A compendious system of midwifery

Front matter

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Chapter I

Sect. I. Of the Pelvis .

II. Of the Sacrum ....

III. Of the Coccyx .

IV. Of the Ossa Innominata

V. Of the separation of the bones of the Pelvis VI. Of the deformity of the Pelvis .

VII. Examination of the Pelvis . .

PAGE

18 19 19 20 26 34

Of the Child's Head

CHAPTER VI. Of the Changes produced by Conception r . . 64

Sect. I. The Membranes . . . . . .68

II. The Placenta ...... 71

III. Foetal Circulation . . . . . .73

IV. Of the Changes which take place in the Uterus from Impreg-

CHAPTER XII. Of Labour

Sect. I. Of Rigours, &c. ....

II. Frequent inclinations to make water, Tenesmus, &c. III. Affections of the Uterine System, in particular

a. Subsiding of the Abdominal Tumour

b. Secretion of Mucus .....

c. Dilatation of the Os Uteri

a. Contraction of the Longitudinal Fibres

b. Contraction of the Circular Fibres

c. Of the Simple Contraction .

d. Of the Compound Contraction .

e. Of the Tonic Contraction and its Effects /. Of the Spasmodic or Alternate Contraction, and its Effects

CHAPTER XIV Conduct during Labour

Sect. I. What may be necessary for the Child II. Unassisted delivery of the Placenta

III. Of Putting to Bed .

IV. Of After-pains .

V. Regimen during the Month, &c.

VI. Of the Lochia .

Excessive Lochia VII. Attention necessary to the Child

a. Of washing the Child

b. The dressing of the Navel .

c. Purging of the Meconium, &c (/. Of the Retention of Urine

VIII. Of Food for the Child

CHAPTER XVI. Of the Presentations of the Head, and their Causes

1*

V

PAGE

89*

191,

VI

CONTENTS.

Sect. I. First Presentation, and its Mechanism

II. Character and Mechanism of the Second Position

III. Third Position

IV. : Fourth Position ■

V. Fifth Position

VI. , Sixth Position .

PAGE

193 195 195 195 199 200

Part II

Of Labours, in which the Child presents the Vertex, but rendered difficult, or preternatural ....

Chapter XVII

Causes of Preternatural Labours Sect. I. Of Flooding .

II. Of Convulsions

III. Of Syncopes

IV. Of Hernia .

V. Of Obliquity of the Uterus

VI. Of Partial Contractions of the Uterus VII. Of Compound Pregnancy VIII. Of Prolapsus of the Umbilical Cord, &c.

IX. Of too short a Cord X. Of the Bati Position of the Head, though the vertex may present ........

a. Of the Bad Position of the Vertex .

b. Of the Chin departing too early from- the Breast

c. Cases in which the Face presents

d. Presentations of the Head and Hand XI. Of Exhaustion .

XII. Of Hemorrhage from other parts than the Uterus .

CHAPTER XVIII. Rules for Conducting a Preternatural Labour

Sect. I. Position of the Woman for Turning

Chapter XIX

The Mode of Operating in each Presentation of the Head Sect. I. First Presentation ....

II. Second do. .....

III. Third do. . . ,

IV. Fourth and Fifth do. .

V. Sixth do.,

233 233 234 234 235 235

Part III

Where it is necessary to use Instruments which do no injury to Mother or Child

23:

