A treatise on the science and practice of midwifery

Front matter

aft

Qass.

Book

Preface To The Ninth English Edition

In the last edition of this work, published in 1893, many changes were made to enable it to keep pace with the rapid advance of Obstetric Science. The exhaustion of the large edition then printed calls for a new one. dj

Twenty-two years have now elapsed since the first edition was published. The author has endeavored to celebrate the fact of his ♦vork having attained its majority by a very thorough revision of text, many parts of which have been completely re- written. wo new plates and seventeen woodcuts have been added, while jveral illustrations which seemed obsolete or unsatisfactory have jeen suppressed. He thus hopes to secure for his book the same favorable reception in the future that has been extended to it in the past, for which he is very grateful. He has specially to acknowledge his obligation to Dr. T. "W. Eden. That gentleman's well-known work in connection with Placental Anatomy and cognate subjects tempted the author to ask him to be good enough to revise the chapter on " Conception and Generation." This he has done so thoroughly as practically to amount to re-writing of the chapter, much, the author feels sure, to the benefit of his readers. His thanks are also due to his colleague, Prof. Crookshank, for permission to use several illustrations from his beautiful work on Bacteriology, and to his cousin, Dr. Hugh Playfair, for much valuable assistance in revision of the proofs.

38 Grosvenor St . , W.

May, 1898.

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Author's Preface To The First Edition

Those who have studied the progress of Midwifery know that there is no department of medicine in which more has been done of late years, and none in which modern views of practice differ more widely from those prevalent only a short time ago. The Author's object has been to place in the hands of his readers an epitome of the science and practice of midwifery which embodies all recent advances. He is aware that on certain important points he has recommended practice which not long ago would have been considered heterodox in the extreme, and which, even now, will not meet with general approval, He has, however, the satisfaction of knowing that he has only done so after very deliberate reflection, and with the profound conviction that such changes are right, and that they will stand the test of experience. He has endeavored to dwell especially on the practical part of the subject, so as to make the work a useful guide in this most anxious and most responsible branch of the profession. It is admitted by all, that emergencies and difficulties arise more often in this than in any other branch of practice ; and there is no part of the practitioner's work which requires more thorough knowledge or greater experience. It is, moreover, a lamentable fact that students generally leave their schools more ignorant of obstetrics than of any other subject. So long as the absurd regulations exist which oblige the lecturer on midwifery to attempt the impossible task of teaching obstetrics in a short three months' course — an absurdity which has over and over again been pointed out — such must of necessity be the case. This must be the Author's excuse for dwelling on many topics at greater length than some will doubtless think their importance merits, since he desires to place in the hands of his students a work which may in some measure supply the inevitable defects of his lectures.

vi author's preface to first edition.

Man}' of the illustrations are copied from previous authors, while some are original. The following quotation from the preface to Tyler Smith's Manual of Obstetrics will explain why the source of the copied woodcuts has not been in each instance acknowledged : "When I began to publish, I determined to give the authority for every woodcut copied from other works. I soon found, however, that obstetric authors of all countries, from the time of Mauriceau downward, had copied each other so freely without acknowledgment as to render it difficult or impossible to trace the originals."

The Author has to express his acknowledgments to many friends for their kind assistance by the loan of illustrations and otherwise, and more especially to his colleague, Dr. Hayes, for his valuable aid in passing the work through the press.

March, 1876.

Chapter I. Anatomy Of The Pelvis

PAGE

Its importance — Formation of pelvis — The os innominatum ; its three divisions —Separation between the true and false pelvis — The sacrum and coccyx — Mechanical relations of the sacrum — Pelvic articulations and ligaments — Movements of the pelvic joints — The pelvis as a whole — Differences in the two sexes — Measurements of the pelvis — Its diameters, planes, and axes — Development of the pelvis — Pelvis in different races — Soft parts in connection with the pelvis . 33

