ; State of the Uterus in these Pregnancies, 442 ; Symptoms attending, 442 ; Prolongation of the Ordinary Period of Gestation, 443 ; Different Termination of these Cases, 443 ; Treatment of Extra- Uterine Pregnancy, 444.

SECTION LXV. Latter Gestation with Labor and Inflammation, §c

Inflammations in the End of Pregnancy, 445 ; Inflammations in conjunction with Delivery, 445 ; Fever in the End of Pregnancy, 446 ; Fever during Labors, 446.

SECTION I. After-management of the Puerperal State

Examination of the Perinaeum, 447 ; Protection of the Patient from Cold, 448 ; Compression of the Abdomen, 448 ; Exhibition of Cordials, 449 ; Necessity of the Recumbent Position, 450 *

State of the Patient, 450 ; Exhibition of an Anodyne, 451 ; Attention during the Earlier Weeks, 451 ; Ascertain whether there be any Incipient Disease, 451 ; Diet of the Patient, 453 ; Exhibition of Medicines, 453 ; Diet of the Infant, 454 ; Conclusion, 454.

SECTION II. On Puerperal Fever

Period of the attack, 455 ; Symptoms of the Fever, 455 ; Chills and Heats, 455 ; Abdominal Pains, 455 ; Frequency of the Pulse, 456 ; Symptoms of Minor Importance, 457 ; Duration of the Complaint, 458; Modes of Termination, 458.

SECTION III. The Treatment of Puerperal Fever

Venesection in the Early Stage, 459 ; On the propriety of a second Venesection, 460 ; On the propriety of a Third Venesection, 462 \ Remarks on Venesection, 462 ; Calomel and Opium, 463 ; Subordinate Remedies, 464.

Section IV

Various Measures proposed for the Treatment of Puerperal Fever. Tonic Remedies, 465 ; Emetics, 466 ; Mercury, 467 ; Turpentine, 467.

section v. Varieties of Puerperal Fever

First, or Mild Variety, 469 ; Second, or Malignant Variety, 470 ; Third, or Sporadic Variety, 471 ; Causes of the difference between the Varieties, 471.

SECTION VI. Concluding Observations on Puerperal Fever

Causes of the Fever, 472 ; Diagnosis, 473 ; Is the Disease Infectious ? 473 j," Post-mortem Appearances, 474 ; Nature of the Disease, 475 ; Conclusion, 476.

[ SECTION VII.

Of Hidrosis, or Hydrotic Fever.

Period of the Attack, 476 ; Symptoms, 476 ; Shuddering and Feeling of Coldness, 477 ; Sweats and Heats, 477 ; Changes of the Pulse, 477 ; Morbid State of the Nervous System, 477 ; Secretion of Milk usually disturbed, 478 ; Abdominal Pains, &c, 478 ; Appearances of the Blood, 478 ; Terminations of the Disease, 478 ; Seven Varieties, 479 ; Ultra-malignant Variety, 479 ; Malignant Variety, 479 ; Acute Variety, 480 ; Lingering, 480 ; Mutable Variety, 481 ; Fugacious Variety, 482 ; Seventh Variety, 482 ; Miscellaneous Observations, 483 ; Causes of Hidrosis, 483 ; Diagnosis of Hidrosis, 484 ; Prognosis of Hidrosis, 484 ; Morbid Appearances, 485. 3

SECTION XII. The Surgical Diseases of Infants

Intumescence of the Scalp, 495 ; Compressions of the Brain, 496 ; Disfigurement of the Face, 496 ; Injury to the Nerves, 496 ; Fractures of the Foetal Skeleton, 497 ; Cerebral and Parietal Tumors, 497; Cohesion of the Nymphae, &c, 498 ; Imperforation of the Genitals, 499 ; Restriction of the Tongue, 499 ; Defects of the Lower Extremities, 501 ; Umbilical Hernia or Exomphalos, 501 ; Dropsy of the Spinal Theca, 502 ; Imperforate (Esophagus, 503 ; Imperforate Anus, 504 ; Obstructed Passage of the Urine, 506 ; Purulent Ophthalmia, 507; Syphilis, 507.

SECTION XIII. The Medical Diseases of Infants

External Signs, 509 ; Causes, 510 ; Evacuations not naturally acescent, 510 ; Nervous Temperament, 511 ; Strophulus, or Gum-Rash, 511 ; Icterus Infantum, or Yellow Gum, 512; Flatulent Cholic, 512; Convulsions, 512 ; Serous Diarrhoea, 515 ; Aphtha Infantum, or Thrush, 515 ; Mesenteric Obstructions, 516 ; Conclusion, 516.

THE PRINCIPLES AND PRACTICE

OF

OBSTETRICY-

Part I. The Anatomy Of The Female System

DESCRIBING IN GENERAL OUTLINE THE STRUCTURE OF THE FEMALE SYSTEM, AS FAR AS IS CONNECTED WITH THE THEORY AND PRACTICE OF MIDWIFERY.