CHAPTER XX. $£the Forceps

23.7

CONTENTS. VU

PAGE

Sect. I. General rules for the use of the Forceps . . . 239

a. Of those which regard the woman . . . 239

b. Of the Condition of the Uterus and Soft Parts . . 240

c. Application, and mode of Action of the Forceps . . 241

a. Of Compression ...... 250

b. Compression and Traction .... 252

d. Mode of Acting after Application .... 252 II. Recapitulation ...... 254

III. General Observations upon the Forceps . . . 255

CHAPTER XXL

Sect. I. a. Application in the First of these Positions . . . 258

II. b. Second .... 259

IV. d. Fourth .... 260

VII. g. Seventh . . ... .261

Chapter XXII

General remarks on the Use of the Forceps, when the head is above the

Superior Strait ....... 262

CHAPTER XXIII. Of the Locked or Impacted Head ..... 263

Sect. I. Of the Causes, Signs, and Accidents of the Locked Head . 264

II. Indications in the Locked Head .... 265

III. Method of using the Forceps in the Locked Head . . 266

Chapter XXIV

Of the use of the Forceps in Face Presentations . . . 267

CHAPTER XXV. Of Presentations of the Breech ..... 269

Sect. I. Species of Breech Presentations . . • . . 271

II. a. Mechanism of First Breech Presentations . . . 271

III. b. Second do. ... 272

IV. c. Third do. . . . 272

V. d. Fourth do. ... 272

Chapter XXVI

Causes which may render Presentations of the Breech Preternatural . 273

a. First degrees of advancement .... 274

Sect. I. Position of the Child ...... 278

II. Size of the Breech ..... 279

III. Mode of bringing down the Feet in the first Breech Presentations ....... 279

IV. Mode in Second Position of the Breech . . . 280 V. Third do 280

VI. Fourth do. i 281

Vlll CONTENTS.

PAGE

Chapter XXVII

On the use of the Forceps, when the body is delivered, and the head

Sect. I. Cases proper for the Forceps . . . . . 288

a. Mode of operating in First Case . . . 288

CHAPTER XXVIII. Of the Presentations of the Feet ..... 289

Sect. I. Species of Feet Presentations .... 290

II. Preternatural Labours when Feet present . . . 291

HI. Mode of Acting in the First and Second Presentations .. 292

IV. Third and Fourth do. . . 293

CHAPTER XXIX. Presentations of the Knees ...... 296

Sect. I. Causes which render Presentations of the Knees preternatural 297

II. Mode of Operating in Presentations of the Knees . . 298

CHAPTER XXX. Of Tedious Labour ........ 298

Sect. I. Of the Want of Contractile Force . . . . 300

II. Of Rigidity, &c. of the Soft Parts, as the cause of Tedious

and Preternatural Labour ..... 302

Of the Species of Rigidity of the Os Uteri . . 308 Rigidity of the first Kind . . .. . .308

2, . . . . .309

3, .... 309

III. Cicatrices, or other Imperfections arising from Local Injuries 311

Relative Rigidity . . . . . .317

IV. Tonic Rigidity; or Rigidity from the premature Escape of the

Sect. V. and VI. Over-distention of the Uterus, and the membranes too

dense, as a cause of Tedious Labour . . 319

CHAPTER XXXI. Hemorrhage from the situation of the Placenta over the mouth of the

Sect. I. Where the Uterus is but little opened, and is very rigid . 333

II. When but little opened, but disposed to dilate . . 335

III. Opened to some extent, but very unyielding . . 336

IV. Where opened to the same extent but soft, . . . 338 V. Where fully dilated ..... 338

A case of fatal Hemorrhage at the Seventh Month of Utero-gestation, from the Placenta being placed over the mouth of the Uterus, together with remarks upon it, and several other modes of treating Uterine Hemorrhage . . 348 VI. Causes of Uterine Inertia ..... 356 VII. Hemorrhage, before the Placenta is expelled . . 356 a. I. Where there is a partial separation, but the Uterus enjoying some tonic power . . . . . 357

CONTENTS. IX

PAGE

b. II. Where there is a partial separation, but the Uterus possess-

ing very little or no tonic power . . . 358

c. III. Where there is a partial saparation of the placenta, while

the remaining portion is too adherent, and the Uterus

contracts but feebly ..... 362

d. IV. Where every thing is as at III. except that the Uterus enjoys

its full power ...... 364

e. V. Where there is an entire or partial separation, but the Uterus

in a state of exhaustion or syncope . . . 365

/. VI. Where there is either a partial or complete separation of the

placenta, and where the body and fundus are in a state of

Inertia, while the neck enjoys its tonic powers . . 368

VIII. Flooding after the expulsion of the Placenta . . 370

IX. On the means for preventing Flooding . . . 371

CHAPTER XXXII. Of the Assisted delivery of the Placenta .... 375

Sect. I. Mode of acting in Retention from want of Tonic Power . 376

II. Retention from too firm adherence .... 376

a. Mode of acting in this Case .... 377

III. Of the Delivery of the Encysted Placenta . . . 379

a. Mode of operating in this Case . ... . 380

IV. On the enclosed and partially protruded Placenta . . 381

Mode of acting in each Case .... 382 V. Of the delivery of the Placenta, when the cord is broken, or is