Chapter II. The Female Generative Organs

Division according to function : 1. External or copulative ; 2. Internal or formative organs — Mons veneris — Labia majora and minora — The clitoris — The vestibule and orifice of urethra — Passing of the female catheter — Orifice of vagina — The hymen — Carunculse myrtiformes — The glands of the vulva — The perineum — The vagina — Bacteriology of the genital tract — The uterus: its position and anatomy — The ligaments of the uterus — The parovarium — The Fallopian tubes — The ovaries — The Graafian follicles and the ova — The mammary glands . . . . . . . ■ . .49

Chapter III. Ovulation And Menstruation

Functions of the ovary — Changes in the Graafian follicle : 1. Maturation ; 2. Escape of the ovum — Formation of the corpus luteum — Quality and source of the menstrual blood — Theory of menstruation— Purpose of the menstrual loss — Vicarious menstruation —Cessation of menstruation .... 83

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Vlll CONTENTS.

PAKT II.

PREGNANCY.

Chapter I. Conception And Generation

PAGE

Impregnation, fertilization, and development — The semen— Transit of spermatozoa — The ovum, penetration of spermatozoon, segmentation of the ovum — The muriform body — The blastoderm — The medullary groove— The amnion and the chorion — The allantois — Changes in the endometrium — The decidua — The chorion villi — Nutrition of the early ovum — The early placenta — Establishment of maternal circulation — Functions of the placenta — The chorion lseve — The amnion — The umbilical cord — The placenta at term 97

Chapter II. The Anatomy And Physiology Of The Foetus

Appearance of the foetus at various stages of development — Anatomy of the foetal head — The sutures and fontanelles — Influence of sex and race on the foetal head — Position of the foetus in utero — Functions of the foetus — The foetal circulation . 124

Chapter III. Pregnancy

Changes in the form and dimensions of the uterus — Changes in the cervix — Changes in the texture of the uterine tissues, the peritoneal, muscular, and mucous coats — General modifications in the body produced by pregnancy ... 139

Chapter IV. Signs And Symptoms Of Pregnancy

Signs of a fruitful conception — Cessation of menstruation — Sympathetic disturbances—Morning sickness, etc. — Mammary changes — Enlargement of the abdomen — Quickening — Intermittent uterine contractions — Vaginal signs of pregnancy — Ballottement, etc. — Auscultatory signs of pregnancy Foetal pulsations — Uterine souffle, etc 151

Chapter V

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY— SPURIOUS PREGNANCY — THE DURATION OF PREGNANCY — SIGNS OF RECENT PREGNANCY.

Adipose enlargement of the abdomen — Distention of the uterus by retained menses, etc. — Congestive enlargement of the uterus — Ascites — Uterine and ovarian tumors— Spurious pregnancy ; its causes, symptoms, and diagnosis —The duration of pregnancy— Sources of fallacy— Methods of predicting date of delivery — Protraction of pregnancy— Signs of recent delivery 165

CONTENTS. IX

CHAPTEE VI.

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER-FCETATION,

EXTRA-UTERINE FOETATION, AND MISSED LABOR.

PAGE

Plural births ; their frequency, relative frequency in different countries, causes, etc. — Super-foetation and super-fecundation — Nature — Explanation — Objections to admission of such cases — Their possibility admitted — Extra-uterine pregnancy— Classification — Causes— Tubal pregnancies — Changes in the Fallopian tubes — Condition of uterus — Progress and termination — Diagnosis — Treatment — Abdominal pregnancy ; description, diagnosis, treatment — Missed labor ; its symptoms, causes and treatment . . . 174

Chapter VII. Diseases Of Pregnancy

Some only sympathetic, others mechanical or complex in their origin — Derangement of the digestive organs; excessive nausea and vomiting, diarrhoea, constipation, hemorrhoids, ptyalism, dyspnoea, etc. — Palpitation — Syncope — Anaemia and chlorosis — Albuminuria 203

Chapter VIII

diseases of pregnancy (continued).

