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diff --git a/40654-0.txt b/40654-0.txt new file mode 100644 index 0000000..eeb13ed --- /dev/null +++ b/40654-0.txt @@ -0,0 +1,23023 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 40654 *** + +Note: Project Gutenberg also has an HTML version of this + file which includes the original illustrations. + See 40654-h.htm or 40654-h.zip: + (http://www.gutenberg.org/files/40654/40654-h/40654-h.htm) + or + (http://www.gutenberg.org/files/40654/40654-h.zip) + + + Images of the original pages are available through + Internet Archive/American Libraries. See + http://archive.org/details/systemidwifer00rigb + + +Transcriber's note: + + The original text includes various symbols that are + represented as [Symbol: description] in this text version. + + + + + +A SYSTEM OF MIDWIFERY. + +by + +EDWARD RIGBY, M. D., + +Physician To the General Lying-In Hospital, Lecturer on +Midwifery, at St. Bartholomew's Hospital, etc. etc. + + + * * * * * * + +_Lea & Blanchard have lately published._ + + +NEW REMEDIES, _The Method of Preparing and Administering them_; THEIR +EFFECTS UPON THE HEALTHY AND DISEASED ECONOMY, &c. &c. + +BY ROBLEY DUNGLISON, M. D. + +_Professor of the Institutes of Medicine and Materia Medica in Jefferson +Medical College of Philadelphia; Attending Physician to the Philadelphia +Hospital_, &c. + +THIRD EDITION BROUGHT UP TO 1841. + +IN ONE VOLUME. + + +A NEW EDITION + +Completely Revised, with Numerous Additions and Improvements, + +OF + +DUNGLISON'S DICTIONARY OF MEDICAL SCIENCE AND LITERATURE: + +CONTAINING + +A concise account of the various Subjects and Terms, with a vocabulary of +Synonymes in different languages, and formulæ for various officinal and +empirical preparations, &c. + +IN ONE ROYAL 8vo. VOLUME. + + +_A Fourth Edition Improved and Modified, of_ + +DUNGLISON'S HUMAN PHYSIOLOGY: + +ILLUSTRATED WITH NUMEROUS ENGRAVINGS. + +IN TWO VOLUMES, OCTAVO. + +_Brought up to the present day._ + + +A PRACTICAL TREATISE ON THE HUMAN TEETH: + +Showing the causes of their destruction and the means of their +preservation. By Wm. Robertson: with plates. First American, from the +second London edition. In one volume. + + +OUTLINES OF A COURSE OF LECTURES, ON MEDICAL JURISPRUDENCE. + +BY THOMAS STEWART TRAILL, M. D. + +_From the Second Edinburgh Edition_, + +WITH AMERICAN NOTES AND ADDITIONS. + + +ARNOTT'S ELEMENTS OF PHYSICS. + +_Complete in One Volume._ + +A new edition of Elements of Physics, or Natural Philosophy, general and +medical, written for universal use, in plain or non-technical language, +and containing New Disquisitions and Practical Suggestions, comprised in +five parts: 1st. Somatology, Statics and Dynamics. 2d. Mechanics. 3d. +Pneumatics, Hydraulics, and Acoustics. 4th. Heat and Light. 5th. Animal +and Medical Physics. Complete in one volume. By Neil Arnott, M. D., of the +Royal College of Physicians. A new edition, revised and corrected from the +last English edition, with additions, by Isaac Hays, M. D. + + +THE NINTH BRIDGEWATER TREATISE. + +A FRAGMENT, + +BY CHARLES BABBAGE, ESQ. + +From the Second London Edition. + +IN ONE VOLUME, 8vo. + + +A New Edition with Supplementary Notes, and Additional Plates; of +BUCKLAND'S GEOLOGY AND MINERALOGY, considered with reference to Natural +Theology; from the last London Edition with nearly one hundred Maps and +Plates. + +PROFESSOR GIBSON'S RAMBLES IN EUROPE, in 1839:--Containing Sketches of +Prominent Surgeons, Physicians, Medical Schools, Hospitals, &c. &c. In One +Volume. + +AN ATLAS OF PLATES, illustrative of the Principles and Practice of +Obstetric Medicine and Surgery, with descriptive Letter Press, by Francis +H. Ramsbotham. This will form a large super royal volume, with over One +Hundred lithographic plates--to be ready in November. + +THE PRINCIPLES AND PRACTICE of MEDICINE, By Professor Dunglison in 2 vols. +8vo. This work will be ready the approaching fall. + +THE LIBRARY OF PRACTICAL MEDICINE. Edited by Tweedie, is now complete in +five volumes, royal octavo, handsomely bound in leather, to match. The +different volumes may be had separate, bound in extra cloth. + + + * * * * * * + + +A SYSTEM OF MIDWIFERY. + +With Numerous Wood Cuts. + +by + +EDWARD RIGBY, M. D., + +Physician to the General Lying-In Hospital, Lecturer on +Midwifery, at St. Bartholomew's Hospital, etc. etc. + +With Notes and Additional Illustrations. + + + + + + + +Philadelphia: +Lea & Blanchard. +1841. + +Entered, according to the Act of Congress, in the year 1841, by Lea & +Blanchard, in the District Court for the Eastern District of Pennsylvania. + +Griggs & Co., Printers. + + + + +THE EDITOR'S PREFACE. + + +This System of Midwifery, complete in itself, was published in London, as +a part of Dr. Tweedie's "_Library of Medicine_." The first series of the +Library, that on "_Practical Medicine_," recently completed, has been +received with extraordinary favour on both sides of the Atlantic, and the +character of the publication is fully sustained in the present +contribution by Dr. Rigby, and will secure for it additional patronage. + +The late Professor Dewees, into whose hands this volume was placed, a few +weeks before his death, in returning it, expressed the most favourable +opinion of its merits; and the judgment of such high authority renders it +supererogatory to add a word farther of commendation. + +It is only necessary for the editor to say that the production of the +author is so complete as to have rendered his labour a light one. He has +restricted himself mainly to such additions and references as he conceived +would render the work more useful to American practitioners. The object of +the publication being to present the most condensed view of each subject, +he believed it to be inexpedient to depart from the plan by making +extensive additions, and entering into the discussion of controversial +points, most of which are of minor practical importance. + + + + +CONTENTS. + + + INTRODUCTION, Page 13 + + + PART I. THE ANATOMY AND PHYSIOLOGY OF UTERO-GESTATION. + + CHAPTER I. THE PELVIS. + + Ossa innominata.--Sacrum.--Coccyx.--Distinction between the + male and female pelvis.--Diameters of the pelvis.--Pelvis + before puberty.--Axes.--Inclination, 15 + + CHAPTER II. FEMALE ORGANS OF GENERATION. + + Internal and external.--Ovaria.--Ovum.--Corpus luteum.-- + Fallopian tubes.--Uterus.--Vagina.--Hymen.--Clitoris.-- + Nymphæ.--Labia, 22 + + CHAPTER III. DEVELOPMENT OF THE OVUM. + + Membrana decidua.--Chorion.--Amnion.--Placenta.--Umbilical + cord.--Embryo.--Foetal circulation, 48 + + + PART II. NATURAL PREGNANCY AND ITS DEVIATIONS. + + CHAPTER I. SIGNS OF PREGNANCY. + + Difficulty and importance of the subject.--Diagnosis in the + early months.--Auscultation.--Changes in the vascular and + nervous systems.--Morning sickness.--Changes in the appearance + of the skin.--Cessation of the menses.--Areola.--Sensation of + the child's movements.--"Quickening."--Auscultation.--Uterine + souffle.--Sound of the foetal heart.--Funic souffle.--Sound + produced by the movements of the foetus.--Ballottement.--State + of the urine.--Violet appearance of the mucous membrane of the + vagina.--Cases of doubtful pregnancy.--Diagnosis of twin + pregnancy, 80 + + CHAPTER II. TREATMENT OF PREGNANCY. + + Sympathetic affections of the stomach during pregnancy.-- + Morning sickness.--Constipation.--Flatulence.--Colicky + pains.--Headach.--Spasmodic cough.--Palpitation.--Toothach.-- + Diarrhoea.--Pruritus pupendi.--Salivation, 101 + + CHAPTER III. SIGNS OF THE DEATH OF THE FOETUS. + + Difficulty of the subject.--Signs before labour.--Motion of + the foetus.--Sound of the foetal heart.--Uterine souffle.-- + Signs during labour where the head presents--where the face, + the nates, the arm, or the cord, present.--Fetid liquor + amnii.--Discharge of meconium, 107 + + CHAPTER IV. MOLE PREGNANCY. + + Nature and origin.--Varieties.--Diagnostic symptoms.-- + Treatment, 112 + + CHAPTER V. EXTRA-UTERINE PREGNANCY. + + Tubarian, ovarian, and ventral pregnancy.--Pregnancy in the + substance of the uterus, 117 + + CHAPTER VI. RETROVERSION OF THE UTERUS. + + History.--Causes.--Symptoms.--Diagnosis.--Treatment.-- + Spontaneous terminations, 126 + + CHAPTER VII. DURATION OF PREGNANCY, 136 + + CHAPTER VIII. PREMATURE EXPULSION OF THE FOETUS. + + Abortion.--Miscarriage.--Premature labour.--Causes.-- + Symptoms.--Prophylactic measures.--Effects of repeated + abortion.--Treatment, 141 + + + PART III. EUTOCIA, OR NATURAL PARTURITION. + + CHAPTER I. STAGES OF LABOUR. + + Preparatory stage.--Precursory symptoms.--First + contractions.--Action of the pains.--Auscultation during the + pains.--Effect of the pains upon the pulse.--Symptoms to be + observed during and between the pains.--Character of a true + pain.--Formation of the bag of liquor amnii.--Rigour at the + end of the first stage.--Show.--Duration of the first stage.-- + Description of the second stage.--Straining pains.--Dilatation + of the perineum.--Expulsion of the child.--Third stage.-- + Expulsion of the placenta.--Twins, 156 + + CHAPTER II. TREATMENT OF NATURAL LABOUR. + + State of the bowels.--Form and size of the uterus.--True and + spurious pains.--Treatment of spurious pains.--Management of + the first stage.--Examination.--Position of the patient during + labour.--Prognosis as to the duration of labour.--Diet during + labour.--Supporting the perineum.--Treatment of perineal + laceration.--Cord round the child's neck.--Birth of the child, + and ligature of the cord.--Importance of ascertaining that the + uterus is contracted after labour.--Management of the + placenta.--Twins.--Treatment after labour.--Lactation.--Milk + fever and abscess.--Excoriated nipples.--Diet during + lactation.--Management of lochia.--After-pains, 169 + + CHAPTER III. MECHANISM OF PARTURITION. + + Cranial presentations--first and second position.--Face + presentations--first and second positions.--Nates + presentations, 199 + + + PART IV. MIDWIFERY OPERATIONS. + + CHAPTER I. THE FORCEPS. + + Description of the straight and curved forceps.--Mode of + action.--Indications.--Rules for applying the forceps.-- + History of the forceps, 216 + + CHAPTER II. TURNING. + + Turning.--Indications.--Circumstances most favourable for this + operation.--Rules for finding the feet.--Extraction with the + feet foremost.--Turning with the nates foremost.--Turning with + the head foremost.--History of turning, 230 + + CHAPTER III. CÆSAREAN OPERATION. + + Indications,--Different modes of performing the operation.-- + History of the Cæsarean operation, 243 + + CHAPTER IV. ARTIFICIAL PREMATURE LABOUR. + + History of the operation.--Period of pregnancy most favourable + for performing it.--Description of the operation, 250 + + CHAPTER V. PERFORATION. + + Variety of perforators.--Indications.--Mode of operating.-- + Extraction.--Crotchet.--Embryulcia, 256 + + + PART V. DYSTOCIA, OR ABNORMAL PARTURITION. + + CHAPTER I. FIRST SPECIES OF DYSTOCIA. + + Malposition of the child.--Arm or shoulder the only faulty + position of a full-grown living foetus.--Causes of + malposition.--Diagnosis before and during labour.--Results + where no assistance is rendered.--Spontaneous expulsion.-- + Malposition complicated with deformed pelvis or spasmodically + contracted uterus.--Embryulcia.--The prolapsed arm not to be + put back or amputated.--Presentation of the arm and head.-- + Presentation of the hand and feet.--Presentation of the head + and feet.--Rupture of the uterus.--Usual seat of laceration.-- + Causes.--Premonitory symptoms.--Symptoms.--Treatment.-- + Gastrotomy.--Rupture in the early months of pregnancy, 264 + + CHAPTER II. SECOND SPECIES OF DYSTOCIA. + + Size and form of the child.--Hydrocephalus.--Cerebral + tumours.--Accumulation of fluid and tumours in the chest or + abdomen.--Monsters.--Anchylosis of the joints of the foetus, 281 + + CHAPTER III. THIRD SPECIES OF DYSTOCIA. + + Difficult labour from faulty condition of the parts which + belong to the child.--The membranes.--Premature rupture of the + membranes.--Liquor amnii.--Umbilical cord.--Knots upon the + cord.--Placenta, 286 + + CHAPTER IV. FOURTH SPECIES OF DYSTOCIA. + + Abnormal state of the pelvis.--Equally contracted pelvis.-- + Unequally contracted pelvis.--Rickets.--Malacosteon, or + mollities ossium.--Symptoms of deformed pelvis.--Funnel-shaped + pelvis.--Obliquely distorted pelvis.--Exostosis.--Diagnosis of + contracted pelvis.--Effects of difficult labour from deformed + pelvis.--Fracture of the parietal bone.--Treatment.--Prognosis, 292 + + CHAPTER V. FIFTH SPECIES OF DYSTOCIA. + + _Obstructed Labour from a Faulty Condition of the Soft Passages._ + + Pendulous abdomen.--Rigidity of the os uteri.--Belladonna.-- + Edges of the os uteri adherent.--Cicatrices and callosities.-- + Agglutination of the os uteri.--Contracted vagina.--Rigidity + from age.--Cicatrices in the vagina.--Hymen.--Fibrous bands.-- + Perineum.--Varicose and oedematous swellings of the labia and + nymphæ.--Tumours.--Distended or prolapsed bladder.--Stone in + the bladder, 308 + + CHAPTER VI. SIXTH SPECIES OF DYSTOCIA. + + _Faulty Labour from a Faulty Condition of the expelling Powers._ + + I. Where the uterine activity is at fault--functionally or + mechanically--from debility--derangement of the digestive + organs--mental affections--the age and temperament of the + patient--plethora--rheumatism of the uterus--inflammation of + the uterus--stricture of the uterus.--Treatment. II. Where the + action of the abdominal and other muscles is at fault.--Faulty + state of the expelling powers after the birth of the child.-- + Hæmorrhage.--Treatment, 324 + + CHAPTER VII. INVERSION OF THE UTERUS. + + Partial and complete.--Causes.--Diagnosis and symptoms.-- + Treatment.--Chronic inversion.--Extirpation of the uterus, 345 + + CHAPTER VIII. ENCYSTED PLACENTA. + + Situation in the uterus.--Adherent placenta.--Prognosis and + treatment.--Placenta left in the uterus.--Absorption of + retained placenta, 354 + + CHAPTER IX. PRECIPITATE LABOUR. + + Violent uterine action.--Causes.--Deficient resistance.-- + Effects of precipitate labour.--Rupture of the cord.-- + Treatment.--Connexion of precipitate labour with mania, 361 + + CHAPTER X. PROLAPSUS OF THE UMBILICAL CORD. + + Diagnosis.--Causes.--Treatment.--Reposition of the cord, 368 + + CHAPTER XI. PUERPERAL CONVULSIONS. + + Epileptic convulsions with cerebral congestion.--Causes.-- + Symptoms.--Tetanic species.--Diagnosis of labour during + convulsions.--Prophylactic treatment.--Treatment--Bleeding.-- + Purgatives.--Apoplectic species.--Anæmic convulsions.-- + Symptoms.--Treatment.--Hysterical convulsions.--Symptoms, 376 + + CHAPTER XII. PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA. + + History.--Dr. Rigby's division of hæmorrhages before labour + into accidental and unavoidable.--Causes.--Symptoms.-- + Treatment.--Plug.--Turning.--Partial presentation of the + placenta.--Treatment, 393 + + CHAPTER XIII. PUERPERAL FEVERS. + + Nature and varieties of puerperal fever.--Vitiation of the + blood.--Different species of puerperal fever.--Puerperal + peritonitis.--Symptoms.--Appearances after death.-- + Treatment.--Uterine phlebitis.--Symptoms.--Appearances after + death.--Treatment.--Indications.--False peritonitis.-- + Treatment.--Gastro-bilious puerperal fevers.--Symptoms.-- + Appearances after death.--Treatment.--Contagious or adynamic + puerperal fevers.--Symptoms.--Appearances after death.-- + Treatment, 415 + + CHAPTER XIV. PHLEGMATIA DOLENS. + + Nature of the disease.--Definition of phlegmatia dolens.-- + Symptoms.--Duration of the disease.--Connexion with crural + phlebitis.--Causes.--Connexion between the phlegmatia dolens + of lying-in women and puerperal fever.--Anatomical + characters.--Treatment.--Phlegmatia dolens in the + unimpregnated state, 463 + + CHAPTER XV. PUERPERAL MANIA. + + Inflammatory or phrenitic form.--Treatment.--Gastro-enteric + form.--Treatment.--Adynamic form.--Causes and symptoms.-- + Treatment, 473 + + + INDEX, 483 + + + + +A SYSTEM OF MIDWIFERY. + + + + +INTRODUCTION. + + +By the term Midwifery is understood the knowledge and art of treating a +woman and her child during her pregnancy, labour, and the puerperal state. +We employ it in this extended sense, because most systematic writers of +later times have adopted this arrangement. The terms, _Art des +Accouchemens_ of the French, the _Ostetricia_, and _Arte della Parteria_, +of the Italians and Spaniards, and the _Geburtshülfe_ of the Germans, are +restricted to the process of parturition, although they have been and +continue to be, used in the same extended sense as that in which we +propose to use the term Midwifery. + +Although pregnancy and parturition, strictly speaking, are perfectly +natural functions, yet they involve such a complication and variety of +other processes, and also changes of such extent, that the whole system is +rendered more or less subservient to them during the periods of their +existence: hence, therefore, their number and variety must ever render +them more or less liable to deviations and irregularities of action, which +will necessarily be aggravated by the effects of civilized life, and in +many instances are productive of derangement in the general economy of the +system. Under such circumstances the irritability of the system increases +at the expense of its strength and vigour, and not only increases its +liability to these derangements, but diminishes its power of resisting +their effects. + +In order that we may render the nature and treatment of the changes +and phenomena, which take place in the human system during the +periods above alluded to, more intelligible, we shall take a short +anatomico-physiological view of the structure, form, arrangement, and +function of the parts and organs which are more or less directly +concerned in these important processes. This will embrace the subject of +embryology, a department of physiological knowledge, which, though it has +lately been much enriched by valuable discoveries, still affords a rich +field of investigation and research. + +The diagnosis and course of healthy pregnancy, and its various diseases, +terminating with the subject of healthy parturition and its treatment will +form the subject of the succeeding part. + +Parturition properly speaking, will come under two separate heads +_eutocia_ and _dystocia_; the one signifying natural or favourable labour, +the other, unnatural, faulty, or unfavourable labour. + +The concluding part will contain a short account of some of the more +important diseases which occur to the female during the first month after +parturition. + + + + +PART I. + +THE ANATOMY AND PHYSIOLOGY OF UTERO-GESTATION. + + + + +CHAPTER I. + +THE PELVIS. + + _Ossa innominata.--Sacrum.--Coccyx.--Distinction between the male and + female pelvis.--Diameters of the pelvis.--Pelvis before puberty.-- + Axes.--Inclination._ + + +The Pelvis, as the frame-work which, in great measure, contains, supports, +and protects, the complicated apparatus of the generative organs, first +claims our attention; since an accurate knowledge of the form, size, and +uses, of its different parts is indispensably necessary, not only to +understand the situation of the viscera it contains, but also to form a +correct view of the mechanism upon which the process of parturition +depends. + +This osseous canal or circular archway, consists essentially of three +bones, the right and left os innominatum, which form the sides of the +arch, with the sacrum between them, acting as a keystone, and supporting +the whole weight of the trunk above. + +_Ossa innominata._ The ossa innominata in early life consists of three +distinct bones, the _iliac_ or _hip bones_ at the sides, the _ischia_ or +lower portion upon which we sit, and the _ossa pubis_ which meet each +other anteriorly to form the front part of the pelvis. In the adult these +are consolidated into one bone, merely leaving irregular lines and ridges +here and there to mark their previous existence. + +These bones present several striking points of resemblance with those +which belong to the upper extremities, viz. the scapula and clavicle; and +in the early stages of development, this similarity is much more +distinctly seen: it is remarkable, that although the ischia and ossa pubis +are formed later than the ilia, yet they unite with each other much sooner +than with the ilia, so that the two consolidated bones bear the same +relation to the ilium which is separated from them, that the clavicle does +to the scapula: many other points of resemblance between the bones of the +shoulder and pelvis might be noticed if necessary. (Meckel, _Anat._ vol. +ii. p. 239.) The ossa innominata meet each other in front, forming the +_symphysis pubis_, having layers of fibro-cartilage interposed between +their extremities, and bound together by ligamentous fibres constituting +the _ligamentum arcuatum_, or _annulare ossium pubis_, and by which a more +rounded appearance is given to the pubic arch. They are united to the +sacrum posteriorly, one on each side of it, forming the _right and left +sacro-iliac symphysis_ or _synchondrosis_; this differs in many respects +from the symphysis pubis, the cartilaginous coverings of the opposing +bones being much thinner, especially those of the ossa innominata; the +surfaces are extremely uneven from the deep indentations which each bone +presents at this part, locking, as it were, into each other, and thus +contributing greatly to increase the firmness of the joint, which is also +still farther strengthened by the support of powerful ligaments. + +Between the ligamento-and cartilaginous layers which cover the surfaces of +the bones at the pubic and sacro-iliac symphyses, a minute collection of +synovial fluid may be detected, like that found in the fibro-cartilages +between the vertebræ; it serves to lubricate their surfaces, and separates +them more or less, thereby increasing the thickness of the intervening +cartilaginous structure; and separating also the edges of the bones, to a +certain extent, more especially at the symphysis pubis. (Portal, _Anat. +Méd._) These laminæ of intervening fibro-cartilage are thicker in the +female than in the male, although of smaller extent; and this is still +more remarkable during pregnancy, this ligamento-cartilaginous structure +becoming now more cushiony and elastic, while in the latter months we can +easily distinguish blood-vessels ramifying through it, which are branches +of the pudic arteries and veins. + +_Sacrum._ The sacrum, which forms the upper and posterior portion of the +pelvis, contributes greatly to the general solidity of the whole bony +circle. From its wedge-like shape, it is admirably adapted to support the +entire weight of the trunk, and acts, as we have before observed, as a +kind of keystone to the arch which is formed by the ossa innominata. It is +of a triangular shape, being concave before and convex behind. In the +foetus it consists of five distinct pieces of bone separated by +intervening layers of cartilage, like the vertebræ of the spinal column, +and from their resemblance to those bones they have been called false +vertebræ. These cartilages, after a time, gradually disappear; bony matter +is deposited in their place; so that by the period of puberty the five +sacral vertebræ become united into one solid bone, although they may be +distinguished, until an advanced period of life, by the ridges which their +edges form. + +The upper surface of the sacrum, having to sustain the whole weight of the +spinal column, is broad and flat, and corresponds to the lower surface of +the last lumbar vertebra. Its anterior surface forms with that of the +other mentioned bone a considerable angle, which projects forwards and +more or less downwards towards the symphysis pubis, and is called the +_promontory of the sacrum_. Beneath this point, the sacrum takes a +considerable sweep backwards as it descends, gradually advancing again +forwards, as we approach its inferior extremity, forming an extensive +concavity upon its anterior surface: this is termed _the hollow of the +sacrum_. + +_Coccyx._ The lower end is prolonged by a small bone, called _Coccyx_ or +_os Coccygis_, from its supposed resemblance to a cuckoo's beak. It +usually consists of four, and sometimes (especially in women) of five +portions; they are much smaller than the bones of the sacrum, and are very +imperfect rudiments of vertebral formation; like these, they are at an +early period little else than cartilage, and even when the bones are fully +formed, they are united by intermediate cartilage, and thus retain so much +mobility upon each other, as well as upon the lower end of the sacrum, as +to admit of being forced backwards to the extent of a full inch, thus +contributing greatly to increase the capacity of the outlet. + +The sacrum not only serves to form the posterior parietes of the pelvis, +but by the curve which its lower portion takes forwards, together with the +coccyx, it gives a powerful support to the pelvic viscera. + +When we take a general view of the bones which collectively form the +pelvis, we find that it is evidently divided into two portions--an upper +and a lower one. On the Continent these have been called the large and the +small pelvis; in Britain we merely speak of the pelvis above or below the +_brim_, the line of demarcation being the linea ilio-pectinea at the +sides, the crista of the os pubis in front, and the promontory of the +sacrum behind. The alæ of the ilia form a prominent feature in the upper +pelvis, and not only afford an attachment for numerous muscles, but +furnish a powerful and ample means of protection and support to the pelvic +and lower abdominal viscera. In the female pelvis this is remarkably the +case, the cavitas iliaca being well expanded and of greater extent than in +the male, the crista of the ilium thrown more outwards; hence the distance +between the antero-superior processes is much more considerable. + +_Distinction between the male and female pelvis._ At the brim, the female +pelvis presents several well-marked points of distinction from that of the +male. The male pelvis has a contracted brim of a rounded or rather +triangular form, with the promontory of the sacrum considerably +projecting; whereas, that of the female is spacious, of an oval shape, and +with a slightly prominent sacrum, thus affording more room for the passage +of the child through the brim. The cavity of the male pelvis is deep, +while in the female pelvis it is shallow, a circumstance which is very +strikingly seen in comparing the length of the symphysis pubis in each, +that of the male pelvis being nearly double the length of the female. This +is an important point of difference as regards parturition, because in a +shallow pelvis, the extent of surface exposed to the pressure of the head +will be much less than where it is deep, and hence the resistance to the +passage of the child will be proportionably diminished: in confirmation of +this, we find that tall women, in whom the pelvis is usually deep, do not, +on the whole, bear children so easily as women of middling stature in whom +the pelvis is more shallow. The capacious hollow of the sacrum in the +female pelvis adds also greatly to the extent of its cavity, and +peculiarly adapts it for parturition, the injurious pressure of the head +upon the soft linings of the pelvis being thus prevented, and every +facility afforded for its quick and easy transit through the cavity. This +applies especially to the neck of the bladder, which would almost +inevitably suffer in every labour, were it not for the ample hollow of the +sacrum relieving the pressure of the head against the anterior portions of +the pelvis. The bones of the female pelvis being more slender and +delicately formed, the foramina ovalia and sacro-ischiatic notches are +wider, and thus add still farther to the capacity of the cavity. + +In no part of the pelvis is the difference between the sexes more strongly +marked than at the outlet. The spacious and well-rounded arch of the pubes +in the female of the slender rami, is a striking contrast to the +contracted angular arch of the male pelvis; and the tuberosities of the +ischium being much wider apart, the head is enabled to pass under the arch +with greater facility, and thus still farther to relieve the anterior of +the pelvis from its pressure. The length of the sacro-sciatic ligaments, +and the mobility of the coccyx upon the sacrum, by which it can be forced +backwards to the extent of an inch by the pressure of the head during +labour, not merely serve to distinguish it from the male pelvis, but +afford a beautiful instance of design and adaptation. + +The greater width of the pubic arch in the female pelvis is seen by +comparing its angle with that of the arch in the male pelvis. In the +female it has been estimated to form an angle varying between 90° and +100°, whereas in the male it is not more than between 70° and 80°. +(Osiander, _Handbuch der Embindungs-kunst_, cap. iv. p. 58.) + +From the greater width of the female pelvis, the acetubula are farther +apart, and the great trochanters of the thigh-bones more projecting; hence +the greater motion of the hips in the female when she walks, which is +still more visible when she runs, for the motion is communicated to the +whole trunk, so that each shoulder is turned more or less forwards as the +corresponding foot is advanced. The thigh-bones, which are so far apart at +their upper extremities, approach each other at the knees, contributing to +produce that unsteady gait which is peculiar to the sex. "The woman," says +Mr. John Bell, "even of the most beautiful form, walks with a delicacy and +feebleness which we come to acknowledge as a beauty in the weaker sex." +(_Bell's Anat._ vol. i.) + +These characteristic marks of the female figure, upon which its beauty in +great measure depends, are well seen in all great works of art, whether of +sculpture or painting. "The ancients," as Mr. Abernethy has observed, "who +had a clear and strong perception of whatever is beautiful or useful in +the human figure, and who, perhaps, delicately exaggerated beauty to +render it more striking, have represented Venus as measuring one-third +more across the hips than the shoulders, whilst, in Apollo, they have +reversed these measurements." (_Physiological Lectures._) + +_Diameters of the pelvis._ It is of the utmost importance to the +obstetrician, that he should be thoroughly acquainted with the various +dimensions of the female pelvis, for, without this, he can form no correct +idea of the manner in which the presenting part of the child passes +through its brim, cavity and outlet during labour; indeed, unless he be +thoroughly versed in this necessary point of obstetric knowledge, he will +remain in almost total ignorance of the whole mechanism of parturition, +which must, in great measure, be looked upon as the basis of practical +midwifery. The dimensions of the brim cavity and outlet of the pelvis may +be given with sufficient correctness for all practical purposes, by +measuring three of their diameters,--1. the _straight_, +_antero-posterior_, or _conjugate_; 2. the _transverse_; and 3. the +_oblique_. At the brim they are as follow:--the straight diameter, drawn +from the middle of the promontorium sacri to the upper edge of the +symphisis pubis, 4·3 inches; the transverse diameter, from the middle of +the linea-ilio-pectinea of one ilium to that of the other, 5·4 inches; and +the oblique diameter, from one sacro-iliac synchondrosis to the opposite +acetabulum, 4·8 inches. The oblique diameters are called right and left, +according to the sacro-iliac symphysis from which they are drawn. + +[Illustration: _Fig. 1. Fig. 2._ + +In the annexed representations of the superior and inferior aspects of the +female pelvis are shown the three diameters of its brim and outlet; those +of the former in _fig. 1._, and those of the latter in _fig. 2._ The same +letters of reference are used in each figure to indicate the several +diameters; thus _a p_ refers to the antero-posterior, _t t_ to the +transverse, _o o_ to the right oblique, and _o' o'_ to the left oblique +diameters. + +In _fig. 2._ the coccyx is represented in situ.] + +In the cavity these dimensions vary more or less. The straight diameter, +measured from the centre of the hollow of the sacrum to that of the +symphysis pubis, is 4·8 inches; the transverse, from the point +corresponding to the lower margin of the acetabulum on one side to that of +the other, 4·3; and the oblique, drawn from the centre of the free space +formed by the sacro-ischiatic notch and ligaments on one side of the +foramen ovale of the other, 5·2. + +At the inferior aperture or outlet the alteration is still more +remarkable. The straight diameter, from the point of the coccyx to the +lower edge of the symphysis pubis, measures only 3·8 inches; but from the +mobility of the coccyx enabling it to be pushed back during labour to the +extent of a whole inch, it is capable of being extended to 4·8 inches. The +transverse diameter from one tuberosity of the ischium to the other, +measures 4·3 inches: and the oblique, from the middle of the lower edge of +the sacro-sciatic ligament of one side, to the point of union between the +ischium and descending ramus of the pubes on the other 4·8 inches. + +Although these are the proportions of the brim cavity and outlet of the +female pelvis in the skeleton state, their real dimensions during life, +when the pelvis is thickly lined with muscular and other structures, are +very different. The large masses of the psoas magnus and iliacus internus, +besides other muscles of inferior size, contribute to alter materially the +relations of the pelvic diameters to each other; hence we find that, so +far from being the longest, the transverse diameter is one of the +shortest, being little more than the antero-posterior. This holds good, +especially during labour, because these muscles being thrown into powerful +contraction, their bellies swell, and thus tend still farther to diminish +its length. The oblique diameters are, in fact, the longest during life, +because not only are the parietes of the pelvis at the brim covered by a +very thin layer of soft tissues in these directions; but as the +extremities of these diameters, in the cavity and outlet, correspond to +free spaces which are merely filled up with soft yielding structure, it +follows that their length can be somewhat increased when pressure is +applied in these directions; the antero-posterior diameter of the outlet +can alone be compared with the oblique diameters in this respect, and then +only when the coccyx is forced backwards to its full extent by the +pressure of the head. + +_Pelvis before puberty._ The proportions of the adult female pelvis are no +longer what they were during childhood; before the age of puberty they +resemble those of the male pelvis, the brim being contracted and more or +less triangular, and the antero-posterior diameter equalling or even +exceeding the transverse. Indeed, at a still earlier period, it presents +many points of resemblance even to the pelvis of animals; as, however, +growth and development advance, and the various changes which constitute +puberty take place, the transverse diameters of the brim, cavity, and +outlet increase at the expense of the antero-posterior, until at length, +it has assumed the proper proportions of the adult female pelvis. + +_Axes._ Of not less importance is it that the obstetrician should be +thoroughly acquainted with the direction which the central line or axis of +the entrance and outlet of the pelvis takes. The axis of the superior +aperture has been considered to form with the horizon an angle varying +between 50° and 60°; this was noticed long ago by Dr. Smellie: "when the +body of a woman," says this valuable author, "is reclined backwards, or +half sitting half lying, the brim of the pelvis is horizontal; and an +imaginary straight line, descending from the navel, would pass through the +middle of the cavity; but in the last month of pregnancy such a line must +take its rise from the middle space between the navel and scrobiculus +cordis in order to pass through the same point of the pelvis." (_Treatise +of Midwifery_, book i. chap. i. sect. 2.) + +_Inclination of the pelvis._ The angle which the axis of the superior +aperture of the pelvis forms with the horizon, when a woman is in the +upright posture, necessarily marks what has been called _the inclination +of her pelvis_, and varies, of course, in proportion to the angle which +the above mentioned axis forms. In a tall woman of slender figure, where +the different curves of the spinal columns are slight, the inclination of +the pelvis is much less than in a short thick set woman, where the spine +is much more strongly curved. Where the inclination is slight, the hollow +of the sacrum is generally small, and the vulva directed more forwards; +where, on the other hand, the pelvis is much inclined, the hollow of the +sacrum is generally observed to be deep, and the vulva directed more or +less backwards. The axis of the lower aperture or outlet appears to +depend, in great measure, on the curve which the lower part of the sacrum +takes downwards and forwards; but, as a general rule, we think it will be +found to form, more or less, a right angle with the axis of the brim. The +greater the angle which the axis of the brim forms with the horizon, the +less will be that which the axis of the outlet forms, and _vice versâ_; +or, in other words, the angle with the horizon which the axis of the one +forms is inversely to that of the other. + +The consideration of the various deviations, as to size and form, from the +natural proportions which the female pelvis occasionally presents, +belongs, more strictly speaking, to that species of faulty labour which +arises from these conditions. We, therefore, refer to the fourth species +of dystocia, viz. _Dystocia Pelvica_, where the different pelvic +anormalities are described. + + + + +CHAPTER II. + +FEMALE ORGANS OF GENERATION. + + _Internal and external.--Ovaria.--Ovum.--Corpus luteum.--Fallopian + tubes.--Uterus.--Vagina.--Hymen.--Clitoris.--Nymphæ.--Labia._ + + +The female organs of generation have been usually classed by the English +authors under the two heads of _internal_ and _external_; a similar +arrangement has also been followed by the Continental writers, but with +the advantage of using distinctive terms which are more expressive of +their peculiar functions, viz. the _formative_ and _copulative_ organs. +Under the first are included the ovaria, Fallopian tubes, and uterus: +under the second, the vagina and external parts. We propose to give a +short description of these in the unimpregnated state, and then to +describe the changes which they present during pregnancy, labour, and the +puerperal condition. In point of situation and arrangement they bear a +considerable resemblance to the generative organs in the male, being +situated at the lower portion of the trunk, and arranged in symmetrical +order, so that they either occur in pairs, one on each side the median +line of the body, or singly, being equally divided by it throughout their +whole length. Although there is in many points considerable difference +between the male and female organs, still there is sufficient resemblance +to entitle them to be considered as being formed upon the same fundamental +type, a resemblance which is seen still more strikingly in the early +periods of foetal life. They differ essentially from all the other organs +of the system, being in activity during a portion of a woman's life only, +and then only at intervals. + +_Ovaria._ The ovaries are situated in the upper part of the cavity of the +pelvis, one on each side, near to the uterus, to which they are merely +attached by a ligament (the _ligamentum ovarii_) which is a portion of +that duplicature of the peritoneum which connects the uterus to the +pelvis, and is known by the name of ligamentum latum, or broad ligament. + +They are of an oval figure; their anterior and posterior surface is +convex, the superior margin is also convex, while their lower edge is +straight or somewhat concave: towards their inner and outer extremities +they become thinner. + +Their external surface in the virgin state is usually smooth, but in +advanced age they become uneven and shrivelled; when fully developed they +are about an inch and a half in length: their greatest breadth, which is +at that portion of the ovary which is farthest from the uterus, is half an +inch; their thickness is somewhat less. + +[Illustration: Convoluted arteries of the ovary, crossing it in nearly +parallel lines.] + +The ovaries are supplied with blood by the spermatic arteries, which are +of course considerably shorter in the female; they pass between the two +layers of the broad ligament to the ovarium, assuming there a beautifully +convoluted arrangement, very similar to the convoluted arteries of the +testis. These vessels traverse the ovary nearly in parallel lines, forming +numerous minute twigs, which have an irregular knotty appearance from +their tortuous condition, and appear to be chiefly distributed to the +Graafian vesicles. The external covering of the ovaries is formed by +peritoneum, which here receives the name of _Inducium_; it envelopes the +parenchymatous tissue of the gland called _stroma_, which is a dense +laminar cellular tissue of a reddish colour; its external portion which is +in contact with and firmly adherent to the indusium, is condensed into a +species of covering of a firm structure and whitish colour, and is called +the _tunica albuginea of the ovary_. In the substance of the stroma are +embedded a number of vesicles of various sizes, which, although previously +described by Vesalius and Fallopius, have been called Graafian vesicles, +after De Graaf. These do not commonly become visible until the seventh +year, from which period they gradually enlarge until puberty, when the +ovaries increase in size, become softer and more vascular, and one or two +of these vesicles may be observed to be larger, more developed, and +projecting considerably from the surface of the gland. + +The proper capsule of the Graafian vesicle is composed of two layers. The +outer is formed of dense cellular tissue, in which are ramified many blood +vessels; the inner layer is thicker, softer, and more opaque than the +preceding, to which it is closely united, and from which it receives +vascular twigs. + +_Ovum._ The contained part or nucleus of the vesicle of De Graaf consists +of, first, a granulary membrane, enclosing, secondly, a coagulable +granular fluid; thirdly, connected with the granulary membrane on one side +is a circular mass or disc of granulary matter, in the centre of which is +embedded, fourthly, the ovum. + +This disc, called by Baer the _proligerous disc_, presents in its centre +on the side towards the interior of the vesicle, a small rounded +prominence, called the _cumulus_, and on the opposite side a small +cup-like cavity hollowed out in the cumulus. The cavity is for the +reception of the ovum.[1] + +[Illustration: _Diagram of a section of the Graafian Vesicle and its +contents, showing the situation of the Ovum._ + +_a_ The granulary membrane. _b_ The proligerous disc. _c_ Ovum. _d_ The +inner and outer walls of the Graafian vesicle. _e_ Indusium of the ovary. +_From T. W. Jones._] + +From the very minute size of the human ovum, and the difficulty of +detecting it, the existence of this little corpuscule was not +satisfactorily ascertained until modern times. Although De Graaf had +observed ova in the Fallopian tube so early as 1668, which fact had been +confirmed by the researches of Dr. Haighton and Mr. Cruickshank, still, as +no traces of such ova had been discovered in the Graafian vesicle, and as +it was evident that the Graafian vesicle, from its size, &c. could not +pass along the Fallopian tube, it was concluded that the inner surface of +the vesicle was a species of glandular structure which secreted the fluid +with which it was filled, and which was analogous to the semen of the male +testicle; hence, in former times, the ovaries were known by the name of +_testes muliebres_. The celebrated anatomist Steno[2] first pointed out +the analogy between these organs and the ovaries of the fish tribe: this +view was afterwards supported by De Graaf,[3] and they have since +continued to retain the name of ovaries. + +To Professor von Baer, now of St. Petersburg, is due the merit of having +first pointed out the distance of the ovum in the Graafian vesicle, and of +thus putting beyond all doubt the accuracy of De Graaf's observations, as +well as those of Dr. Haighton and Mr. Cruickshank. + +_Corpus luteum._ Upon impregnation taking place, one or more of the most +prominent Graafian vesicles begins to show marks of considerable +vascularity, both in its external capsule and in the surrounding stroma of +the ovary. The vesicle swells, and at length bursts, discharging its +contents into the funnel-shaped extremity of the Fallopian tube, which +firmly grasps the ovary at this point by means of its fimbriæ. + +These changes begin to take place immediately after impregnation; the +inner lining of the vesicle, which Professor von Baer considers to be a +mucous membrane, appears to undergo a rapid development, much more so than +the external capsule which contains it. It is, therefore, thrown into a +number of corrugations by which the cavity of the vesicle is greatly +diminished; it becomes much thicker, and assumes a yellow colour. As its +growth proceeds, the cavity of the vesicle becomes still farther +contracted, until being unable longer to retain its contents, it bursts +and discharges them as above described. + +[Illustration: Corrugation of the lining membrane of the Graafian capsule +after impregnation. _From Baer._] + +The remains of the ruptured vesicle form a round glandular yellow coloured +body, called _corpus luteum_: it projects considerably from the surface of +the ovary, attaining the size of a small mulberry. In the middle of this +projection there is a little irregular and generally triangular depression +or indentation, which is the opening through which the ovum was discharged +from the Graafian vesicle: this after a short time closes, forming a +little cicatrix on the surface of the ovary. + +[Illustration: Corpus luteum in the third month. _From Dr. Montgomery._] + +"Upon slitting the ovarium at this part, the corpus luteum appears a round +body, of a very distinct nature from the rest of the ovarium. Sometimes it +is oblong or oval, but more generally round. Its centre is white, with +some degree of transparency; the rest of its substance has a yellowish +cast, is very vascular, tender and friable, like glandular flesh. Its +larger vessels cling round its circumference, and these send their smaller +branches inwards through its substance: a few of these larger vessels are +situated at the cicatrix or indentation on the outer surface of the +ovarium, and are there so little covered as to give that part the +appearance of being bloody when seen at a little distance."