very feeble ...... 383

a. The signs by which the Placenta may be detected , 384

b. Mode of acting in this case . . . 385

CHAPTER XXXVII. Of the Presentation of the Arm and Shoulder . . . 433

Sect. I. Of the Condition of the Uterus .... 438

II. Of the Situation of the Arm and Shoulder within the Pelvis 440

a. The Manner of Acting, if the Child be living . . 440

b. Of Spontaneous Evolution , 442

c. Mode of Acting, if the Child be dead . . . 444

CHAPTER XL. Deformity of the Pelvis

Sect. I. Of Turning in a Deformed Pelvis, as a means of saving the

Child's Life

II. Of the Forceps in a Deformed Pelvis

III. Of Cephalotomy ,

Observations, &c, on Eliaabeth Sherwood's Case, as related by Dr. Osbom

IV. Of the Caesarean Operation ....

a. Mode of Performing it

b. Treatment after the operation V. On Premature Delivery ....

VI. Section of the Pubes .....

VII. Regimen ......

PUBLISHERS ADVERTISEMENT.

Chapter XLII

Uncertainty of the Child's Death . . . .

CHAPTER XLIII. On the Secale Cornutum, or ergot ..... 529

PAGE

On Deliveries performed by Cutting Instruments, applied either to the the Child or Mother .;.... 469

470 472 475

The present Edition of this valuable work contains the revisions and additions of the author made by him a short time previously to his death.

Philadelphia, January, 1847.

INTRODUCTION.

It has often been declared, that labour, being a natural act, it did not require the interference of art for either its promotion, or its accomplishment ; and, consequently, that when this becomes necessary, it only forms an exception to the rule. This view of the subject has had many followers ; and has, from its influence, retarded more, perhaps, than any other circumstance, the progress of improvement in this most important branch of medical science. It so entirely comported with the theories of the fastidious admirers of nature ; it so completely coincided with the feelings of those, whose supineness made them averse from inquiry ; so effectually apologized for ignorance, and so plausibly extenuated the evils arising from neglect, or the want of the proper and judicious application of skill, as to secure in its favour by far the greater portion of the practitioners of Midwifery.

Errors in premises must almost necessarily lead to errors in deduction ; hence the too exclusive reliance on the powers of nature to overcome all the obstacles connected with parturition — hence the almost total disregard of the first, and most important principles in the art of midwifery ! These errors doubtless originated in ignorance ; and were perhaps at first excusable from this cause ; but how reprehensible do they become now, since the powers of nature are better calculated, and the resources of art better understood ! In what light, then, should we view writers, who still inculcate such doctrines — teachers who make the whole art of midwifery consist in doing nothing !

Were the constitutional powers of the system, the physical conformation of the pelvis, and the size of the child's head, always and undeviatingly the same ; were the most favourable presentation of the child, the best construction, and the most healthy play of the powers concerned in this operation, never to be 'assailed by accident, or complicated by disease — the opinions of those who contend

XiU INTRODUCTION.

for the supremacy of unassisted nature would deserve much, and perhaps exclusive attention. But it is too well known, that this never has nor never can be the case ; for the powers of nature must necessarily have their limits, and consequently the interference of art becomes sometimes absolutely necessary.

I am very far from wishing to be understood, as advocating the indiscriminate interference of art during the progress of a healthy labour — it is the very reverse of my. opinion, and of my practice ; I wish merely to insist that nature is not competent to all exigencies. For in very many instances, when permitted to proceed without interruption, and is eventually able to effect her object, the sufferings of the patient, most probably, might have been very much abridged by the judicious interposition of skill. Of this, from long experience, I am entirely convinced.

If this be true in the most healthy or practicable labour, how much more important does the judicious and timely application of adventitious aid become, when it is well known, that the deviations from healthy power and structure, are almost constant in their occurrence, and almost infinite in their variety. It is the knowledge of these aberrations, and the mode of obviating them when necessary, that emphatically declare midwifery to be a science — for it has, and must have, its principles ; principles, that must not only be known in the abstract, but constantly employed; and it is the happy application of these fundamental rules, that makes one practitioner superior to another.