Disorders of the nervous system ; insomnia, headaches, and neuralgia, paralysis — Chorea ; tetanus and tetany ; disorders of the urinary organs ; retention of urine ; irritability of the bladder, incontinence of urine, phosphatic deposits — Leucorrhoea — Effects of pressure — Laceration of veins — Displacements of the gravid uterus ; prolapse, anteversion, retroversion — Diseases co-existing with pregnancy ; eruptive fevers, smallpox, measles, scarlet fever, continued fever, phthisis, cardiac disease, syphilis, icterus, mollitis ossium carcinoma — Pregnancy complicated with ovarian and fibroid tumors 216

Chapter IX. Pathology Of The Decidua And Ovum

Pathology of the decidua — Hydrorrhoea gravidarum — Pathology of the chorion ; vesicular degeneration, myxoma fibrosum — Deciduoma malignum — Pathology of the placenta ; blood extravasations, fatty degeneration, etc. — Pathology of the umbilical cord — Pathology of the amnion, hydramnios, deficiency of liquor amnii, etc. — Pathology of the foetus; blood diseases transmitted through the mother, smallpox, measles and scarlet fever, intermittent fevers, lead poisoning, syphilis— Inflammatory diseases — Dropsies — Tumors — Wounds and injuries of the foetus — Intra-uterine amputations — Maternal impressions — Death of the foetus 234

Chapter X. Abortion And Premature Labor

Importance and frequency — Definition and classification — Frequency — Recurrence — Causes — Causes referable to foetus — Changes in a dead ovum retained in utero — Extravasations of blood— Moles, etc. — Causes depending on maternal state, syphilis — Causes acting through nervous system, physical

CONTENTS

PAGE causes, etc. — Causes depending on morbid states of uterus— Symptoms — Preventive treatment — Prophylactic treatment — Treatment when abortion is inevitable— Detention in utero of a blighted ovum — Spurious abortion — After-treatment 255

Chapter I. The Phenomena Of Labor

Causes of labor — Mode in which the expulsion of the child is effected — The uterine contraction — Mode in which the dilatation of the cervix is effected — Rupture of the membranes — Character and source of pains during labor — Effect of pains on mother and foetus — Division of labor into stages — Preparatory stage — False pains — First stage — Second stage — Third stage — Mode in which the placenta is expelled — Duration of labor . . . 268

Chapter II. Mechanism Of Delivery In Head Presentations

Importance of subject — Frequency of head presentations — The different positions of the head — First position — Division of mechanical movements into stages— Flexion — Descent and levelling movement — Rotation — Extension — External rotation — Second position — Third position — Fourth position — Caput succedaneum — Alteration in shape of head from moulding . . 282

Chapter III. Management Of Natural Labor

Preparatory treatment — Dress of patient during pregnancy — The obstetric bag — Duties on first visiting patient — Antiseptic precautions— False pains — Their character and treatment — Vaginal examination — The position of patient — Artificial rupture of membranes — Treatment of propulsive stage — Relaxation of the perineum — Treatment of lacerations — Expulsion of child — Promotion of uterine contraction — Ligature of the cord — Management of the third stage of labor — Application of the binder — After-treatment 295

Chapter IV. Anaesthesia In Labor

Agents employed — Chloral : its object and mode of administration — Ether, chloroform, A.C.E. mixture; their use, objections to, and mode of administration 312

CONTENTS. XI

Chapter V. Pelvic Presentations

PAGE

Frequency — Causes — Prognosis to mother and child — Diagnosis by abdominal palpation and by vaginal examination — Differential diagnosis of breech, knee, and feet — Mechanism — Treatment — Management of impacted breech presentations ............ 315

Chapter VI. Presentations Of The Face

Erroneous views formerly held on the subject— Frequency — Mode of production — Diagnosis — Mechanism — Four positions of the face — Description of delivery in first face position — Mento-posterior position in which rotation does not take place — Prognosis — Treatment— Brow presentation . . 327

CHAPTER VH.

DIFFICULT OCCIPITO-POSTERIOR POSITIONS.

Causes of face to pubes delivery — Mode of treatment — Upward pressure on forehead — Downward traction on occiput — Manual rectification of — Use of forceps — Peculiarities of forceps delivery 337

Chapter VIII

PRESENTATIONS OF SHOULDER, ARM, OR TRUNK — COMPLEX PRESENTATIONS — PROLAPSE OF THE FUNIS.