[4] Upon making +a section of a corpus luteum, we observe that its cavity has an angular +form, from which, as from a centre, white lines radiate to the +circumference of the vesicle; an appearance which is evidently produced by +the corrugation of the inner membrane of the vesicle, as above alluded to. +To a similar cause we may also attribute the lobular appearance, which the +structure of the corpus luteum presents when a section is made of it. The +number of these corpora lutea corresponds exactly with the number of newly +formed ova. Meckel, after having examined no less than two hundred +pregnant animals of the class mammalia, found that the number of corpora +lutea corresponded exactly with that of the young produced. "When there is +only one child," says Dr. W. Hunter, "there is only one corpus luteum, and +two in the case of twins. I have had opportunities of examining the ovaria +with care in several cases of twins, and always found two corpora lutea. +In some of these cases there were two distinct corpora lutea in one +ovarium, in others there was a distinct corpus luteum in each ovarium." + +A Graafian vesicle cannot be converted into a corpus luteum except by +actual and effective sexual intercourse; and the strange and discrepant +accounts which have every now and then been published, even by authors of +considerable repute, of corpora lutea having been found in the ovaries of +virgin and even newly-born animals merely prove that the true +characteristics of the corpus luteum were not sufficiently known. The +irregular cysts, cavities, or deposites of whitish or yellowish structure +which are frequently found in the ovary, independent of impregnation, and +which have been improperly enough called virgin corpora lutea, present +points of difference so marked that they can scarcely be mistaken by an +experienced eye. The angular cavity opening externally, the stellated, +radiated, cicatrix-like appearance, which a section of the corpus luteum +presents, its soft and delicate structure as described by Dr. Hunter, and +above all its vascularity, and the facility with which its vessels can be +injected from the general tissue of the ovary, are characters only found +in a true corpus luteum. Virgin corpora lutea frequently occur under +circumstances of disease, especially those of a tubercular character. They +frequently appear as distinct cysts, the walls of which are +semi-cartilagenous; at other times they seem to be nothing more than a +coagulum of blood: they seldom project much from the ovary, and in no +instance have they the peculiar structure of the corpus luteum, nor the +external cicatrix, nor are they capable of being injected. + +After awhile the cavity of the corpus luteum contracts, and the opening +into it closes. The surrounding stroma loses its vascularity, the +prominence at this part of the ovary gradually subsides, and the ovary +returns to its former size. The periods at which these changes take place +vary, but with the exception of those first mentioned they proceed slowly +whilst pregnancy lasts, after which time, now that the increased activity +of the pelvic circulation peculiar to that period has ceased, they advance +more rapidly. + +[Illustration: Corpus luteum at the end of the ninth month. _From Dr. +Montgomery._] + +"If an examination be made within the first three or four months after +conception, we shall, I believe, always find the cavity still existing, +and of such a size as to be capable of containing a grain of wheat at +least, and very often of much greater dimensions: this cavity is +surrounded by a strong white cyst (the inner coat of the Graafian +vesicle,) and as gestation proceeds the opposite parts of this +approximate, and at length close together, by which the cavity is +completely obliterated, and in its place there remains an irregular white +line, whose form is best expressed by calling it radiated or +stelliform."[5] Dr. Montgomery adds, "I am unable to state exactly at what +period the central cavity disappears, or closes up to form the stellated +line. I think I have invariably found it existing up to the end of the +fourth month. I have one specimen in which it was closed in the fifth +month, and another in which it was open in the sixth: later than this I +never found it." + +When pregnancy is over, the corpus luteum gradually diminishes and +disappears. Dr. Montgomery states that "the exact period of its total +disappearance I am unable to state, but I have found it distinctly visible +so late as at the end of five months after delivery at the full time, but +not beyond this period." Hence it will be seen that in a few months after +the termination of pregnancy, all traces of the corpus luteum are lost, +and that, therefore, it will be impossible to decide as to how frequently +impregnation has taken place, merely by examining the ovaries, as has been +supposed. There is also another point to which Dr. Montgomery has alluded, +which is well worthy of notice: in mentioning the fact that a vesicle may +contain two ova, and thus a woman be delivered of twins, and yet there be +but one corpus luteum, he observes that "the presence of a corpus luteum +does not prove that a woman has _borne a child_, although it would be a +decided proof that she has been impregnated, and had conceived, because it +is quite obvious that the ovum, after its vivification, may be, from a +great variety of causes, blighted and destroyed, long before the foetus +has acquired any distinct form. It may have been converted into a mole or +hydatids: thus, however paradoxical it may at first sight appear, it is +nevertheless obviously true, that a woman may conceive and yet not become +truly with child, a fact already alluded to, as noticed by Harvey; but the +converse will not hold good. I believe no one ever found a foetus in utero +without a corpus luteum in the ovary; and that the truth of Haller's +carollary, 'nullus unquam conceptus est absque corpore luteo' remains +undisputed." + +During childhood, the ovaries present a perfectly smooth surface, and +their structure appears to be homogeneous, consisting of a dense cellular +tissue. About the seventh year, the first traces of the Graafian vesicles +make their appearance; as the period of puberty approaches, the whole +gland enlarges, becomes softer and more vascular; the Graafian vesicles +are more numerous, and generally one or two will be found larger and more +prominent than the rest. After repeated impregnations, and especially +towards that time of life when the catamenia are about to disappear, the +ovary becomes more or less flabby and corrugated, and at a still more +advanced age presents a shrivelled appearance. + +The ovaries are liable to inflammation and its consequences, more +especially abscess, general enlargement, and induration: the malignant +changes of structure, viz. cephaloma, hæmatoma, and cancer, rarely have +their origin in the ovaries, but extend to these organs from the adjacent +parts. Lipomatous or fatty tumours are occasionally met with, containing +hair, rudiments of teeth, &c. Cysts not unfrequently occur in the ovaries, +and attain a very considerable size; they are simple or compound, +sometimes consisting of several cysts one within the other, and distended +with fluids, which vary considerably in their character. These tumours +come under the general head of OVARIAN DROPSY. The ovaries are also liable +to many remarkable morbid changes in the puerperal state, such as +softening and complete disorganization, the natural structure of the organ +being entirely broken down and converted into a bloody pulpy mass; in some +cases the whole gland is apparently dissolved away, so as scarcely to +leave a trace of its previous existence. + +_Fallopian tubes._ The Fallopian tubes, which act as excretory ducts to +the ovaries, take their course through the upper portion of the broad +ligaments, running from without inwards, towards the superior margin of +the uterus, the ovaries being situated behind and somewhat above them. +They are somewhat contorted, and are considerably more dilated at their +abdominal extremity where they are unattached, than where they are +connected to the uterus, being as much as from three to four lines at the +former point; whereas, at the latter, they are not more than half a line. + +Their abdominal extremity, which is like the mouth of a funnel, has its +edge strongly fimbriated, and has hence been called the _morsus diaboli_. +Their other extremity opens into the cavity of the uterus at the angle +which the fundus forms with its sides, and the whole of the tube is about +five inches. + +The Fallopian tubes receive their external covering from the peritoneum, +which becomes connected at their open extremity with the membrane which +lines them. Between the external and internal membrane is the proper +tissue of the tubes, and which, except in very muscular subjects, seldom +display the fibrous structure; still, nevertheless, two layers of fibres +have been observed--an outer or longitudinal, and an inner or circular +layer. The Fallopian tubes are lined with mucous membrane, forming +numerous longitudinal rugæ. The canal is not pervious during the early +months of foetal life, the abdominal extremity being closed and rounded; +this appears to open about the fourth month. The canal is relatively +larger, the younger the embryo is, and may, therefore, be easily +demonstrated at this time. + +At the period of impregnation, the Fallopian tubes implant themselves by +means of their fimbriated extremity upon that part of the ovary where the +Graafian vesicle is about to burst; they become remarkably engorged with +blood, assuming a deep purple colour, and are now much thicker; the canal +enlarges, so that a tolerably-sized probe can be introduced, whereas, at +other periods it will scarcely admit a large bristle. The uterine +extremity of the tube is closed by a continuation of that pulpy coagulable +lymph-like secretion which now lines the cavity of the uterus, forming the +membrana decidua of Hunter, and which, especially on the side where the +corpus luteum is found, extends into the tube to nearly the distance of an +inch. The tubes are now observed to be in a state of distinct peristaltic +motion, "like writhing worms," as Mr. Cruickshank has well expressed it; +"the fimbriæ were also black and embraced the ovaria (like fingers laying +hold of an object) so closely and so firmly, as to require some force and +even slight laceration to disengage them."[6] From the great degree of +vascularity which is observed in the Fallopian tubes at this period, some +anatomists have been induced to consider that their proper tissue was +vascular, analogous to the corpora cavernosa penis. Besides the +peristaltic motion already mentioned, other movements called ciliary have +been observed in the Fallopian tubes at this period, consisting of minute +portions of mucous membrane moving briskly and whirling round their axis, +apparently for the purpose of propelling the ovum.[7] + +As pregnancy advances, the Fallopian tubes undergo other changes as +respects their situation, which are worthy of notice. The broad +ligaments, in the upper parts of which the Fallopian tubes take their +course, are well known to be merely expansions of peritoneum from each +side of the uterus, and therefore become gradually unfolded and shorter as +the uterus increases in size. "In proportion as the fundus uteri rises +upwards and increases in size, the upper part of the broad ligament is so +stretched that it clings close to the side of the uterus, so that in +reality the broad ligament disappears, no more of it remaining than its +very root, viz. its upper and outer corner, where the group of spermatic +vessels pass over the iliacs immediately to the side of the uterus. In +this state, though the small end of the tube opens in the same part of the +uterus as before impregnation, yet the tube has a very different +direction. Instead of running outwards in the horizontal direction, it +runs downwards, clinging to the side of the uterus. And behind the fimbriæ +lies the ovarium, for the same reason clinging close to the side of the +uterus."[8] + +_Uterus._ The uterus is a hollow fibrous viscus situated in the +hypogastric region between the bladder and the rectum, below the +intestinum ileum and above the vagina, and is by far the largest of the +generative organs. It is of a pyriform figure: its upper portion which is +the largest is triangular, becoming gradually smaller inferiorly; that +portion of it which is above the spot where the Fallopian tubes enter is +called the _fundus uteri_; the lower and cylindrical portion receives the +name of _cervix_; that between the cervix and fundus is called the _body +of the uterus_. + +The parietes of the adult uterus are nearly half an inch in their greatest +thickness, which is about the middle of the body, the body being slightly +thicker than the cervix, which is of a somewhat harder structure. Near the +point at which the Fallopian tubes enter the uterus the parietes become +thinner, gradually diminishing from four or five to only one line in +thickness. + +The cavity of the uterus is triangular, its base being directed upwards, +the superior angles corresponding to the points where the Fallopian tubes +enter it. The cavity of the uterus is so small, owing to the thickness of +its parietes, that they are nearly in contact: it is only four lines in +breadth; the fundus, which forms the base of the triangle, is convex both +internally as well as externally; whereas, the sides which form the body +are convex internally, but somewhat concave externally. + +The cavity of the uterus is most contracted at the point where the cervix +is united to the body, which here forms the _os uteri internum_; from this +point the cervix gradually dilates as far as its middle portion, when it +again contracts; its lower extremity terminates in the upper part of the +vagina by an anterior and posterior cushion-like projection, of which the +posterior is usually the longest, although from the direction of the +uterine axis the anterior is commonly felt lowest in the pelvis. Between +these there is a transverse fissure known by the name of _os tincæ_ or _os +uteri externum_, the lips or labia of which are formed by the two +above-mentioned prominences. The internal surface of the body of the +uterus is smooth, whereas that of the cervix is uneven, forming upon its +anterior and posterior wall a number of delicate rugæ diverging obliquely +in an arborescent form, and hence called the _arbor vitæ_. The lips of the +os uteri are smooth, except when slight lacerations have taken place +during labour. + +In the virgin state the uterus is about two inches long, of which the +cervix occupies the smaller half: the greatest breadth of the body is +sixteen lines; that of the cervix from nine to ten. The uterus which has +been impregnated, especially when this has been frequently the case, +scarcely ever regains its original dimensions, and the fissure which the +os tincæ forms becomes broader from before backwards. The weight of an +adult virgin uterus is from seven to eight drachms, but the uterus which +has been once impregnated is seldom less than an ounce and a half. It lies +between the bladder and rectum, its upper half being covered by +peritoneum, which closely adheres to it. In the adult state it is situated +entirely in the cavity of the pelvis; the fundus, which is below the upper +edge of the symphysis pubis, is turned forwards and upwards, while its +mouth is directed downwards and backwards, so that its long axis is nearly +parallel to the axis of the superior aperture of the pelvis. + +The uterus is connected to the neighbouring parts by several duplicatures +of peritoneum, which are continuous with that portion of it which covers +the fundus. The most considerable are the _broad_ or _lateral ligaments_: +these arise from the sides of the uterus, which is enclosed between their +anterior and posterior layers or laminæ; they proceed transversely +outwards towards the sides of the pelvic cavity, which is thus divided +into two portions, and are then continued into that portion of the +peritoneum which lines the cavity. + +The _round ligaments_ arise from the sides of the uterus close beneath and +a little anterior to the uterine extremity of the Fallopian tubes. They +pass between the two layers of the broad ligaments, behind the umbilical +arteries, and before the iliac vessels, in a direction upwards and +outwards to the external opening of the inguinal canal; they then make a +turn round the epigastric artery downwards, inwards, and forwards, and +pass through the abdominal ring, and dividing into numerous fasciculi and +fibres are gradually lost in the cellular substance of the mons Veneris +and upper portion of the labia. Besides consisting of cellular substance +and blood-vessels, the round ligaments contain some very distinct bundles +of muscular fibres, of which the upper arise from the external layer of +uterine fibres, and the lower from the inferior edge of the internal +oblique muscle, and pass upwards. + +Upon a superficial examination, the structure of the uterus would almost +seem to be homogeneous, nevertheless a number of reddish yellow strata +interspersed with whitish streaks running from behind forwards may be +perceived even in the unimpregnated state; between these strata the +vessels of the uterus take their course, forming numerous anastomoses. + +There is much difference of opinion among anatomists as to the fibrous +structure of the uterus. The majority however agree as to the presence of +muscular fibres,[9] some considering that they always exist, while others, +and by far the greater number, consider them as appearances peculiar to +pregnancy: they are, it is true, extremely indistinct in the unimpregnated +state, but they are far from being peculiar to pregnancy, as they are +frequently developed by any circumstances by which the formative powers of +the uterus are excited. Thus in cases where the uterus has been much +distended by some anormal growth, its fibres become much developed and +distinctly fasciculated. Lobstein observed them very distinctly in a +uterus which had been distended to the size of a seven months' pregnancy +by a fatty tumour. + +The uterine fibres have been usually considered as fleshy, but they differ +from the red fibres of voluntary muscles, in being of a paler colour, +flatter, and remarkably interwoven with each other: nevertheless they +appear to be really muscular fibres from the powerful contraction with +which they expel the foetus and placenta, and nearly obliterate the cavity +of the uterus. In the unimpregnated state they resemble the fibrous coat +of an artery, whereas, those of the gravid uterus are more like the fibres +of muscle. Most anatomists agree in describing two sets of fibres, viz. +longitudinal and transverse. The external layer of fibres appears to form +the round ligaments, which seem to have the same relation with them as +tendon and muscle. "The fibres arise from the round ligaments, and +regularly diverging spread over the fundus until they unite and form the +outmost stratum of the muscular substance of the uterus. The round +ligaments of the womb have been considered as useful in directing the +ascent of the uterus during gestation, so as to throw it before the +floating viscera of the abdomen: but in truth it could not ascend +differently; and on looking to the connexion of this cord with the fibres +of the uterus, we may be led to consider it as performing rather the +office of a tendon than that of a ligament."[10] "On the outer surface and +lateral part of the womb, the muscular fibres run with an appearance of +irregularity among the larger blood-vessels, but they are well calculated +to constringe the vessels, whenever they are excited to contraction. The +substance of the gravid uterus is powerfully and distinctly muscular, but +the course of the fibres is less easily described than might be imagined: +this is owing to the intricate interweaving of the fibres with each +other--an intermixture however which greatly increases the extent of their +power in diminishing the cavity of the uterus. After making sections of +the substance of the womb in different directions, we have no hesitation +in stating that towards the fundus the circular fibres prevail, that +towards the orifice the longitudinal fibres are most apparent, and that on +the whole, the most general course of the fibres is from the fundus +towards the orifice. + +"This prevalence of longitudinal fibres is undoubtedly a provision for +diminishing the length of the organ, or for drawing the fundus towards the +orifice. At the same time these longitudinal fibres must dilate the +orifice and draw the lower part of the uterus over the head of the child. + +"In making sections of the uterus while it retained its natural muscular +contraction, I have been much struck in observing how entirely the +blood-vessels were closed and invisible, and how open and distinct the +mouths of the cut blood-vessels became when the same portions of the +uterus were distended or relaxed. This fact of the natural contraction of +the substance of the uterus closing the smallest pore of the vessels, so +that no vessels are to be seen, where we nevertheless know that they are +large and numerous, demonstrates that a very principal effect of the +muscular action of the womb is the constringing of the numerous vessels +which supply the placenta, and which must be ruptured when the placenta is +separated from the womb." + +"Upon inverting the uterus, and brushing off the decidua, the muscular +structure is very distinctly seen: the inner surface of the fundus +consists of two sets of fibres, running in concentric circles round the +orifices of the Fallopian tubes; these circles at their circumference +unite and mingle, making an intricate tissue. Ruysch, I am inclined to +believe, saw the circular fibres of one side only; and not adverting to +the circumstance of the Fallopian tube opening in the centre of these +fibres, which would have proved their lateral position, he described the +muscle as seated in the centre of the fundus uteri. This structure of the +inner surface of the fundus of the uterus is still adapted to the +explanation of Ruysch, which was that they produced contraction and +corrugation of the surface of the uterus, which, the placenta, not +partaking of, the cohesion of the surface was necessarily broken. Farther, +I have observed a set of fibres on the inner surface of the uterus, which +are not described: they commence at the centre of the last described +muscle, and having a course in some degree vortiginous, they descend in a +broad irregular band towards the orifice of the uterus: these fibres +co-operating with the external muscle of the uterus, and with the general +mass of fibres in the substance of it, must tend to draw down the fundus +in the expulsion of the foetus, and to draw the orifice and lower segment +of the uterus over the child's head." (C. Bell, _op. cit._) + +There are other circumstances which prove the muscularity of the uterus, +beyond the mere evidence of its fibres, as seen during pregnancy. "In the +quadruped," as Dr. Hunter observes, "the cat particularly and the rabbit, +the muscular action or peristaltic motion of the uterus is as evidently +seen as that of the intestines, when the animal is opened immediately +after death." It is also proved by the powerful contraction which it +exerts during labour, and "by the thickness of the fibres corresponding +with their degree of contraction." (_Ibid._) + +The inner surface of the uterus is lined by a smooth or somewhat +flocculent membrane of a reddish colour, which is continued superiorly +into the Fallopian tubes; inferiorly it becomes the lining membrane of the +vagina. + +Mucous follicles are only found in the cervix, especially at its lower +part: when by chance these become inflamed, the orifice closes, and the +follicle becomes more or less distended by a collection of thin fluid. The +mucous casts of these follicles have been known by the name of _ovula +Nabothi_, having been mistaken by an old anatomist for Graafian vesicles, +which had been detached from the ovary, and conveyed into the cavity of +the uterus. + +The mucous membrane which lines the cervix uteri is corrugated into a +number of rugæ, between which the mucous follicles are chiefly found. + +[Illustration: Uterus duplex.] + +Before quitting this subject, it will be necessary to point out the +changes which the uterus presents at different periods of foetal life, and +the great resemblance it has at these periods to the uterus, as it appears +in the lower classes of the mammalia. We may, however, observe in the +first place, that the uterus is not found to exist as a separate organ +until we come to the class mammalia; and even in the lower genera of this +class it bears a strong resemblance to the tubular character of the +generative organs in the inferior classes of animal life. The nearest to +the tubular uterus, and where the transition from the oviduct in birds, +&c. to the uterus in mammalia is least distinctly marked, is in the +_uterus duplex_. Although the uterus is double, there is but one vagina +into which the two ora uteri open; its low grade of development is marked +by the resemblance which each uterus bears to an intestinal tube: there +are as yet no traces of a cervix, each os uteri merely forming a simple +opening at the lower end of what is little more than a cylindrical canal. +We do not find that thickening at the lower extremity of the uterus which +distinguishes the cervix in the higher mammalia. This species of uterus is +found among a large portion of the rodentia, and is also occasionally met +with as an abnormal formation in the human subject. The next grade of +uterine development appears under the form of the _uterus bicollis_. The +double os uteri here ceases to exist, and the division begins a little +higher up, so that the two cavities of the uterus communicate for a short +space: the ova, however, do not reach the common cavity, but remain each +in its separate cornu. In this form of uterus, the os uteri is not only +single, but the lower portion is thickened, although it has not yet formed +a distinct neck or cervix; it is met with among some of the rodentia, and +also certain carnivora. + +[Illustration: Uterus bicollis.] + +[Illustration: Uterus bicorporeus.] + +In the _uterus bicorporeus_, the union of the cornua is higher up, so that +the lower portion is single, while the upper part alone is double, +consisting of two strongly curved cornua. This conformation is peculiar to +ruminating animals. If two ova be present they are separate from each +other, each being contained in its own distinct body or cornu, but a +portion of the membranes extends along the common cervix, from one body to +the other. + +[Illustration: Uterus bifundalis.] + +A still higher grade is the _uterus bifundalis_, where the fundus alone is +double, the cornu being formed only by this portion. This formation is +observed in the horse, ass, &c.: the common cavity is here the receptacle +of the ovum, so that in the unimpregnated state, the cornua appear only as +appendices, into which a portion of the membranes extend. + +In the _uterus biangularis_, the double formation has nearly disappeared, +except at the fundus, where the uterus imperceptibly passes into the +tubes: this is the case among the edentata, and some of the monkey tribes. + +The highest grade is the _uterus simplex_: every trace here of the double +form is lost; the fundus no longer forms an acute angle, where it +bifurcates into two cornua; but is convex. We now for the first time see +the divisions of the uterus into body and cervix distinctly marked. + +[Illustration: Uterus biangularis.] + +The human uterus presents a similar variety of forms, as it gradually +rises in the scale of development during the different periods of +utero-gestation. It is at first divided into two cornua, and usually +continues so to the end of the third month, or even later; the younger the +embryo the longer are the cornua, and the more acute the angle which they +form; but even after this angle has disappeared, the cornua continue for +some time longer. + +[Illustration: Uterus simplex.] + +The uterus is at first of an equal width throughout; it is perfectly +smooth and not distinguished from the vagina either internally or +externally by any prominence whatever. This change is first observed when +the cornua disappear and leave the uterus with a simple cavity. The upper +portion is proportionably smaller, the younger the embryo is. The body of +the uterus gradually increases, until at the period of puberty it is no +longer cylindrical, but pyriform: even in the full-grown foetus the length +of the body is not more than a fourth part of the whole uterus; from the +seventh even to the thirteenth year it has only a third, nor does it reach +a half until puberty has been fully attained. The os tincæ or os uteri +externum first appears as a scarcely perceptible prominence projecting +into the vagina; it increases gradually, in size until the latter months +of gestation, when the portio vaginalis is relatively much larger than +afterwards. + +The parietes of the uterus are thin in proportion to the age of the +embryo. They are of an equal thickness throughout at first: at the fifth +month, the cervix becomes thicker than the upper parts; between five or +six years of age, the uterine parietes are nearly of an equal thickness, +and remain so until the period of puberty, when the body becomes somewhat +thicker than the cervix. + +As the function of menstruation with its various derangements will be +considered among the diseases of the unimpregnated state, we proceed to +consider these changes which the uterus undergoes during pregnancy as well +as during and after labour: these are very remarkable both as regards its +structure, form, and size. + +Shortly after conception, and before we can perceive any traces of the +embryo, the uterus becomes softer and somewhat larger, its blood-vessels +increased in size, and the fibrous layers of which its parietes are +composed looser and more or less separated. The internal surface when +minutely examined has a flocculent appearance, and very quickly after +conception becomes covered with a whitish paste-like substance, which is +secreted from the vessels opening upon it; this pulpy effusion soon +becomes firmer and more dense; it bears a strong analogy to coagulable +lymph, and forms a membrane which lines the whole cavity of the uterus, +and which in the course of a few weeks (from changes to be mentioned +hereafter) crosses the os uteri and thus closes it. The uterine cavity in +a short time becomes still farther closed by the canal of the cervix being +completely sealed, as it were, by a tough plug of gelatinous matter which +is secreted by the glandules of that part. + +The structure of the uterus becomes remarkably altered; its fibrous +structure is much more apparent; in fact, it is only during pregnancy, or +when the uterus has been distended by some anormal growth, that we are +able to detect the uterine fibres with any degree of certainty. This has +led some anatomists to consider that they are only formed at such periods, +a supposition which is not very probable; at any rate they now become very +distinct: hence the uterus does not owe its increasing size to mere +extension, but it evidently acquires a considerable increase of substance, +a fact which is not only proved by examining the contracted uterus after +labour at the full period, but also by comparing its weight with that of +the unimpregnated organ. The adult virgin uterus weighs about one ounce, +whereas the gravid uterus at the full term of pregnancy, when emptied of +its contents, weighs at least twenty-four ounces, showing that there has +been an actual increment of substance in the proportion of one to +twenty-four. Having ascertained this point, it next becomes a question, +whether the parietes of the gravid uterus increase in thickness during +pregnancy, or whether they become thinner. Meckel, who is one of the +greatest modern authorities on these subjects, states that from careful +admeasurement of sixteen gravid uteri at different periods of gestation, +he finds the parietes become thicker during the first, second, or third +months, but after this period they become gradually thinner up to the full +time: they are thicker in the upper parts of the uterus, whereas +inferiorly they are a third or nearly a half less. + +Nothing proves the actual increase of bulk and substance in the uterus +more than its appearance when contracted immediately after labour at the +full term; it forms a fleshy mass as large as the head of a new-born +child, the parietes of which are at least an inch in thickness. + +"The spongy or cellular tissue (says M. Leroux) becomes considerably +developed during pregnancy, and its porous cells increase in proportion as +the uterus dilates, more especially at the fundus and the spot where the +placenta is attached, where they become so large as to admit a goosequill. +The internal membrane is pierced with numerous orifices, of which some are +the mouths of arteries, and others communicate with the cells already +mentioned. This membrane also during pregnancy forms those irregular +tufted rugæ, which serve to give a more intimate connexion between the +uterus and the placenta. In the unimpregnated uterus and in the intervals +between the menstrual periods the little orifices which are observed in +the lining membrane of the uterus contain only a transparent lymph, which +lubricates the interior of the uterus; during the appearance of the menses +they contain blood, and during pregnancy they are connected with the +vessels of the placenta and chorion."[11] + +There is no circumstance in which the gravid uterus differs more from the +unimpregnated than in the size and termination of its blood-vessels. The +arteries, both spermatic and hypogastric, are very much enlarged. The +hypogastric is commonly considerably larger than the spermatic, and we +very often find them of unequal sizes in the different sides. They form a +large trunk of communication all along the side of the uterus, and from +this the branches are sent across the body of the uterus both before and +behind. The cervix uteri has branches only from the hypogastrics, and the +fundus only from the spermatics; or, in other words, the hypogastric +artery gives a number of branches to the cervix, besides sending up the +great anastomosing branch, and the spermatic artery supplies the tube and +fundus uteri before it gives down the anastomosing branch on the lateral +parts of the uterus. All through the substance of the uterus there are +infinite numbers of arteries large and small, so that the whole arterial +system makes a general network, and the arteries are convoluted or +serpentine in their course.[12] Hardly any of the larger arteries are seen +for any length of way upon the outside of the uterus. As they branch from +the sides where they first approach the uterus, they disappear by plunging +deeper and deeper into its substance. + +The arterial branches which are most enlarged are those which run towards +the placenta, so that wherever the placenta adheres, that part appears +evidently to receive by much the greatest quantity of blood, and the +greatest number both of the large and small arteries at that part pass +through to the placenta, and are necessarily always torn through upon its +separation. The veins of the uterus would appear to be still more enlarged +in proportion than the arteries. The spermatic and hypogastric veins in +general follow the course of the arteries, and like them anastomose on the +side of the uterus. From thence they ramify through the substance of the +uterus, running deeper and deeper as they go on, and without following +precisely the course of the arterial branches. They form a plexus of the +largest and most frequent communications which we know of in the vessels +of the human body, and this they have in common with the arteries that +their larger branches go to, or rather come from, that part of the uterus +to which the placenta adheres: so that when the venous system of the +uterus is well injected, it is evident that that part is the chief source +of returning blood. Here, too, both the large and small veins are +continued from the placenta to the uterus, and are always necessarily +broken, upon the separation of these two parts. As I know no reason for +calling the veins of the uterus sinuses, and as that expression has +probably occasioned much confusion among the writers upon this subject, I +have industriously avoided it.[13] + +The form of the uterus changes considerably during pregnancy: the upper +part appears to increase in greater proportion than the lower, a fact +which appears to be proved from the alteration which takes place in the +relative position of the Fallopian tubes, which are situated much lower +down the sides of the uterus at full term than in the unimpregnated state, +nor do they entirely regain their former position after labour, until the +female has attained an advanced age; hence as the cervix diminishes in +length during the latter half of pregnancy, it follows that the difference +in point of size between the fundus and the body of the uterus, and this +part will be continually increasing. + +As the uterus increases, the fundus of course rises and can be felt +through the distended abdominal parietes: its anterior surface, especially +in the latter month of pregnancy, lies immediately behind the anterior +wall of the abdominal cavity, and pushes the small intestines upwards, +backwards, and to the sides. + +The form of the gravid uterus differs also from that in the unimpregnated +state in other respects, and this difference appears to depend in great +measure upon its increase of size, and upon the form of the cavities which +it occupies. Thus in the unimpregnated state when it occupies the cavity +of the pelvis, its anterior surface which corresponds to the bladder is +flattened; whereas its posterior surface, which is turned towards the +hollow of the sacrum, is convex; it is however the reverse during the +latter half of pregnancy. The anterior surface is now strongly convex, +being merely covered by the yielding anterior wall of the abdomen; whereas +posteriorly the uterus is nearly concave, corresponding to the solid +convexity of the lumbar vertebræ, a fact which may be easily ascertained +by examining the abdomen of a patient in the last month of pregnancy while +lying down. The situation and position of the uterus are also changed in +the unimpregnated state; the fundus is inclined somewhat backwards, the +os uteri being nearly in the centre of the pelvic cavity, but the gravid +uterus during the latter half of pregnancy has its fundus strongly +inclined forwards and the os uteri directed backwards towards the upper +part of the hollow of the sacrum.[14] + +A minute and intimate knowledge of the changes and appearances which the +uterus presents at every period of pregnancy, is essential to the +diagnosis and treatment of the various derangements to which this process +is subject. The numerous and important questions in medical jurisprudence +connected with pregnancy can alone be determined by its means; and it is +only by more close and attentive observation of every step in the gradual +development of the uterus up to the full term of gestation, that we can +expect to increase our means of forming a correct and certain diagnosis in +those cases of doubtful pregnancy, where not merely professional +reputation is more or less at stake, but the character, happiness, and +even life of the individual upon whose case we are required to decide. + +During the first month of pregnancy the changes are not very appreciable +upon examination during life. The uterus has become larger, softer, and +more vascular, much as it does during a menstrual period. The portio +vaginalis of the cervix, which in the unimpregnated state is hard and +almost cartilaginous to the feel, becomes softer and larger:[15] the +transverse fissure which the os uteri forms is more oval. + +In the second month, the abdomen becomes somewhat flat: the portio +vaginalis can be now reached by the finger with greater ease than at any +time of pregnancy, which is not from the uterus itself being lower in the +pelvis, but from not yet having altered its position; any increase of its +size therefore will cause its inferior extremity to be felt lower down and +nearer to the os externum. The os uteri has undergone a considerable +change, inasmuch as its edges have lost their lip-like figure; they now +form a ring or rather dimple-like concavity at the lower end of the +cervix, its canal being closed by the gelatinous plug already mentioned. + +In primiparæ, or women pregnant for the first time, the margin of the os +uteri thus closed is not only circular but perfectly smooth; whereas in +multiparæ, not only is the cervix usually larger in every direction, but +the os uteri itself is larger, thicker, and of an irregular shape; it is +also knotty here and there from little callous cicatrices, where its edge +has been torn in former labours. + +In the third month of pregnancy the uterus rises above the brim of the +pelvis. A slight protrusion of the abdomen may be sometimes observed above +the pubes; the os uteri is not reached so easily as in the preceding +month. The alteration which takes place in the situation of the uterus +during the third month appears to result from gradual shortening of the +broad ligament as it increases in size. As the uterus rises it pushes up +that portion of the small intestines which rests upon it; these however +being confined by the mesentery to the spine, and therefore prevented +ascending before the uterus, at length slip down behind it, and the fundus +being freed from the superincumbent pressure rises in a direction upwards +and forwards into the cavity of the abdomen. The direction of the uterus +becomes much altered; the os uteri is no longer in the middle of the +pelvic cavity, but inclines towards the upper part of the hollow of the +sacrum, whereas the fundus approaches more and more to the anterior +parietes of the abdomen. + +In the fourth month, the fundus uteri has risen about two or three +fingers' breadth above the symphysis pubis; this is not very easily +ascertained even in a thin person, still less where the patient is stout +and the parietes of the abdomen therefore thick. The directions which the +celebrated Roederer has given for making an examination of the abdomen +during the early months of pregnancy, are well worthy of notice. Having +evacuated the bladder and rectum, the patient should be placed in a +half-sitting posture with the knees drawn up, so as to relax the abdominal +parietes as much as possible: she must then breathe slowly and deeply; and +if the hand be suddenly pressed against the abdomen a little above the +symphysis pubis, at the moment of her making a full expiration, we shall +in all probability feel the hard globe of the uterus. + +In the fifth month, the fundus will be felt half way, or a little more, +between the symphysis pubis and umbilicus. The increased size of the +abdomen cannot be concealed by the dress; the portio vaginalis has become +distinctly shorter, and the os uteri is situated higher in the pelvis and +more posteriorly. + +In the sixth month, the fundus has risen as high as the umbilicus; the +irregular folds of the skin which form the fovia umbilici or navel +depression begin to disappear; the first perceptible movements of the +child may occasionally be felt; the portio vaginalis has lost half its +length, being scarcely half an inch in length. + +[Illustration: Cervix uteri about the sixth or seventh month.] + +In the seventh month, the fundus rises an inch or so above the umbilicus, +the folds of which have nearly disappeared. In some cases it begins to +protrude, forming a species of umbilical hernia: this varies a good deal +in different individuals, being more marked in primiparæ; whereas in +women, whose abdomen has been distended in previous pregnancies, little or +no convexity of the navel is produced until a later period, and not always +even then, the umbilical depression being merely diminished in point of +depth, and its folds not so strongly marked. The movements of the child +are now perfectly distinct; the portio vaginalis is still shorter, and +approaches more and more to the upper part of the hollow of the sacrum. +The anterior portion of the inferior segment of the uterus, or that part +which extends from the os uteri towards the symphysis pubis, is now +considerably developed and convex, and on pressing the point of the finger +against it, the presenting part of the child will be felt. When this is +the head as is usually the case, it will feel like a light ball which +rises when pushed by the finger, but which, if the finger be held still, +in a few moments descends and may again be felt. + +[Illustration: Cervix uteri in the eighth month.] + +In the eighth month, the fundus has risen half way between the umbilicus +and the scrobiculus cordis. The abdomen has increased considerably in +size, and has become more convex; the umbilical depression in primiparæ +has entirely disappeared. The portio vaginalis is still shorter, being +barely a quarter of an inch in length. The os uteri is so high up as not +to be reached without difficulty; the presenting part of the child can be +distinctly felt. + +[Illustration: Cervix uteri in the ninth month.] + +In the ninth month, the fundus has reached nearly to the scrobiculus +cordis, and by the end of the month is quite in it; this is more +especially the case with primiparæ: the anterior parietes of the abdomen +not allowing the fundis to incline so strongly forwards, the oppression of +breathing is therefore more marked in them than in multiparæ, for the +fundus uteri rising so high prevents in great measure the action of the +diaphragm, so that the chest is expanded by other muscles; hence the +shortness of breath and inability of moving, so frequently complained of +at this period of utero-gestation. The portio vaginalis is still shorter, +and in the primipara forms little more than a soft cushiony ring which +marks the os uteri. The inferior part of the uterus is becoming more +spherical, and is usually occupied by the presenting part of the child: +this latter is no longer so moveable as before, its size as also its +weight being evidently increased. That portion of the uterus which extends +between the symphysis pubis and os uteri is now not only more convex but +lower in the pelvis than the os uteri itself. + +During the last four weeks of pregnancy a considerable change is observed. +The fundus is now lower than it was in the preceding month, being about +half way between the scrobiculus cordis and umbilicus; the abdomen has, as +it is called, _fallen_; and from the diaphragm being now able to resume +its functions the breathing becomes more easy, and the female feels more +comfortable and capable of moving about. On examination per vaginam the +anterior portion of the inferior segment of the uterus will be felt still +deeper in the pelvis: if the head presents it distends this part of the +uterus, so that, in many cases, we have to pass the finger round it before +we can reach the os uteri, which is now in the upper part of the hollow of +the sacrum. All traces of the cervix have now disappeared, it having been +required to complete the full development of the uterus; the situation of +the os uteri itself is marked merely by a small depression or dimple; +there is no longer any distinction between the os uteri internum and +externum; the edges of the opening are so thin as to be nearly membranous, +but remain closed in primiparæ until the commencement of labour.