I trust my last assertion will not be considered gratuitous ; for if there be a difference in the skill of the practitioners, w T hich most certainly there is, it can only arise from a more perfect acquaintance with the rules which should govern, the extent of experience, and the justness of deduction. But does not this declare there is something more to be learnt, than the bare exercise of patience ? What practitioner has ever been eminently successful, who has neglected the first principles of the art ? He may be extensively employed, and tolerably lucky, (for it is nothing more,) without a correct notion of either the structure of the pelvis, the mechanism of labour, or the powers of the uterus; but will he be qualified to act where the first is faulty ; the second obstructed ; or the third impaired ? will he not, in most instances where either of these conditions obtain, wait in vain for all-sufficient exertions of nature ?

Experience, however necessary and important, is not alone suffi-

INTRODUCTION. Xlll

cient: a correct foundation must be laid, by the study of first principles ; and with even these, the progress must be slow ; since variety in labour is so multiplied. It is only by a happy and well-balanced generalization, that the practitioner can arrive at principles ; and it is but by judiciously acting upon these, that he can be extensively useful. I may safely appeal to the candour of almost any practitioner, whether he has not admitted to himself, that had he been better acquainted with principles at a previous period of practice, he could have procured, in certain cases of labour, either a speedier termination of it, or a more fortunate issue — I am sure he will answer in the affirmative.

Too much importance can easily be attached to experience alone ; for though I consider it a sine qua non to the successful exercise of the profession, yet it becomes only decidedly useful in difficult cases, when it is based upon the fundamental principles of obstetrics. Without an acquaintance with these, every practitioner must act empirically ; and this to the too frequent destruction of human life. If he be ignorant of all that is essential to be known ©f the well-formed and diseased pelvis ; or unacquainted with the various ways the head may pass through it, he will be totally incompetent to act,, when there is any material deviation from the healthy economy of labour. On the one hand, he may rashly suppose, there is no alternative but in the use of the crotchet, where a little address might have immediately relieved the patient by rectifying the error in presenta-* tion ; and on the other, he may negligently and reprehensibly wait for the successful operation of nature, until the patient expire.

In making an estimate of the value of experience alone, I must admit that many pursue the safer plan in submitting the case to nature ; for I confess that in many cases of desperate appearances, he successfully overcomes the dangers. that menace her; but this is. only submitting to a choice of evils : while the well-instructed practitioner would triumph over them by his skill, and spare nature this hazardous conflict. That in many instances we should be only the silent observers of nature, is unhesitatingly acknowledged ; but I must insist, and I am persuaded I shall be supported by every well-instructed accoucheur, that it requires no less judgment to determine when we should be so, than when it is proper to offer assistance, or to take the business entirely out of her hands.

But the decisions of ignorance do not always result in an entire reliance upon the poweri of nature ; they sometimes, and this but 2 I

XIV INTRODUCTION.

too frequently, end in the contrary extreme — in these cases, there is, on the part of the practitioner, an overweening desire to aid her efforts ; and his ill-directed endeavours but too soon eventuate in a destructive subversion of her powers. To this we must attribute the very many instances of injury that take place in the hands of the ill-instructed. Who has not witnessed a labour, which, had it been let alone, would have been but an ordinary one, as regards duration or severity, converted into one of great hazard, and protracted duration ? Can such mischievous ignorance be too severely reprehended, or could it be too severely punished ? What has he not to answer for, who shall permit a fellow creature to die, w T hen a little address or knowledge might have saved her ; or, what is perhaps still worse, who shall absolutely destroy her, by ill-judged and rude manoeuvres, under the spacious pretence of relieving her, when the case should have been trusted to the powers of nature alone. A self-sufficient practitioner informed me he thought that he had made a great improvement in those cases of delayed labour, where the child's head frequently advanced and receded from the outlet of the pelvis, owing, as he asserted, to the coccyx losing its faculty of receding upon the impulses of the uterus, by introducing two fingers into the rectum over the point of the bone, and pulling it back, and thus destroying its connexion with the point of the sacrum. He said he gained much room from this procedure. He did not take into consideration the immense amount of suffering he created, and other extreme unpleasant consequences. The patient was obliged ever after to use a pierced chair.