Position of the foetus — Division into dorso-anterior and dorso-posterior position — Causes — Prognosis and frequency — Diagnosis — Mode of distinguishing position of child — Differential diagnosis of shoulder, elbow, and hand — Mechanism — The two possible modes of delivery by the natural powers — Spontaneous version — Spontaneous evolution — Treatment — Complex presentation ; foot or hand with head, hand and feet together — Dorsal displacement of the arm — Prolapse of the umbilical cord — Frequency — Prognosis — Causes — Diagnosis — Postural treatment — Artificial reposition — Treatment when reposition fails ........ 340

Chapter IX. Prolonged And Precipitate Labors

Evil effects of prolonged labor — Influence of the stage of labor in protraction — Delay in the first stage rarely serious — Temporary cessation of pains — Symptoms of protraction in the second stage — State of the uterus in protracted labor — Cases of protraction due to morbid condition of the expulsive powers — Causes of protraction — Treatment — Oxytocic remedies — Ergot of rye, etc. — Manual pressure — Instrumental delivery (case of Princess Charlotte of Wales) — Precipitate labor: its causes and treatment 354

Xll CONTENTS.

Chapter X. Labor Obstructed By Faulty Condition Of The Soft Parts

PAGE

Rigidity of the cervix : its causes, effects, and treatment — Antepartum hour-glass contraction — Bands and cicatrices in the vagina — Extreme rigidity of the perineum — Labor complicated with tumor — Vaginal cystocele — Calculus — Hernial protrusions — (Edema of vulva — Haematic effusions, etc. 370

Chapter XI. Difficult Labor Depending On Some Unusual Condition Of The Fcetus

Plural births, treatment of — Locked twins — Conjoined twins — Intra-uterine hydrocephalus: its dangers, diagnosis, and treatment — Other dropsical effusions — Foetal tumors —Excessive development of foetus — Shortness of the umbilical cord 383

Chapter XII. Deformities Of The Pelvis

Classification — Causes of pelvic deformity — Rickets and osteomalacia — The equally enlarged pelvis — The equally contracted pelvis — The undeveloped pelvis — Masculine or funnel-shaped pelvis — Contraction of conjugate diameter of the brim — Scolio-rhachitic pelvis — Figure-of-eight deformity — Spondylolithesis — Spondylolizema — Narrowing of the oblique diameters — Obliquely contracted pelvis — Kyphotic pelvis— Robert's pelvis — Deformity from old-standing hip-joint disease— Deformity from tumors, fractures, etc. Effects of contracted pelvis on labor — Risks to the mother and child — Mechanism of delivery in head presentation : a, in contracted brim ; b, in generally contracted pelvis — Diagnosis — External measurements — Internal measurements — Mode of estimating the conjugate diameter of the brim — — Mode of diagnosing the oblique pelvis — Treatment — The forceps — Turning — Craniotomy — The induction of premature labor — Induction of abortion ............. 396

Chapter XIII. Hemorrhage Before Delivery: Placenta Previa

Definition— Causes — Symptoms —Sources and causes of hemorrhage — Prognosis

—Treatment 420

Chapter XIV. Hemorrhage From Separation Of A Normally-situated Placenta

Causes and pathology — Symptoms and diagnosis —Prognosis — Treatment . 431

Chapter XV. Hemorrhage After Delivery

Its frequency — Generally a preventible accident — Causes — Nature's method of controlling hemorrhage — Uterine contraction — Thrombosis — Secondary

CONTENTS. XU1 causes of hemorrhage— Irregular uterine contraction — Placental adhesions Constitutional predisposition to flooding — Symptoms — Preventive treatment — Curative treatment — Secondary treatment — Secondary post-partum hemorrhage : its causes and treatment 434

Chapter XVI. Rupture Of The Uterus, Etc

Its fatality — Seat of rupture — Causes, predisposing and exciting — Symptoms — Prognosis — Treatment : when the foetus remains in utero ; when the foetus has escaped from the uterus — Lacerations of the cervix — Recapitulation — Lacerations of the vagina — Vesico- and recto-vaginal fistula? — Their mode of formation — Treatment . . 452