To the student it is of the utmost importance, in order that he may thoroughly understand the art and science of midwifery, that he should be well acquainted with the structure of the parts connected with the subject. I shall, therefore, first enter into a general account of the pelvis ; secondly, of the external organs of generation ; thirdly, of the internal organs ; fourthly, of the other pelvic viscera ; and, finally, close the anatomical department with a general outline of the soft parts which line the pelvis. These remarks, I would have you observe, will extend so far only as will be interesting to the accoucheur.

Section I

Of the Structure and Obstetric Properties of the Pelvis.

When the accoucheur gives his attention to the study of the pelvis, he soon discovers that there are two modes in which it can be advantageously examined. He may consider the different bones and joints and ligaments of which it is formed, and he may examine likewise the obstetric properties which belong to the bony case produced by the connection of its different parts.

Bones of the Pelvis.*

The pelvis is a considerable bony cavity, formed by the two ossa innominata, or side bones ; the sacrum, or that large bone which is fitted in behind ; and, in connection with the end of the sacrum, the os coccygis.

* Pelvis : — From pelvis, a basin ; because it is shaped like a basin used in former days.

We find in the young child and foetus, the bones of the pelvis more numerous than in the adult, being at least eight in number ; the os ilium, the ischium, the pubis, on either side, the sacrum, and the os coccygis ; but in the adult, although nominally this division exists, it is in reality wanting, the bones of the pelvis being in number four only.

Os coccygis : * — Is a small triangular bone, c, connected with the extremity of the sacrum, and from its liability to be pressed upon when the child's head is emerging, is not altogether without obstetric interest.

Though usually considered as consisting of one piece only, in reality we find that the os coccygis is made up of two or three, not unfrequently connected together by cartilage, so that the bon^ience acquires a certain degree of flexibility which may adapt it a little to the passage of the child.

It has been asked sometimes, why this bone, the os coccygis, has been given to the pelvis both in the male and female, or why it is connected with the sacrum by means of a movable joint ?t

In the female there is an obvious advantage derived from its mobility on the sacrum, for the bone of consequence receding when the child comes into the world, gives more room for its passage, as you will find hereafter ; but this cannot be the reason why this bone should be found in the male, though a pregnant male is not an impossible phenomenon. My own notion is, that the coccyx may properly be recorded as a tail -bone of our species.

Sacrum.% — The next of the bones of the pelvis to which I shall request your obstetric attention, is that which is fitted into the back of the pelvis, a large triangular bone, b, called the sacrum.

When we examine the sacrum, we find it to be a bone of considerable size, triangular in its shape, curved, the convexity of the bone being posteriorly, the concavity in front, the latter being frequently mentioned by the accoucheur under the name of the hollow of the sacrum. On the upper edge (the basis of the triangle) there is a projection in the middle, and it is this projection, which, in connection with the body of the last lumbar vertebra, forms what the accoucheur mentions so frequently under the name of the promontory of the sacrum. Besides the form of the bone, I wish you to notice the articulatory surfaces, those which unite it above with the last lumbar vertebra, that which connects it below with the os coccygis, and those, lastly, which unite it laterally with the ossa innominata.

Ossa innominata.^ — When, turning our attention from the sacrum and coccyx, we again examine the pelvis, we find that the principal bulk of it is formed by two very large bones, called the ossa innominata.

* Coccyx : — From kokkux, the cuckoo, the bill of which bird it is said to represent.

f It is denied by many that the coccyx has a movable joint ; Burns, Dewees, and Velpeau, assert that it is movable until a late period in life ; while Hamilton, Denman, and others, are of the contrary opinion. — Ed.

| Sacrum. — So called from sacer, sacred ; because it was formerly offered in sacrifices

§ Innominatum. — From in, without, and nomen, a name : so called because the three bones of which it originally was formed grew together, and formed one complete bone, which was then left nameless.

In the adult, the os irmominatum is made up of two pieces ; this the obstetrician should notice, the one forming the body, eih, the other the wing of the bone, dk; and those two pieces are connected or consolidated to each other in such a manner as to form a salient angle, or edge, which I shall frequently have to mention under the appellation of the brim of the pelvis, in. In the young child and the foetus, we find that the os innominatum is differently divided, consisting of three pieces, the os ilium, d,* the ischium, E,t and the pubis, f.J

There are a few more anatomical points, which it is necessary I should slightly mention. First, then, in the os innominatum, on either side, you must observe the large acetabulum, h,§ which, in conjunction with the head of the femur, forms the hip-joint; secondly, in the front of the pelvis, the large aperture, g, called the obturator foramen ;[| thirdly, the tuberosity of the ischium, u, or the part upon which we sit ; fourthly, the spinous process of the ischium, a pointed process of the bone projecting backwards and downwards a little ; and lastly, the hollow of the ilium, k.

It is also necessary I should mention the vernacular terms by which the bones of the pelvis are commonly called in our maternal tongue, because female practitioners, with whom you must occasionally meet, use them in preference to technical names. The bone on which we sit, the ischium, nurses very properly call the sitting bone ; the pubis the shear bone ; the os ilium the haunch bone; the sacrum the rump bone ; and the os coccygis, they call the huckle bone.