Besides, the peculiar situation of our country, imposes a necessity upon every medical student, to become well acquainted with the theory of midwifery ; for every one almost must practice it, if he pursue the object for which he is educated. A change of manners within a few years has resulted in the almost exclusive employment of the male practitioner. This was mainly effected by a conviction, that the well instructed physician is better calculated to avert danger, and surmount difficulties, than the ignorant pretender : but how ill is this confidence repaid ! a confidence which costs the female so severe a struggle ! Should they submit their welfare, nay their lives, to the ill-instructed practitioner, what security have they that they shall escape, without having entailed on them a permanent derangement of organ, or the perpetuation of a harrassing and loathsome disease ?

INTRODUCTION. XV

In whatever point of view we regard this subject, it must be highly interesting to the philosopher, and the philanthropist ; shall it be less so, then, to the physician who should be both, and who is more immediately concerned in its influence ? Shall it be a matter of indifference to him, who has almost the control of the future comfort and happiness of, perhaps, an extensive population, and who shall become, as it were, the arbiter of the lives of thousands ? A man of very loose morality shudders at the idea of a single murder ; yet an ignorant practitioner of midwifery, may feel no " compunctious visitations of conscience" for a hundred, committed professionally, from ignorance.

I hope to be credited when I declare, that the present work was not undertaken, without due deliberation upon the responsibility attached to such an enterprize : and that my aim most honestly was to be useful — I have endeavoured to make my experience available to the interests of humanity ; and should I even fail to instruct, I feel a confidence, I shall not dangerously mislead.

I have ventured to depart from common usage, in treating of the various objects belonging to my subject ; but it is the method I have pursued for more than thirty years in teaching ; and to me it appears the most natural. That is, to bring under one view all that may belong to any particular labour, or class of labours — whether natural, and to be trusted to the powers concerned in the operation ; or complicated, and requiring a departure from this rule ; or when essentially bad. I make all the modes of treating it under the various circumstances which may affect it, follow each other without interruption.

Generally speaking, I have followed Baudelocque's distribution of subjects, but not rigorously ; and to him I hold myself indebted for nearly all I know ; or, at least, his masterly manner of treating every thing connected with this branch of medicine, has enabled me to comprehend at once, the seeming intricacies of obstetrics, and to profit by bed-side experience. I, therefore, cannot too earnestly recommend the study of his works to such practitioners, as well as the student of midwifery, who rnay not have profited already by his genius, and his long and well-tried experience.

I occasionally, in the course of the present work differ from this great man; but when I do, it is doubtingly ; and only when a careful examination of my own experience has produced a conviction that it is correct so to do ; accompanied, however, at the same time, by a regret, that I am forced to the alternative.

XVI INTRODUCTION.

I have added Plates, to represent the different positions of the head, that no embarrassment might follow from mere description. These, I hope, will prove as acceptable, as I am persuaded they will be useful.

I have materially altered the arrangement of the present edition, by removing from it all the Chapters which related to the diseases of women and children. My motive for this will be obvious, w T hen it is recollected, I have written separate treatises on both these subjects, since the first publication of this system.

I have also added several very important Chapters on subjects strictly obstetrical ; together with several new plates, illustrative of the topics to which they have reference. In a word, I have attempted to make this present edition deserving of the high patronage this work continues to receive.

COMPENDIOUS SYSTEM

OF

MIDWIFERY,

Section I. — Of tlte Pelvis

1. The complete knowledge of the pelvis, as well in its healthy as in its diseased state, is essentially necessary to the successful practice of midwifery. Had more attention been paid to acquiring an acquaintance with its natural, and its deranged dimensions, by those who profess to practice this important branch of medicine, we should have had fewer instances of gross errors in practice, and, of course fewer victims. Without understanding the pelvis well, it is impossible that any one can safely give assistance where either the operation of turning, or the application of the forceps, is required to terminate the labour ; nor can the mechanisms of the various presentation's be understood in their most simple forms, without a thorough knowledge of it. We hope, then, we shall be excused when we say, that no man should be trusted to practice obstetrics, who is ignorant of this important assemblage of bones.

2. The pelvis is that structure which is situated below the last lumbar vertebra, with which it is by one of its surfaces articulated ; and above the superior extremities of the thigh bones, with w T hich it is connected, by means of the acetabula. It is composed, properly, but of four bones in the adult, state viz., on its posterior and inferior part, by the sacrum and coccyx ; and on the lateral inferior and anterior parts, by the ossa innominata. But in treating of this structure, it is useful and proper to consider its constituent parts, as each is composed of several others to which appropriate divisions and names have been given ; we shall, therefore, pursue this plan, as it has both propriety and utility to recommend it; and, first, of

18 THE SACRUM.

Sect. II. — The Sacrum.