Chapter XVII. Inversion Of The Uterus

Division into acute and chronic forms — Description — Symptoms — Diagnosis —

Mode of production — Treatment ........ 462

Chapter I. Induction Of Premature Labor

History — Objects — May be performed either on account of the mother or child Modes of inducing labor — Puncture of membranes — Administration of oxytocics — Means acting indirectly on the uterus — Dilatation of cervix — Separation of membranes — Vaginal and uterine douches — Injection of glycerin — Introduction of flexible catheter— Rearing of the child . . 468

Chapter II. Turning

History — Turning by external manipulation — Object and nature of the operation — Cases suitable for the operation — Statistics and dangers — Method of performance — Cephalic version — Method of performance — Podalic version — Position of patient — Administration of anaesthetics — Period when the operation should be undertaken — Choice of hand to be used — Turning by bipolar method — Turning when the hand is introduced into the uterus — Turning in abdomino-anterior positions — Difficult cases of arm presentation ........... 478

XIV CONTEXTS.

Chapter III. The Forceps

PAGE

Frequent use of the forceps in modern practice — Description of the instrument — The short forceps — Its varieties— The long forceps — Suitable to all cases alike — Action of the instrument — Its power as a tractor, lever, and compressor — Preliminary considerations before operation— Use of anaesthetics — Description of the operation— Low forceps operation — High forceps operation — Possible dangers of forceps delivery — Possible risks to the child 493

Chapter IV. The Vectis — The Fillet

Nature of the vectis — Its use as a lever or tractor — Cases in which it is applicable — Its use as a rectifier of malpositions — The fillet — Nature of the instrument — Objection to its use ........ 509

Chapter V. Operations Involving Destruction Of The Fcetus

Their antiquity and history — Division of subject — Nature of instruments employed — Perforator — Crotchet — Craniotomy forceps — Cephalotribe — Forceps saw — Ecraseur — Basilyst — Cases requiring craniotomy — Method of perforation — Extraction of the head — Comparative merits of cephalotripsy and craniotomy — Extraction by the craniotomy forceps — Extraction of the body — Embryotomy — Decapitation and evisceration 511

CHAPTER VI. THE CESAREAN SECTION — PORRO's OPERATION

History of the operation — Statistics — Results to mother and child — Causes requiring the operation — Post-mortem Cesarean section — Causes of death after the Csesarean section — Preliminary preparations — Description of the operation — Subsequent management — Porro's operation — Substitutes for the Csesarean section 526

Chapter VII. Laparo-elytrotomy And Symphyseotomy

History — Nature of the operation — Advantages over the Cesarean section — Outline of the operation — Symphysiotomy — History — Limits of the operation—Dangers of the operation — Method of performance — Subsequent results 539

Chapter VIII. The Transfusion Of Blood

History — Nature and object of the operation— Use of blood taken from the lower animals — Difficulties from coagulation of fibrin— Modes of obviating

CONTENTS. XV

PAGE them — Immediate transfusion — Addition of chemical agents to prevent coagulation — Defibrination of the blood — Injection of saline solutions — Statistical results — Possible dangers of the operation— Cases suitable for transfusion — Description of the operation — Schafer's directions for immediate transfusion — Effects of successful transfusion — Secondary effects of transfusion .........:.. 546

Chapter I. The Puerperal State And Its Management

Importance of studying the puerperal state — The mortality of childbirth — Alterations in the blood after delivery — Condition after delivery — Nervous shock — Fall of the pulse — The secretions and excretions— Secretion of milk — Changes in the uterus after delivery — The lochia — The after-pains — Management of women after delivery — Treatment of severe after-pains — Diet and regimen ........... 557

Chapter II. Management Of The Infant, Lactation, Etc

Commencement of respiration after the birth of the child — Apparent death of the newborn child — Its treatment — Washing and dressing the child — Application of the child to the breast— The colostrum and its properties — Secretion of milk — Importance of nursing — Selection of a wet-nurse — Management of lactation — Diet and regimen of nursing women — Period of weaning— Disorders of lactation — Means of arresting the secretion of milk Defective secretion of milk — Depressed nipples— Fissures and excoriations of the nipples — Excessive flow of milk — Mammary abscess — Hand-feeding Causes of mortality in hand-feeding — Various kinds of milk — Method of hand-feeding — Sterilization of milk— Other kinds of food . . . 568