[16] + +In women who have had several children, a considerable difference is +observed as regards the state of the cervix and os uteri: the cervix does +not undergo that shortening during the latter half of pregnancy, which is +the case in a primipara, a portion of it at least remaining up to the full +term of utero-gestation: in many cases, especially where the female has +had a large family, it is nearly an inch long at this period; nor is the +lower portion of the uterus so spherical as in the primipara; to this +circumstance may probably be attributed the fact of the head not +descending so deep into the pelvis just before labour. In multiparæ the os +uteri is also very different: instead of being perfectly round with its +edges smooth, it is irregular and uneven, and seldom loses altogether the +lip-like shape of the unimpregnated state in consequence of the greater +thickness and elongation of its lips from former labours; its edges here +and there is uneven and knotty, from little callous cicatrices, where it +has been torn; moreover it does not remain closed till the commencement of +labour, but the os uteri externum (commonly called os tincæ,) and +sometimes even the os uteri internum will be more or less open during the +last three or four weeks of pregnancy. These peculiarities are of great +importance in coming to a conclusion as to whether a patient be in her +first pregnancy or not: although not invariable in the utmost sense of the +word, still their occurrence, even after a single labour, is sufficiently +frequent to make them worthy of careful observation. Indeed, on more than +one occasion, we have known them occur even after a miscarriage, a +circumstance on the strength of which the patient had ventured to deny +that she was pregnant. On the other hand, we sometimes meet with the os +uteri in a second pregnancy so little altered by the effects of the +previous labour, that it would be extremely difficult to come to a +decision. + +When labour is over, the uterus contracts very considerably, and, in a few +days after, its parietes will be found at least an inch in thickness. It +now gradually diminishes in size, and continues to do so for some weeks; +the blood-vessels contract, and losing the peculiarly loose spongy +structure of pregnancy it becomes harder, firmer, and more compact. It +nevertheless remains softer and larger than in the virgin state, and does +not attain its original size and hardness until an advanced period of +life. + +The os uteri, which in the latter months of pregnancy had formed a +circular opening, resumes its former shape, except that its lips, +especially the posterior one, which are more or less irregular and uneven, +are thicker and longer than in the virgin state. For the first weeks after +labour, the os uteri is high in the pelvis, soft, and easily admits the +tip of the finger; at the end of the second week it is much lower in the +pelvis, and no longer permits the finger to pass. Immediately after +labour, the contracted uterus forms a hard solid ball, the size of a +new-born child's head; this state of contraction is not, however, of long +continuance: in the course of half an hour, or even less, it begins to +increase in size, becoming softer and larger, and continuing to increase +slowly for some hours, when it again gradually diminishes, until, as +before observed, it approaches its original size in the unimpregnated +state. The state of powerful contraction in which the uterus is felt +immediately after labour, after a time gradually relaxes; its spongy +texture, from which the blood had been forcibly expelled by the violent +action of its fibres, becomes again filled with blood; the organ swells +and becomes softer and more bulky, and the orifices of the vessels which +open into the cavity of the uterus are again partly pervious, and emit a +sanious fluid called the _lochia_. This state lasts for two or more days +after delivery, when the vessels begin to recover their former caliber, +and lose that degree of dilatation peculiar to the gravid state. The +lochia become less and less coloured, and now, and not before the uterus +undergoes that gradual diminution of size and bulk which we have just +alluded to. + +The copulative or external organs of generation are the _vagina_, _hymen_, +_clitoris_, _nymphæ_, and _labia_, the three last being known by the term +_vulva_. + +_Vagina._ The vagina is a canal of about four inches in length and one in +breadth, broader above than below; its parietes are thin and are +immediately connected with the uterus. It envelopes the portio vaginalis +of the uterus at its upper or blind extremity (fundus vaginæ,) and is +continuous with its substance; inferiorly, where it is narrowest, it +passes into the vulva. It is situated between the bladder and rectum, and +attached to each by loose cellular tissue. Its direction differs from that +of the uterus, for its axis corresponds very nearly with that of the +pelvic outlet, running downwards and forwards. Posteriorly it is somewhat +convex, anteriorly concave. + +The vagina consists of two layers; the external, which is very thin, firm, +of a reddish-white colour, and continuous with the fibrous tissue of the +uterus; and a lining mucous membrane which is closely united to it. This +latter is much corrugated, especially in the virgin state, the rugæ +running transversely in an oblique direction, and gathered together on its +anterior and posterior surface, forming the _columna rugarum anterior and +posterior_, which appear to be a continuation of the corrugations which +form the arbor vitæ of the cervix. + +In the upper part of the vagina there are considerable mucous follicles, +which moisten the canal with their secretion, and which during sexual +intercourse, and particularly during the first stage of labour, pour forth +an abundant supply of colourless mucus for the purpose of lubricating the +vagina, and rendering it more dilatable. Near its orifice, especially at +the upper part, the veins of the vagina form the _plexus retiformis_, a +congeries of vessels which has almost a cellular appearance, and from this +reason has been called the _corpus cavernosum_ of the vagina; it appears +to be capable of considerable swelling from distension with blood, like +the corpus cavernosum penis, and by this means serves to contract still +farther the os externum during the presence of venereal excitement. A +similar disposition to form plexuses of vessels is seen in the venous +circulation of the nymphæ, bladder, and rectum. + +_Hymen._ The lining membrane of the vagina is of a reddish-gray colour, +interspersed here and there, especially at its upper part, with livid +spots like extravasation. At the os externum it forms a fold or +duplicature called _hymen_, running across the sides of the posterior part +of the opening, and usually of a crescentic figure, the cavity looking +upwards. The duplicatures of membrane are united by cellular tissue. In +some instances, the hymen arises from the whole circumference of the os +externum, having a small orifice in the centre for the escape of the +menses and vaginal secretions: in some rare cases it is cribriform; and in +others it completely closes the vaginal entrance. When torn in the act of +sexual intercourse, it generally forms three or four little triangular +appendages, called _carunculæ myrtiformes_, arising from the posterior and +lateral portions of the os externum. + +From the identity of its fibrous coat with that of the uterus, the vagina +possesses considerable powers of contraction, when excited by the presence +of any body which distends it; hence it is a valuable assistance to the +uterus during labour: it also stands in the same relation to the abdominal +muscles that the rectum does, so that as soon as it is distended by the +head, &c. it calls them into the strong involuntary action, which +characterizes the bearing down pains of the second stage of labour. The +orifice of the vagina (os externum) is surrounded by a thin layer of +muscular fibres, which arise from the anterior edge of the sphincter ani; +they enclose the outer margin of the vagina, cover its corpus cavernosum, +and are inserted into the crura clitoridis at their union. It has been +called the sphincter or constrictor vaginæ, and assists the corpus +cavernosum still farther in contracting the os externum. + +_Clitoris._ The clitoris is an oblong cylindrical body, situated beneath +the symphysis pubis, arising from the upper and inner surface of the +ascending rami of the ischium, by means of two crura of about an inch +long, and uniting with each other at an obtuse angle. It terminates +anteriorly in a slight enlargement, called the _glans clitoridis_, which +is covered with a thin membrane or a loose fold of skin, viz. the +_preputium clitoridis_. It is a highly nervous and vascular organ, and +like the penis of the male, is composed of two crura and corpora +cavernosa, which are capable of being distended with blood; they are +contained in a ligamentous sheath, and have a septum between them. The +clitoris is also provided with a suspensory ligament, by which it is +connected to the ossa pubis. Like that of the penis, the glans clitoridis +is extremely sensible, but has no perforation. Upon minute examination, it +will be found that the gland is not a continuation of the posterior +portion of the clitoris, but merely connected with it by cellular tissue, +vessels, and nerves; the posterior portion terminates on its anterior +surface in a concavity which receives the glans. In the glans itself there +is no trace of the septum, which separates the corpora cavernosa. On the +dorsum of the clitoris several large vessels and nerves take their course, +and are distributed upon the glans, and upon its prepuce are situated a +number of mucus and sebaceous follicles. + +The crura clitoridis at their lower portion are surrounded by two +considerable muscles, called the erectores clitoridis, arising by short +tendons close beneath them from the inner surface of the ascending ramus +of the ischium, and extending nearly to their extremity. + +_Nymphæ._ The _nymphæ_ or _labia pudendi interna_, are two long corrugated +folds, resembling somewhat the comb of a cock, arising from the prepuce +and glans clitoridis, and remaining obliquely downwards and outwards along +the inner edge of the labia, increasing in breadth, but suddenly +diminishing in size. At their lower extremity they consist of a spongy +tissue, which is more delicate than that of the clitoris, but resembles +considerably that of the glans, of which it appears to be a direct +continuation. It has been called the _corpus cavernosum nympharum_, and is +capable of considerable increase in size when distended with blood. The +two crura of the prepuce terminate in their upper and anterior +extremities; they are of a florid colour, and in their natural state they +are contiguous to, and cover the orifice of the urethra. The skin which +covers them is very thin and delicate, bearing a considerable resemblance +to mucous membrane, especially on their inner surface, where it is +continuous with the vagina; externally it passes into the labia. + +The space between the nymphæ and edge of the hymen is smooth, without +corrugation, and is called _vestibulum_. + +Close behind the clitoris, and a little below it, is the orifice of the +urethra, lying between the two nymphæ: it is surrounded by several lacunæ +or follicles of considerable depth, secreting a viscid mucus; its lower or +posterior edge is, like the lower portion of the urethra, covered by a +thick layer of cellular tissue, and a plexus of veins, which occasionally +become dilated and produce much inconvenience; it is this which gives the +urethra the feel of a soft cylindrical roll at the upper part of the +vagina; and in employing the catheter, by tracing the finger along it, the +orifice will be easily found. + +_Labia._ The labia extend from the pubes to within an inch of the anus, +the space between the vulva and anus receiving the name of _perineum_. + +The opening between the labia is called the _fossa magna_: it increases a +little in size and depth, as it descends, forming a scaphoid or boat-like +cavity, viz. the _fossa navicularis_. + +The labia are thicker above, becoming thinner below, and terminate in a +transverse fold of skin, called the _frænulum perinei_, or _fourchette_, +the edge of which is almost always slightly lacerated in first labours. +They are composed of skin cushioned out by cellular and fatty substance, +and lined by a very vascular membrane, which is thin, tender, and red, +like the inside of the lips; they are also provided with numerous +sebaceous follicles, by which the parts are kept smooth and moist. + + + + +CHAPTER III. + +DEVELOPMENT OF THE OVUM. + + _Membrana decidua.--Chorion.--Amnion.--Placenta.--Umbilical + cord.--Embryo.--Foetal circulation._ + + +_Membrana decidua._ The earliest trace of impregnation which is to be +observed in the cavity of the uterus, and even before the ovum has reached +it, is the presence of a soft humid paste-like secretion, with which the +cavity of the uterus is covered, and which is furnished by the secreting +vessels of its lining membrane. This is the _membrana decidua_ of Hunter: +properly speaking, it should be called the _maternal membrane_, in +contra-distinction to the chorion and amnion, which, as belonging +peculiarly to the foetus, are called the _foetal_ membranes.[17] + +Although at first in a semi-liquid state, it soon becomes firmer and more +compact, assuming the character of a membrane: it appears to be nothing +else than an effusion of coagulable lymph on the internal surface of the +uterus, having "scarcely a more firm consistence than curd of milk or +coagulum of blood." (Hunter, _op. cit._ p. 54.) Hence, although much +thicker than the other membranes, it is weaker; it is also much less +transparent. + +It is not of an equal thickness, being considerably thicker in the +neighbourhood of the placenta than elsewhere; inferiorily, and especially +near the os uteri, it becomes thinner: during the first weeks of pregnancy +it is much thicker than afterwards, becoming gradually thinner as +pregnancy advances, until it is not half a line in thickness. In the +earlier months its external surface is rough and flocculent, but +afterwards it becomes smoother as its inner surface was at an earlier +period. + +It is much more loosely connected with the uterus during the first months +of pregnancy than afterwards, and this is one reason why premature +expulsion of the ovum is more liable to take place at this period than +during the middle and latter part of utero-gestation. It is more firmly +attached to the uterus in the vicinity of the placenta than any where +else, which is owing to the greater number of blood-vessels it receives +from the uterus at this point; whereas commonly "it has no perceptible +blood-vessels at that part which is situated near the cervix uteri," +(_Ibid._,) this portion being much more loosely connected with the uterus. +The course which the decidual vessels take on coming from the inner +surface of the uterus is admirably adapted to render the attachment of +this membrane to it as firm as possible. + +[Illustration: Vascularity of the decidua. _From Baer._] + +Upon examining the lining membrane of the uterus at a very early period, +when the decidua was still in a pulpy state, Professor v. Baer +observed[18] that its villi, which in an unimpregnated state are very +short, were remarkably elongated: between these villi, and passing over +them, was a substance, not organized but merely effused, and evidently the +membrana decidua at an extremely early age. The uterine vessels were +continued into this substance, and formed a number of little loops round +the villi, thus anastomosing with each other. On account of this reticular +distribution it was impossible to distinguish arteries from veins; there +is evidently the same relation between the uterus and the decidua as +between an inflamed surface and the coagulable lymph effused upon it. + +[Illustration: Decidual cotyledons. _From Dr. Montgomery._] + +Professor v. Baer considers that at a later period the connexion between +the decidua and mucous membrane becomes so intimate, that it is impossible +to separate the former without also separating the latter from the fibrous +tissue of the uterus. This, we apprehend, is the stratum which, as Dr. +Hunter observes, "is always left upon the uterus after delivery, most of +which dissolves and comes away with the lochia." He does not appear to +have been fully aware of the close connexion between the decidua and +lining membrane of the uterus, although he evidently observed the fact +from the following sentence: "in separating the membranes from the uterus +we observe that the adhesion of the decidua to the chorion, and likewise +its adhesion to the _muscular fibres of the uterus_, is rather stronger +than the adhesion between its external and internal stratum, which, we may +presume, is the reason that in labour it so commonly leaves a stratum +upon the inside of the uterus." According to the observations of Dr. +Montgomery, a great number of small cup-like elevations may be seen upon +the external surface of the decidua vera, "having the appearance of little +bags, the bottoms of which are attached to, or embedded in, its substance; +they then expand or belly out a little, and again grow smaller towards +their outer or uterine end, which, in by far the greater number of them, +is an open mouth when separated from the uterus: how it may be while they +are adherent, I cannot at present say. Some of them which I have found +more deeply embedded in the decidua were completely closed sacs. They are +best seen about the second or third month, and are not to be found at the +advanced periods of gestation."[19] + +[Illustration: _a_ Uterus. _d_ Decidua reflexa. _b_ Fallopian tube. _e_ +Ovum. _c_ Decidua.] + +The membrana decidua does not envelope the ovum with a single covering, +but forms a double membrane upon it, somewhat like a serous membrane; in +fact, the descent of the ovum through the Fallopian tube is very similar +to that of the testicle through the inguinal canal into the scrotum. The +ovum pushes before it that portion of the decidua which covers the uterine +extremity of the Fallopian tube, and enters the cavity of the uterus, +which is already lined with decidua, covered by the protruded portion +which forms the _decidua reflexa_. It must not be supposed that this +reflexion of the decidua is completed as soon as the ovum enters the +uterine cavity; the ovum usually remains at the mouth of the Fallopian +tube, from which it has emerged, covered by the plastic mass of soft +decidua, and the reflexion of this membrane will take place in proportion +as the ovum gradually increases in size. The external layer of decidua is +called _decidua vera_; the internal or reflected portion is called the +_decidua reflexa_, having received this appellation from its discoverer, +Dr. Hunter. These membranes would, as Dr. Baillie has correctly observed, +be more correctly named the _decidua uteri_ and _decidua chorii_: the +decidua chorii or reflexa is reflected inwardly from above downwards; it +is connected on its inner surface with the chorion: externally it is +unattached, whereas, the decidua uteri or vera is unconnected on its inner +surface, but attached to the uterus externally. + +The membrana decidua differs in its arrangement from that of a serous +membrane, inasmuch, as it is not only reflected so as to cover the +chorion, but at the point of reflexion it is continued over the chorion +externally, where it forms the placenta, so that the chorion is enclosed +in all directions by the decidua: this latter portion, however, is not +formed till about the middle of pregnancy. The decidua uteri or vera does +not extend farther than the os uteri internum, which is filled up by the +plug of tough gelatinous substance above described; the decidua chorii or +reflexa, from its forming the outer covering of the chorion, of course +passes over the os uteri. + +[Illustration: _Membrana decidua._ + +The lower orifice corresponds to the os uteri, the two upper ones to the +Fallopian tubes. _From Dr. Hunter._] + +According to Mr. John Hunter, the decidua vera is continued some little +way into the Fallopian tubes, more especially, on that side where the +corpus luteum has been formed; it is perforated at the points where the +Fallopian tubes enter, as well as at the os uteri, a fact which is +beautifully shown in Dr. Hunter's last plate: but this does not continue +long, for, as Mr. John Hunter observes, the inferiour opening becomes +closed in the first month, and, according to Lobstein's observations, the +openings of the Fallopian tubes are closed after the second month. "Where +the decidua reflexa is beginning to pass over the chorion, there is, at an +early period of pregnancy, an angle formed between it and the decidua, +which lines the uterus; and here the decidua is often extremely thin and +perforated with small openings so as to look like a piece of lace. + +"In proportion as pregnancy advances, the decidua reflexa becomes +gradually thinner and thinner, so that at the fourth month it forms an +extremely fine layer covering the chorion; it comes at the same time more +and more closely in contact with the decidua, which lines that part of the +uterus to which the placenta is not fixed, till at length they adhere +together."[20] That portion of the decidua which passes between the +placenta and uterus during the latter half of gestation, is called the +_placental decidua_, the description of which will be given with that of +the placenta. + +To Dr. W. Hunter are we indebted for the first correct description of the +decidua; indeed, so excellent is it, that the membrane has been called +after him, the _decidua of Hunter_. Although he was the undoubted +discoverer of the reflexa, the existence of the decidua was distinctly +noticed by Burton, in 1751. In stating the _post mortem_ examination of a +woman, who died undelivered at the full time of pregnancy, he says, "Upon +wiping the inside of the uterus very gently with a sponge, there seemed to +be pieces of a very tender thin transparent membrane adhering to it in +such parts of the uterus where the placenta did not stick to it; but as +the womb was somewhat corrupted, and the membrane so very tender, we could +not raise any bulk of it so as to be certain what it was." (Burton's +_Midwifery_.) + +The decidua seems chiefly intended to form the maternal part of the +placenta: (see _Placenta_:) hence in all those quadrupeds when the +maternal part of the placenta is permanently appended to the internal +surface of the uterus, no decidua is found. + +Having described the maternal membranes of the ovum, we come now to the +membranes which form the parietes of the ovum. These are called the +_foetal membranes_, for they are essentially connected with the origin of +the foetus itself. They are the _chorion_ and the _amnion_; besides which, +there are two others that require notice, viz. the _vesicula umbilicalis_ +and _allantois_. + +_Chorion._ The chorion is the proper covering of the ovum, and corresponds +to the membrane lining the shell of an egg, in oviparous animals. It is a +thin and transparent membrane, and presents on its external surface a +ragged tufted appearance, being covered externally with groups of +arborescent villous processes, which after a time unite into trunks to +form the umbilical vessels, which, according to Lobstein's observations, +are merely veins during the early period of gestation. These loose tufts +of venous radicles appear to absorb nourishment for the ovum, much in the +same manner as the roots of a plant. Although the chorion is so thin and +transparent, it consists nevertheless of two laminæ or layers, between +which the villi, which produce this shaggy appearance, take their course. +Although the chorion on its external surface is nothing but a net-work of +villi, which in process of time become vascular, anatomists have been +unable to detect blood-vessels in the structure of the membrane itself. +Its vascularity, however, has been asserted chiefly on the ground of the +known vascularity of the decidua, it being supposed that the vessels of +the decidua penetrate into the chorion. The chorion, however, belongs so +essentially and exclusively to the foetus, that it appears extremely +improbable that any maternal vessels should ramify in its structure for +the purposes of its nourishment and growth, and the more so when we +reflect that the nutrition of the foetus itself at this early period is +obtained in so different a manner. It is, moreover, extremely difficult to +distinguish between the venous absorbing radicles of the chorion, which +form the early rudiments of the umbilical vessels, and any vessels which +may take their course in the structure of the membrane itself; and the +more we consider the relation between the chorion and the decidua, the +less are we inclined to accept Meckel's explanation of the vascularity of +the chorion, viz. that the vessels of the decidua have the same relation +to those of the chorion as the blood-vessels of the maternal part of the +placenta have to those of the foetal part. + +Neither nerves nor lymphatics have been discovered in the structure of the +chorion, unless, indeed, those white filaments, which are observed here +and there about the edge of the placenta, perform the office of +lymphatics. This has been hinted at by Dr. Hunter, where he says, "these +are the remains of those shaggy vessels which shoot out from the chorion +in a young conception, and give the appearance of the ovum being +altogether surrounded by the placenta at that time. With a magnifying +glass, they appear to be transparent ramifying vessels, which run in +corresponding furrows upon the internal surface of the decidua, and a good +deal resemble lymphatics." (W. Hunter, _op. cit._ p. 53.) + +The chorion undergoes various changes during the different periods of +pregnancy, and forms a very important part of the physiology of +utero-gestation. Its thickness, which in the earlier months of pregnancy +is more considerable than afterwards, at this period is uniform in every +part of the ovum: its external surface covered with those villous +prolongations which have already been alluded to. In the second month of +pregnancy these become larger, and much more arborescent; after the third +month a considerable portion of them gradually disappears, generally from +below upwards, so that the greater part of its external surface becomes +nearly smooth, except at that point where the umbilical cord has its +origin, at which spot the villous prolongations become more developed, and +unite to form the umbilical vessels. This part of the chorion, together +with the corresponding portion of the membrana decidua, forms a flat +circular mass, which at the end of pregnancy covers nearly one-third of +the surface of the ovum, and constitutes the placenta or after-birth. At +this point the chorion, which forms its inner surface, is considerably +thicker than elsewhere. + +At the commencement of pregnancy the chorion is but loosely connected with +the decidua, but by degrees it becomes so closely connected by fibres, +which are the remains of the little vascular prolongations, especially +where these two membranes combine to form the placenta, that in the latter +months of pregnancy, they can scarcely, if at all, be separated. + +For the more minute consideration of the formation, development, and +functions of the chorion, we must refer to the description of the placenta +and foetus. + +_Amnion._ The amnion is the inner membrane of the ovum. It is transparent, +and of great tenuity, "yet its texture is firm, so as to resist laceration +much more than the other membranes." (W. Hunter, _op. cit._ p. 50.) It is +loosely connected with the chorion on its external surface, except when +this membrane unites with the decidua to form the placenta at which spot +it adheres to the chorion much more firmly. Its inner surface, which is in +immediate contact with the liquor amnii, is very smooth; whereas +externally, from being connected with the chorion by an exceedingly fine +layer of cellular tissue, its surface is not so smooth. Dr. W. Hunter +considers that this intervening tissue, is a gelatinous substance: it +seems, however, to possess too much elasticity for such a structure; and, +from the reticular appearance which it generally presents upon the +membranes to which it adheres, we are inclined to adopt the opinion of +Meckel in considering it cellular. "In the very early state of an ovum the +amnium forms a bag, which is a good deal smaller than the chorion, and, +therefore, is not in contact with it." (_Ibid._ p. 75:) hence, therefore, +a space is formed between the two membranes which is filled with a fluid +called the _liquor amnii spurius_, or more correctly the _liquor +allantoidis_. "In the course of some weeks, however, it comes nearly into +contact with the chorion, and through the greater part of pregnancy the +two membranes are pretty closely applied to each other." (_Ibid._) +Lobstein, in his admirable _Essai sur la Nutrition du Foetus_, observes, +that the membranes continues separate from each other so late as the third +and fourth month. Cases every now and then occur where a considerable +quantity of fluid is found between the chorion and amnion in labour at the +full period of pregnancy. + +We shall defer the minute description of the amnion and its relations, +during the very early periods of utero-gestation, until we describe the +embryo. The amnion is reflected upon the umbilical cord at its insertion +into the placenta, envelopes the umbilical vessels, the external covering +of which it forms, and is continued to the anterior surface of the child's +abdomen, passing into that projecting portion of the skin which forms the +future navel. + +Blood-vessels and nerves have not as yet been discovered in the structure +of the amnion, but Meckel considers it extremely probable that the fine +layer of cellular tissue by which it is connected with the chorion +contains vessels for its nutrition. + +_Liquor amnii._ The amnion contains a fluid known by the name of liquor +amnii. In the earlier months of pregnancy it is nearly, if not quite +transparent; as pregnancy advances it becomes turbid, containing more or +less of what appears to resemble mucus: it has a distinctly saline taste; +its specific gravity is rather more than that of water. Its relative and +absolute quantity vary considerably at different periods of pregnancy: +thus the relative weight of liquor amnii to that of the foetus is very +considerable at the beginning of pregnancy, at the middle they are nearly +equal, but towards the end, the weight of fluid to that of the child, +diminishes considerably, so that during the last weeks of pregnancy it +scarcely equals a pound, and seldom more than eight ounces, whereas the +medium weight of the child is usually between six and seven pounds: the +quantity, however, varies considerably, sometimes amounting to several +quarts. In the early months the absolute quantity increases, so that +between the third and fourth months it sometimes equals as much as +thirty-six ounces. Chemically it consists chiefly of water, a small +quantity of albumen and gelatine, a peculiar acid called amniotic, with a +little muriate of soda and ammonia, and a trace of phosphate of lime. + +The source of the liquor amnii is still unknown. Dr. Burns asserts that +"it is secreted from the inner surface of the membrane by pellucid +vessels," but as he confesses that "these have never been injected or +traced to their source (_Principles of Midwifery_, by J. Burns, M. D. p. +222.,) little weight can be attached to such a view." Meckel considers +(_Handbuch der Menschlichen Anatomie_, vol. iv. p. 707,) that the greater +part of it, especially in the early months, is a secretion from the +maternal vessels, but that afterwards, as pregnancy advances, it becomes +mingled with the excretions of the foetus. It appears to be a means of +nourishment to the foetus during the first part of pregnancy, from the +fact that it contains more nutritious matter in the early than in the +latter months, since at that time a considerable coagulation is produced +by alcohol, &c. The disappearance of this coagulable matter of the liquor +amnii, towards the end of pregnancy, may be attributed to its having been +absorbed at an earlier period, and to the process of nutrition being now +carried on by other means. Besides being a source of nourishment to the +foetus, it serves many useful purposes; it secures the foetus against +external pressure or violence, and supports the regular distension of the +uterus; on the other hand it diminishes and equalises the pressure of the +foetus upon the uterus; during labour by distending the membranes into an +elastic cone, it materially assists to dilate the os uteri; it also serves +to lubricate and moisten the external passages. + +_Placenta._ The placenta is formed essentially by the chorion and +decidua; it is a flat, circular, or more or less oval mass, soft, but +becoming firmer towards its edge. It is the most vascular part of the +ovum, and by which it is connected most intimately with the uterus. Its +longest diameter is generally about eight, its shortest about six inches; +its greatest thickness is at that spot where the umbilical cord is +inserted, which is usually about the middle of the placenta, although it +occasionally varies considerably in this respect, the cord coming off +sometimes at the edge. The placenta, as ordinarily seen after labour, is +barely an inch in its thickest part, but when filled with blood or +injection it swells very considerably, and is then little short of two +inches. It is generally attached to the upper part of the uterus in the +neighbourhood of one of the Fallopian tubes, and more frequently on the +left side than on the right; its inner or foetal surface is smooth, being +covered by the chorion, which at this part is much thicker. + +The placenta cannot be distinguished from the other parts of the ovum +until the end of the second month, at which period it covers nearly half +the surface of the ovum, gradually diminishing in relative size, but +increasing in thickness and absolute bulk up to the full period of +utero-gestation. It forms a spongy vascular mass, its uterine surface +being divided unequally into irregular lobes called _cotyledons_. + +The uterine surface of a full-grown placenta is covered by a pulpy +membrane, resembling in structure the decidua which covers the chorion, +and of which it seems to be a continuation. This is always found present +at the end of pregnancy: it covers the lobes of the uterine surface of the +placenta, descending into the sulci which runs between them: in some parts +it is thicker than in others, especially where it is connected with, or in +fact becomes, the decidua of the chorion or decidua reflexa. This +membrane, which has been called the _placenta decidua_, is pretty firmly +attached to the vessels of the placenta, so as not to be separated without +rupture; but by maceration, its texture is more or less destroyed, so that +we may easily distinguish the extremities of these vessels. "This decidua, +or uterine portion of the placenta," says Dr. Hunter, "is not a simple +thin membrane expanded over the surface of the part: it produces a +thousand irregular processes, which pervade the substance of the placenta +as deep as the chorion or inner surface; and are every where so blended +and entangled with the ramifications of the umbilical system, that no +anatomist will perhaps be able to discover the nature of their union. +While these two parts are combined, the placenta makes a pretty firm mass, +no part of it is loose or floating; but when they are carefully separated, +the umbilical system is evidently nothing but loose floating ramifications +of the umbilical vessels, like that vascular portion of the chorion, which +makes part of the placentula in a calf; and the uterine part is seen +shooting out into innumerable floating processes and rugæ, with the most +irregular and minutely subdivided cavities between them that can be +conceived. This part answers to the uterine fungus in the quadrupeds: it +receives no vessels demonstrable by the finest injection from those of the +navel string; yet it is full of both large and small arteries and veins: +these are all branches of the uterine vessels, and are readily filled by +injecting the arteries and veins of the uterus, and they all break through +in separating the placenta from the uterus, leaving corresponding orifices +on the two parted surfaces." (Hunter, _op. cit._ p. 42.) + +According to Lobstein's observations, although this membrane appears to be +a continuation of the decidua which covers the chorion, it nevertheless +does not exist during the earlier months. During the first months of +pregnancy the placenta does not present a solid mass, with its uterine +surface covered with projecting lobuli, as it does at the full term of +pregnancy; but the vessels of which it is composed (foetal) are loose and +floating, as if it had been subjected to maceration. It has been supposed, +that this irregular lobulated appearance of the uterine surface of the +placenta was produced at the moment of its separation from the uterus +during labour; this, however, is not the case, for Lobstein having opened +the uterus of a woman who died in the fifth month of pregnancy, and +separated the placenta with great care, found these lobular prominences, +although not yet covered by the membrane of which we have just spoken. +Wrisberg, professor of anatomy at Göttingen, considered that this membrane +was distinct from the decidua reflexa, since with care the two membranes +can be easily separated. + +[Illustration: _Uterine surface of the Placenta._] + +In examining the uterine surface of a full grown placenta it is necessary +to place it upon something convex, in order that it may resemble, as +nearly as possible, the form which it had when attached to the concave +surface of the uterus; the cotyledons are thus rendered prominent and +separated from each other; the sulci, which run between them, are wide and +gaping: whereas, when the placenta is laid upon a flat surface, its +cotyledons are closely pressed together, and the sulci more or less +completely concealed. On minute examination of these sulci a number of +openings may be observed, varying in size and shape, but usually more or +less oval, their edges distinct, smooth, and thin; on directing a strong +light into some of the larger ones a number of smaller apertures may be +observed opening into them, in much the same way as is observed when +looking down a large vein. Some of these canals do not immediately lead to +smaller orifices as above described, but open at once into an +irregular-shaped cell or cavity, in the parietes of which numerous small +apertures may be observed, through which blood oozes when the adjacent +parts of the placenta are slightly pressed upon. Besides these openings at +the bottom of the interlobular sulci, others may be seen here and there +upon the cotyledons; these are generally smaller, their edges thicker, and +in most instances they are round; but they are not so invariably met with +as the openings between the cotyledons, these lobular projections being +sometimes very thickly covered with placental decidua. The openings +observed on the uterine surface of the placenta correspond to the mouths +of the uterine veins and arteries, which, in the unimpregnated state, open +into the cavity of the uterus, but which now, by means of the decidua, +convey maternal blood to and from the placenta. "Any anatomist," says Dr. +W. Hunter, "who has once seen and understood them, can readily discover +them upon the surface of any fresh placenta; the veins, indeed, he will +find have an indistinct appearance from their tenderness and frequent +anastomoses, so as to look a good deal like irregular interstitial void +spaces: the arteries which generally make a snake-like convolution or two, +on the surface of the placenta, and give off no anastomosing branches, are +more distinct." (Hunter, _op. cit._ p. 46.) From the observations of +Messrs. Mayo and Stanley, and from their examination of the original +preparations in the Hunterian museum at the College of Surgeons, London, +illustrating this subject, it appears that, in all probability, most of +the large thin-edged apertures at the bottom of the interlobular sulci are +connected with the uterine veins; whereas, the smaller orifices, the +margins of which are thicker, and which are chiefly observed upon the +cotyledons, are continuations of the uterine arteries. + +These openings were also pointed out by the late Dr. Hugh Ley, in +describing the _post mortem_ examination of a woman who had died at the +full term undelivered (_Med. Gaz._ June 1, 1833:) "The uterine surface (of +the placenta) thus detached from the uterus, exhibited its lobules with +their intersecting sulci, even more distinctly than they are seen in the +uninjected placenta; and in several parts there could be perceived, with +the naked eye, small apertures of an oval form, with edges perfectly +smooth, regularly defined, and thicker, as well as more opaque, than the +contiguous parts which they penetrated." The communication between the +openings of the placental cells, and the mouths of the uterine veins and +arteries, which convey their blood to the placenta, as before observed, +is effected by means of the placental decidua. The connecting portion of +canal is of a flattened shape, runs obliquely between the uterus and +placenta, and appears to be formed entirely of decidua. The manner in +which the arteries pass to the placenta is very different to that of the +veins: "the arteries," as Dr. W. Hunter observes, "are all much convoluted +and serpentine; the larger, when injected, are almost of the size of +crow-quills: the veins have frequent anastomoses." Mr. J. Hunter has +described this point more minutely, and gives still more precise notions +of the manner in which the arteries pass to the placenta. "The arteries of +the uterus which are not immediately employed in conveying nourishment to +it, go on towards the placenta, and, proceeding obliquely between it and +the uterus, pass through the decidua without ramifying: just before they +enter the placenta, making two or three close spiral turns upon +themselves, they open at once into its spongy substance, without any +diminution of size, and without passing beyond the surface as above +described. + +The intention of these spiral turns would appear to be that of diminishing +the force of the circulation as it approaches the spongy substance of the +placenta, and is a structure which must lessen the quick motion of the +blood in a part where a quick motion of this fluid was not wanted. The +size of these curling arteries at this termination is about that of a +crow's quill. The veins of the uterus appropriated to bring back the blood +from the placenta, commence from this spongy substance by such wide +beginnings as are more than equal to the size of the veins themselves. +These veins pass obliquely through the decidua to the uterus, enter its +substance obliquely, and immediately communicate with the proper veins of +the uterus; the area of those veins bear no proportion to their +circumference, the veins being very much flattened."