3. This bone has sometimes been called the false vertebra, because it is a kind of continuation of the true ; and because, in the foetal state, it may be divided into five portions. The union of these five pieces can readily be detected in adult age, by four transverse seams.* Its general figure is triangular or pyramidal ; the base of which is upwards, and is connected to the last lumbar vertebra, by a cartilaginous intervention. The apex of the triangle or pyramid is below, and has the coccyx united to its extremity by means of cartilage. It may be divided into four surfaces; namely, an anterior, posterior, and two lateral surfaces : its anterior surface is smooth and concave ; while its posterior is very rough and convex ; its anterior face is smooth, that no obstacles may be offered, or abrasions take place, by the passage of the child's head through the cavity of the pelvis ; its posterior is studded with processes or eminences, to give greater security and surface to the various muscles that originate, and that are inserted into it ; as, also, to afford greater firmness of connexion to the many ligaments which aid in its union with the ossa innominata. Its lateral surfaces are rough or -scabrous ; and are covered in the recent subject with cartilage, by means of which they are united to corresponding surfaces, offered by the ilia. This bone is pierced on each side by four holes, which transmit the sacral nerves. There is also on its posterior portion, a canal, along which the spinal marrow is continued.

4. The manner in which the sacrum is set into the ossa innominata, is well calculated to give firmness and security to its position ; as it acts, in some measure, as a keystone does to an arch ; this arises from two peculiarities of form ; the anterior part of this bone is broader than the posterior ; consequently, enters like a wedge between the ossa innominata ; this enables it to sustain, without injury any force that may operate from within, outwards : the superior portion is also broader than the inferior ; and, of course is placed precisely analogous to the key stone of an arch, by which it is enabled to support the superincumbent weight of the body, &c, without yielding. We cannot fail to remark, how admirably this arrangement gives stability to the whole of the pelvic circle.

5. The union of the last lumbar vertebra with the base of the sacrum T is permitted to take place in such a manner as to look over, and into, the superior opening of the pelvis, so as to form a promon-

* Velpeau speaks doubtingly of the number of pieces and lines in which the sacrum may be divided — why, we are at a loss to understand, as our impression is, that nature is uniform in this respect. He says, a sa face (the sacrum) antereure, plus ou moins concave, offre, au milieu quotre ou cinq fadeites quadrdngidaries et aittant de lignes transversales" p. 3. Baudelocque makes but four lines, as it requires five pieces to give four lines when united. He makes but four holes for the transmission of the sacral nerves, whereas Velpeau makes five. It is true, that the upper portion of the coccyx unites with the inferior portion of the sacrum, and thus forms an additional hole. In general, however, this is merely a notch in each of these bones, forming thus an imperfect foramen, for the transmission of the fifth nerve of the sacrum ; but this hole is not proper to (he sacrum.

COCCYX. 19

tory ; and hence it is called the projection or promontory of the sacrum.

6. The length of this bone is usually from four inches, to four and a half ; its breadth is about four inches. Its thickness, if measured from the middle of its base anteriorly, to the extremity of the superior spinous tubercle on its posterior face, is very constantly two inches and a half; and we are informed by Baudelocque, (System, page 18, par. 35.) that this measurement is so constant, that he did not find it vary a line in between thirty and forty pelves, the greater part of which were deformed. The concave form of this bone gives a hollo wness to a greater part of its length; the depth of this, in a well formed bone, is about three-quarters of an inch.

Sect. III. — The Coccyx.

7. This appendage to the sacrum is also of a pyramidical form, and is about and inch and a quarter in length ; like the sacrum itself, it resembles an inverted pyramid ; its base being united with this bone by intervening cartilage ; it is formed of three bony portions, whose connexion with each other is readily observed by the transverse ridges which their union forms. Its connexion is such as to permit of a regressive motion ; especially in the earlier parts of life. Lateral motion is prevented by the insertion into the sides of this bone, of the coccygael muscles ; of parts of the lavatores ani ; and portions of the sacro-sciatic ligaments.