Chapter III. Puekperal Eclampsia

Its doubtful etiology — Premonitory symptoms — Symptoms of the attack — Condition between the attacks — Relation of the attacks to labor — Results to mother and child — Pathology — Treatment — Obstetric management . . 585

Chapter IV. Puerperal Insanity

Classification — Proportion of various forms — Insanity of pregnancy — Predisposing causes — Period of pregnancy at which it occurs — Type of insanity

XVI CONTENTS

PAGE

Prognosis — Transient mania during delivery — Puerperal insanity (proper) — Type of insanity — Causes — Theory of its dependence on a morbid state of the blood— Objections to the theory— Prognosis — Post-mortem signs — Duration — Insanity of lactation — Type — Symptoms — Of mania — Of melancholia — Treatment — Question of removal to asylum — Treatment during convalescence 594

Chapter V. Puerperal Septic Disease

Differences of opinion — Confusion from this cause — Modern view of this disease — History — Its mortality in lying-in-hospitals — Numerous theories as to its nature — Theory of local origin — Theory of an essential zymotic fever — Theory of its identity with surgical septicaemia — Nature of this view — Channels through which septic matter may be absorbed — Character and origin of septic matter often obscure — Division into autogenetic and heterogenetic cases — Objections to term " autogenetic " — Can autoinfection occur? — Sources of saprsemia— Sources of heterogenetic infection — Influence of cadaveric poison — Infection from erysipelas — Infection from other zymotic diseases — Infection from sewer gas — Cases illustrating this mode of infection — Contagion from other puerperal patients — Mode in which the poison may be conveyed to the patient — Conduct of the practitioner in relation to the disease — Nature of the septic poison — Bacteriology — Local changes resulting from the absorption of septic material — Channels through which systemic infection is produced — Pathological phenomena observed after general blood infection — Four principal types of pathological change — Intense cases, without marked post-mortem signs — Cases characterized by inflammation of the serous membranes — Cases characterized by the impaction of infected emboli, and secondary inflammation and abscess — Description of the disease — Duration — Varieties of symptoms in different cases — Symptoms of local complications — Treatment .... 605

CHAPTER, VI.

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM.

Puerperal thrombosis and its results — Conditions which favor thrombosis — Conditions which favor coagulation in the puerperal state — Distinction between thrombosis and embolism — Is primary thrombosis of the pulmonary arteries possible? — History— Symptoms of pulmonary obstruction — Is recovery possible? — Causes of death — Post-mortem appearances— Treatment — Puerperal embolic pneumonia : its causes and treatment . . 642

Chapter VII. Puerperal Arterial Thrombosis And Embolism

Causes — Symptoms — Treatment ......... 654

CONTENTS

XV11

Chapter VIII. Other Causes Of Sudden Death During Labor And The Puerperal, State

PAGE

Organic and functional causes — Idiopathic asphyxia — Pulmonary apoplexy — Cerebral apoplexy — Syncope — Shock and exhaustion — Entrance of air into the veins ............ 656

Chapter IX

PERIPHERAL. VENOUS THROMBOSIS (SYN. : CRURAL PHLEBITIS — PHLEGMASIA DOLENS — ANASARCA SEROSA — OEDEMA LACTEUM — WHITE LEG, ETC.).

Nature — Symptoms — History and pathology — Anatomical form of the thrombi

in the veins — Detachment of emboli — Treatment . . . . . 659

Chapter X. Pelvic Cellulitis And Pelvic Peritonitis

Two forms of disease — Variety of nomenclature — Importance of differential diagnosis — Etiology — Connection with septicaemia — Seat of inflammation — Relative frequency of the two forms of disease — Symptomatology — Results of physical examination — Terminations — Prognosis — Treatment . 666

THE SCIENCE AND PRACTICE

OF

MIDWIFERY.