[21] + +On examining these vessels in an injected uterus to which the placenta is +attached, we shall therefore find that all traces of a regular canal or +tube are suddenly lost upon their entering the placenta; each vessel +(whether artery or vein) abruptly terminating in a spongy cellular tissue. +If a blow-pipe be introduced into a piece of sponge, we shall have a very +simple but correct illustration of the manner in which the uterine blood +circulates through the placenta. The cell into which each vessel +immediately opens is usually much larger than the rest, so that when the +cellular structure of the placenta is filled with wax, a number of +irregular nodules[22] are found continuous with these vessels and passing +into an infinity of minute granules, which are merely so many casts of +smaller cells. That this cellular tissue pervades the whole mass of the +placenta, and communicates freely with the uterine vessels by which it is +filled with blood, is proved by repeating a very simple experiment of Dr. +Hunter, viz. "if a blow-pipe be thrust into the substance of the placenta +any where, the air which is blown into the cellular part opens, and rushes +out readily by, the open mouths both of the arteries and veins." (Hunter, +_op. cit._ p. 46.) That it also envelopes the umbilical vessels of the +cord is shown by the fact, that if a pipe be inserted beneath the outer +covering of the cord near to its insertion into the placenta, we shall be +able to "fill the whole placenta uniformly in its cellular part, and +likewise all the venous system of the uterus and decidua, as readily and +fully as if we had fixed the pipe in the spermatic or hypogastric vein; so +ready a passage is there reciprocally between the cells of the placenta +and the uterine vessels." (_Ibid._ p. 47.) + +The maternal portion of the placenta therefore consists of a spongy +cellular tissue, which is filled by the uterine vessels, and also of those +trunks which pass through the decidua, and which form the communication +between these vessels and the placental cells. + +[Illustration: _Foetal surface of the placenta._] + +The foetal surface of the placenta is smooth and glossy, being covered by +the amnion and chorion; it is much harder than the uterine surface, and is +streaked over by the larger branches of the umbilical vein and arteries, +which radiate irregularly from the point where the cord is inserted; and +which pass beneath the amnion, and between the two layers of which the +chorion is composed, to which they are intimately connected. These vessels +supply the various lobuli of which the placenta is composed, so that each +lobulus receives at least one of these branches; for, although the +umbilical cord consists of two arteries and one vein, this arrangement +does not continue into the body of the placenta. "Every branch of an +artery," as Dr. Hunter observes, "is attended with a branch of a vein: +these cling to one another, and frequently in the substance of the +placenta entwine round one another, as in the navel string." (_Ibid._ p. +40.) Each cotyledon receives its own vessels, so that the vessels of one +cotyledon have no direct communication with those of the adjacent ones, as +proved by Wrisberg's examinations; for if we inject the vessel or vessels +of one of these lobuli, the injection will not pass into those of the +others. When the vessels have reached the cotyledons, they are divided and +subdivided _ad infinitum_; they are connected together by a fine cellular +membrane, which may be very easily removed by maceration, and then they +may be seen ramifying in the most beautiful and delicate manner possible; +the main branches having no communication or anastomosis with each other. + +The umbilical arteries anastomose freely with each other upon the foetal +surface of the placenta, before dividing into the branches +above-mentioned; hence, if an injection be thrown into one umbilical +artery it will return almost immediately by the other; but if this be tied +also, the injection, after a time, will return by the umbilical vein, but +not until all the vessels of the placenta have been filled, proving that +there is a free passage of blood from the arteries into the veins. + +From these remarks, founded chiefly on the admirable observations of the +Hunters, and repeated examinations of the placenta, which we have made +with the greatest care and impartiality, it may be stated with confidence, +that the placenta consists of two portions--a maternal and a foetal. The +maternal portion consists, as we have before observed, of a spongy +cellular tissue; and also of those trunks which pass through the decidua, +and which form the communication between the uterine vessels and the +placental cells. The foetal part is formed by the ramifications of the +umbilical vessels: "that each of those parts has its peculiar system of +arteries and veins, and its peculiar circulation, receiving blood by its +arteries, and returning it by its veins; that the circulation through +these parts of the placenta differs in the following manner: in the +umbilical portion the arteries terminate in the veins by a continuity of +canal; whereas, in the uterine portion there are intermediate cells into +which the arteries terminate, and from which the veins begin." (Hunter, +_op. cit._ p. 48.) + +Although various observations and anatomical injections show that to a +certain degree, there is a communication between the uterus and the +placenta, inasmuch as the blood of the former is received into the sinuses +or cells of the latter, we possess no proof that the blood can pass from +these sinuses into the umbilical vessels: on the contrary, every thing +combines to prove that the circulation of the foetus is altogether +independent of that of the mother. We know from daily experience that in +labour at the full term of pregnancy, the placenta is easily expelled +from the uterus: that, upon examining the surface which had been attached +to the uterus we find no laceration, and that a discharge of more or less +blood takes place for some days afterwards. We know, also, that when the +placenta becomes detached from the uterus during the progress of +gestation, it is followed by a considerable hemorrhage, which greatly +endangers the life of the mother. These facts prove that there is a +circulation of uterine blood in the placenta, which is destroyed upon its +being separated from the uterus. That this uterine circulation in the +placenta is unconnected with the circulation of foetal vessels in the +placenta is proved by the fact first pointed out by Wrisberg, viz. that, +where the mother has died from loss of blood, and the maternal vessels +therefore drained of their contents, those of the foetus have been full of +blood. Still farther to illustrate this fact, he killed several cows big +with calf, by a large wound through the heart or great vessels, so as to +ensure the most profuse and sudden loss of blood possible, and never found +that the vessels of the calf were deprived of blood, although those of the +mother were perfectly empty; moreover, no anatomist has ever yet succeeded +in making injections pass from the foetal into the uterine vessels, or +_vice versâ_. Lobstein has mentioned a mode of illustrating this fact +(_Essai sur la Nutrition du Foetus_,) which is both simple and striking. +Upon examining the uterine surface of a placenta which has been expelled +at the full term, it presents the appearance of a spongy mass gorged with +blood, which may be removed by washing or maceration, and if a placenta +thus prepared be injected, the fluids will pass with the greatest facility +from the umbilical arteries into the umbilical vein, but not one drop into +its cellular structure; it is evident, therefore, that the blood which had +filled the intervals between the vessels, and which had been removed by +washing and maceration, could not have belonged to the foetus, but must +have come from the mother; for if any of the vessels had been ruptured the +injection would not have succeeded. + +In concluding these observations upon the placenta, we may briefly state, +that there is the same relation between the umbilical vessels and the +maternal blood, which fills the placental cells, as there is between the +branches of the pulmonary artery, and the air which fills the bronchial +cell.[23] + +_Umbilical cord._ The umbilical cord, funis, or navel string, is a +vascular rope extending between the foetus and placenta, by which they are +connected together. It usually arises, as we have before observed, from +about the middle of the placenta, and terminates at the umbilical ring of +the foetus; it consists of two umbilical arteries and one umbilical vein; +the former conveying the blood from the common iliac arteries of the +foetus to the cotyledons of the placenta; the latter formed by the union +of the collected umbilical veins, on the inner surface of the placenta, +and returning this blood to the foetus. In the early periods of pregnancy +it also consists of the duct and vessels of the vesicula umbilicalis, the +urachus, and more or less of the intestinal canal. The umbilical cord does +not present the same form or appearance at every period of gestation; the +younger the embryo, the shorter and thicker is the cord; in fact, there +are no traces whatever of a cord at first, the embryo adhering, by its +lower or caudal extremity, directly to the membranes. By the fifth or +sixth week it becomes visible; at this early period the vessels of which +it is composed pass from the foetus in a straight direction, but as +pregnancy advances they become more or less spiral, winding round each +other, and usually from left to right: according to Meckel, they take the +opposite direction much less frequently, viz. in the proportion of one to +nine. + +The vessels of the umbilical cord are imbedded in a thick viscid +substance; upon minute examination, it will be found to consist of a very +fine cellular tissue, containing an albuminous matter which slowly exudes, +when pressed between the fingers. This cellular tissue itself may be +demonstrated by the inflation of air or injection with mercury: it seems +to accompany the umbilical vessels as far as the posterior surface of the +peritoneum; and Lobstein is of opinion that it is a continuation of the +cellular tissue, which covers this membrane. (Lobstein, _sur la Nutrition +du Foetus_. § 75.) + +Externally, the umbilical cord is covered by a continuation of the amnion, +which, although it be the inner membrane of the ovum, is the outer +covering of the cord: in some places it is very thick and strong, and not +easily ruptured. From repeated observations, the weakest part of the cord +seems to be at about three or four inches distant from the umbilicus, this +being the spot where it has invariably given way in every case we have +seen, where the cord has been broken at the moment of the child's birth. + +From the time of the commencement to the full time of utero-gestation, the +cord becomes gradually longer, so that it attains an average length of +from eighteen to twenty inches; this, however, varies remarkably. We have +known the cord exceed forty inches; and a case is described by +Baudelocque, where it was actually fifty-seven inches long: on the other +hand, it is sometimes not more than four or five inches in length. + +It is remarkable that the cord, which at the end of pregnancy is usually +of about the same length as the foetus, is relatively much longer during +the sixth month; hence we may conclude, that in those cases where knots +have been found upon the cord, the knot must have been formed at this +period when the foetus was small enough to pass through a coil of it. + +Neither blood-vessels nor lymphatics have as yet been found in the +structure of the cord itself. A filament of nerve from the solar plexus +has been occasionally seen passing through the umbilical ring, and +extending to a distance down the cord. + +The vesicula umbilicalis and allantois, being essentially connected with +the earliest grades of foetal development, will be considered under that +head. + +_Embryo._ There is, perhaps, no department of physiology which has been so +remarkably enriched by recent discoveries, as that which relates to the +primitive development of the ovum and its embryo. The researches of Baer, +Rathke, Purkinje, Valentin, &c. in Germany; of Dutrochet, Prevost, Dumas, +and Coste, &c. in France; and of Owen, Sharpey, Allen Thomson, Jones, and +Martin Barry in England, but more especially those of the celebrated Baer, +have greatly advanced our knowledge of these subjects, and led us deeply +into those mysterious processes of Nature which relate to our first origin +and formation. + +These researches have all tended to establish one great law, connected +with the early development of the human embryo, and that of other +mammiferous animals, viz, that it at first possesses a structure and +arrangement analogous to that of animals in a much lower scale of +formation: this observation also applies of course to the ovum itself, +since a variety of changes take place in it after impregnation, before a +trace of the embryo can be detected. + +At the earliest periods, the human ovum bears a perfect analogy to the +eggs of fishes, amphibia, and birds; and it is only by carefully examining +the changes produced by impregnation in the ova of these lower classes of +animals, that we have been enabled to discover them in the mammalia and +human subject. + +As the bird's egg, from its size, best affords us the means of +investigating these changes, and as in all essential respects they are the +same in the human ovum, it will be necessary for us to lay before our +readers a short account of its structure and contents, and also of the +changes which they undergo, after impregnation. In doing this we shall +merely confine ourselves to the description of what is applicable to the +human ovum. + +[Illustration: _Section of a hen's egg within the ovary._ + +_a_ The granulary membrane forming the periphery of the yelk. _b_ Vesicle +of Purkinje imbedded in the cumulus. _c_ Vitellary membrane. _d_ Inner and +outer layers of the capsule of the ovum. _e_ Indusium of the ovary.] + +The egg is known to consist of two distinct parts, the vitellus or yelk +surrounded by its albumen or white; to the former of these we now more +particularly refer. The yelk is a granular albuminous fluid, contained in +a granular membranous sac (the _blastodermic membrane_) which is covered +by an investing membrane called the _vitelline membrane_ or _yelk-bag_. +The impregnated vitellus is retained in its capsule in the ovary, +precisely as the ovum of the mammifera is in the Graafian vesicle. The +whole ovary in this case has a clustered appearance, like a bunch of +grapes, each capsule being suspended by a short pedicle of indusium. + +[Illustration: _a_ Vitelline membrane _b_ Blastoderma. _From T. W. +Jones._] + +In those ova which are considerably developed before impregnation, the +granular blastermodic membrane is observed to be thicker, and the granules +more aggregated at that part which corresponds to the pedicle, forming a +slight elevation with a depression in its centre, like the cumulus in the +proligerous disc of a Graafian vesicle. This little disc is the +blastoderma, germinial membrane or cicatricula; in the central depression +just mentioned is an exceedingly minute vesicle first noticed by Professor +Purkinje of Breslau, and named after him: in more correct language it is +the _germinal vesicle_. + +According to Wagner, the germinal vesicle is not surrounded by a disc +before impregnation; and it is only after this process that the +above-mentioned disc of granules is formed. By the time the ovum is about +to quit the ovary the vesicle itself has disappeared, so that an ovum has +never been found in the oviduct containing a germinal vesicle, nothing +remaining of it beyond the little depression in the cumulus of the +cicatricula. + +The rupture of the Purkinjean or germinal vesicle has been supposed by Mr. +T. W. Jones to take place before impregnation; but the observations of +Professor Valentin seem to lead to the inference that it is a result of +that process, and must be therefore looked upon as one of the earliest +changes which take place in the ovum or yelk-bag upon quitting the +ovary.[24] + +During its passing through the oviduct (what in mammalia is called the +Fallopian tube,) the ovum receives a thick covering of albumen, and as it +descends still farther along the canal the membrane of the shell is +formed. + +On examining the appearance of the ovum in mammiferous animals, and +especially the human ovum, it will be found that it presents a form and +structure very analogous to the ova just described, more especially those +of birds. It is a minute spherical sac, filled with an albuminous fluid, +lined with its blastodermic or germinal membrane, in which is seated the +germinal vesicle or vesicle of Purkinje. When the ovum has quitted the +ovary the germinal vesicle disappears, and on its entering the Fallopian +tube it becomes covered with a gelatinous, or rather albuminous covering. +This was inferred by Valentin, who considered that "the enormous swelling +of the ova, and their passage through the Fallopian tubes," tended to +prove the circumstance. (_Edin. Med. and Surg. Journ._ April, 1836.) It +has since been demonstrated by Mr. T. W. Jones in a rabbit seven days +after impregnation. The vitellary membrane seems, at this time, to give +way, leaving the vitellus of the ovum merely covered by its spherical +blastoderma, and encased by the layer of albuminous matter which surrounds +it. + +From what we have now stated, a close analogy will appear between the ova +of the mammalia and those of the lower classes, more especially birds, +which from their size afford us the best opportunities of investigating +this difficult subject. + +In birds, the covering of the vitellus is called _yelk-bag_; whereas, in +mammalia and man it receives the name of _vesicula umbilicalis_. Its +albuminous covering, which corresponds to the white and membrane of the +shell in birds, is called _chorion_: by the time that the ovum has reached +the uterus, this outer membrane has undergone a considerable change; it +becomes covered with a complete down of little absorbing fibrillæ, which +rapidly increase in size as development advances, until it presents that +tufted vascular appearance, which we have already mentioned when +describing this membrane. + +The first or primitive trace of the embryo is in the cicatricula or +germinal membrane, which contained the germinal vesicle before its +disappearance. In the centre of this, upon its upper surface, may be +discovered a small dark line;[25] "this line or primitive trace is swollen +at one extremity, and is placed in the direction of the transverse axis of +the egg." + +[Illustration: _a_ Transparent area. _b_ Primitive trace.] + +As development advances, the cicatricula expands. "We are indebted to +Pander,"[26] says Dr. Allen Thomson in his admirable essay above quoted, +"for the important discovery, that towards the twelfth or fourteenth hour, +in the hen's egg the germinal membrane becomes divided into two layers of +granules, the serous and mucous layers of the cicatricula; and that the +rudimentary trace of the embryo, which has at this time become evident, +is placed in the substance of the upper-most or serous layer." "According +to this observer, and according to Baer, the part of this layer which +surrounds the primitive trace soon becomes thicker; and on examining this +part with care, towards the eighteenth hour, we observe that a long furrow +has been formed in it, in the bottom of which the primitive trace is +situated; about the twentieth hour this furrow is converted into a canal +open at both ends, by the junction of its margins (the _plicæ primitivæ_ +of Pander, the _laminæ dorsales_ of Baer:) the canal soon becomes closed +at the cephalic or swollen extremity of the primitive trace, at which part +it is of a pyriform shape, being wider here than at any other part. +According to Baer and Serres, some time after the canal begins to close, a +semi-fluid matter is deposited in it, which on its acquiring greater +consistence, becomes the rudiment of the spinal cord; the pyriform +extremity or head is soon after this seen to be partially subdivided into +three vesicles, which being also filled with a semi-fluid matter, gives +rise to the rudimentary state of the encephalon." "As the formation of the +spinal canal proceeds, the parts of the serous layer which surrounds it, +especially towards the head, become thicker and more solid, and before the +twenty-fourth hour we observe on each side of this canal four or five +small round opaque bodies, these bodies indicate the first formation of +the dorsal vertebræ. + +[Illustration: _a_ Transparent area. _b_ Laminæ dorsales. _c_ Cephalic +end. _d_ Rudiments of dorsal vertebræ. _e_ Serous layer. _f_ Lateral +portion of the primitive trace. _g_ Mucous layer. _h_ Vascular layer. _k_ +Laminæ dorsales united to form the spinal canal.] + +"About the same time, or from the twentieth to the twenty-fourth hour, +the inner layer of the germinal membrane undergoes a farther division, and +by a peculiar change is converted into the vascular mucous layers." (A. +Thomson, _op. cit._) It will thus be seen, that the germinal membrane is +that part of the ovum in which the first changes produced by impregnation +are observed. The rudiments of the osseous and nervous systems are formed +by the outer or serous layers; the outer covering of the foetus or +integuments, including the amnois, are also furnished by it. "The layer +next in order has been called _vascular_, because in it the development of +the principal parts of the vascular system appears to take place. The +third, called the _mucous_ layer, situated next the substance of the yelk, +is generally in intimate connexion with the vascular layer, and it is to +the changes which these combined layers undergo, that the intestinal, the +respiratory, and probably also the glandular systems owe their origin." +(A. Thomson, _op. cit._ p. 298.) + +[Illustration: _a_ Serous layer. _b c_ Vascular layer. _d_ Mucous layer. +_e_ Heart.] + +The embryo is therefore formed in the layers of the germinal membrane, and +becomes, as it were, spread out upon the surface of the ovum: the changes +which the ovum of mammalia undergoes appear from actual observation, to be +precisely analogous to those in the inferior animals. (_Baer_, _Prevost_ +and _Dumas_.) From the primitive trace, which was at first merely a line +crossing the cicatricula, and which now begins rapidly to exhibit the +characters of the spinal column, the parietes of the head and trunk +gradually approach farther and farther towards the anterior surface of the +abdomen and head until they unite; in this way the sides of the jaws close +in the median line of the face, occasionally leaving the union incomplete, +and thus appearing to produce in some cases the congenital defects of +hare-lip and cleft palate. In some way the ribs meet at the sternum; and +it may be supposed that sometimes this bone is left deficient, and thus +may become one of the causes of those rare cases of malformation, where +the child has been born with the heart external to the parietes of the +thorax. In like manner the parietes of the abdomen and pelvis close in the +linea alba and symphysis pubis, occasionally leaving the integuments of +the navel deficient, or, in other words, producing congenital umbilical +hernia, or at the pubes a non-union of its symphysis with a species of +inversion of the bladder, the anterior wall of that viscus being nearly or +entirely wanting. + +The cavity of the abdomen is therefore at first open to the vesicula +umbilicalis or yelk, but this changes as the abdominal parietes begin to +close in; in man and the mammalia merely a part of it, as above mentioned, +forms the intestinal canal, whereas, in oviparous animals the whole of the +yelk-bag enters the abdominal cavity, and serves for an early nutriment to +the young animal. Another change connected with the serous or outer layer +of the germinal membrane is the formation of the _amnion_. The foetal +rudiment which from its shape has been called _carina_, now begins to be +enveloped by a membrane of exceeding tenuity, forming a double covering +upon it; the one which immediately invests the foetus is considered to +form the future epidermis; the other, or outer fold, forms a loose sac +around it, containing the liquor amnii. Whilst these changes are taking +place in the serous layer of the germinal membrane, and whilst the +intestinal canal, &c. are forming on the anterior surface of the embryo, +which is turned towards the ovum, by means of the inner or mucous layer, +equally important changes are now observed in the middle or vascular +layer. "In forming this fold," says Dr. A. Thomson, "the mucous layer is +reflected farthest inwards; the serous layer advances least, and the space +between them, occupied by the vascular layer, is filled up by a dilated +part of this layer, the rudiment of the heart." (_Op. cit._ p. 301.) + +Whilst this rudimentary trace of the vascular system is making its +appearance, minute vessels are seen ramifying over the vesicula +umbilicalis, forming, according to Baer's observations, a reticular +anastomosis, which unites into two vessels the vasa omphalo-meseraica. +(_British and Foreign Med. Rev._ No. 1.) These may be demonstrated with +great ease in the chick: the cicatricula increases in extent; it becomes +vascular, and at length forms a heart-shaped net-work of delicate vessels, +which unite into two trunks, terminating one on each side of the abdomen. + +[Illustration: _b_ Is a portion of the convexity of the amnion, upon +which, at _a_ is the fundus of the diminutive human allantois. + +_c_ The duct of the vesicula umbilicalis, dividing into two intestinal +portions; and besides this duct are two vessels which are distributed upon +the vesicula umbilicalis, and form a reticular anastomosis with each +other. _From Baer._] + +The umbilical vesicle now begins to separate itself more and more from the +abdomen of the foetus, merely a duct of communication passing to that +portion of it which forms the intestinal canal. The first rudiment of the +cord will be found at this separation; its foetal extremity remains for a +long time funnel-shaped, containing, besides a portion of intestine, the +duct of the vesicula umbilicalis, the vasa omphalo-meseraica (the future +vena portæ,) the umbilical vein from the collected venous radicles of the +chorion, and the early trace of the umbilical arteries. These last-named +vessels ramify on a delicate membranous sac of an elongated form which +rises from the inferior or caudal extremity of the embryo, viz. the +_allantois_; whether this is formed by a portion of the mucous layer of +the germinal vesicle, in common with the other abdominal viscera, appears +to be still uncertain: in birds this may be very easily demonstrated as a +vascular vesicle, arising from the extremity of the intestinal canal; and +in mammalia, connected with the bladder by means of a canal called +_urachus_: from its sausage-like shape, it has received the name of +_allantois_. + +The existence of an allantois in the human embryo has been long inferred +from the presence of a ligamentous cord extending from the fundus of the +bladder to the umbilicus, like the urachus in animals. But from the +extreme delicacy of the allantois, and from its function ceasing at a very +early period, it had defied all research, until lately when it has been +satisfactorily demonstrated in the human embryo by Baer and Rathke. It +occupies the space between the chorion and amnion, and gives rise +occasionally to a collection of fluid between these membranes, familiarly +known by the name of the liquor amnii spurius, which, strictly speaking is +the liquor allantoidis. + +The function of the allantois is still in a great measure unknown. In +animals it evidently acts as a species of receptaculum urinæ during the +latter periods of gestation; but it is very doubtful if this be its use +during the earlier periods. It does not seem directly connected with the +process of nutrition, which at this time is proceeding so rapidly, first +by means of the albuminous contents of the vitellus, or vesicula +umbilicalis, and afterwards by the absorbing radicles of the chorion; but, +from analogy with the structure of the lower classes of animals, it would +appear that it is intended to produce certain changes in the rudimentary +circulation of the embryo, similar to those which, at a later period of +pregnancy, are effected by means of the placenta, and after birth by the +lungs, constituting the great functions of respiration. + +In many of the lower classes of animals, respiration (or at least the +functions analogous to it) is performed by organs situated at the inferior +or caudal extremity of the animal: thus for instance, certain insect +tribes, as in hymenoptera, or insects with a sting, as wasps, bees, &c.; +in diptera, or insects with two wings, as the common fly; and also the +spider tribe, have their respiratory organs situated in the lower part of +the abdomen. In some of the crustacea, as, for instance, the shrimp, the +organs of respiration lie under the tail between the fins, and floating +loosely in the water. Again, some of the molusca, viz. the cuttle-fish, +have the respiratory organs in the abdomen. We also know that many +animals, during the first periods of their lives, respire by a different +set of organs to what they do in the adult state: the most familiar +illustration of this is the frog, which, during its tadpole state, lives +entirely in the water. + +[Illustration: _a_ Bronchial processes. _b_ Vesicula umbilicalis. _c_ +Vitellus. _d_ Allantois. _e_ Amnion. _From Baer._] + +As the growth of the embryo advances, other organs whose function is as +temporary as that of the allantois, make their appearance: these also +correspond to the respiratory organs of a lower class of animals, although +higher than those to which we have just alluded,--we mean bronchial +processes or gills. It is to Professor Rathke (_Acta Naturæ Curios._ vol. +xiv,) that we are indebted for pointing out the interesting fact, that +several transverse slit-like apertures may be detected on each side the +neck of the embryo, at a very early stage of development. In the chick, in +which he first observed it, it takes place about the fourth day of +incubation: at this period the neck is remarkably thick, and contains a +cavity which communicates inferiorly with the oesophagus and stomach, and +opens externally on each side by means of the above-mentioned apertures, +precisely as is observed in fishes, more especially the shark tribe; these +apertures are separated from each other by lobular septa, of exceedingly +soft and delicate structure. Rathke observed the same structure in the +embryo of the pig and other mammalia; and Baer has since shown it +distinctly in the human embryo. It is curious to see how the vascular +system corresponds to the grade of development then present: the heart is +single, consisting of one auricle and one ventricle; the aorta gives off +four delicate, but perfectly simple branches, two of which go to the +right, and two to the left side; each of these little arteries passes to +one of the lobules or septa at the side of the neck, which correspond to +gills, and having again united with the three others, close to what is the +first rudiment of the vertebral column, they form a single trunk which +afterwards becomes the abdominal aorta. In a short time these slit-like +openings begin to close; the bronchial processes or septa become +obliterated, and indistinguishable from the adjacent parts; the heart +loses the form of a single heart; a crescentic fold begins to mark the +future division into two ventricles, and gradually extends until the +septum between them is completed. It is also continued along the bulb of +the aorta, dividing it into two trunks, the aorta proper and pulmonary +artery; at the upper part the division is left incomplete, so that there +is an opening from one vessel to the other, which forms the ductus +arteriosus.[27] A similar process takes place in the auricles, the +foramen ovale being apparently formed in the same manner as the ductus +arteriosus; these changes commence in the human embryo about the fourth +week, and are completed about the seventh. + +At first the body of the embryo has a more elongated form than afterwards, +and the part which is first developed is the trunk, at the upper extremity +of which a small prominence less thick than the middle part, and separated +from the rest of the body by an indentation, distinguishes the head. There +are as yet no traces whatever of extremities, or of any other prominent +parts; it is straight, or nearly so, the posterior surface slightly +convex, the anterior slightly concave, and rests with its inferior +extremity directly upon the membranes, or by means of an extremely short +umbilical cord. + +The head now increases considerably in proportion to the rest of the body, +so much so, that at the beginning of the second month, it equals nearly +half the size of the whole body: previous to, and after this period, it is +usually smaller. The body of the embryo becomes considerably curved, both +at its upper as well as its lower extremity, although the trunk itself +still continues straight. The head joins the body at a right angle, so +that the part of it which corresponds to the chin is fixed directly upon +the upper part of the breast; nor can any traces of neck be discerned, +until nearly the end of the second month. + +The inferior extremity of the vertical column, which at first resembles +the rudiment of a tail becomes shorter towards the middle of the third +month, and takes a curviture forwards under the rectum, in the fifth week +the extremities become visible, the upper usually somewhat sooner than the +lower, in the form of small blunt prominences. The upper close under the +head, the lower near the caudal extremity of the vertebral column. Both +are turned somewhat outwards, on account of the size of the abdomen; the +upper are usually directed somewhat downwards, the lower ones somewhat +upwards. + +[Illustration: _Diagram of the foetus and membranes about the fourth +week._ + +_a_ Vesicula umbilicalis already passing into the ventricular and rectum +intestine at _g_. _b_ Vena and arteria omphalo-meseraica. _c_ Allantois +springing from the pelvis with the umbilical arteries. _d_ Embryo. _e_ +Amnion. _f_ Chorion. _From Carus._] + +The vesicula umbilicalis may still be distinguished in the second month as +a small vesicle, not larger than a pea, near the insertion of the cord, at +the navel, and external to the amnion. From the trunk, which is almost +entirely occupied by the abdominal cavity, arises a short thick umbilical +cord, in which some of the convolutions of the intestines may still be +traced. Besides these it usually contains, as already observed, the two +umbilical arteries and the umbilical vein, the urachus, the vasa +omphalo-meseraica, or vein and artery of the vesicula umbilicalis, and +perhaps, even at this period, the duct of communication between the +intestinal canal and vesicula umbilicalis, the foetal extremity of which, +according to Professor Oken's views, forms the processus vermiformis. + +[Illustration: _Diagram of the foetus and membranes about the sixth week._ + +_a_ Chorion. _b_ The larger absorbent extremities, the site of the +placenta. _c_ Allantois. _d_ Amnion. _e_ Urachus. _é_ Bladder. _f_ +Vesicula umbilicalis. _g_ Communicating canal between the vesicula +umbilicalis and intestine. _h_ Vena umbilicalis. _i i_ Arteriæ +umbilicales. _l_ Vena omphalo-meseraica. _k_ Arteria omphalo-meseraica. +_n_ Heart. _o_ Rudiment of superior extremity. _p_ Rudiment of lower +extremity. _From Carus._] + +The hands seem to be fixed to the shoulders without arms, and the feet to +adhere to the ossa illi; the liver seems to fill the whole abdomen; the +ossa innominata, the ribs, and scapulæ are cartilaginous. + +In a short time the little stump-like prominences of the extremities +become longer, and are now divided into two parts, the superior into the +hand and the fore arm, the inferior into the foot and leg; in one or two +weeks later, the arms and thighs are visible. These parts of the +extremities which are formed later than the others, are at first smaller, +but as they are gradually developed they become larger. When the limbs +begin to separate into an upper and lower part, their extremities become +rounder and broader, and divided into the fingers and toes, which at first +are disproportionately thick, and until the end of the third month are +connected by a membranous substance analogous to the webbed feet of water +birds; this membrane gradually disappears, beginning at the extremities of +the fingers and toes, and continuing the division up to their insertion. +The external parts of generation, the nose, ears, and mouth appear after +the development of the extremities. The insertion of the umbilical cord +changes its situation to a certain degree; instead of being nearly at the +inferior extremity of the foetus as at first, it is now situated higher up +on the anterior surface of the abdomen. The comparative distance between +the umbilicus and pubis continues to increase, not only to the full period +of gestation, when it occupies the middle point of the length of the +child's body, as pointed out by Chaussier, but even to the age of puberty, +from the relative size of the liver becoming smaller. + +Though the head appears large at first, and for a long time continues so, +yet its contents are tardy in their development, and until the sixth month +the parietes of the skull are in great measure membranous or +cartilaginous. Ossification commences in the base of the cranium, and the +bones under the scalp are those in which this process is last completed. + +The contents of the scull are at first gelatinous, and no distinct traces +of the natural structure of the brain can be identified until the close of +the second month; even then it requires to have been sometimes previously +immersed in alcohol to harden its texture. There are many parts of it not +properly developed until the seventh month. In the medulla spinalis no +fibres can be distinguished until the fourth month. The thalami nervorum +opticorum, the corpora striata, and tubercula quadrigemina, are seen in +the second month; in the third, the lateral and longitudinal sinuses can +be traced, and contain blood. In the fifth we can distinguish the corpus +callosum; but the cerebral mass has yet acquired very little solidity, for +until the sixth month it is almost semi-fluid. (Campbell's _System of +Midwifery_.) + +About the end of the third, during the fourth, and the beginning of the +fifth months, the mother begins to be sensible of the movements of the +foetus. These motions are felt sooner or later, according to the bulk of +the child, the size and shape of the pelvis, and the quantity of fluid +contained in the amnion, the waters being in larger proportionate quantity +the younger the foetus. + +The secretion of bile, like that of the fat, seems to begin towards the +middle of pregnancy, and tinges the meconium, a mucous secretion of the +intestinal tube which had hitherto been colourless, of a yellow colour. +Shortly after this the hair begins to grow, and the nails are formed about +the sixth or seventh month. A very delicate membrane (membrana +pupillaris,) by which the pupil has been hitherto closed, now ruptures, +and the pupil becomes visible. The kidneys, which at first were composed +of numerous glandular lobules (seventeen or eighteen in number,) now +unite, and form a separate viscus on each side of the spine; sometimes +they unite into one large mass, an intermediate portion extending across +the spine, forming the horse-shoe kidney. + +Lastly, the testes, which at first were placed on each of the lumbar +vertebræ, near the origin of the spermatic vessels, now descend along the +iliac vessels towards the inguinal rings, directed by a cellular cord, +which Hunter has called _Gubernaculum testis_: they then pass through the +openings carrying before them that portion of the peritoneum which is to +form their tunica vaginalis. + +The length of a full-grown foetus is generally about eighteen or nineteen +inches; its weight between six and seven pounds. The different parts are +well developed and rounded; the body is generally covered with the vernix +caseosa;[28] the nails are horny, and project beyond the tips of the +fingers, which is not the case with the toes; the head has attained its +proper size and hardness; the ears have the firmness of cartilage; the +scrotum is rugous, not peculiarly red, and usually containing the testes. +In female children the nymphæ are generally covered entirely by the labia, +the breasts project, and in both sexes frequently contain a milky fluid. +As soon as a child is born, which has been carried the full time, it +usually cries loudly, opens its eyes, and moves its arms and legs briskly; +it soon passes urine and fæces, and greedily takes the nipple. (Naegelé's +_Hebammenbuch_.) + +Thus, then, in the space of forty weeks, or ten lunar months, from an +inappreciable point, the foetus attains a medium length of about eighteen +or nineteen inches, and a medium weight of between six and seven pounds. +As these observations on the development of the ovum show that the +structural arrangement of the embryo undergoes a succession of changes, by +which it gradually rises from the lowest to the highest scale of +formation, so we shall find it furnished with a succession of means for +its nutrition, each corresponding more or less to the particular grade of +development which it may have attained. Its earliest source of nourishment +is doubtless the vitellus, or albuminous contents of the vesicula +umbilicalis. The radicle or primitive trace, in this respect, bears a +strong analogy to the seed of a plant; it brings with it its own supply of +nourishment for its first stage of growth; in the latter, the cotyledons +afford nourishment to the little plumula, until, by the formation of roots +and absorption of moisture from the surrounding soil, it is enabled to +support the early rudiment of the future plant. The early function of the +chorion is very analogous to that of roots; it is an absorbing apparatus, +collecting nourishment by means of its numerous absorbing fibrillæ: hence, +according to Lobstein, the umbilical vein exists for some time previous to +the umbilical arteries, and seems to perform an office in the foetus +similar to that of the thoracic duct at a later period; its radicles or +absorbing extremities seem to absorb a milky fluid, which after the first +two months is found in the placenta, and which must be looked upon as a +means of nourishment which does not exist in the latter months. This milky +fluid was noticed by Leroux, who even then expressed his doubts, whether +the radicles of the umbilical vein receive blood from the mother, or +whether they only serve to absorb a white fluid which resembles chyle. In +some manuscript notes of Dr. Young's lectures, which were taken by the +late Dr. Parry, of Bath, when a student at Edinburgh, we find the +following observation: "There is evidently in the placenta, besides +blood-vessels, some other substance, which serves to absorb juices from +the uterus, and to convert these into a chylous matter proper to nourish +the foetus, and this matter is absorbed by the umbilical veins. This seems +to be proved from the consideration of the placenta of animals which have +cotyledons; for, on squeezing these glandular substances, we force out a +sort of chylous liquor, and these are surrounded by the placenta, which +absorb their liquor and convey it to the foetus." + +The absorbing power of the umbilical vein continues till the fifth month; +during the second or third, the foetus receives a good deal of nourishment +from the liquor amnii, which at this period contains a considerable +quantity of albuminous matter; this diminishes in the latter months of +pregnancy. Moreover the body of the foetus begins to be covered with the +vernix caseosa towards the seventh month, so that in the eighth and ninth +months the absorption of liquor amnii by the skin is considerably impeded. + +How far the full formed placenta, as seen after the fifth month, serves as +a means of nutrition to the foetus, may still be a matter of doubt; its +chief use after this period is, as we have already shown, for the purpose +of producing certain changes in the blood of the foetus analogous to those +of respiration;[29] still, however, it would seem that its function of +nutrition is not entirely at an end, even at a late period of pregnancy. +The numerous little granules of phosphate of lime, which are frequently +found on the uterine surface of a full-grown placenta at a time when +ossification is rapidly advancing in the foetal skeleton, would surely +lead us to infer that the placenta in some way or other supplies the +materials for this process. + +_Foetal circulation._ We have already shown, that, in the early stages of +development, the heart of the embryo is single, consisting of one auricle +and one ventricle; that a septum gradually divides these into two parts +until the double heart is formed, leaving two openings of communication +between the right and left sides, the one between the auricles called the +_foramen ovale_, the other between the pulmonary artery and aorta, viz. +the _ductus arteriosus_. + +From these and other peculiarities it will be seen that the foetal +circulation differs essentially from that of a child after birth; and, in +order to comprehend the nature and mechanism of the changes which take +place in it when respiration first commences, it will be necessary that +these peculiarities should be thoroughly understood. The condition of the +foetus must also be remembered: surrounded by the liquor amnii, the foetus +does not respire; its lungs have as yet been unemployed; they are +therefore small and collapsed, and present a firm solid mass, nearly +resembling liver in appearance. In this state but little blood from the +pulmonary arteries can circulate through them; for, as the extreme +ramifications of these vessels are distributed upon the mucous membrane +lining the bronchi and air-cells, the free passage of blood through them +will in great measure depend upon a previous condition of the air-cells. +The pulmonary arteries in the foetal state are therefore small, and +transmit but a small quantity of blood into their numerous ramifications, +just sufficient to keep pervious these vessels which after birth are to be +so greatly distended: in this state the lungs when thrown into water sink. + +Hence, as the pulmonary arteries do not afford a sufficiently free exit to +the contents of the right side of the foetal heart, nature has provided it +with a peculiar means for carrying off the overplus quantity of blood, +which is poured into the right auricle from the vena cava. This is +attained first by the _foramen ovale_, an oval-shaped opening in the +septum between the right and left auricles, and furnished with a semilunar +valvular flap, so constructed, as to allow a free passage for the blood +from the right to the left auricle, but none in the contrary direction. By +this means a considerable quantity of blood is transmitted at once from +the right to the left auricle, and, consequently, much less into the right +ventricle and pulmonary artery. Still, however, more blood passes into the +right ventricle than the pulmonary artery, in the collapsed state of the +foetal lungs, is capable of conveying away. The pulmonary artery is +therefore continued beyond its bifurcation into the aorta at its +curvature, by means of the _ductus arteriosus_, which, in the full-grown +foetus, forms a short thick passage between these two vessels; and in this +manner is the right ventricle enabled to get rid of its surplus quantity +of blood. Thus we see that the foetal heart although consisting of two +auricles and two ventricles, continues to perform the functions only of a +single heart, both ventricles assisting simultaneously to propel the same +column of blood, viz. that of the aorta, and thus enabling the heart to +act with considerable power. + +The chief part of the blood, which flows through the iliac arteries, +instead of being sent to the inferior extremities, is carried into the +umbilical arteries, which passing up along the sides of the bladder meet +the umbilical vein at the navel, and thus form the vessels of the +umbilical cord. These arteries convey the blood of the foetus to the +placenta, where, having undergone changes to which we have already +alluded, it is returned by the umbilical vein. This vessel, which +afterwards forms the round ligament of the liver, passes through the +umbilicus along the anterior edge of the suspensory ligament; it supplies +the left lobe with blood, and having given off a communicating branch to +the vena portæ, which supplies the right lobe, it passes at once by a +short passage, called _canalis venosus_, into the vena cava. + +Thus, then, the peculiarities of the foetal circulation may be considered +as four, viz. the _foramen ovale_, or passage from the right to the left +auricle; the _ductus arteriosus_, or communication from the bifurcation of +the pulmonary artery into the arch of the aorta; the _umbilical arteries_ +arising from the iliac arteries, and carrying the blood along the cord +into the placenta; and, lastly, the _canalis venosus_, or passage between +the umbilical vein and vena cava. + +Let us now examine the changes which take place in the foetal circulation +at the moment of the child's birth. The child, which had hitherto been +immersed in the bland and warm medium of the liquor amnii, is at once +exposed to the action of the external air. By means of the sympathy +existing between the skin and respiratory muscles, sudden and convulsive +efforts at inspiration take place; the air-cells of the lungs become +partially inflated, and, after a short time as the respiration increases +in power and activity, become distended throughout their whole extent. The +thorax rises; the flaccid diaphragm, which hitherto had been pushed up by +the large foetal liver, now contracts, pressing down the liver into its +natural situation. The lungs, from being a hard solid heavy substance, +resembling liver, at once become inflated, elastic, and crepitous, light +and permeable to air in every part. + +The capillary terminations of the pulmonary artery, which ramify in the +mucous membrane, forming the parietes of the air-cells, and which +hitherto had been firmly compressed by the collapsed state of the foetal +lungs, are suddenly rendered pervious throughout their whole extent. By +this means, a vacuum, as it were, is formed in the ramifications of the +pulmonary artery; each inspiration is accompanied by a rush of blood from +the right ventricle into the newly-inflated structure. The pulmonary +artery, at its bifurcation, swells and becomes turgid: the blood is +carried off into its numerous ramifications as fast as the right ventricle +can supply it; this may be easily understood from the law, in anatomy, +viz. that the area of two arteries is greater than that of the trunk from +which they bifurcate. From this state of distension, the distance between +the pulmonary artery and the aorta is increased; the ductus arteriosus, +which has now become empty, is stretched, and thus partially closed; the +right auricle, which, but for the foramen ovale, could not have cleared +itself of the whole quantity of blood which was poured into it from the +vena cava, is now enabled to transmit its entire contents into the right +ventricle; the left auricle, which before birth was supplied only by the +foramen ovale from the right auricle, is now rapidly filled by the blood +brought into it by the four pulmonary veins;--the equilibrium between the +two auricles becomes altered;--the right, which hitherto had been somewhat +gorged with blood, is now able to clear itself with facility; whereas, the +left, which was but partially supplied, is now distended with a much +greater quantity: there is now rather a disposition for the blood to +regurgitate from the left to the right auricle; this, however, is +prevented by the semilunar fold of the foramen ovale, which now acts as a +valve, and generally becomes firmly attached to the septum. The +obliteration of the canalis venosus at the posterior margin of the liver, +and of the umbilical vein at the anterior edge, may, we think, be +explained by the changes which necessarily follow the inflation of the +lungs: the diaphragm, when it contracts, pulls down the liver into its +natural situation; the distance, therefore, between the liver and the +heart is increased, and the canalis venosus is consequently stretched, and +considerably pressed upon, and precisely the same results follow with the +umbilical vein. + + + + +PART II + +NATURAL PREGNANCY AND ITS DEVIATIONS. + + + + +CHAPTER I. + +SIGNS OF PREGNANCY. + + _Difficulty and importance of the subject.--Diagnosis in the early + months.--Auscultation.--Changes in the vascular and nervous + systems.--Morning sickness.--Changes in the appearance of the + skin.--Cessation of the menses.--Areola.--Sensation of the child's + movements.--"Quickening."--Ausculation.--Uterine souffle.--Sound of + the foetal heart.--Funic souffle.--Sound produced by the movements of + the foetus.--Ballottement.--State of the uterine.--Violet appearance + of the mucous membrane of the vagina.--Cases of doubtful + pregnancy.--Diagnosis of twin pregnancy._ + + +There is, perhaps, no subject connected with midwifery, which is of such +importance, or which, from its difficulty and the serious questions it +involves, demands such attentive consideration, and requires so familiar +an acquaintance with every part of it, as the diagnosis of pregnancy. The +responsibility which a medical man incurs in deciding cases of doubtful +pregnancy, and in thus giving an opinion which may not only affect the +fortune, happiness, character, but even life itself of the individual +concerned, is rendered more painful by the perplexing obscurity of the +circumstances under which these cases sometimes occur, being not +unfrequently complicated with diseases which add still farther to the +difficulty of coming at the truth, and occasionally rendered peculiarly +obscure by wilful and determined falsehood and duplicity. + +To render this subject more intelligible to our readers, we propose first +to consider the general effects which pregnancy produces upon the system, +and then to describe those changes and phenomena which are _peculiar_ to +this state, and which may therefore be taken as so many means of +diagnosis. + +Under all circumstances, the diagnosis of pregnancy must ever be difficult +and obscure during the early months; the development of the uterus is +still inconsiderable, and the effects which it may have produced upon the +system, although appreciable and even distinct, are nevertheless too +capable of being also produced by other causes, to warrant our drawing any +decided conclusion from them. + +The effects over the whole animal economy, which result from the presence +and advance of this great process, are very remarkable, and show +themselves in every portion of it. + +The vascular system undergoes a considerable change; the actual quantity +of blood in the circulation appears to be increased; the pulse is harder, +stronger, and more full; in many instances the blood, when drawn, exhibits +the buffy coat, as in cases of inflammation; the vagina is more vascular, +it is warmer, and the secretion of mucus considerably increased; there is +a disposition to headach, and occasional flushing of the face; the animal +heat over the whole body is increased. In the nervous system we also +observe distinct evidences of a change having taken place: the +irritability is increased; there is weariness, lassitude, and a peculiar +alteration of taste and disposition; women, who otherwise are of a +cheerful disposition, are now gloomy and reserved, and _vice versâ_; in +some the temper becomes fretful and hasty, and in those who are naturally +so, a most agreeable change for the better is sometimes observed.[30] Some +are liable to spasmodic affections, palpitations, spasmodic cough, +vomiting, fainting, headach, toothach, &c.: under this head will come the +"morning sickness," which is so commonly observed during the first weeks; +the nature and treatment of which will be considered under the DISEASES OF +PREGNANCY; on the other hand, women who are constantly suffering from +spasmodic affections, for instance, asthma, &c. are now entirely free from +them, and appear to be insensible to causes which, in the unimpregnated +state, would induce an attack. To changes in the nervous system must we, +in great measure, attribute not only the sickness just mentioned, but also +those extraordinary longings or antipathies for certain articles of food +or drink, and in some cases, as in chlorosis, for substances which, under +other circumstances, would excite disgust. In many, the changes in the +function of the digestive apparatus does not amount to actual disease, the +stomach merely refusing to digest articles of food which before had agreed +with it: but in others, producing severe cardialgia, acidity, or even +vomiting. Hence, we not unfrequently observe that women who had hitherto +enjoyed a good digestion, now suffer from dyspepsia, and are obliged to be +exceedingly careful in their diet; whereas those, in whom the digestion +had been previously weak, are now able to digest almost any thing. The +secretions of the whole alimentary canal are altered both in quality and +quantity; the saliva frequently becomes tenacious, white, and frothy +(_Dewees_,) and at times is so much increased in quantity as to amount to +actual salivation; the secretions of the stomach are remarkably altered, +as shown by the copious formation of acid in some cases during pregnancy; +the mucus is ropy, and frequently vomited up in considerable quantities. +The bowels are in some cases much relaxed; in others, constipated. This +latter condition, however, may in part be attributed to the pressure of +the gravid uterus obstructing the peristaltic motion. + +The changes in the appearance of the skin during pregnancy are also worthy +of notice. Women, who are naturally pale and of a delicate complexion, +have frequently a high colour, and _vice versâ_; in some the skin assumes +a sallow or cadaverous hue; copper-coloured blotches appear on the face +and forehead: in others the skin appears loose and wrinkled, giving the +patient an aged haggard expression, and destroying her good looks. Mole +spots become darker and larger, and these, with a dark ring beneath the +eyes and the changes already mentioned, combine to alter the whole +appearance of the face. In some women a considerable quantity of hair +appears in those parts of the face where the beard is seen in the other +sex; it disappears after labour, when the skin resumes its natural +functions, but returns on every succeeding pregnancy. In others a similar +appearance takes place upon the breasts. The secretions of the skin are +more or less altered; women who perspire freely have now a dry, rough +skin; whereas those who at other times have seldom or never a moist skin, +have copious perspiration, which is not unfrequently of a peculiarly +strong odour. Cutaneous affections, also, which have been very obstinate, +or had even become habitual, sometimes disappear, or at least are +suspended during the period of utero-gestation. Similarly favourable +changes are observed for a time in severe structural diseases of certain +organs: the fact of well-marked phthisis apparently disappearing whilst +pregnancy lasts, is well known. + +The breasts become larger, blue veins are seen ramifying beneath the skin, +and the circular disc of rose-coloured skin which surrounds the nipples +becomes remarkably changed in colour, &c.; appearances, the description +of which we shall defer until we come to the consideration of those +phenomena produced by pregnancy, which may be looked upon as diagnostic. + +The urine undergoes various changes; it is sometimes considerably +increased, at others it is very high-coloured, or shows a peculiar milky +sediment. A case has been quoted by Dr. Montgomery from Professor Osann's +_Clin. Rep._ for 1833, p. 27., where the patient in three successive +pregnancies was affected with diabetus mellitus, which each time +completely ceased on delivery, and again returned when she became +pregnant. None of the changes above enumerated excepting of those of the +breasts, whether taken separately or conjointly, will enable us to form a +correct diagnosis as to the existence of pregnancy. The appearance and +feel of the abdomen during the early months afford no sure data: in fact, +there is not a single symptom of pregnancy at this period, upon which we +can rely with any degree of certainty. + +_Cessation of the menses._ One of the most remarkable changes produced by +pregnancy, and one which most constantly appears, is the cessation of the +menstrual discharge. From its occurring so uniformly and so soon after +conception, it is generally used by women as the best means of reckoning +the duration of their pregnancy: still, however, it is very far from being +a certain sign, and never can be depended upon by itself in forming our +diagnosis. It is well known how many causes produce suppression of the +catamenia, independent of pregnancy; and, on the other hand, ample +experience has shown that suppressed catamenia are by no means a necessary +consequence of pregnancy. + +Although the fact has been contradicted by men of experience, still the +regular appearance of the menses for the first few months of pregnancy is +of such frequent occurrence as to place the matter beyond all doubt: in +stating this, we do not allude to occasional discharges of blood from the +vagina, but to regular periodical appearances of fluid distinctly bearing +all the characters and peculiarities of the catamenia. This fact has been +noticed so long ago, as by Mauriceau, who says, "I know a woman who had +four or five living children, and who had with every child her menses from +month to month, as at other times, only in a little less quantity, and was +so till the sixth month, yet notwithstanding she was always brought to bed +at her full time."[31] + +It is rare, however, to meet with the catamenia at so late a period, +although cases do now and then occur where it lasts throughout pregnancy; +more frequently it does not continue beyond the third or fourth month. The +source of this discharge appears to be from the vessels of the upper part +of the vagina[32] and from the cervix uteri;[33] the gradually shortening +of the latter as pregnancy advances may be considered as the reason why, +in the majority of instances, the discharge diminishes after the second or +third month, and usually ceases by the fifth or sixth. Dr. Dewees supports +the same opinion with some excellent observations which are worthy of +attention. "We are" says he "acquainted with a number of women who +habitually menstruate during pregnancy until a certain period, but when +that time arrives it ceases: several of these menstruated until the second +or third months, others longer, and two until the seventh month; the last +two were mother and daughter. We are certain there was no mistake in all +the cases to which we now make reference. First, they (the menses) were +regular in their returns, not suffering the slightest derangement from the +impregnated condition of the uterus; 2. they employ from two to five days +for their completion; 3. that the evacuation differed in no respect from +the discharge in ordinary, except that they did not think it so abundant; +4. there were no coagula in any one of these discharges, consequently it +could not be common blood of hæmorrhage; 5. in the two protracted cases, +the quantity discharged regularly diminished after the fourth month, a +circumstance perhaps not difficult of explanation." (_Compendious System +of Midwifery_, § 235.) + +It occasionally happens that the first appearance of the catamenia after +conception is more abundant than usual, a circumstance which had been +noticed by Dr. W. Johnson in 1769, and confirmed by Dr. Montgomery in his +admirable work on the signs of pregnancy, who also confirms the general +fact of the menses occasionally appearing during pregnancy by his own +experience, and by very ample references. (_Op. cit._ p. 46.) + +The rarest and most extraordinary deviation of this kind from the usual +course of things is the appearance of the menses _only during pregnancy_. +Cases of this sort have been recorded by authors of the highest +respectability, so that there can be no doubt as to the correctness of +their statements. Thus, for instance, Baudelocque says, "I have met with +several women, who assured me that they had not had their menses +periodically except during their pregnancies; their testimony appeared to +me to deserve more credit, because they only applied for an explanation of +this extraordinary phenomenon."[34] + +By far the most interesting and detailed case of this nature is one +described by Dr. Dewees. "A woman applied for advice for a long standing +suppression of the menses; indeed she never had menstruated but twice. She +had been married a number of months, and complained of a good deal of +derangement of stomach, &c. We prescribed some rhubarb and steel pills; +about six months after this she called to say that the medicine had +brought down her courses, but that she was more unwell than before. The +sickness and vomiting had increased, besides swelling very much in her +belly; we saw this pretty much distended and immediately examined it, as +we suspected dropsy; but from the feel of the abdomen, the want of +fluctuation and the solidity of the tumour, we began to think it might be +pregnancy, and told the woman our opinion. On mentioning our impression +she submitted to an examination per vaginam; this proved her to be six +months advanced in pregnancy. After this she had the regular returns of +the catamenial period, until the full time had expired; during suckling +she was free from the discharge. She was a nurse for more than twelve +months; she weaned her child, and shortly after was again surprised by an +eruption of the menses, which as on a former occasion proved to be a sign +of pregnancy." (_Op. cit._ § 237.) + +There are other circumstances also connected with the catamenia, which +warn us against placing too much confidence in its disappearance as a sign +of pregnancy: a woman may become pregnant who has never menstruated, a +fact which has been noticed by several authors, and which has been +explained as well as confirmed by Levret in his _Art des Accouchemens_, § +230:--"A woman," says he, "may conceive, although she has not yet +menstruated, provided menstruation would otherwise have made its +appearance shortly."[35] + +Another circumstance, of much more frequent occurrence, is the fact that a +woman may become pregnant without having had a return of the menses since +her last confinement; hence we occasionally meet with cases where, from a +rapid succession of pregnancies, the menstruation has not appeared for +several years. From what has now been said, it will be seen, beyond all +doubt, that the non-appearance of the menses cannot be looked upon by +itself as a diagnostic of pregnancy, or _vice versâ_: this is more +particularly the case when any morbid condition of the system is also +present; under such circumstances, little or no confidence can be placed +upon it as a guide in forming our diagnosis. In cases where it is an +object to conceal pregnancy, the appearance of the menstrual fluid upon +the clothes has been imitated in order to deceive. (Montgomery, _op. cit._ +p. 50.) Although, therefore, the cessation of the menses, when taken in +connexion with other symptoms, will prove useful in assisting us to a +correct opinion, nevertheless, when taken by itself, it will scarcely ever +enable us to decide with certainty. + +_Areola._ Among the earliest of those symptoms which must be considered as +diagnostic are the changes observed in the appearance of the breasts; +"they increase, become full; they are occasionally painful and grow hard: +the veins in them are rendered conspicuous from their blue colour; the +nipple becomes more bulky and appears inflated, its colour becomes darker, +the surrounding disc undergoes a similar change, increases in extent, and +is covered with little prominences like so many diminutive nipples."[36] +"The several circumstances (says Dr. Montgomery, p. 59,) here enumerated +at least ought in all cases to form distinct subjects of consideration, +when we propose to avail ourselves of this part as an indication of the +existence or absence of pregnancy. One other, also, equally constant and +deserving of particular notice, is a soft and moist state of the +integument, which appears raised and in a state of turgescence, giving one +the idea that if touched by the point of the finger it would be found +emphysematous. This state appears, however, to be caused by infiltration +of the subjacent cellular tissue, which together with its altered colour, +gives us the idea of a part in which a greater degree of vital action is +going forward than is in operation round it, and we not unfrequently find +that the little glandular follicles, or tubercles, as they are called by +Morgagni, are bedewed with a secretion sufficient to damp and colour the +woman's inner dress. + +These changes do not take place immediately after conception, but occur in +different persons after uncertain intervals. We must therefore consider, +in the first place, the period of pregnancy at which we may expect to gain +any useful information from the condition of the areola. I cannot say +positively what may be the earliest period at which this change can be +observed, but I have recognised it fully at the end of the second month, +at which time the alteration in colour is by no means the circumstance +most observable; but the puffy turgescence, though as yet slight, not +alone of the nipple, but of the whole surrounding disc, and the +development of the little glandular follicles, are the objects to which we +should principally direct our attention, the colour at this period being +in general little more than a deeper shade of rose or flesh colour, +slightly tinged occasionally with a yellowish or light brownish hue. +During the progress of the next two months the changes in the areola are +in general perfected, or nearly so, and then it presents the following +characters: a circle around the nipple, whose colour varies in intensity +according to the particular complexion of the individual, being usually +much darker in persons with black hair, dark eyes, and sallow skin, than +in those of fair hair, light-coloured eyes, and delicate complexion.[37] +The extent of this circle varies in diameter from an inch to an inch and a +half, and increases in most persons as pregnancy advances, as does also +the depth of the colour."[38] + +"In the centre of the coloured circle the nipple is observed partaking of +the altered colour of the part, and appearing turgid and prominent, while +the surface of the areola, especially that part of it which lies more +immediately around the base of the nipple, is studded over, and rendered +unequal by the prominence of the glandular follicles, which, varying in +number from twelve to twenty, project from the sixteenth to the eighth of +an inch; and lastly the integument covering the part appears turgescent, +softer, and more moist than that which surrounds it; while on both there +are to be observed at this period, especially in women of dark hair and +eyes, numerous round spots, or small mottled patches of a whitish colour, +scattered over the outer part of the areola, and for about an inch or more +all round, presenting an appearance as if the colour had been discharged +by a shower of drops falling on the part. I have not seen this appearance +earlier than the fifth month, but towards the end of pregnancy it is very +remarkable, and constitutes a strikingly distinctive character exclusively +resulting from pregnancy. The breasts themselves are at the same time +generally full and firm, at least more so than was natural to the person +previously, and venous trunks of considerable size are perceived ramifying +over their surface, and sending branches towards the disc of the areola, +which several of them traverse along with these vessels. The breasts not +unfrequently exhibit about the sixth month, and afterwards, a number of +shining, whitish, almost silvery lines like cracks; these are most +perceptible in women, who, having had before conception very little +mammary development, have the breasts much and quickly enlarged after +becoming pregnant." + +In enumerating these various changes which are observed in the breasts, we +fully agree with Dr. Montgomery in saying, that the alteration in the +colour of the areola is by no means that upon which we can depend with +most certainty: in the first place, we frequently meet with so little +discolouration during the earlier months as to be altogether +inappreciable; we have also already shown that if the patient be a +brunette, and has already had children, the colour of the areola cannot be +trusted to, as it never entirely disappears after her first pregnancy. On +the other hand, we occasionally meet with a considerable change of colour +in the unimpregnated state, arising from uterine irritation, as in +dysmenorrhoea, &c. Where, however, this is accompanied by the other +changes above enumerated, there can be, we apprehend, no doubt as to the +existence of the pregnancy. Dr. Smellie, and also Dr. W. Hunter both +considered the areola as proof positive of pregnancy. The latter one +decided upon a case of pregnancy under very extraordinary circumstances; +the body of a young female was brought into the dissecting room, which at +the first glance he pronounced to be pregnant, but the accuracy of his +diagnosis was not a little doubted when it was ascertained that a perfect +hymen was present: to decide the point he had the abdomen opened when the +uterus was found to contain a small foetus. + +_Movements of the foetus._ The sensation to the mother of the child moving +in the uterus, cannot be looked upon as a certain sign of pregnancy, for +even women who have had large families of children are frequently deceived +in this respect by the movement of flatus in the intestines, by occasional +spasmodic twitchings of the abdominal muscles, &c.; but when the motion of +the child can be distinctly felt by the hand of an experienced +practitioner, it will no longer admit of any doubt: this, however, is a +symptom which can seldom be made use of before the middle of the sixth or +seventh month. + +_Quickening._ This leads us to the subject of quickening as a symptom of +pregnancy. The very vagueness of the term _quickening_ is of itself a +sufficient objection to its use as a source of information on these +points. Strictly speaking, it refers to that moment of pregnancy when the +woman is supposed to have become _quick with child_, or in other words, +when the foetus becomes endued with life, "an error," as Dr. Montgomery +observes, "which the continued use of the term was obviously calculated to +foster and to prolong" (p. 75.) As far as we can understand, the word +"quickening" at the present day refers to two different events during +pregnancy: the one is when the motion of the child first becomes +perceptible to the mother; the other consists of those effects which are +frequently observed when the uterus quits the pelvis, and rises into the +abdominal cavity, viz. fainting, sickness, &c.; in either case it will be +evident that no correct conclusion can be formed by this means. It may +safely be asserted that until the last twenty years we possessed only +three diagnostic marks of pregnancy, viz. the appearance of the areola, a +series of changes but little understood; the being able to feel the +movements of the child through the abdominal parietes, and the head of it +per vaginam. Hence Dr. W. Hunter in describing the uncertainty of the +signs of pregnancy says, "I find I cannot determine at four months, I am +afraid of myself at five months, but when six or seven months are over, I +urge an examination." + +In the primipara, the changes which pregnancy produces upon the os and +cervix uteri are generally sufficient to lead to an accurate conclusion. +The round dimple-like depression which the os uteri forms, the soft +cushiony state of the cervix, are changes which we consider as peculiarly +the effects of pregnancy, but their distinctness and certainty ceases when +the patient has had several children; the irregular shape of the os uteri, +its thickened edges, hard here and there, and the os tincæ, itself more or +less open, the cervix scarcely, if at all, shortened, even at a late +period of gestation, tend not a little to perplex the diagnosis furnished +by this mode of examination; and where disease is complicated with +pregnancy, the difficulty is greatly increased, and not unfrequently so +much, that scarcely a single satisfactory point will be obtained. + +_Auscultation._ Of late years, an immense advance has been made in the +diagnosis of pregnancy, by means of the stethoscope. M. Major of +Geneva,[39] in 1819, observed the interesting fact that he could hear the +pulsations of the foetal heart through the parietes of the mother's uterus +and abdomen: he appears, however, to have carried his researches no +farther; and little attention was excited to the circumstance until three +years afterwards, when a masterly essay on the subject was read before the +Académie Royale de Médecine of Paris, by Lejumeau de Kergaradec.[40] In +this interesting memoir, the author has described two sounds, which are +perfectly distinct from each other in point of character. One of them +consists of single pulsations, synchronous with those of the mother's +heart, accompanied with the deep whizzing rushing sound, which may be +heard over a large portion of the uterus at once; the other of sharp, +distinct, double pulsations, producing a ticking sound, and following a +rythm, which is not synchronous with that of the maternal circulation. +Kergaradec supposed that the former sound was produced by the circulation +of the blood in the spongy structure of the placenta, and hence called it +the _souffle placentaire_; later observations[41] have, however, shown +that it is not connected with the placenta, but depends upon the increased +vascularity and peculiar arrangement of the uterine vessels during the +gravid state. The other sound is produced by the pulsations of the foetal +heart. + +_Uterine souffle._ The uterine sound, or _souffle_, may invariably be +heard in one or other of the inguinal regions, and usually over a +considerable portion of the uterus, extending anteriorly or along the +sides of the organ; and according to the observations of Professor Naegelé +jun.,[42] there is no part of the uterus, capable of being osculted, in +which this sound may not be heard. He considers that the souffle, which is +so uniformly heard in the lower parts of the uterus, especially in the +inguinal regions, seems to be produced by the uterine arteries before they +enter the uterus; these vessels, as soon as they arrive at the broad +ligament, assume a different character, become larger than they were on +branching off from their original trunk, and are much contorted before +entering the parietes of the uterus. Dubois first pointed out the +similarity which exists between the sound heard in the gravid uterus, and +that of aneurismal varix, where there is a direct passage of blood from an +artery into a vein: the sound in this latter condition is produced by the +current of blood rapidly issuing from the dilated artery, and mixing with +the slower flowing stream of the dilated vein. The circulation of blood in +the dilated arteries of the uterus present a considerable resemblance, in +many respects, to that of the above-mentioned disease. + +That the uterine sound is not confined to that part of the uterus where +the placenta is attached, as was supposed by Professor Hohl,[43] is proved +by the fact that we can frequently hear it in two different and sometimes +opposite parts of the uterus at the same time, which, if his opinion be +correct, would indicate the presence of twins; and yet the result of +labour has proved that the uterus has contained but one child, and that +the placenta had neither been attached in the one or other of these +situations. The very circumstance which we have already mentioned, of this +sound being invariably heard in one, if not in both, of the inguinal +regions, shows that it is independent of the vicinity of the placenta; +nevertheless, it must be allowed, that as the uterine vessels undergo the +greatest degree of development at this part, the sound will usually be at +least as distinct here as in any other portion of the uterus. + +The uterine souffle is the first sound which auscultation detects during +pregnancy; it may be heard as early as the fifteenth or sixteenth week, +but cases now and then occur where it has been even distinguished in the +thirteenth or fourteenth week, and Dr. Evory Kennedy, has given some very +interesting examples where he was able to hear it with certainty at the +twelfth, eleventh, and even in one instance, at the tenth week. (Kennedy, +_op. cit._ p. 80.) During these earlier periods, the sound is weaker, but +extends over the whole uterus, from the diminutive size of which it can be +heard most readily immediately above the symphysis pubis; in fact, there +is every reason to suppose, that the uterine souffle might be detected at +a still earlier period, if the uterus were at this time within reach of +the stethoscope. As pregnancy advances, it becomes more distinct and +powerful, and is occasionally so to a remarkably degree. During the latter +periods of pregnancy, it frequently presents considerable modifications of +tone, especially where there is general or local vascular excitement, as +in cases of fever, or dispositions to hæmorrhage, where the vessels are +usually distended, or where (Naegelé, _op. cit._ p. 86,) the placenta is +situated near the os uteri, it assumes a piping, twanging sound of +considerable resonance: the same is also observed where, either from the +weight of the gravid uterus or any other cause, pressure has been exerted +on any of the main arterial trunks: hence, as we shall show more fully +when speaking of labour, a remarkable change is produced in the tone of +the uterine souffle by the first contractions of that process. The causes +of these modifications are not always very easily explained; we sometimes +observe the souffle on the same side of the uterus vary rapidly in its +degree of intensity, and occasionally even disappear for awhile without +our being able to assign any satisfactory reason for such changes. + +The uterine souffle taken by itself, although a very valuable sign of +pregnancy, can scarcely be looked upon as one which is perfectly certain +and diagnostic, since a similar sound may be produced by aneurism of the +abdominal aorta and its large branches: there is much reason to think that +the uterus, enlarged from other causes than that of pregnancy, and +pressing upon the iliac arteries, will produce a similar sound. Professor +Naegelé, jun., has also shown that the sounds of the patient's heart may +sometimes be heard very low in the abdomen, even as far as the ossa ilii, +a circumstance which seems to have depended upon the sound being +transmitted through the intestines distended with flatus. Where any of +these causes of abdominal souffle have existed in connexion with +suppressed catamenia, swelling of the breasts, &c., we might be liable to +be deceived if we allowed ourselves to be entirely guided by this sound. + +With regard to the foetal pulsations, we find them generally beating at +the rate of from 130 to 150 double strokes in a minute, and the age of the +foetus appears to have no effect upon their rapidity, for even at the +earliest periods at which we can detect these sounds the rate of the +pulsation is the same as at the full term of pregnancy. + +Although Dr. Kennedy has in a few cases detected this sound even before +the expiration of the fourth month, it will not in the majority be +possible until a later period. "At the fourth month it frequently requires +not only close attention, but considerable perseverence to detect the +foetal heart; and at this period it has occurred to us to examine patients +whom there was strong reason to suppose pregnant, and after spending a +considerable time in endeavouring to detect this sound, we have been on +the point of giving up the search as hopeless, when it has been suddenly +discovered in the identical spot that had before perhaps been explored +without success." (Kennedy, _op. cit._ p. 101.) + +The sound of the foetal heart is usually heard at about the middle point +between the scrobiculus cordis and symphysis pubis, usually to one side, +and that, generally speaking, the left. The extent of surface over which +the sound may be heard varies a good deal, and depends, in great measure, +on the distance which intervenes between the foetus and stethoscope; +hence, when the uterus is distended with a large quantity of liquor amnii, +or when the uterine and abdominal parietes are very thick, it is heard +over a much larger space, although with diminished intensity; on the other +hand, when there is but little liquor amnii in the uterus, it is audible +over a small portion only, but is remarkably distinct: this is peculiarly +the case during labour after rupture of the membranes. The rapidity and +strength of the foetal pulsations appear to be entirely independent of the +mother's circulation; violent exercise, spirituous liquors, &c., which +will raise her pulse to a considerable degree, have no influence whatever +on the foetal pulse. In cases of fever, where the mother's pulse has +ranged between 110° and 120°, and even higher, not the slightest change +was observable in the sound of the foetal heart; even in acute +inflammatory affections, in pneumonia, pleurisy, where there was severe +dyspnoea, and also in tubercular phthisis; in cases where the patient has +been bled; in cases of menstruation during pregnancy; and even in severe +flooding, and when the mother's pulse has been greatly reduced, no +perceptible change has been observed in that of the foetus. (Naegelé, _op. +cit._ p. 39.) Dr. Kennedy has observed some remarkable cases where the +foetal pulse appeared to vary in accordance with that of the mother (_op. +cit._ p. 91;) but when we bear in mind the frequent changes in point of +rapidity, &c., to which the foetal heart is subject, independent of any +thing of the kind in the mother's pulse, and that similar changes are +constantly observed in the child shortly after birth; and, moreover, that +very considerable acceleration of the maternal pulse has decidedly no +effect upon that of the foetus in many well-marked instances, we cannot +agree with him in supposing that a connexion of the sort to which he has +alluded exists. The double pulsations of the foetal heart can only be +heard at one point of the uterus at a time, provided there be but one +child; but if there be twins, then the sound is heard in two places at +once. It has been supposed by some authors (_Dubois_) that the heart of +the second child could not be distinctly heard until labour, when the +membranes of the first child had ruptured. Generally speaking, both sounds +can be heard pretty distinctly during the last weeks of pregnancy, one of +them being low down on one side, and the other high up in an opposite +direction. Although in some twin cases there is an evident difference of +rhythm between the two foetal hearts, still in many others they are so +nearly synchronous as to be scarcely if at all distinguishable in this +respect. Hence, therefore, from the known variable character of the foetal +pulse, it will be necessary that the sound of each heart should be +ausculted at the same moment, minute for minute, by two observers, and +thus the slightest appreciable difference between them determined. + +_Funic souffle._ Dr. Kennedy has shown that, where a portion of the +umbilical cord passes between the child's body and the anterior wall of +the uterus, or crosses any of its limbs or other projections, pulsations +are heard synchronous with those of the foetal heart; although not +possessing the same characters. "In some cases where the uterus and +parietes of the abdomen were extremely thin, I have been able," says Dr. +K., "to distinguish the funis by the touch externally, and felt it rolling +distinctly under my finger, and then, on applying the stethoscope, its +pulsations have been discoverable remarkably strong; and, on making +pressure with the finger for a moment on that part of the funis which +passed towards the umbilicus of the child, I have been able to render the +pulsations less and less distinct, and even, on making the pressure +sufficiently strong, to stop it altogether." (_Op. cit._ p. 121.) In many +cases where the umbilical arteries, by their convolutions round a limb, or +by any other cause, are subjected to slight pressure, a distinct whizzing +sound is produced, which is called by Dr. Kennedy the _funic souffle_. + +The sound of the foetal heart must be looked upon as a sign of the highest +value in the diagnosis of pregnancy, since, however complicated and +obscure the other symptoms may be, whether from co-existing disease, +wilful deception, &c. if this sound be once heard unequivocally, the real +nature of the case is satisfactorily established beyond all possibility of +doubt. + +Another sound in the gravid uterus has been lately noticed by Professor +Naegelé, junior, which promises to equal that of the foetal heart, as a +certain diagnostic of pregnancy, and must be looked upon as a valuable +addition to our means of ascertaining the truth in cases of this sort. The +movements of the foetus may be distinguished by the stethoscope at a very +early period of pregnancy, long before they are perceptible to the hand of +the accoucheur, and in many cases before the patient has been aware of +them herself. According to Professor Naegelé's observations, these sounds +may usually be heard some little time before the foetal heart is audible, +and are sounds which can neither be feigned nor concealed: they can only +be heard in the gravid uterus, and under no other circumstances. + +Although the sounds of the heart and movements of the foetus are +unequivocal proofs of pregnancy, which may be heard at a very early +period, still it must, in some degree, remain uncertain at this time, how +far their absence can be looked upon as a proof of its non-existence. +Under such circumstances, the examinations require to be conducted with +the greatest possible care, and to be repeated at favourable +opportunities, until no doubt as to the correctness of their results can +any longer exist. + +The soft cushiony feel of the cervix uteri is a change produced by +pregnancy, which, in our opinion, has not received that attention which it +deserves; as far as we are able to judge, this condition of the cervix is +peculiar to pregnancy, and exists very shortly after conception. We +occasionally meet with a soft flaccid state of the os and cervix uteri in +certain diseases; but the feel which this communicates to the finger is +very different to that above-mentioned, which resembles more the elastic +inflated condition of the nipple during pregnancy, than any thing to which +we can compare it. + +_Ballottement._ At the beginning of the seventh month we shall be able to +feel the head of the foetus upon examination per vaginam. If we direct our +finger against the uterus, midway between the os uteri and symphysis +pubis, and suddenly exert a slight degree of pressure, we shall become +sensible of having struck against something hard within the cavity of the +uterus; upon repeating the experiment immediately, we shall probably not +feel it, the foetus having risen in the liquor amnii to the upper parts of +the uterus; but if hold our finger still for a few moments, it will, by +this time, have again descended, and we shall again feel it; at other +times, when the foetus is larger and heavier, the head will rest like a +light ball, on the tip of the finger, from which circumstance it has +received the name of _ballottement_ by the French authors. + +_Motion of the child._ The sensation of the child's movements to the +mother is a symptom of very little value, and is liable to mislead the +practitioner if he place much reliance upon it; for the passage of the +flatus along the bowels, or little spasmodic flickerings of the abdominal +muscles, will produce a very similar sensation, and will even completely +deceive a patient who has been the mother of several children; but when +they become perceptible to the experienced hand of the practitioner, this +may also be looked upon as a certain indication that pregnancy exists. The +foetal movements can seldom be felt distinctly until the beginning of the +seventh month, and even then it requires some caution before we can +venture upon a positive opinion. Their activity varies considerably in +different cases; in some their nature is almost immediately evident; +whereas, in others they are so few and feeble, as to make it very +difficult to decide. It has been recommended to put the head in cold water +previous to applying it upon the abdomen, as, by this means, a +considerable shock is produced which excites these movements more +distinctly. We cannot say that we have found this proceeding of any use, +since, by this means, the abdominal muscles are rendered so irritable as +frequently to obstruct the examination considerably: it is rather +desirable to have them in as perfect a state of repose as possible, in +order that no movement of the foetus, however slight, should escape our +notice. It is in cases of abdominal enlargement from disease; that this +means of diagnosis is occasionally very difficult, and where men, even of +great experience, have been led to form a very erroneous opinion. The +celebrated Peter Franck has related a case of this sort which occurred to +himself, where the patient was supposed pregnant, and where he imagined +that he had felt the motions of the child: she died shortly afterwards, +and the examination of the body showed it to have been a case of ascites +complicated with hydatids. Dr. Dewees has given a still more remarkable +case of a similar error having occurred to himself. A young lady had her +menses suppressed for several months; the abdomen swelled very much, the +breasts became enlarged, she had nausea and vomiting in the morning, and +other indications of pregnancy; "examining the abdomen carefully, I found +it," says Dr. Dewees, "considerably distended; there was a circumscribed +tumour within it, which I was very certain was an enlarged uterus. While +conducting this examination I thought I distinctly perceived the motions +of a foetus. The case proved to be one of accumulation of menstrual fluid +in the uterus." (Dewees's _Essays on several Subjects connected with +Midwifery_, p. 337-8.) + +In reviewing what has now been stated respecting the diagnosis of +pregnancy, it will be observed that we have enumerated four symptoms, +which must be looked upon as perfectly diagnostic of this condition, and +in the accuracy and certainty of which we may place the fullest +confidence: two may be recognised at an early period by means of +auscultation, viz. the sounds produced by the movements of the foetus and +by the pulsations of its heart; the two others are not appreciable until +a later period, and are afforded by manual examination, viz. the being +able to feel the head of the foetus per vaginam, and its movements through +the abdominal parietes. The next in point of value after these are the +changes in the os and cervix uteri, those connected with the formation of +the areola in the breasts, and, at a somewhat later period, the sound of +the uterine circulation, changes, which, although they cannot separately +be entirely depended upon, are nevertheless symptoms of very great +importance in the diagnosis of pregnancy. + +Two other signs of pregnancy have also been mentioned, viz. the appearance +of a peculiar deposite in the urine as described by M. Nauche, or rather +by Savonarola (Montgomery, _op. cit._ p. 157.,) and the purple or violet +appearance of the mucous membrane lining the vagina and os externum, as +described by Professor Kluge of the Charité at Berlin, and by M. M. +Jacquemin, Parent Duchatelet, &c. of Paris. With regard to the first, +which is an old popular symptom of pregnancy, there is too much variety in +the appearances of the urine, depending on general health, diet, +temperature, &c., to enable us to place much confidence in any change of +this sort. "I have myself tried it," says Dr. Montgomery, "in several +instances, and the result of my trials has been this:--In some instances +no opinion could be formed as to whether the peculiar deposite existed or +not, on account of the deep colour and turbid condition of the urine; but +in the cases in which the fluid was clear, and pregnancy existing, the +peculiar deposite was observed in every instance. Its appearance would be +best described by saying that it looks as if a little milk had been thrown +into the urine, and having sunk through it had partly reached the bottom, +while a part remained suspended and floating through the lower part of the +fluid in the form of a whitish semi-transparent filmy cloud." (_Op cit._ +p. 157.)[44] + +The purple colour of the vaginal entrance appears, from the extensive +experience of the above-mentioned authors, to be a pretty constant change +produced by the state of pregnancy; it probably occurs at a very early +period. How far a similar tinge is produced by the state of uterine +congestion immediately before a menstrual period, we are unable to say; at +any rate, the character of the examination itself must ever be sufficient +to preclude its being practised in this country. + +The diagnosis of pregnancy is a subject well worthy of the student's most +serious attention; for he will of course be liable, when in practice, to +be called upon to give his evidence before a court of justice under +circumstances when the responsibility must ever be of the most serious and +not unfrequently of the most fearful nature, the more so as the old custom +of impanelling a jury of "twelve discreet matrons" to determine whether +the woman be _quick with child_ has fallen deservedly into disrepute. He +should lose no opportunity of making himself familiar with the various +symptoms of pregnancy above enumerated, and of so practising the different +senses of hearing, touch, and sight, as instantly and certainly to detect +their presence. + +Numerous cases are on record, where a false diagnosis in women convicted +of capital offences, has led to most lamentable results, and where +dissection of the body after death has shown that she was pregnant. Dr. +Evory Kennedy has recorded an interesting case of this sort which occurred +at Norwich in 1833, when a pregnant woman was on the point of being +executed through the ignorance of a female jury. (E. Kennedy's +_Observations on Obstetric Auscultation_, &c., p. 197.) We may also +mention a dreadful case of this nature which occurred to the celebrated +Baudelocque at Paris, during the horrors of the French revolution.[45] A +young French countess was imprisoned during the revolution, being +suspected of carrying on a treasonable correspondence with her husband, an +emigrant. She was condemned, but declared herself pregnant; two of the +best midwives in Paris were ordered to examine her, and they declared that +she was not pregnant. She was accordingly guillotined, and her body taken +to the school of anatomy, where it was opened by Baudelocque, who found +twins in the fifth month of pregnancy. + +Equally important is it (and perhaps in some respects even more so) to +determine the absence of pregnancy in cases where it has been supposed to +exist. In many instances the character and happiness of the individual +must depend upon the judgment which the practitioner pronounces; and, +painful as will be the task of communicating an opinion which implies +guilt and loss of honour, how infinitely revolting and inexcusable must +that step be considered, which turns out to have been founded upon an +incorrect diagnosis. Hence the importance of separating those symptoms of +pregnancy which may be considered certain, and therefore trustworthy, from +the crowd of others, which, although collectively they may warrant a +suspicion, yet never can justify a decision that pregnancy exists, more +especially in cases where so much is at stake. No two symptoms have led +more frequently to this cruel error, and therefore to the most unjust +suspicions, than the cessation of the menses with swelling of the abdomen, +and yet from how many different causes may they arise besides that of +pregnancy? Putting even the impulse of common feeling aside, we would ask +how a practitioner can dare recklessly to incur the responsibility of +injuring a woman's character by hazarding an opinion which involves so +much, and is based upon symptoms which, by themselves, prove so little? +Whether he exercise his profession in town or country, cases of doubtful +pregnancy will constantly come under his notice. We cannot, therefore, too +strongly urge the importance of ascertaining how many of the certain +symptoms are present, before we allow ourselves to be influenced by those +which are uncertain. In speaking of the enlargement of the abdomen as a +sign of pregnancy which is extremely equivocal, Dr. Dewees well observes, +"But little reliance can be placed upon this circumstance alone, or even +when combined with several others; for I have had the pleasure in several +instances of doing away an injurious and cruel suspicion, to which this +enlargement had given rise. Within a short time, I relieved an anxious and +tender mother from an almost heart-breaking apprehension for the condition +of an only and beautiful daughter on whom suspicion had fallen, though not +quite fifteen years of age: this case, it must be confessed, combined +several circumstances which rendered it one of great doubt, and, without +having had recourse to the most careful and minute examination, might +readily have embarrassed a young practitioner. This lady's case was +submitted to a medical gentleman, who, from its history and the feel of +the abdomen, pronounced it to be a case of pregnancy, and advised the +sorrow-stricken mother to send her daughter immediately to the country as +the best mode of concealing her shame. Not willing to yield to the opinion +of her physician (a young man,) and moved by the positive denials of her +agonized child, the mother consulted me in this case. The menses had +ceased, the abdomen had gradually swelled, the stomach was much affected, +especially in the morning, and the breasts were a little enlarged. On +examination it proved to be a case of enlarged spleen." (Dewees, _on the +Diseases of Females_, p. 178.) + +We occasionally, also, meet with cases of self-deception, as to the +existence of pregnancy, to an extent which would scarcely seem credible. +Women who have been the mothers of several children, will, upon some very +slight foundation, suppose themselves with child. Knowing from previous +experience many of the symptoms of this state, they will frequently +enumerate them most accurately to the practitioner, who, if he rest +satisfied with general appearances, may easily be led into a wrong +diagnosis. A case of this kind we published in our midwifery reports, +where the patient, the mother of two children, came into the General +Lying-in Hospital, not only under the supposition that she was pregnant, +but that labour had actually commenced; the catamenia had ceased about +nine months previously, and the abdomen was considerably enlarged. +Examination proved that she was not pregnant. (_Med. Gaz._ June, 1834.) + +In a work solely devoted to cases of doubtful pregnancy by the late W. J. +Schmitt, of Vienna, these cases have been very fully discussed. "We +occasionally observe certain conditions of the female system, which put on +a most striking resemblance to pregnancy, both functionally as well as +organically, without at all depending on the actual presence of pregnancy. +The abdomen begins to swell from the pubic region exactly in the same +gradual manner as in pregnancy; the breasts become painful, swell, and +secrete a lymphatic fluid, frequently resembling milk; the digestive +organs become disordered; there is irregular appetite, nausea, and +inclination to vomit; constipation, muscular debility, change in the +colour of the skin, and frequently of the whole condition of the body; the +nervous system suffers, and even the mind itself frequently sympathizes; +the patient is sensible of movements in the abdomen like those of a living +foetus, then bearing down pains running from the loins to the pubes; at +last actual labour-pains come on as with a woman in labour, and if by +chance her former labours have been attended by any peculiar symptoms, +these, as it were, to complete the illusion, appear likewise." (W. J. +Schmitt, _Zweifelhafte Schwangerschafts-fälle_.) A most extraordinary case +of the self-deception with regard to pregnancy, has been published by the +celebrated Klein of Stuttgardt: it has been quoted in the work of W. J. +Schmitt above alluded to, and a brief sketch of it has been given by Dr. +Montgomery in his _Expositions of the Signs and Symptoms of Pregnancy_, p. +172, to which we must refer the reader for much valuable information on +this and all other subjects connected with the diagnosis of pregnancy. + +_Diagnosis of twin pregnancy._ Before concluding this chapter, we shall +offer a few observations on the diagnosis of twins. A variety of symptoms +have been enumerated as indicating the presence of two foetuses in utero, +such as the great size of the abdomen, its flat square shape, the +movements of a child at different parts of it, &c. The size of the abdomen +can never be admitted as a diagnostic mark of twin pregnancy; first, +because it equally indicates the presence of an unusual quantity of liquor +amnii, or of a very large child; and secondly, because women pregnant with +twins are not always remarkable for their size: the flatness, &c., of the +abdomen is, we presume, a symptom based on the supposition that there is a +foetus in each side of the uterus: this is very far from being correct, as +it is well known that the children usually lie obliquely, the one being, +perhaps, downwards and backwards, while the other is situated upwards and +forwards. The sensation of the child's movements in different or opposite +parts of the uterus is no proof whatever that there are twins, because it +is constantly observed where there is but one child--a circumstance which +is very easy of explanation. + +The stethoscope affords us the only certain diagnosis of twin pregnancy; +and even here it is limited to the sounds of the foetal hearts; the +increased extent and power of the uterine souffle, as remarked by Hohl, +arising, as he supposed, from the large mass of the double placenta, is +not a proof which can be depended upon. In cases of suspected twin +pregnancy the auscultation must be conducted with the greatest possible +care, and, generally speaking, a certain diagnosis can only be obtained by +two observers ausculting the two hearts at one and the same moment; for, +otherwise, the difference between their rhythm is frequently so small as +to be inappreciable. The sounds are seldom or never heard at the same +level, one being generally heard high up on one side, the other in a +contrary direction. + + + + +CHAPTER II. + +TREATMENT OF PREGNANCY. + + _Sympathetic affections of the stomach during pregnancy.--Morning + sickness.--Constipation.--Flatulence.--Colicky pains.--Headach.-- + Spasmodic cough.--Palpitation.--Toothach.--Diarrhoea.--Pruritus + pudendi.--Salivation._ + + +In the preceding chapter we have enumerated those changes and phenomena +which are observed to take place in the system during pregnancy: many of +these amount to actual derangements of function, and will, therefore, as +such, demand our attention in a practical point of view, for the purpose +of alleviating or removing them. Many of these changes are produced by the +altered distribution of blood, as well as by the actual increase of +quantity which now exists in the circulation; the nervous and also the +vascular system of the uterus are now in a state of high excitement and +activity--a condition which must necessarily communicate itself to those +organs which are supplied by the same nerves; viz. the sympathetic, and by +the same portion of the circulation, viz. the branches of the abdominal +aorta. + +No organ, except the stomach, possesses sympathetic connexions so widely +extended over the rest of the system as the uterus; and, we may add, that +no two organs are so intimately and reciprocally united as the uterus and +the stomach. In the unimpregnated state, we see this manifested in a +remarkable degree; if the stomach becomes deranged the uterus sympathizes; +thus the states of gastric disturbance, known under the general term of +dyspepsia, are frequently followed by leucorrhoea, or some derangement of +the menstrual function: on the other hand, uterine disease is invariably +accompanied by symptoms of gastric disturbance, and, in many cases, to +such an extent as to conceal the real seat of the evil, and mislead the +attention of the patient and her medical attendant. In like manner we find +that during pregnancy, especially in the early stages of it, the patient +is annoyed with a great variety of symptoms more or less indicative of +derangement in the functions of the primæ viæ. + +_Morning sickness._ One of the most troublesome, and by no means the least +frequent, is vomiting, which, from coming on usually in the morning, is +commonly called morning sickness; in some cases the female merely rejects +what food or mucus may be present in the stomach, after which she feels +relieved; in others she continues to strain violently and ineffectually +for some time. In the former case it resembles the common vomiting from a +deranged stomach, and cannot be considered as the direct result of +sympathy with the uterus: the tone of the stomach has become impaired, and +vomiting has followed as a consequence of its being loaded with undigested +food and depraved secretions. Hence, in these cases, it is generally +preceded by nausea and the other common precursory symptoms of this act: +in the latter, however, it appears to be the immediate result of +irritation transmitted from the uterus, and assumes rather a spasmodic +character; the patient is suddenly seized with involuntary efforts to +vomit, which are not preceded by nausea or oppression, and come on +independently of the stomach being full or empty. + +Morning sickness usually appears during the first few weeks after +conception, and continues until the third or fourth month; in some cases +it continues throughout pregnancy; in a few it does not begin till much +later, and in many it does not appear at all. It scarcely deserves to be +called a disease of pregnancy, for it frequently appears as a salutary +effort of nature to relieve a cause of much gastric irritation, and, +unless it proceeds to a very exhausting degree, must rather be looked upon +as a favourable symptom, as it tends to prevent the formation of too much +blood, which is so frequent a cause of abortion during the early months. +(Hamilton, _on Female Complaints_.) Hence, therefore, experience verifies +the correctness of the old proverb, that a "sick pregnancy is a safe one." + +The ejected matter on these occasions, when there is but little or no food +upon the stomach, consists of a glairy ropy mucus, sometimes mixed with a +considerable quantity of intensely sour fluid, containing a large +proportion of muriatic and acetic acid: in some cases more or less bile is +vomited. + +The treatment of morning sickness will depend in great measure on the +severity of the attack: where it is slight, the patient may assist its +operation with a little warm water, or chamomile tea: after which the +bowels should be briskly opened by a saline laxative, as for instance, a +seidlitz powder, sulphate and carbonate of magnesia, &c.: small doses do +more harm than good, as, from their slow and ineffective action, they +rather tend to increase the irritation and aggravate the symptoms. In +severe cases, especially where the pulse is excited, a small bleeding may +be used with much advantage, but in most instances the usual treatment of +gastric derangement, as it occurs in the unimpregnated state, produces +most relief. The bowels should be first opened in the way already +mentioned, after which a combination of Pil. Hydrarg. and Extr. Hyosc. or +Extr. Humuli, is to be given at night, and a vegetable tonic during the +day. + +Acids, more especially the mineral, have been very judiciously recommended +by Dr. Dewees, and, when combined with any bitter infusion, will be found +of great service. Where the constant secretion of acid is very +distressing, the nitric acid will be found particularly useful; it allays +the irritability of the stomach, and produces a healthy state of its +secretion. Opiates are by no means desirable remedies, and rather tend to +aggravate the disease by still farther injuring the tone of the stomach +and producing constipation. We have known them given in considerable doses +and in very powerful forms, but without relief. Hydrocyanic acid, +creosote, &c., have also been tried, but with no permanent success; in +such cases Dr. Burns has found the application of leeches useful, +"especially if accompanied with pain or tension in the epigastric region." +On the same principle, we presume, have we found a sinapism of great +service. Where the vomiting, in spite of all the above modes of treatment, +still goes on unabated, there is nothing which, in our experience, is so +useful as covering the epigastrium with a hot flannel, upon which a +mixture of camphorated spirits of wine and laudanum has been sprinkled. +"We have," says Dr. Dewees, "in several instances, confined patients for +days together, upon lemon juice and water with the most decided advantage. +We have repeatedly found much benefit from the use of the spirit of +turpentine three or four times a day, in doses of twenty drops: this +medicine is very easily taken, if it be mixed in cold sweetened water. +When the system is not excited to febrile action, and where the stomach +rejects every thing almost as soon as swallowed, we have often known a +table-spoonful of clove-tea act most promptly and successfully." +(_Compendious System of Midwifery._) + +_Heartburn_ is another form of gastric derangement which frequently occurs +to a very distressing degree, and must be looked upon as a modification of +morning sickness; in many cases it arises from the presence of acid in the +stomach, but in others it is merely a sympathetic result of gastric +irritation, without any proof of acidity being present. The treatment of +heartburn is much the same as that just described for morning sickness, +the main object being to restore the stomach and bowels to a healthy +condition. Besides the mineral acids, small quantities of iced water will +be found very grateful, relieving the sense of burning in the back of the +pharynx, and diminishing, in great measure, that gastric irritability of +which it is a symptom. + +The frequent, and sometimes almost unlimited, use of antacid absorbents, +viz. magnesia or chalk, in this disease, is a practice much to be +deprecated: compounds are thus formed in the stomach which are positively +injurious, and, beyond the temporary relief procured by removing the acid, +they tend to aggravate these symptoms, by increasing the state of gastric +derangement. The only chemical antacid which should be given in these +cases is the carbonate of soda; by this means a compound is formed (the +common muriate of soda,) which of all others is most grateful to the +stomach, and which, from its gently laxative effects, is well adapted to +keep up a healthy action of the bowels. It is scarcely credible to what +extent the use of antacids may be carried to relieve the cardialgia of +pregnancy. Dr. Dewees mentions having attended a lady with several +children, "who was in the constant habit of eating chalk during the whole +term of pregnancy; she used it in such excessive quantities as almost +rendered the bowels useless. We have known her many times not to have an +evacuation for ten or twelve days together, and then only procured by +enemata, and the stools were literally nothing but chalk. Her calculation, +we well remember, was three half pecks for each pregnancy. She became as +white nearly as the substance itself, and it eventually destroyed her, by +deranging her stomach so much that it would retain nothing whatever upon +it." (_System of Midwifery_, § 275.) + +The _constipation, flatulence, colicky pains, and headach, the spasmodic +cough, palpitation, toothach_, &c. are symptoms arising from the same +cause, a knowledge of which circumstance will influence our treatment of +them more or less. Still, however, the indications are the same, viz. to +restore and keep up a healthy action of the stomach and bowels. Thus, we +frequently find that a severe headach, obstinate cough, or attacks of +palpitation, are relieved by aperient medicines; that toothach may be +relieved, or even removed, by occasional doses of carbonate of soda, or by +blue pill and aperient tonics. Indeed, it is a question in many cases, +whether it is proper to extract a carious tooth under these circumstances, +for the shock which it produces is sometimes so great as to run the risk +of exciting abortion; and in many instances we might extract every tooth +on the painful side, and yet not relieve the suffering which arises from +nervous pain induced by gastric irritation, and, if carefully examined, +the pain will be found to be not confined to a single tooth but to spread +over the whole side of the face, darting from the edge of the ear, and +extending even to the forehead. The breath is usually sour, and the acid +state of the saliva is indicated by the instantaneous reddening of litmus +paper laid upon the tongue; in many cases there is at the same time a +considerable deposit of lithic acid observed in the urine. + +Spasmodic cough, or palpitation, if allowed to continue, may ultimately +bring on abortion. The treatment just detailed is equally applicable here, +and if the circulation be at all excited blood-letting will prove useful. +In bleeding women at this early stage of pregnancy it is not desirable, or +even safe, to draw a large quantity suddenly from the system, as it may +greatly endanger the life of the foetus, and from the state of the +nervous irritability, may even run the risk of bringing on convulsions; +syncope is always more or less hazardous to a pregnant woman, and should +if possible be avoided. Some caution will be also necessary in our choice +of aperient medicines; drastic purgatives, as aloes, colocynth, scammony, +&c. are not suited to the state of pregnancy, as they irritate the lower +bowels, and thus excite a disposition to uterine contraction; mild, but +effectual laxatives, such as castor oil, confectio sennæ, a seidlitz +powder, are better adapted; the latter, especially will be found useful, +as, from its being taken during effervescence, it is better calculated to +quiet the stomach. + +_Diarrhoea_ is sometimes an exceedingly troublesome symptom during +pregnancy. It not only weakens the patient and thus tends indirectly to +induce abortion by destroying the life of the foetus, but it acts also in +a more direct manner by exciting uterine contractions, particularly when +accompanied, as is frequently the case, with tenesmus. The diarrhoea which +is met with in pregnant women is not so frequently, as has been supposed, +the result of irritation from the uterus, producing simply an increased +peristaltic action of the bowels without any considerable derangement of +their functions; by far the most usual form is connected with a very +deranged state of the alimentary canal; the evacuations are offensive and +generally very acrid; the liver is torbid or secretes an unhealthy bile, +so that at length a state approaching to dysentery is produced. Even if +the patient go to the full term of utero-gestation, she is much reduced, +and is ill able to make those exertions which will be required during +labour. If the motions, though frequent, are scanty in proportion to the +ingesta, or if scybala are occasionally expelled, one or two doses of +castor oil will be required; a few drops of Liq. Opii Sedativ. may be +added with advantage to allay the irritability of the bowels, after which, +equal parts of blue pill, or Hydr. c. Cretâ, and Dover's powder, will +excite the liver to a healthier action, and still farther control their +inordinate activity. If the disposition to tenesmus be troublesome, a +small injection of starch and opium will afford relief. If the stomach +will bear it, a rice-milk diet for a day or two is desirable; it is a +gentle demulcent to the irritable intestines, and has a slightly +constipating effect. + +_Pruritus pudendi_ to a very distressing degree occasionally comes on +during pregnancy, and though in most instances a very manageable form of +disease, yet if its nature be not properly understood it proves +exceedingly obstinate, and much suffering is the result. It appears to be +essentially different from the common prurigo, being an aphthous state of +the lining membrane of the vagina and skin which covers the perineum and +external organs. There is great heat and redness of the parts, which are +more or less swollen, and from the scratching which the intense itching +demands, the cuticle, where it has been raised by the pustules, becomes +abraided, so that severe excoriations, and, where there has not been +sufficient attention to cleanliness, even ulcerations may be produced. The +pustules on the external parts frequently attain a considerable size, +being more distinct than in the vagina, which is usually incrusted with +one confluent mass of aphthæ; whereas, on the perineum and margins of the +labia we have seen them as large as peas. These cases for the most part +yield to the tepid Goulard lotion, or solution of borax. + +Where the patient is plethoric, and the system in a state of considerable +excitement from the irritation, blood-letting will be necessary, followed +by cooling saline laxatives; and if there be much inflammation of the +parts, leeches will prove of great service. In every case the bowels ought +to be attended to, for constipation will greatly increase the +inflammation, and the obstinacy of the disease. It is to Dr. Dewees that +we are indebted for first pointing out the real cause and nature of this +troublesome affection.[46] + +Aphthæ of the vagina are not unfrequently met with in cases of uterine +disease, where the discharge is extremely acrid, but the prominent +symptom, viz. the intense pruritus, is absent. The aphthous vagina of +pregnancy is not a common affection. + +_Salivation_ is another affection which is occasionally, though rarely, +met with in pregnancy. It is usually attended with morning sickness, +constant nausea, and deranged bowels, and may reduce the patient +excessively: attention to the state of the bowels, followed by gentle +alteratives and tonics, generally gives relief. + + + + +CHAPTER III. + +SIGNS OF THE DEATH OF THE FOETUS. + + _Difficulty of the subject.--Signs before labour.--Motion of the + Foetus.--Sound of the foetal heart.--Uterus souffle.--Signs during + labour where the head presents--where the face, the nates, the arm, or + the cord, present.--Fetid liquor amnii.--Discharge of meconium._ + + +Well has the celebrated Mauriceau observed, "S'il y a occasion où le +chirurgien doive faire plus grande reflexion, et apporter plus de +précaution aux choses qui concernent son art, c'est en celle où il s'agit +de juger si l'enfant qui est dans la matrice est vivant, ou bien s'il est +mort." There are few circumstances more painful to the feelings of an +accoucheur, than the uncertainty as to whether the child be alive or dead, +in a labour where the passage of the head is rendered unusually difficult +or dangerous for the mother, even with the aid of the forceps; whether the +difficulty be produced by want of proportion between the head and pelvis, +unusual rigidity of the os uteri, &c. Could he assure himself that it was +alive, he would feel justified in either trusting still longer to the +efforts of nature, or in applying the forceps, even although he knows that +the delivery cannot be effected without considerable difficulty and +suffering: whereas, if he could once feel satisfied that the child had +ceased to exist, he would have recourse to perforation, for the purpose of +diminishing the size of the head, and thus releasing the mother from the +dangers of her situation. + +The increasing success which has attended the Cæsarean operation of late +years, adds still more to the importance of having the signs of the +child's life or death in utero carefully investigated and understood; for, +under such circumstances, it becomes a most serious question whether we +are always justified in destroying the life of the foetus by perforation, +when we might in all probability have saved it by resorting to another +means of delivery, which, formidable as it is, is now infinitely less so +than it was in former times. It becomes a question whether we ought not, +in certain cases to adopt the same indications for performing the Cæsarian +operation, as are used upon the Continent, and apply it not only to those +cases where the child cannot be delivered _par vias naturales_, but also +in those cases of minor pelvic obstruction, where, if we could feel sure +of the child's death, we should have recourse to perforation. Under +circumstances of this nature, the question becomes one of fearful +responsibility, the painfulness of which is not a little increased by the +uncertainty as to whether the child be alive or not. Mauriceau was the +first author who devoted a chapter expressly to the consideration of this +subject, and those few who have done the same since his time, have +borrowed largely from his observations. + +A great number of symptoms have been enumerated as indicating the child's +death in utero, but for the most part they are deserving of very little +confidence, frequently occurring where the result of labour has shown the +child to be alive and strong, or _vice versâ_. The most practical +arrangement of these symptoms will, we think, be under the two following +heads: those which occur _before_ labour, and those which occur _during_ +labour. + +The symptoms of the child's death, which are usually enumerated as +occurring _before_ labour, are, cessation of the child's movements; the +abdomen undergoes no farther increase of size, but rather diminishes; the +uterus has no longer the tense elastic feel of pregnancy, but becomes +flaccid and moveable; the patient has a sensation of coldness and weight +in the abdomen, so that when she turns from one side to the other, she +feels as if a heavy weight rolled over to that part of the abdomen which +is lowest; the breasts are flabby, and sometimes there is a fetid slimy +discharge from the vagina. These changes are accompanied by some or all of +the following symptoms: the patient is seized with a sudden shivering, +languor, and debility; she loses her appetite and spirits; the stomach and +bowels become disordered; the breath is fetid, and the face pale, sallow, +and of a dark leaden colour under the eyes. All these symptoms taken +collectively will enable us to decide, with a tolerable degree of +certainty, that the child is dead: but scarcely any of them alone can be +trusted to. The most trust-worthy is the sensation of a heavy weight +rolling about the abdomen: when the female turns in bed, rises from her +chair, or in any way alters her position, this weight is felt as it were +tumbling down to that side which is lowest. A woman who is pregnant with a +living child, feels nothing of the sort; she may even dance or jump, and +yet she feels no more of a living foetus than she does of her own liver or +spleen. The living foetus obeys the laws of organic life; the dead foetus +those of gravity. When once the child has ceased to exist, it acts like +any other mass of inanimate matter, and pushes the uterus down to that +side which is lowest. + +In most instances this symptom will be sufficient to make us suspect that +the child is dead, but it now and then occurs where the result of labour +proves the child to be alive; this must rather be looked upon as an +exception to the rule, for it is not of frequent occurrence. We have +observed it in two or three cases: it has been also noticed by Dr. E. +Kennedy, (_op. cit._;) and, therefore, cannot invariably be looked upon as +a certain sign of the child's death. We have observed it frequently in +cases threatening abortion at an early period: in many it has been +followed by premature expulsion, but in others the symptom has gradually +disappeared as the health improves, and the patient has eventually been +delivered of a living child at the full period. + +In these cases, we should rather attribute the source of this symptom to a +loss of the firmness and tone peculiar to the uterine parietes during +pregnancy, and which depends upon the increased activity of the +circulation in them at this period: when this is considerably diminished, +the uterine parietes will necessarily become more flaccid, and, therefore, +less able to withstand the influence of gravity, or sustain the uterus in +its proper situation. The embryo itself during the first two or three +months is too small and too light to produce this symptom itself. + +The sensation (to the mother) of the child's movements is as fallacious an +indication of the child's life as it is of pregnancy; nor can the absence +of this sensation be looked upon as a proof of its death. Women are very +liable to be misled in this respect; so much so, that it will be much +safer for the practitioner never to allow his diagnosis to be at all +influenced by their statements; the more so, as it applies equally to +mothers of large families as to primiparæ. Thus cases every now and then +occur where the patient declares her conviction that the child is dead; +that she has not felt it move for several days before labour; that she +feels altogether differently to what she did in any of her former +pregnancies, and yet she is delivered of a healthy living child. On the +other hand, we as frequently meet with cases where, up to the very +commencement of labour, the patient asserts that she has distinctly felt +the motion of the child, and yet she brings forth a child in such a state +of decomposition as proves beyond all doubt that it must have been dead +some eight, ten, or more days. + +As the sound of the foetal heart is the surest sign of pregnancy, so it is +an equally certain proof of the child's life: but is the absence of this +sound, a certain symptom of its death? at the best it is a negative +evidence, and the value of it must entirely depend upon the skill of the +ausculator and the care with which he makes his examination. If, after +repeated and careful auscultation of the abdomen, the well-practised ear +can no where detect a trace of the foetal pulsations, it may be asserted +on very safe grounds that the foetus has ceased to live. This is more +particularly the case during the last weeks of pregnancy, when the +pulsations are stronger, and the bulk of the child, in proportion to that +of the liquor amnii being absolutely, as well as relatively, greater. The +distance between the heart and surface of the abdomen is less during the +last weeks of pregnancy also; the child's movements are not so free as at +an earlier period; and hence, if the foetal heart is beating, it will be +more easily discovered. + +The uterine souffle affords us little aid in the diagnosis of the child's +death: it is frequently very distinct when the child is evidently alive; +and where it has been heard previous to its death, it will continue for +some hours afterwards, although with diminished strength and over a +smaller space. + +During labour there are a variety of symptoms, by the aid of which we can +pronounce, with a very tolerable degree of certainty, whether the child is +alive or not; if alive, the foetal heart can invariably be detected; and, +for the reasons above stated, will be heard more distinctly than in the +earlier months of pregnancy. If, from the violence or duration of the +labour, or any other cause, the child is becoming exhausted, the +pulsations become weaker and slower until they stop; so that by the aid of +auscultation we possess distinct evidence of the child's life being +endangered, and of its complete extinction. + +If the _head_ presents during labour, a firm elastic swelling (caput +succedaneum) will rise on that portion of it which first enters the +vagina: this is produced by the circulation in the presenting part of the +scalp being obstructed by the pressure which the os uteri and vagina exert +upon it, an effect which can only be produced upon the head of a living +child: where, on the other hand, the child is dead, the scalp will be felt +to be soft, flabby, and without swelling. This may be looked upon as a +very certain proof of the child's death in primiparæ, where the head is +advancing slowly, and where it is tightly encircled by the distended +vagina. But in multiparæ, where the soft passages have been dilated by +repeated labours, the pressure upon the head is so slight, and its passage +through them so rapid, that little or no swelling is produced: even in +these cases the finger of the accoucheur will easily distinguish the head +of a dead child by the loose yielding flabby feel of its integuments; the +cranial bones are more moveable, and overlap each other at the sutures +more than usual; their edges feel sharp, as if no longer covered by the +scalp; and frequently communicate a grating sensation when they rub +against each other. The great fontanelle is flaccid and loose; the bones, +which form it, appear falling together, from a want of sufficient contents +to keep them asunder, a circumstance which probably arises from the +circulation in the brain having ceased; and in those cases where the child +has already been dead some time, a crackling or crepitous sensation is +communicated to the finger from emphysema, the result of decomposition. + +The only case in which the swelling of the head is capable of misleading +us, is in lingering difficult labours, where the child has been alive at +the beginning, the swelling has formed, but from the duration and severity +of the labour the child has died: wider such circumstances, a dead child +may be born with the usual swelling of the cranial integuments which is +observed in a living child. This can only happen where it has been +expelled almost immediately after its death, for in two or three hours the +swelling loses its former firm tense feel, and becomes so soft and +flaccid, as not to be easily mistaken. + +If the face presents during labour, the flabby state of the lips will +instantly lead us to suspect that the child is dead: the tongue is also +flaccid and motionless. Whereas, in a living child the lips are firm and +full; if the face be approaching the os externum, a considerable swelling +will be felt on that side which presents; the tongue is firm, and +frequently moves upon the finger. + +If the nates present, the state of the sphincter ani will be a sure guide +in ascertaining whether the child be alive or not. If it be alive, it will +be found closed, and will contract distinctly upon the finger; whereas, if +dead, it will be relaxed, and insensible to the stimulus of the finger. + +In an arm presentation, where the child is alive, the arm will swell, and +grow livid or nearly black; but if it be dead, no swelling will be +observed, the arm will be very flabby, and where it has been dead some +time, the epidermis will peel off. In this case, as in head presentations, +the date of the child's death will more or less modify these appearances; +if it has not taken place until some time after the commencement of +labour, a dead child may be born exhibiting the swelling and +discolouration above-mentioned. The pulse in the wrist of the prolapsed +arm is no guide, as the very degree of pressure, which produces these +changes in its appearance, will be generally sufficient to render it +imperceptible. + +In cases where the cord has prolapsed, we have certain evidence with +respect to the child's life: if alive the cord is firm, turgid, and +distinctly pulsating; if dead, it is flaccid, empty, and without +pulsation. + +Fetid liquor amnii, and the discharge of the meconium, have also been +enumerated as signs of the child's death, which occur during labour. The +first affords no proof whatever, as cases not unfrequently occur in which +the liquor amnii is excessively fetid, and of a thick slimy consistence, +and yet the child is born alive and healthy. + +The appearance of meconium during labour is a suspicious sign where the +nates do not present, and will at any rate justify the supposition, that +if the child be not actually dead, it is very weakly; in nates +presentations, however, this will not hold good, for the meconium is +constantly discharged during labour, where the child is in this position, +and yet it will be born alive and well. + + + + +CHAPTER IV. + +MOLE PREGNANCY. + + _Nature and origin.--Varieties.--Diagnostic Symptoms.--Treatment._ + + +When any cause has occurred to destroy the life of the embryo during the +early weeks of pregnancy, one of two results follows, either that +expulsion takes place sooner or later, or the membranes of the ovum become +remarkably changed, and continue to grow for some time longer, until at +length they form a fleshy fibrous mass, called _mole_, or _false +conception_.[47] + +It is well known that the venous absorbing radicles of the chorion, which +give it that shaggy appearance during the first months of pregnancy are +the means by which the embryo is furnished with a due supply of +nourishment at this period: if the embryo should die from any cause, and +the uterus show no disposition to expel the ovum, the nourishment which +has been collected by the absorbing power of the chorion appears now to be +directed to the chorion itself, which therefore puts on a fleshy growth +and increases very rapidly in size. (Roederer, _Elementa Artis +Obstetricæ_, p. 738.) + +In other instances, the thick fleshy character of the ovum is not produced +by a growth of substance, but is the result of hæmorrhage from rupture of +some of the vessels which run between the uterus and the ovum. In this +case, if the placental cells be already formed, they become distended with +the blood of the hæmorrhage which solidifies by coagulation; and not only +render the chorion or incipient placenta much thicker and more solid, but +give it also a lobulated tuberculated appearance: from the same reason, +the little funis, which is probably not an inch long, is greatly +distended, being in some cases as thick as the body of the embryo itself, +the blood having penetrated from the placental cells into the cellular +tissue of the chord. This is by no means an uncommon form of mole; +externally it is covered by the decidua, which appears to be in a natural +condition, and the inner surface of the cavity is lined by a fine +membrane, having all the usual characters of the amnion. The lobulated +appearance is chiefly seen from within, the amnion being raised by a +number of irregular convexities. + +"When the blood is poured out from its containing vessels into the +substance or cells of the placenta, or between the membranes, gradually +coagulates, and assumes a very dark purple, and sometimes almost a +melanotic black colour: after a time, however, it begins to lose this +tint, the colouring matter gradually becomes removed, and the coagulum +successively assumes a chocolate brown, a reddish or brownish yellow hue; +and latterly, if time sufficient be allowed, it presents a pale yellowish +white or straw-coloured substance, the fibrinous portion of the coagulum +being then left alone."[48] This form of mole, as far as our own +observation goes, seldom attains any considerable size, rarely exceeding +four inches in length, and is usually expelled between the eighth and +twelfth week. The size and condition of the foetus varies a good deal; in +some cases it appears nearly healthy, although the cord is much thickened +and distended; this is probably owing to its having been expelled shortly +after its death, or to its having gone on to live a short time after the +injury which had caused hæmorrhage: in this way alone can we explain why +we occasionally meet with cases where the parietes of the ovum are much +thickened and solidified, and yet the embryo is in such a state of +integrity as to prove that its death must have been very recent. The +extravasation of blood between the ovum and uterus does not appear to be +sufficient to annihilate immediately the nutrition of the embryo, so that +the blood has had sufficient time to solidify before the ovum was +expelled. At other times the embryo exhibits evident marks of having been +dead some time: it is much smaller and younger in proportion to the size +of the ovum; sometimes it has disappeared entirely, a short rudiment of +the funis merely remaining to mark its previous existence. + +"Should the embryo die (suppose in the first or second month) some days +before the ovum is discharged, it will sometimes be entirely dissolved, so +that when the secundines are delivered, there is nothing to be seen. In +the first month the embryo is so small and tender, that this dissolution +will be performed in twelve hours; in the second month, two, three, or +four days will suffice for this purpose." (_Smellie._) + +Where the growth of the ovum proceeds after the destruction of the embryo, +it increases very rapidly in size, much more so than would be the case in +natural pregnancy, so that the uterus, when filled with a mole of this +sort, is as large at the third month as it would be in pregnancy at the +fifth. + +Another form of mole is where the uterus is filled with a large mass of +vesicles of irregular size and shape like hydatids, which appear to be +the absorbing extremities of the veins of the chorion distended with a +serous fluid; it is difficult to distinguish these from real hydatids; the +more so, as Bremser asserts that he has occasionally met with real +hydatids among them. Perhaps the mode of their attachment will in some +degree assist the diagnosis: these vessicles, or _hydatids of the +placenta_, as they have been called, are attached over a large portion of +the uterus,--an arrangement we believe, not generally seen in real +hydatids, which are mostly attached to a single stalk or pedicle. Indeed, +it may be doubted if the masses of vesicles which are occasionally +expelled from the uterus are ever true acephalocysts, as they are +invariably connected with a blighted ovum, and are, therefore, formed as +before observed, by a dropsical state of the venous radicles of the +chorion. + +A variety of other molar growths have also been enumerated by authors; in +fact, "the term _mole_ has been rather vaguely applied to almost every +shapeless mass which issued from the uterus, whether this proved to be +coagulated blood, detached tumours, or a blighted conception." (Churchill, +_on the Principal Diseases of Females_, p. 153.) Thus a fibrinous cast of +the uterus, which has been formed by a coagulum of blood, from which the +colouring matter has been drained, has been called a fibrous mole: these, +however, may easily be distinguished from real moles, which are invariably +the product of conception: from inattention also to this circumstance, +fungoid, bony, and calcareous tumours have been described as so many +species of moles.[49] + +_Diagnostic symptoms._ The diagnosis of a mole pregnancy is exceedingly +obscure; in fact, for the first eight or ten weeks we know of no symptom +by which we can distinguish it from natural pregnancy. As the death of the +embryo is intimately connected with the first morbid changes in the +condition of the ovum, and in most cases precedes them, the earliest +symptoms which can excite our suspicions are those which indicate this +event: thus we shall find that the face becomes pale and chlorotic, the +digestion deranged, the breasts flaccid, with unusual lassitude, debility, +and depression of spirits; many of the sympathetic affections which belong +to early pregnancy, such as the morning sickness, nausea, &c. cease +suddenly; in some cases, an attack of hæmorrhage comes on, and may be +repeated several times, causing much loss of strength and exhaustion, and +attended with a good deal of pain, more especially if the uterus be about +to throw off its contents. In that form of mole where the parietes of the +ovum have been thickened and lobulated by masses of coagulated blood, the +uterus undergoes little or no more increase of size, but the mole, +especially the hydatic, continues to grow rapidly; and the unusual +increase in the size of the abdomen, as already mentioned, will be an +additional reason for suspicion. In all cases, hæmorrhage sooner or later +makes its appearance, the patient's health still farther declines, +leucorrhoea comes on, followed by oedema of the feet, general breaking up +of the health, and even incipient cachexia. Occasionally the discharge is +excessively putrid and offensive. Where it is of the hydatic species, we +can frequently ascertain its character by the expulsion of two or three +hydatids which have separated from the main mass, or by the escape of some +limpid colourless water resulting from the rupture of one or more of them. +The expulsion of the mole itself clears up all doubts. + +The amount of hæmorrhage will chiefly depend upon the extent of surface by +which the mole is attached to the uterus: hence it is observed to be +greatest in cases of hydatic mole, from the large size of the mass to be +expelled: indeed, under these circumstances, it is frequently more profuse +than hæmorrhage from detachment of the placenta. The process of the +expulsion itself resembles that of an abortion: pain in the back, groins, +and lower part of the abdomen comes on, with more or less discharge of +blood; at length bearing down pains succeed, and the mass is expelled. + +We cannot better describe the symptoms produced by the presence of a +hydatic mole, and the mode of its expulsion, than by quoting a case from +the work of Dr. Gooch, _on some of the most Important Diseases peculiar to +Women_. + +"I was sent for to ----, a few miles from London, to see a lady, who, +having ceased to menstruate for one month, and becoming very sick, +concluded that she was pregnant. The next month she had a slow hæmorrhage +from the uterus, which had continued incessantly a month when I saw her: +she kept nothing on her stomach. On examining the uterus through the +vagina, its body felt considerably enlarged, and there was a round +circumscribed tumour in the front of the abdomen, reaching from the brim +of the pelvis nearly to the umbilicus. I saw her several times at +intervals of a fortnight, during which the hæmorrhage and the vomiting +continued unrelieved: the peculiarity about the case was the bulk of the +uterus, which was greater than it ought to be at this period of pregnancy; +it felt also less firm than the pregnant uterus, more like a thick bladder +full of fluid. Eleven weeks from the omission of the menstruation, she was +seized with profuse hæmorrhage; towards evening there came on strong +expelling pains, during which she discharged a vast quantity of something +which puzzled her attendants. The next morning I found her quite well--her +pain, hæmorrhage, and vomiting, having ceased. I was then taken into her +dressing-room, and shown a large wash-hand basin full of what looked like +myriads of little white currants floating in red-currant juice. They were +hydatids floating in bloody water." + +_The treatment_ previous to the expulsion of the mole should be gently +alterative and tonic; the chylopoietic functions should be kept in regular +action, and the strength sustained. When hæmorrhage comes on, we must be +guided a good deal by the quantity lost, and by the effect which it has +upon the pulse. Generally speaking, when the pulse has been a good deal +reduced in strength and volume, we shall find the os uteri relaxed and +dilated, and in all probability a portion of the mass protruding into the +vagina, which may be hooked down by the fingers, and thus the expulsion of +the whole mass facilitated. For farther details regarding the management +of such cases, we must refer to the chapter on premature expulsion of the +ovum, between the symptoms and treatment of which, and of mole pregnancy, +there is a close analogy. The after treatment will always be a matter of +considerable importance, and will, in a great measure resemble that in +abortion or mis-carriage. + +Patients who have suffered from a mole pregnancy generally have their +strength seriously reduced and their health much broken: hence, they are +liable to leucorrhoea, menorrhagia, or dysmenorrhoea, which entail a long +series of troublesome and even dangerous affections, the recovery from +which will be slow and difficult, requiring a long course of tonic +medicines, and removal to the sea-coast or some watering-place where there +are chalybeate springs. + + + + +CHAPTER V. + +EXTRA-UTERINE PREGNANCY. + + _Tubarian, ovarian, and ventral pregnancy.--Pregnancy in the substance + of the uterus._ + + +The ovum when impregnated does not always quit the ovary and pass along +the Fallopian tube into the uterus. It may remain in the ovary and become +here developed; it may pass into the Fallopian tube and remain there; or +from some defect in the action of the fimbriated extremity of this canal, +it may escape into the cavity of the abdomen, and become attached to some +of the viscera. Hence, extra-uterine pregnancy has been divided into three +species, viz. _graviditas tuberia_, _ovaria_, and _ventralis_, according +to the situation which the ovum takes. A fourth has been also described by +M. Breschet, which he has called _graviditas in substantia uteri_, a +modification probably of tubarian pregnancy. + +[Illustration: _a_ The uterus, its cavity laid open. _b_ Its parietes +thickened, as in natural pregnancy. _c_ A portion of decidua separated +from its inner surface. _d_ Bristles to show the direction of the +Fallopian tubes. _e_ Right Fallopian tube distended into a sac which has +burst, containing the extra-uterine ovum. _f_ The foetus. _g_ The chorion. +_h_ The ovaries; in the right one is a well marked corpus luteum. _i_ The +round ligament.] + +This singular deviation from the usual course of conception is fortunately +of rare occurrence, for few cases terminate favourably. If it be in the +Fallopian tube or ovary, these become immensely distended into a species +of sac or cyst, to the sides of which the placenta adheres: as the ovum +increases, this at length gives way from excessive distension, and the +patient usually dies from internal hæmorrhage. In ventral pregnancy, the +sac is attached to the abdominal viscera, and is usually imbedded among +the convolutions of the intestines: hence the duration of extra-uterine +pregnancy will depend upon its situation; thus, if it be in the Fallopian +tube, it rarely lasts beyond two months; whereas, ovarian pregnancy will +continue for five or six months; on the other hand, in ventral pregnancy +the foetus will not only be carried to the full term, but far beyond that +period, amounting to several years.[50] + +Although the uterus does not receive the ovum into its cavity as it does +in natural conception, it nevertheless undergoes many of those changes +which are known to take place in regular pregnancy. The layer of +coagulable lymph, which is effused upon its internal surface, and which +forms the membrana decidua of Hunter, is present, and the uterus undergoes +a slight increase of volume. As the ovum increases, excruciating pains are +felt in the lower part of the abdomen, coming on at irregular intervals, +and of irregular duration; in some cases lasting for a short time, in +others continuing for twenty-four hours. These attacks of pain are +generally accompanied with very painful forcing and tenesmus, and not +unfrequently with a discharge of bloody mucus from the vagina. In tubarian +pregnancy, however, the case generally follows a much shorter course: the +patient is suddenly seized with an acute pain in the lower part of the +abdomen, followed by nausea and vomiting; she becomes faint and weak; the +abdomen evidently increases in size (from effusion of blood into the +cavity;) the debility becomes more alarming, and death quickly follows. + +In ovarian pregnancy the fatal termination is merely postponed till a +later period, during which the patient has to undergo attacks of most +terrible suffering: at length, after a paroxysm more than usually severe, +and frequently attended with the sensation of something giving way in the +abdomen, faintings come on, speedily followed by death. During the attacks +there is obstinate constipation, which is attended with painful and +fruitless efforts to evacuate the bladder and rectum; the face is pale, +and expressive not only of the most acute suffering, but of great anxiety +and mental depression; nevertheless, in the intervals of the attacks she +feels easy, and appears well and cheerful. + +The termination of a ventral pregnancy is very different; after a time the +foetus dies, and may either remain enclosed in the cyst for life, or it +may be discharged in portions by means of an abscess, either through the +intestines, uterus, vagina, or abdominal parietes. Cases have occurred +where it has come away by the bladder; in the former case, where it is +retained, it diminishes more or less in size, becomes hard and closely +packed together, and, in some instances, encrusted with a layer of +calcareous matter. + +It is to our venerable friend, the late Dr. Heim, of Berlin, that we are +indebted for much curious and interesting knowledge respecting +extra-uterine pregnancy. Although the symptoms in the very early stages +are so obscure as to render it nearly impossible to detect its presence, +he has nevertheless observed some facts connected with it, which are +peculiar, and deserve to be noticed. No morning sickness has been observed +in cases of extra-uterine pregnancy, a circumstance which can easily be +accounted for, if we bear in mind the causes of morning sickness in +natural pregnancy: the patient could only lie on the affected side, and +the abdomen was observed to swell irregularly, not in the same manner as +in regular pregnancy. + +In tubarian and ovarian pregnancy, the pain was in the pelvis, but in +ventral pregnancy it occupied more or less the whole abdomen, the parietes +of which were very tender upon pressure. In cases where the foetus died at +an early period, the symptoms gradually disappeared after a time, +especially when followed by the bursting of an abscess through the rectum +or any other part. One of the most remarkable facts which Dr. Heim +observed, was a peculiar whining tone of voice, with which the patient +expressed her sufferings during a paroxysm of pain; so peculiar, that when +once heard, the sound can never be mistaken. On several occasions Dr. Heim +was enabled by means of this symptom alone to decide confidently as to the +nature of the case the moment he entered the room, a fact which would +appear scarcely credible had not the results of the cases proved the +correctness of his assertion. A most interesting case of this sort +occurred, which he pronounced to be ventral pregnancy, and when it had +gone the full term gastrotomy was performed, a living child was extracted +but the unfortunate mother perished: she could not be induced to submit to +the operation until inflammation had come on, and she died in two days +after. + +It must always remain a matter of great obscurity as to the immediate +_causes_ of extra-uterine pregnancy, more especially of the ovarian and +ventral species; and the more so as we are still ignorant of the mechanism +by which the fimbriated extremity of the Fallopian tube grasps the ovary +immediately over the impregnated vesicle of de Graaf at the moment of +conception. In many cases we are inclined to think that this function of +the Fallopian tube is destroyed by adhesions between it and the ovary, a +circumstance of not uncommon occurrence; but from the alteration in the +shape and size of these parts, as also from the extensive adhesions which +are usually found after death, in such cases it will ever be difficult, +and perhaps impossible, to prove it. + +The _treatment_ of extra-uterine pregnancy must be chiefly guided by the +prevailing symptoms: where any portion of the abdomen is very tender to +the touch, leeches and warm fomentations will be required; the pain during +the attacks can only be alleviated by frequently repeated opiates; and +constipation must be carefully guarded against by laxatives and enemata +between the paroxysms. Where an effort is made by nature to discharge the +foetus by means of an abcess, the case will require all our care to +sustain the powers of the system through a long protracted struggle. +Portions of the foetus come away from time to time, and if the exit +afforded them be by way of the intestine, the suffering produced is very +great, particularly when any of the larger bones are passing. The presence +of such a mass of semi-decomposed animal matter in the abdomen is of +itself sufficient to injure the general health materially: hence it is +that patients, during the process of expulsion, suffer greatly from severe +attacks of fever, which recur from time to time. Where the abscess opens +through the abdominal parietes, the whole is completed with much greater +ease and safety to the patient: in some instances the tumour has been +opened, and a foetus with a large quantity of putrid pus has been removed. +(_Medical Obs. and Inquiries_, vol. ii. p. 369.) + +A case of ventral pregnancy has recently come under our care, a short +account of which will enable the reader to understand the subject better +than a mere enumeration of symptoms; the more so as we believe it to have +been the first case of extra-uterine pregnancy in which the stethoscope +has been used. + +The patient, æt. 32, and the mother of four children, was admitted, May +26, 1837, into St. Bartholomew's Hospital, under Dr. Latham, who kindly +consigned her to our charge. She considers herself to be six months +advanced in pregnancy; is continually suffering from attacks of acute pain +in the lower part of the abdomen, both at the sides and front, causing her +to moan from its great severity; this is accompanied with a constant +dragging pain on the right side, and in the loins: the attacks of +abdominal pain go off at intervals, leaving her comparatively easy. She is +pale, with an anxious expression of face. Pulse 120, and firm. Tongue +moist. Bowels very constipated. + +The abdomen is as large as in common pregnancy at the sixth month, but +does not present the same uniform distension, being irregularly shaped. At +the left hypogastrium is a soft tympanitic prominence of considerable +extent, and appears, from its feel and also from auscultation, to consist +of a large portion of the intestines pushed over to that side: at the +inner edge of this tumour a solid mass, as large as the head of a six +months' foetus, can be felt. Between this and the median line of the +abdomen, and half way between the pubes and umbilicus, a small hard +knob-like and moveable prominence is felt immediately beneath the +abdominal parietes, and intensely painful to the touch. From this point, +quite to the right side, the abdomen has a solid irregular feel; below +this to the symphysis pubis, a very loud souffle is heard, synchronous +with the mother's pulse, having all the characters of the uterine souffle +in common pregnancy except its extraordinary loudness. Its limits, +superiorly, are remarkably defined; below a transverse line, drawn half +way between the umbilicus and pubes, it is heard in full strength, +whereas, immediately above it the sound ceases: it is also heard some way +to the right side. At the upper part of the right iliac region two +ridge-like prominences, like the extremities of a child, may be felt close +beneath the abdominal parietes. No trace of foetal pulsation can be heard +over any part of the abdomen, although it has been carefully ausculted +round to the loins: it was however distinctly heard the day before we saw +her, by two gentlemen who are proficients in the use of the stethoscope, +and whom we consider fully capable of judging in such a case. + +On examining per vaginam, the os uteri is found high up and backwards, +barely within reach. Its edges are thick, soft, and closed; the cervix is +short, and seems less than half an inch. The anterior portion of the +inferior segment of the uterus feels somewhat firm and full, as if there +was something in the uterus. We were confirmed in this respect by our +friend, Dr. Nebel, jun., of Heidelberg, who was on a visit to this country +at the time, and who examined the case with us. He was at first induced to +suppose that it was the head. We considered that it was the uterus more or +less anteverted, the fundus being pressed forwards and downwards, and the +os uteri backwards, by the extra-uterine cyst above; farther examinations +tended to confirm this view. + +She states that the catamenia appeared last in November, during the middle +of which month she was attacked with inflammation of the bowels, for which +she was treated, and soon afterwards began to have the violent attacks of +pain of which she now complains. She felt the child move at the usual +time; it evidently formed the mass which occupies the lower part of the +abdomen, and its movements appeared unusually close to the surface. During +the last few days they have ceased altogether. The above-mentioned attacks +of pain have continued to recur ever since at short intervals and with +increasing severity. + +As leeches had been applied without relief, and as the pulse was quick +and hard, she was ordered to be bled to eight ounces, and to take half a +grain of morphia immediately. + +_June 2._--Has been in constant suffering, in spite of leeches and +morphia; bowels obstinately constipated, but moved at length by repeated +injections and doses of house medicine. Has not felt the motions of the +child since the intestines have become tympanitic: still, however, the +mass can be felt lying across the abdomen, half-way between the pubes and +umbilicus, commencing from about three inches to the left of the median +line, and extending to about four inches on the opposite side. On the left +side it feels firm and rounded, and so superficial, that it can almost be +grasped through the abdominal integuments. Face very pale and anxious. +Pulse 120. + +_June 10._--Was easy and free from pain when we first saw her: the souffle +is heard over a smaller extent; in the centre of the space where it is +heard it is as remarkably loud as ever, but it gradually becomes +indistinct towards the circumference. As she was able to rise we examined +her standing: the os uteri is exceedingly high up to the left sacro-iliac +symphysis, so that it can scarcely be reached; the cervix is short, the +lips somewhat larger than usual, and the whole very firm and immoveable. +The anterior portion of the uterus, to be felt through the vaginal +parietes, is somewhat firmer and larger than usual: on pressing the tumour +in the left hypogastrium, this appeared to lie altogether anterior to the +uterus. Little motion is communicated to the os uteri when this is moved. + +_June 20._--Has been in much suffering since last report; much emaciated; +complains of a fetid taste in the mouth; bowels inclined to be purged; +stools of a whitish purulent appearance; tongue clean; pulse tolerably +natural; has continued to pass portions of fibrinous matter from the +vagina, mixed with bloody mucus, since last report. The hard globular +swelling at the left side of the abdomen is more distinct at times: the +hand can almost pass round it: it has the precise feeling of the head; the +mass which lies across the abdomen is also more distinct: the souffle is +heard over a much smaller space and is diminished in strength. + +_June 27._--Much the same, except that, after severe bearing down and +tenesmus, she has passed a considerable quantity of blood from the rectum +and vagina. The little prominences on the right side, presumed to be the +extremities, are remarkably distinct, like two heels or knees. + +_July 18._--No material change has taken place since last report; she has +suffered from irregular attacks of pain, and has had repeated discharges +of blood from the vagina, which always give relief; is weaker than usual, +and feels exhausted from the continued character of the pain; abdomen less +swollen; the globular mass on the left side is lower and much nearer to +the median line; the little prominences on the right are also lower, and +nearer the median line; the whole mass appears much more compressed +together and nearer to the pubes; it is extremely painful on the left +side, and at the most painful spot the skin is red and inflamed; the +bowels, appetite, &c. are natural; pulse feeble, but regular; scarcely any +trace of souffle to be heard. + +Shortly after this she left the hospital, and for some time continued to +enjoy tolerable health, occasionally suffering from severe paroxysms of +abdominal pain; the abdomen diminished considerably in size, and the +various prominences became indistinct. + +In _May, 1839_, she was again admitted in a state of great exhaustion from +constant severe pain. The abdomen had diminished still more, and a portion +of the mass had descended between the uterus and rectum; the constipated +bowels were moved with great difficulty, but with much relief. The +symptoms gradually diminished, and she was discharged in the first week of +the following _August_. + +In _January, 1840_, she returned to the hospital, all her former +sufferings being greatly aggravated. The abdomen had subsided still +farther; early in _February_ she passed a quantity of putrid purulent +matter from the rectum, after which the abdomen diminished considerably. +The pain appeared to be chiefly situated in the upper part of the rectum, +accompanied with severe bearing down, and on examining per vaginam the +mass was felt deep at the posterior part of the pelvic brim: the debility +and emaciation increased, and she died early in _February_. Our notes of +the post mortem examination were as follows:-- + +Much emaciated, abdomen concave, but on pressing it the tumour can be felt +at the brim of the pelvis. On opening the abdominal cavity, the mass was +found adhering firmly to the neighbouring intestines, and on the right +side to the soft linings of the pelvis: it was of an irregular form, with +spots of livid vascularity in different parts: on the upper and left side +of it, fetid purulent matter was seen exuding from a small orifice. The +uterus was below, its fundus pushed over to the left side. On separating +its adhesions, and attempting to raise the sac from the pelvis, the +half-softened parietes gave way, and the decomposed putty-like mass of the +foetus became visible; the cranial bones were at the left side; the feet +were still distinct on the right side; the whole was immersed in a +quantity of thick fetid pus, and there were no traces either of umbilical +cord or placenta. + +Cases of ventral pregnancy have been recorded where the child has remained +in the mother's abdomen without producing any dangerous symptoms, and +where she has again become pregnant in the natural way. The earliest +instance of this sort was recorded so long ago as by Albucasis. A very +interesting case of this nature is described by Dr. Bard of New York. +(_Med. Obs. and Inquiries_, vol. ii. p. 369.) It was the patient's second +pregnancy; at the end of nine months she had pains, which after a time +went off; the tumour gradually diminished somewhat, and in about five +months after she conceived again, and in due time was delivered, after an +easy labour, of a healthy child. "Five days after delivery she was seized +with a violent fever, a purging, suppression, pain in the tumour, and +_profuse fetid sweats_:" an abscess formed in the abdomen, which was +opened, and a vast quantity of extremely fetid matter was discharged; the +opening was enlarged, and a foetus of the full size was extracted. Dr. +Bard "imagined the placenta and funis umbilicalis were dissolved in the +pus, of which there was a great quantity." + +It becomes a question of deep interest whether it be really possible to +save the patient and the child in cases of ventral pregnancy, by +performing gastrotomy. The separation of the placenta from the walls of +the cyst can only be effected with much difficulty and hazard; indeed, we +are at a loss to conceive how it can be removed with any degree of safety, +where the child has been found alive. The attachment in these cases was +more than usually firm, and it has been left to undergo that process of +solution which has been described in Dr. Bard's case. In all the cases +where gastrotomy has been performed some time after the child's death, +little or no trace of the placenta has been found, but in its place a +quantity of ill-conditioned purulent matter, which was excessively fetid. + +The fourth species of extra-uterine pregnancy, which M. Breschet has +described as taking place in the substance of the uterus, is of very rare +occurrence, four cases only having been recorded by him. (_Med. Chir. +Trans._ vol. xiii.) M. Breschet has attempted a variety of explanations of +this singular anomaly, but without success; and from the circumstance of +the cyst having always been found situated in the fundus to one side, the +Fallopian tube of which was closed at its uterine extremity, we think that +there can be little doubt of its having been a modification of tubarian +pregnancy, where the ovum had been obstructed at that portion of the +Fallopian tube where it passes obliquely through the wall of the uterus: +in one case the tube appears to have given way at this part, and the ovum +to have insinuated itself between the uterus and peritoneum. In these +cases the sac ruptured at about the same period as in tubarian pregnancy, +except in one instance, where she went five months. A rather inexplicable +case of extra-uterine pregnancy has been recorded by Mr. Hay, of Leeds +(_Med. Obs. and Inquiries_, vol. iii.,) where a full grown foetus was +found enclosed in a large sac, which filled the abdominal cavity, and +which communicated inferiorly with the uterus. On tracing the umbilical +cord, "we were led," says Mr. Hay, "to a large aperture in the right side +of the inferior globular sac already mentioned, from which that which +contained the foetus seemed to have its origin. This inferior sac we now +found to be the uterus, containing a very thick placenta, which adhered +very firmly to about three-fourths of its internal surface, having the +navel string attached to its centre, and this centre corresponded nearly +with the centre of the fundus uteri. The placenta filled up the greatest +part of the aperture of communication between the uterus and sac. The +Fallopian tube on the left side was very small; the place of that on the +right was occupied by the beginning or orifice of the sac." (_Op. cit._) + +This would seem to have been a case of pregnancy in the substance of the +uterus, and where a portion of the ovum had burst its way into the cavity +of the uterus lined with decidua, to which it adhered; the other portion, +containing the embryo, distended the uterine parietes in a contrary +direction, and thus formed the large sac which communicated with the +cavity of the uterus. + + + + +CHAPTER VI. + +RETROVERSION OF THE UTERUS. + + _History.--Causes.--Symptoms.--Diagnosis.--Treatment.--Spontaneous + terminations._ + + +During the earlier months of pregnancy the uterus is liable, although +rarely, to a peculiar species of displacement, called _retroversion_, in +which the fundus is forced downwards and backwards into the hollow of the +sacrum, between the rectum and posterior wall of the vagina, and its os +and cervix are carried forwards and upwards behind the symphysis pubis. + +[Illustration: _a a_ Half the bladder on each side turned over the spine +of the os ilium. _b_ Anterior extremity of the vertical incision by which +the bladder was opened. _c_ One turn of the rectum, which was seen at the +posterior end of the same incision. _W. Hunter._] + +Retroversion of the uterus appears to have been known to the ancients, as +we find it alluded to by Hippocrates (_De Nat. Mulieb._ sect. 5.) and +Philumenus (_Histoire de la Chirurg._ par Dujardin and Peyrhille, t. ii. +p. 280.) Oetius, who has quoted the works of the celebrated Aspasia, +describes this displacement of the uterus very exactly, and gives rules +for introducing two fingers into the rectum, in order to remedy it. Rod. a +Castro, who wrote in the sixteenth century, in his work on the diseases of +women, quotes what Hippocrates had written on the subject of this +displacement; and it is astonishing that no farther notice was taken of it +until the eighteenth century, when it excited considerable attention among +accoucheurs. (_Martin le Jeune_, p. 137.) Gregoire appears to have been +the first who gave a good description of it; his pupil, Mr. W. Wall, on +his return to England, met with what he considered to be a case of this +displacement, and not being able to restore the uterus to its natural +position, requested the advice of Dr. W. Hunter. On passing his finger +between the os uteri and symphysis pubis, and thus removing, in some +degree, the pressure upon the neck of the bladder, a considerable quantity +of urine was discharged, but he was unable to return the uterus to its +natural situation, and the patient gradually sunk. The bladder was found +immensely distended; the lower part of it, "which is united with the +vagina and cervix uteri, and into which the ureters are inserted, was +raised up as high as the brim of the pelvis by a large round tumour, (viz. +the uterus,) which entirely filled up the whole cavity of the pelvis. The +os uteri made the summit of the tumour upon which the bladder rested, and +the fundus uteri was turned down towards the os coccygis and anus." +(_Medical Obs. and Inquiries_, vol. iv. 404.) + +_Causes._ This displacement may also occur in the unimpregnated state, +either from the fundus being pushed into that position by some morbid +growth, or where this effect has been produced by the violent pressure of +the abdominal muscles in lifting heavy weights, under circumstances where +the uterus has been larger and heavier than usual;[51] but it is in the +early months of pregnancy that it is most likely to happen, because now +the fundus is both larger and heavier than before, and, therefore, more +liable to be affected by the pressure of the intestines and abdominal +muscles, and has not yet attained a sufficient size to prevent its +undergoing this displacement in the pelvis: this period is about the third +or fourth month, often before it, but never after it. (Burns's _Anatomy of +the Gravid Uterus_, p. 17.) + +It has been supposed by many authors, especially Dr. Burns, that +distension of the bladder is, in many instances, the immediate cause of +retroversion, owing to the intimate connexion which exists between the +lower part of the uterus and this organ, inasmuch, "that whenever the +bladder rises by distension, the uterus must rise also." In the later +editions of his work on the principles of midwifery, he has considerably +modified this opinion, and from careful examination of the parts in situ, +in the third month, is not disposed to consider the distension of the +bladder as the cause, but the effect of retroversion. In every case which +has come under our own observation, the bladder has not been distended +until the retroversion had taken place, in consequence of which the os and +cervix uteri had been tilted up behind the symphysis pubis, and having +thus compressed its neck had caused the difficulty in passing water.[52] +Whenever any force is applied to the fundus uteri at this period of +pregnancy, either from external violence, or the action of the abdominal +muscles pressing the intestines and bladder against it, it will be pushed +against the rectum, in which case the rectum will be flattened at that +part against which the fundus rests; and if any mass of fæculent matter be +passing along the intestine, its course will be obstructed at this point, +and the rectum quickly become distended with an accumulation of fæces +above, by which means the fundus will not only be prevented from rising, +but in all probability be forced still lower down. If the force which has +originally pushed the fundus backwards be of sufficient degree and +duration to carry it past the promontory of the sacrum, the increase of +space which it will meet with in the hollow of the sacrum, and the +straining efforts which are induced by the displacement itself, contribute +powerfully to complete the mischief, and to bring the fundus so low into +the pelvic cavity as at length to turn it nearly upside down. + +As soon as the fundus of the uterus is pressed with any degree of force +against the posterior parietes of the pelvis, its os and cervix will be +directed forwards and upwards against the symphysis pubis, and from the +pressure which they exert against the neck of the bladder, the patient +either experiences complete retention of urine, or, at any rate, +considerable difficulty in passing it; hence, therefore, we find, that +where retroversion has come on suddenly, the patient is generally sensible +of the pain produced by the displacement, before she has experienced any +difficulty in evacuating the bladder. + +A modern French author of great experience, (_Martin le Jeune_, p. 178,) +in enumerating the causes of retroversion, appears to take a similar view +of the subject, and places retention of urine very far down in his list. +"Sudden and violent contractions of the abdominal muscles and diaphragm in +attempting to vomit, to evacuate the bowels or bladder, or to lift heavy +weights; the throes during an abortion at an early period of pregnancy; +strong mental emotions; retention of urine; tumours in the neighbourhood +of the fundus, which by their weight or pressure force it backwards +towards the sacrum, are the causes which may produce a retroversion of the +uterus." + +Retroversion may also come on gradually, from "the uterus remaining too +long in that situation which is natural to it when unimpregnated, namely, +with its fundus inclined backwards. This may depend on various causes; +such as too great width of the pelvis, or the pressure of the ileum full +of fæces on the fore part of the uterus. In this case the weight of the +fundus must gradually produce a retroversion, and she will be sensible of +its progress from day to day." (Burns's _Anat. of the Gravid Uterus_. p. +18.) + +It will thus be seen how peculiarly liable the uterus is to retroversion +during the early months of pregnancy. At this time, the fundus is not yet +free from the weight of the superincumbent coils of intestine; and if from +any cause its ascent out of the pelvis be delayed beyond the usual time, +its liability to retroversion is still farther increased; for, not only +does the size of the fundus press it still farther backward, but any +sudden contractions of the abdominal muscles, or external violence, act +upon it with increased effect. + +The _symptoms_ of this displacement are as follow:--the patient is seized +with violent pain, bearing down, and sense of distension about the hollow +of the sacrum, with a feeling of dragging and even tearing about the +groins, produced by the violent stretching of the broad and round +ligaments; the bearing down is sometimes so severe and involuntary as to +resemble labour pains, and cases have occurred where it has been mistaken +for labour. With all this she finds herself unable to pass fæces or urine, +from the pressure of the fundus upon the rectum and of the os uteri upon +the neck of the bladder. Upon examination per vaginam, the altered +position and form of this canal instantly excite our suspicion: instead of +running nearly in a straight direction backwards and somewhat upwards, it +now takes a curved direction upwards and forwards behind the symphysis +pubis; the hollow of the sacrum is occupied with the globular and nearly +solid mass, (the fundus uteri,) which is evidently behind the vagina, the +posterior wall of this canal being felt between it and the finger; behind +the symphysis pubis, the vagina is more or less flattened, and its +anterior wall put violently upon the stretch, so much so that, according +to Richter, the orifice of the urethra is sometimes dragged up above the +pubic bones, (_Anfangsgründe der Wundarztneikunst_, vol. ii. p. 45:) the +os uteri is found high up behind the symphysis pubis, and in most cases +can be reached, although with much difficulty; sometimes we shall be able +to reach the posterior lip only, which is now the lowest: but "if the +retension of urine has been of some duration, it will be impossible to +reach the os uteri above the pubic bones with the finger. On examining per +rectum, we shall feel the same tumour pressing firmly upon it, and +preventing the farther passage of the finger, thus proving that the tumour +is situated between the rectum and the vagina; for, in such cases, the +bladder forms a considerable swelling below it, and prevents the finger +from passing up." (_Op. cit._) + +"The uterus being situated in the centre of the pelvis, between the rectum +and bladder, its retroversion cannot take place without deranging the +functions of these organs: the symptoms thus produced come on rapidly when +the displacement is sudden, slowly when it is gradual. Their severity is +in proportion to the size of the uterus, the degree of retroversion, its +duration, and the various circumstances which increase the impaction of +the uterus in the cavity of the pelvis: they also determine the degree of +inflammation and gangrene of this organ and the neighbouring parts." +(_Martin le Jeune_, p. 178.) Hence we frequently observe in the earlier +stages of retroversion, before the displacement has become complete, that +the patient is able to relieve the bladder to a certain extent, although +very imperfectly, and that with some difficulty; a slight dribbling of +urine continues to a very advanced stage, when the bladder is enormously +distended, and upon the point of bursting: this is not so much the case +with the rectum, the passage of fæces being generally completely +obstructed at an early period, partly from the pressure of the fundus +against it, and partly from the solid nature of its contents. "When such +suppressions once begin they aggravate the evil, not merely by causing +pain, but by occasioning a load of accumulated fæces in the abdomen above +the uterus, which presses it still lower into the cavity of the pelvis, at +the same time that the distension of the bladder in this state draws up +that part of the vagina and cervix uteri with which it is connected, so as +to throw the fundus uteri still more directly downwards." (Dr. W. Hunter, +_Med. Obs. and Inquiries_, vol. iv. p. 406.) These conditions of the +bladder and rectum, and the retroversion of the uterus, act reciprocally +as cause and effect; for the continuance of the distension of the bladder +and the descent of the fæces from the part of the intestine above the +obstruction, must elevate still more the os uteri, and depress to a still +greater degree the fundus. The retroversion, on the other hand, increases +the affection of the bladder and rectum, from which the principal danger +of the disease arises. (Burns's _Anat. of the Gravid Uterus_.) + +The _diagnosis_ of retroversion is, generally speaking, not very +difficult, the os uteri tilted up behind the symphysis pubis, and the +fundus forced downwards and backwards between the vagina and rectum, are +sufficiently characteristic of this displacement. We cannot agree with Dr. +Dewees that it can easily be mistaken for prolapsus uteri; in cases of +sudden prolapsus which has been caused by great violence, there will be, +it is true, intense pain in the pelvis, with sensation of forcing and +tearing in the direction of the broad and round ligaments; there will +also, probably, be inability to evacuate the rectum and bladder; but then +the examination, per vaginam, will present such a totally different +condition of parts as to preclude all possibility of mistake: the vagina +merely shortened, neither altered in direction or form; the os uteri at +the lower part of the tumour, which is in the vagina; the mobility of the +tumour itself, all conspire to show that the case is one of prolapsus not +retroversion. + +We occasionally meet with cases of retroversion where the os uteri, +although carried more or less upwards and forwards, is not forced, to that +extreme height behind the symphysis pubis as is usually observed. Instead +of looking towards, or rather above, the symphysis, the os uteri itself +looks downwards, the neck or lower part of the body of the uterus being +bent upon the fundus like the neck of a retort.[53] If, under such +circumstances, we cannot satisfy ourselves as to the existence of +pregnancy, we might easily be led to form an erroneous diagnosis, and to +conclude that some tumour had forced itself down into the hollow of the +sacrum, between the rectum and vagina, and had thus pushed the uterus +upwards and forwards, above the brim of the pelvis. An extra-uterine ovum +of the ventral species may occupy this situation, but its slow and gradual +growth, its greater softness and elasticity, and the slight degree of +uterine displacement produced in its early stages, would enable us to +ascertain its real character. The same would hold good to a certain extent +with an ovarian tumour, although in all probability this would produce +more or less displacement of the uterus to one side. + +The danger in retroversion of the uterus chiefly arises from the +distension or rupture of the bladder, and from the gangrenous inflammation +which may then take place, not only in it, but also in the uterus and +neighbouring parts. The very displacement itself is sometimes immediately +attended by alarming symptoms, such as faintness, vomiting, cold sweats, +weak irregular pulse, as seen in cases of inversion or strangulated +hernia. In some cases the suffering at first is but trifling, and only +increases in proportion to the degree with which the bladder is distended. + +Retroversion not reduced may experience a spontaneous termination in two +ways, either by abortion being excited, after which the uterus, now +diminished in size, returns to its natural situation, or it may go on to +increase in this position until a more advanced period of pregnancy, when +if it be not capable of being replaced by the action of the pains, +sloughing takes place in the fundus, and the foetus is discharged, either +by the rectum or vagina, as in a case of ventral pregnancy. + +In the _treatment_ of retroversion of the uterus, our object should be, +first, to remove the accumulated contents of the bladder and rectum, and +secondly, to endeavour to restore the uterus to its natural position. The +relief of the bladder must be our first aim, for here is the greatest +source of danger. The elastic catheter should always be used in these +cases, and greatly facilitates the operation of drawing off the water. The +altered direction of the urethra must be borne in mind; in many cases we +must pass the catheter nearly perpendicularly behind the symphysis pubis: +by pressing the uterus backwards, we shall diminish its pressure upon the +urethra, and thus enable the catheter to pass with great ease.[54] + +"The catheter should be employed occasionally, and the bowels emptied +daily, either by medicines of a mild kind, or by injections: if this plan +do not succeed in restoring the fundus, we should then consider the +propriety of mechanically replacing it. To aid us in our judgment, we +should consider, first, the period of gestation; secondly, the degree of +development the uterus has undergone; thirdly, the nature and severity of +existing symptoms. The period of gestation ought almost always to +influence our conduct in this complaint, and we may lay it down as a +general rule, the nearer that period approaches four months, the greater +will be the necessity to act promptly in procuring the restoration of the +fundus: the reason for this is obvious, every day after this only +increases the difficulty of the restoration from the continually +augmenting size of the ovum. The degree of development should also be +taken into consideration, as some uteri are much more expanded at three +months, than others are at four. The extent or severity of symptoms must +ever be kept in view; as, for instance, where the suppression of urine is +complete, and not to be relieved by the catheter, in consequence of the +extreme difficulty and impossibility to pass it: here we must not +temporize too long, lest the bladder become inflamed, gangrenous, or +burst; for the bladder, from its very organization, cannot bear distension +beyond a certain degree, or beyond a certain time, without suffering +serious mischief." (Dewees, _Compend. Syst. of Midwifery, 6th Ed._ § 276.) +Our next step should be to relieve the rectum of its contents by emollient +enemata; this is not always very practicable, owing to the flattened state +of it: hence a glyster pipe of the ordinary sort is too large, and meets +with much resistance; in such cases it will be desirable to use a common +elastic catheter, or thin elastic tube without an ivory nozzle, which +will, therefore, better adapt itself to the form of the bowel. A few doses +of a saline laxative should be given to render the contents of the bowels +more fluid, and the enemata repeated until a sufficient evacuation has +been effected. Where the retroversion is not of long standing, and the +patient not far advanced in her pregnancy, these means are generally +sufficient; and the uterus, in the course of a few hours, will return to +its natural position, either spontaneously or with very slight assistance. +Where, however, the uterus is large and firmly impacted, where it has +already been displaced more than twenty-four hours, where the suffering +from the very beginning has been acute, independently of that produced by +the distended bladder, we cannot expect that the spontaneous replacement +will follow the mere removal of the accumulated urine and fæces; nor must +the uterus be suffered to remain in the state of retroversion, as not only +will its pressure on the neighbouring parts produce serious mischief, but +from the increasing growth of the ovum, every day will add to the +difficulty of moving it out of the pelvis. In determining upon the +artificial reposition of the uterus, it must be borne in mind that the +chief difficulty is to raise the fundus above the promontory of the +sacrum, for if we can once succeed in gaining this point, the rest will +follow of itself; our object, therefore, will be to raise the fundus +upwards and forwards, in a direction towards the umbilicus of the patient. +To effect this purpose various methods have been proposed: some have +recommended that, with a finger in the vagina, we should hook down the os +uteri, while with one or two fingers of the other hand passed into the +rectum, we endeavour to push the fundus out of the hollow of the sacrum. +Some object to any attempt being made through the rectum. (Naegelé, +_Erfahrungen und Abhandlungen_, p. 346.) We agree with Richter in the +utter inutility of attempting to bring down the os uteri; in most +instances we can barely reach it with the tip of the finger, and even were +we able to lay hold of it, we should run little or no chance of moving it +so long as the fundus is impacted in the hollow of the sacrum. The fingers +which are in the vagina must endeavour to raise the fundus, and in doing +so may be assisted by one or two fingers in the rectum according to +circumstances; the very effort to press per vaginam against the fundus, +necessarily puts the anterior wall of the vagina upon the stretch, and +thus tends of itself to bring the os uteri downward.[55] In all cases +where the reposition of the uterus is at all difficult, Professor Naegelé +recommends the introduction of the whole hand into the vagina, by which we +gain much greater power. Under such circumstances it is desirable to place +the patient upon her knees and elbows, as in a difficult case of turning, +because now the very weight of the fundus will dispose it to quit the +pelvis. The only difficulty which we shall meet with in thus using the +whole hand, is the violent straining and efforts to bear down, which the +patient is involuntarily compelled to make, from the presence of the hand +in the vagina. Dr. Dewees in such cases very judiciously recommends +bleeding to fainting, not only to obviate these efforts which would have +prevented our raising the fundus, but also to relax the soft parts as much +as possible. In our attempts to replace the uterus we must not be +discouraged by finding that at first no impression is made upon it; by +degrees it will begin to yield, and with a little more perserverance we +shall be enabled to push the fundus above the promontory of the sacrum. +(See Mr. Hooper's Case, _Med. Obs. and Inquiries_, vol. v. p. 104.) + +Where the pain in the pelvis indicates considerable pressure of the uterus +upon the surrounding parts, arising probably from swelling and +engorgement with blood, the result of vascular excitement, a smart +bleeding will afford great relief; the size and firmness of the tumour are +diminished, the soft parts in which it is imbedded are relaxed, the +general turgor and sensibility are alleviated, and if the moment of +temporary prostration which it has produced be seized upon by the +practitioner, he will find that the reposition of the uterus, which was +before nearly impracticable, is now comparatively easy. + +Where, however, the circumstances of the case are so unfavourable, and the +fundus so firmly impacted in the hollow of the sacrum as to resist the +above-mentioned means, Dr. Hunter proposed, "Whether it would not be +advisable, in such a case, to perforate the uterus with a small trocar or +any other proper instrument, in order to discharge the liquor amnii, and +thereby render the uterus so small and so lax as to admit of reduction." +(_Med. Obs. and Inq._ vol. iv. p. 406.) Dr. Hunter did not live to see +this plan carried into execution. In latter years, several cases of +otherwise irreducible retroversion have thus been successfully relieved: +the remedy, it is true, necessarily brings on premature expulsion of the +foetus sooner or later. Under such circumstances, this result cannot be +made a ground of objection. In cases of such severity as to require +paracentesis uteri, there can be little or no chance of the foetus being +alive; and even if it were, of what avail would this be, when almost +certain death is staring the mother in the face, unless relieved by this +operation?[56] Puncture of the bladder has also been tried where the urine +could not be drawn off.[57] + +Cases have now and then been met with where the retroversion of the uterus +has continued to an advanced period of pregnancy without producing serious +injury to the patient: Dr. Merriman has even recorded some, where the +uterus has continued in this state up to the full term. Some of these had +been actually published as cases of ventral pregnancy; but for their +history he has shown that they evidently were cases of retroversion: the +patient had been subject to occasional suppressions of urine and +difficulty in passing fæces; these symptoms had gradually diminished as +pregnancy advanced; the os uteri could not be felt, or, if it were +capable of being reached, was found high up behind the pubes, the head of +the child forming a large hard tumour between the rectum and vagina. The +condition of the vagina afforded strong evidences of the nature of the +complaint: on introducing the finger in the usual direction, it was +stopped, as if in a cul-de-sac: but on passing it forwards, the vagina was +found pulled up behind the symphysis pubis. In some of these cases the +uterine contractions gradually restored the fundus to its natural +position: the os uteri descended from behind the symphysis, and the child +was born after long protracted suffering; in others, which have been +mistaken for ventral pregnancy, the fundus has inflamed and ulcerated, and +the child has been gradually discharged by piecemeal. + + + + +CHAPTER VII. + +DURATION OF PREGNANCY. + + +There are few questions of great importance and interest respecting a +subject under our daily observation, about which such uncertainty and so +much diversity of opinion exists, as the duration of human pregnancy; and +yet, as is the case with the diagnosis of pregnancy, upon a correct +decision frequently depend happiness, character, legitimacy, and fortune. +In like manner it frequently happens, that the data upon which we have to +found our opinion are exceedingly doubtful and obscure; and to increase +the difficulties of the investigation still farther, we have not +uncommonly to contend with wilful deception and determined concealment. + +The duration of pregnancy must ever remain a question of considerable +uncertainty so long as the data and modes of calculation vary so +exceedingly. "Some persons date from the time at which the monthly period +intermits; others begin to calculate from a fortnight after the +intermission; some reckon from the day on which the succeeding appearance +ought to have become manifest; some are inclined to include in their +calculation the entire last period of being regular; and others only date +from the day at which they were first sensible of the motions of the +infant."[58] + +"A good deal of the confusion on this point seems to have arisen from +considering forty weeks and nine calendar months as one and the same +quantity of time, whereas, in fact, they differ by from five to eight +days. Nine calendar months make 275 days, or if February be included, only +272 or 273 days, that is thirty-nine weeks only instead of forty. Yet we +constantly find in books on law, and on medical jurisprudence, the +expression "nine months or forty weeks." Another source of confusion has +evidently had its origin in the indiscriminate use of lunar and solar +months, as the basis of computation in certain writings of authority."[59] + +It is owing to this uncertainty that a considerable latitude has been +allowed by the codes of law in different countries for the duration of +pregnancy, in order to prevent the risk of deciding where the data are so +uncertain. + +Experience has shown that the ordinary term of human pregnancy, wherever +it has been capable of being determined with any degree of accuracy, is +280 days or forty weeks; and this period seems to have been generally +allowed even from the remotest ages. As, however, it is so difficult to +fix the precise moment of conception, it has been customary in different +countries to allow a certain number of days beyond the usual time; thus +the Code Napoléon ordains 300 days as the extreme duration of pregnancy, +allowing twenty days over to make up for inaccuracy of reckoning. In +Prussia it is 301 days, or three weeks beyond the usual time. In this +country the limit of gestation is not so accurately determined by law, and +therefore gives rise occasionally to much discrepancy of opinion. + +The grand question which this subject involves, is, whether a woman can +really go beyond the common period of gestation. A great number of authors +have considered that the _partus serotinus_, or over-term pregnancy, is +perfectly possible; but by far the majority use such an uncertain mode of +reckoning that little confidence can be placed in them. + +Two questions here arise, the determining of which will greatly assist us +in forming a correct view of this intricate subject, viz. _first_, what +has been the duration of those cases of pregnancy where the moment of +conception has been satisfactorily ascertained? _secondly_, what are the +causes which determine the period at which labour usually comes on? + +The circumstances under which it happens that we are able to ascertain the +precise date of impregnation occur so rarely, that it is nearly impossible +to collect any considerable number of such cases. Three have occurred +under our own notice, in which there could be little doubt as to the +accuracy of the information given, and in each of these the patient went a +few days short of the full period. One, a case of rape, was delivered on +the 260th day; in the two others, sexual intercourse had only occurred +once; in one case she went 264, in the other, 276 days. We could have +mentioned several others, but where even the slightest shadow of doubt as +to their accuracy has existed, we have rejected them as inconclusive. + +The mode of calculating the duration of pregnancy, which is ordinarily +adopted, viz. by reckoning from the last appearance of the catamenia, +although the chief means which is afforded us for so doing, is +nevertheless much too vague and uncertain to ensure a decided result; for +although it is a well-known fact, that conception very frequently takes +place shortly after a menstrual period, there can be no doubt that it is +liable to occur at any part of the catamenial interval, and particularly +so shortly before the next appearance: hence, by this mode of reckoning, +we are not more justified in expecting labour in nine months time from +the last appearance of the catamenia, than at any part of the interval +between this and what would have been the next appearance. + +Dr. Merriman, who has devoted much attention to this intricate but +important subject, says, "When I have been requested to calculate the time +at which the accession of labour might be expected, I have been very exact +in ascertaining the _last day_ on which any appearance of the catamenia +was distinguishable, and having reckoned 40 weeks from this day, assuming +that the _two hundred and eightieth_ day from the last period was to be +considered as the legitimate day of parturition" (_Synopsis of Difficult +Parturition_, p. xxiii. ed. 1838;) and gives a valuable table of "one +hundred and fifty mature children, calculated from, but not including, the +day on which the catamenia were last distinguishable." Of these, + + 5 were born in the 37th week, + 16 --- in the 38th, + 21 --- in the 39th, + 46 --- in the 40th, + 28 --- in the 41st, + 18 --- in the 42nd, + 11 --- in the 43rd; + +so that about one-third were born three weeks after the 280 days from the +last appearance of the catamenia; a circumstance which is perfectly easy +of explanation, from what we have just observed, without the pregnancy +having overstepped its usual duration: in other words, it would appear +that 28 of these cases had conceived one week, 18 two weeks, and 11 three +weeks after the last appearance of the catamenia. + +The question therefore of the _partus serotinus_; as far as these data are +concerned, remains still undecided: of 10 cases which have occurred under +our own immediate notice, where the patients determined the commencement +of their pregnancy from other data than the last appearance of the +catamenia, a similar variation was observed, viz. that nearly one-third +went beyond 280 days, six of these individuals reckoned from their +marriage, and four from peculiar sensations connected with sexual +intercourse, which convinced them that impregnation had taken place: of +these, seven did not go beyond the 280th day, two having been delivered +upon that day, and three went beyond it, viz. to the 285th, 288th, and +291st days: the two former reckoned from their respective marriages; the +latter, who went 291 days, from her peculiar sensations. + +The calculation from the date of marriage is liable to the same objections +as that taken from the last appearance of the catamenia; for if it had +been solemnized (as is usually the case where it is possible) shortly +after a menstrual period, and if conception did not take place until a +fortnight or three weeks afterwards, the patient's pregnancy would thus +have appeared to have lasted so much longer than the natural term. The +case, however, which is stated to have gone 291 days, does not come under +this head, for here the pregnancy really appears to have lasted 10 or 11 +days beyond the full period, which cannot be accounted for in the way +above mentioned: we should not have ventured to quote this, if a similar +instance had not been recorded by Dr. Dewees. "The husband of a lady, who +was obliged to absent himself many months, in consequence of the +embarrassment of his affairs, returned, however, one night clandestinely, +and his visit was only known to his wife, her mother, and ourselves. The +consequence of this visit was the impregnation of his wife; and she was +delivered of a healthy child in 9 months and 13 days after this nocternal +visit. The lady was within a week of her menstrual period, which was not +interrupted, and which led her to hope she had suffered nothing from her +intercourse; but the interruption of the succeeding period gave rise to +the suspicion she was not safe, and which was afterwards realized by the +birth of a child."[60] + +Although it is to be regretted that this case has been calculated in the +ordinary vague manner of calendar months, yet it is perfectly evident that +the pregnancy was longer than the ordinary duration. We shall, therefore, +endeavour to investigate the possibility of over-term pregnancy still more +closely by a consideration of the second question, viz. what are the +causes which determine the period at which labour usually comes on? + +It is now ten years ago since we first surmised that "the reason why +labour usually terminates pregnancy at the 40th week is from the +recurrence of a menstrual period at a time during pregnancy when the +uterus, from its distension and weight of contents, is no longer able to +bear that increase of irritability which accompanies these periods without +being excited to throw off the ovum." + +Under the head of PREMATURE EXPULSION, we shall have occasion to notice +the disposition to abortion which the uterus evinces at what, in the +unimpregnated state, would have been a menstrual period: for some months +after the commencement of pregnancy, a careful observer may distinctly +trace the periodical symptoms of uterine excitement coming on at certain +intervals, and it may be easily supposed that many causes for abortion act +with increased effect at these times. Where the patient has suffered from +dysmenorrhoea before pregnancy, these periods continue to be marked with +such an increase of uterine irritability as to render them for some time +exceedingly dangerous to the safety of the ovum. Even to a late period of +gestation, the uterus continues to indicate a slight increase of +irritability at these periods, although much more indistinctly; thus, in +cases of hæmorrhage before labour, especially where it arises from the +attachment of the placenta to the os uteri, it is usually observed to come +on, and to return, at what in the unimpregnated state would have been a +menstrual period. We mention these facts as illustrating what we presume +are the laws on which the duration of pregnancy depends, and also as being +capable of affording a satisfactory explanation of those seeming over-term +cases which are occasionally met with. + +From this view of the subject it will be evident, that the period of the +menstrual interval at which conception takes place, will in great measure +influence the duration of the pregnancy afterwards; that where it has +occurred immediately after an appearance of the menses, the uterus will +have attained such a dilatation and weight of contents by the time the +ninth period has arrived, that it will not be able to pass through this +state of catamenial excitement without contraction, or, in other words, +labour coming on: hence it is that we find a considerable number of +labours fall short of the usual time, so much so that some authors have +even considered the natural term of human gestation to be 273 days or 39 +weeks: for a somewhat similar reason we can explain why primiparæ seldom +go quite to the full term of gestation, the uterus being less capable of +undergoing the necessary increase of volume in a first pregnancy than it +is in succeeding ones. + +On the other hand, where impregnation has taken place shortly before a +menstrual period, the uterus, especially if the patient has already had +several children, will probably not have attained such a volume and +development as to prevent its passing the ninth period without expelling +its contents, but may even go on to the next before this process takes +place: it is in this way that we would explain the cases related by Dr. +Dewees and Dr. Montgomery. We are aware that, under such a view of the +subject, the duration of time between the catamenial periods of each +individual should be taken into account, some women menstruating at very +short, and others at very long, intervals; but although this will affect +the number of periods during which the pregnancy will last, it will not +influence the actual duration of time, as this will more immediately +depend upon the size and weight of contents which the uterus has attained. + +The valuable facts collected by M. Tessier respecting the variable +duration of pregnancy in animals, which have been quoted by some authors +in proof of the partus serotinus, are scarcely applicable to this question +in the human subject; the absence of menstruation, and the different +structure of the uterus, prevent our making any close comparison. + + + + +CHAPTER VIII. + +PREMATURE EXPULSION OF THE FOETUS. + + _Abortion.--Miscarriage.--Premature labour.--Causes.--Symptoms.-- + Prophylactic measures.--Effects of repeated abortion.--Treatment._ + + +The uterus does not always carry the ovum to the full term of pregnancy, +but expels it prematurely. This expulsion of its contents may occur at +different periods, and is characterized accordingly: thus, among most of +the Continental authors, it has been divided under three heads; those +cases which occur during the first sixteen weeks coming under the head of +_abortion_; those which occur between this period and the twenty-eighth +week are called _miscarriages_; and when they take place at the latter +period, until the full term of utero-gestation, they receive the name of +_premature labours_. + +It is perhaps useful to distinguish those cases of premature expulsion +which occur before from those which occur after the fourth month, inasmuch +as they seldom prove dangerous before that time, from the diminutive size +of the ovum and from the slight degree of development which the uterine +vessels have undergone; whereas, after this period the hæmorrhage is more +severe, and the general disturbance to the system greater. In other +respects it will be more simple to divide premature expulsion of the ovum +under two heads only; those cases which happen before the twenty-eighth +week, or seventh month, being termed _abortions_, and after this period +(as before) _premature labours_. This division is highly important in a +practical point of view, since it marks the period before which the child +has little chance of being born alive; whereas, after this date it may +with care be reared.[61] A foetus may be expelled, at a very early stage +of pregnancy, not only alive but capable of moving its limbs briskly for a +short time afterwards, but it is unable to prolong its existence separate +from the mother beyond a few hours. Cases do occur now and then where a +child is born in the sixth month, and where it manages to struggle +through, but these are rare, and must rather be looked upon as exceptions +to the general rule. + +Abortions usually occur from the eighth to the twelfth week, a period +which is decidedly the least dangerous for such accidents. "The liability +to abortion is greater in the early than in the later periods of +pregnancy; for as the union between the chorion and decidua is not well +confirmed, as the attachment of the latter to the internal face of the +uterus is proportionably slight, and as the extent of surface which the +ovum now presents is very small to that which it offers in the more +advanced state of pregnancy, and as it can of course be affected by +smaller causes, it will be seen that a separation will be more easily +induced, and prove much more injurious to the well-being of the embryo, +than a larger one at another stage." (Dewees, _Compendious System of +Midwifery_, § 929.) Abortions coming on at a later period, viz. from the +sixteenth to the twenty-eighth week, which corresponds to the second +division, or _miscarriages_, of the continental authors, are not only more +dangerous than abortions at an early stage, for the reasons +above-mentioned, but also than premature labours, as in this last division +the uterus has attained such a size as to make the process rather resemble +that of natural labour at the full term. + +_Causes._ Premature expulsion may be induced by a great variety of causes, +which may be brought under the two following heads: those which act +indirectly, by destroying the life of the embryo, and those which act +directly on the uterus itself. These various causes may be general or +local; the process of nutrition for the growth and development of the +embryo may be defective and scanty, from general debility or disease: +hence, whatever depresses the tone of the patient's health renders her +liable to abortion by causing the death of the embryo. Thus, dyspepsia and +derangement of the chylopoietic viscera; debilitating evacuations; +depressing passions of the mind; bad or insufficient nourishment; intense +pain, as in toothach; severe suffering from existing disease, especially +where the health is much broken down by some chronic affection; syphilis, +and febrile attacks, all act as indirect causes of abortion.[62] +Salivation from mercury not unfrequently has a similar effect; in some +instances, however, febrile affections appear to act much more directly, +stimulating the uterus to powerful contractions and rapid expulsion of its +contents. The symptoms which indicate the death of the child have already +been detailed in the chapter upon that subject. + +The period which may elapse between the death and the expulsion of the +embryo varies exceedingly: in the early months the one usually follows the +other pretty quickly, owing probably to the slight attachment of the ovum +to the uterus; during the middle third of pregnancy the interval may be of +considerable duration, and cases every now and then occur where the foetus +is retained, not only several weeks, but even some months after its death; +whereas, during the latter third of pregnancy, expulsion follows the death +of the child after a short interval, seldom exceeding two or three days; +for now the weight of the dead foetus speedily irritates the uterus to +contraction, and, as has been observed by Smellie, the membranes, running +gradually into putrefaction, and being now unable to bear the weight of +the liquor amnii, burst, and expulsion soon follows. + +Among the causes which act locally in inducing premature expulsion by +first destroying the child, may be enumerated external violence applied to +the abdomen, such as blows, falls, and other violent concussions; these +act indirectly by producing separation of the ovum from the uterus, and +thus destroying the life of the child. Under the same head may be classed +all violent exertions, as lifting heavy weights, straining to reach +something high above the head, &c. The mere act of walking, when carried +to such an extent as to induce exhaustion, will suffice, in weakly +delicate females, to bring on expulsion; sudden and violent action of the +abdominal muscles, when excited by a half-involuntary effort to save +herself from falling, or receiving any other injury, may produce a similar +effect: if the foetus be so young that its movements cannot be felt by the +mother, she feels from this moment more or less pain in the pelvis, with a +sensation of weight and bearing down; and this, in all probability, will +be followed by a discharge of blood from the vagina: where pregnancy has +sufficiently advanced for the motions of the foetus to be perceptible, the +mother will frequently feel them in an unusually violent degree for a +short time immediately after the injury, and then they cease entirely. + +Premature expulsion may also be induced immediately without the previous +death of the child, by causes which directly excite the uterus to action: +thus, various violent mental emotions, as rage, joy, horror, may act in +this manner, although they may also act more indirectly; sudden exposure +to cold, as sudden immersion in cold water, will occasionally produce it +instantly. Irritation in the intestinal canal will directly excite uterine +contraction; hence an attack of dysentery is frequently a cause of +abortion, and we not unfrequently meet with patients who are liable to +this affection in every pregnancy: a similar effect may be produced by the +improper use of drastic purgatives, which irritate the lower bowels, viz. +aloes, scammony, savin, &c.; or the uterus may, in some cases, be excited +to contract from the peculiar action of secale cornutum. On the other +hand, a loaded state of the bowels equally predisposes to abortion, by +impeding the free return of blood from the pelvis. A state of general +plethora acts in the same manner; and this is more particularly the case +if it takes place at what would, in the unimpregnated state, have been a +menstrual period; for, occurring in conjunction with the increased +vascular action which prevails at these periods in the uterine system, it +produces, as it were, an apoplectic state of the uterine sinuses, which +form the maternal portion of the placenta; blood is extravasated between +the ovum and uterus; their connexion is more or less destroyed, and the +death of the foetus becomes unavoidable: hence, in these cases the +expulsion may result either from this latter circumstance, or from the +uterus being irritated to contract by the effused blood between itself and +the membranes. + +In patients who have suffered from attacks of dysmenorrhoea in the +unimpregnated state, the irritable uterus, when pregnant, is very apt to +contract upon its contents and expel them. This usually happens at what +would have been a menstrual period, and not unfrequently takes place so +soon after impregnation as merely to be looked upon as an unusually severe +attack, the little ovum having been imperceptibly expelled among the +discharges. Under this head must be brought those cases of spasmodic +affection of the uterus, which Dr. Burns has described, and where, from +the diminutive size of the ovum, the case has rather resembled one of +menorrhagia. Cases of abortion are also mentioned by authors where the +uterus is stated to be incapable of undergoing the necessary dilatation +and increase of size which pregnancy requires; but we are strongly +disposed to refer them to the above head of great uterine irritability, as +we neither know of any diagnostic marks which will enable us to detect +this condition during life, nor are we aware of any physical condition of +the uterus short of actual disease, to be detected after death, which can +produce this inability. + +The uterus may be also excited to expel the foetus, without its previous +death by local causes, as acute leucorrhoea, or other inflammatory +affections of the vagina, by inflammation and other affections of the +bladder, as calculus, &c. Too frequent sexual intercourse during the early +months of pregnancy is peculiarly liable to excite abortion: this is +especially observed among primiparæ of the better ranks, where, from +luxurious living, &c., there is but little physical strength in proportion +to the great irritability of the system: hence we find that a fifth, or +even a fourth, of these females abort in their first pregnancies. In +conclusion we may briefly state that the same circumstances which in the +unimpregnated condition produce menstrual derangement and other disorders +of the uterine system, now act as so many causes of abortion. + +The sudden cessation of the breeding symptoms, with sense of weight and +coldness in the lower part of the belly, flaccid breasts, pain in the back +and loins, and discharge of blood from the uterus, are pretty sure signs +of abortion: they are those which are "produced by separation of the ovum +and contraction of the uterus," (_Burns_;) the one is attended by +hæmorrhage, the other by pain. Although these are two chief symptoms which +characterize a case of threatened abortion, and although they must +necessarily be present more or less in every instance where premature +expulsion actually happens, still neither of them, either separately or +conjointly, can be considered as a certain proof that the uterus will +carry its contents no longer. Cases not unfrequently happen where patients +have repeated attacks of hæmorrhage during the early months of pregnancy, +and sometimes to a considerable amount, without any apparent disturbance +to the process of gestation, and are delivered of a living healthy child +at the full term: on the other hand, we have known instances where the +pain of the back was severe, and where, on assuming the erect posture even +for a minute, the sense of weight and bearing down in the lower part of +the abdomen was so great as to make the patient fear that the ovum was on +the point of coming away; still even these threatening symptoms have +gradually subsided, and the pregnancy has continued its natural period. +Puzos considered that neither pain nor hæmorrhage were necessarily +followed by expulsion. (_Mém. de l'Acad. de Chir._ vol. i. p. 203.) When, +however, both occur together, and to a considerable extent, the case must +be looked upon as one of at least doubtful if not unfavourable +termination. Where pain comes on at regular intervals, with hardness of +the uterus, and dilatation of its mouth, this is a serious symptom, for it +shows that the uterus will no longer retain its contents, but is evidently +preparing to expel them. + +The part of the ovum at which the separation of it from the uterus has +taken place, not only determines which of the above symptoms will appear +first, but also the probability of expulsion. "When a considerable +separation takes place, as must be the case when it commences at the upper +parts of the uterus, pain will more likely occur than when it happens near +the neck; hence we sometimes have pain before the blood issues externally. +The uterus in this instance suffers irritation from partial distension +from the blood insinuating itself behind the ovum; contraction ensues; the +blood is thus forced downwards, and is made to separate the attachment +between the ovum and the uterus in its course, until it finally gains an +outlet at the os tincæ. In consequence of the uterus being excited to +contraction, the friendly coagula which may have formed from time to time +are driven away, and the bleeding each time is renewed and accompanied +most probably with increased separation of the ovum, until at last from +its extent the ovum becomes almost an extraneous body, and is finally cast +off. Hence a separation at or near the os uteri will not be so dangerous, +and in all probability there will be hæmorrhage without pain, which is +the contrary when it takes place near the fundus." (Dewees, _Compend. +System of Midwifery_, § 981, 982.) The pain during the abortion is +sometimes exceedingly severe, and not unlike that of dysmenorrhoea: this +is probably owing to the violent contractions of the uterus, which are +required to dilate the os and cervix before the ovum can pass: they are +frequently attended with nausea, vomiting, and fainting, and sometimes +with more or less general fever and local inflammatory action; the pain is +generally attended with much irritability of the bladder, and frequent +desire to pass water; the pulse is mostly quick and small, and where there +is arterial excitement, it is sharp and resists the finger. + +_Treatment._ The treatment of premature expulsion consists in, 1, that +which is intended to guard the patient against its occurrence, or +_prophylactic_; and 2, in that which is required _during an attack_. + +A knowledge of the various causes of premature expulsion will materially +assist us in the prophylactic treatment; under all circumstances, even +where there is not the remotest fear of such an accident coming on, it is +nevertheless highly important to pay strict attention to the state of the +stomach and bowels, for these are almost always more or less influenced by +the presence of pregnancy; the vomiting and sickness must be relieved in +the manner already pointed out under the chapter on the TREATMENT OF +PREGNANCY; the bowels, if constipated, must be moved by the mildest +laxatives, such as castor oil, Confect. sennæ, or a Seidlitz powder; and +thus all sources of irritation in the primæ viæ prevented as far as +possible. The patient must carefully avoid every thing which may excite +the circulation, such as violent affections of the mind, rich indigestible +and stimulating food, violent exertion, &c. The diet should be light, +nourishing, and moderate; heavy meals must be forbidden, and especially +suppers; she should keep early hours, take gentle and regular exercise, +and in fact, endeavour by every means in her power to raise her health to +a full degree of tone and regularity. In those patients who have already +miscarried in their previous pregnancies, these precautions must be +enforced with double vigilence; for the system becomes exceedingly +irritable, and the uterus soon acquires, as it were, a habit of retaining +its contents only to a certain period, and then prematurely expelling +them. When this is the case, it becomes exceedingly difficult, and is +often actually impossible, to make it carry the ovum to the full term of +utero-gestation, and, despite of the greatest care, the symptoms of +premature expulsion will come on at about the same time at which they +occurred in former pregnancies, and sometimes to the very same week. + +In the treatment of such cases, where there is so much liability to +abortion, we must first examine the precise condition of the circulation, +and ascertain whether it be above or below the natural standard of +strength; for as abortion may arise from very opposite conditions of the +circulation, our treatment must consequently vary. If there be signs of +arterial excitement, a small bleeding may be necessary; it unloads the +congested vessels, diminishes the force of the circulation, and therefore +also the chance of an extravasation of blood between the uterus and ovum; +the bowels must be kept open by cooling saline laxatives, and the +circulation may be still farther controlled, by the use of nitre two or +three times a day. The diet must be spare; she must take regular exercise +in the open air, wear light clothing, dress loosely, and sleep upon a hard +mattress. + +In these cases we are often warned that congestion of the uterine vessels +is present, by pain and throbbing, and sense of fulness in the groins; +leeches applied to these parts give much relief, and frequently render +venesection unnecessary. Tight lacing ought to be strictly prohibited in +all cases of pregnancy, particularly where there is a disposition to +plethora: among other bad effects, it prevents the proper development of +the breasts, the nipples are pressed so flat as to be nearly useless, the +child being unable to get sufficient hold of them: this may in some degree +be avoided, by putting thick ivory rings upon the breasts, and thus +shielding the nipples from injurious pressure. It will, however, be much +better to have the dress made loosely, to allow for the development of the +breasts, which takes place during pregnancy; for there can be little +doubt, that irritation of these glands is very liable to be followed by a +corresponding state in the uterus. + +The common but erroneous notion that it is necessary to take an extra +quantity of nourishment for the support of the child as well as of the +mother must be strenuously opposed. Nature contradicts it in the most +striking manner; for, by the nausea and sickness which most women +experience during the first half of their pregnancy, she raises an +effectual obstacle to any error of this kind. "It certainly cannot be +intended for any other purpose, since it is not only almost universal, but +highly important when it occurs, as it would seem to add much to the +security of the foetus; for it is a remark as familiar as it is well +grounded, that _very sick women rarely miscarry_; while on the contrary, +women of very full habits are disposed to abortion, if exempt from this +severe, but as it would seem, important process." (Dewees, _on Children_, +§ 45.) + +Where the case has become one of habitual abortion, the patient's only +chance will be by living separate from her husband for twelve or more +months: the uterus, not being exposed to any sexual excitement during this +period, becomes less irritable, and it gradually loses the disposition +which it has acquired of expelling its contents prematurely. In such a +case, when pregnancy has again commenced, it requires to be watched most +narrowly; every possible source of irritation must be removed by the +strictest attention to diet and regimen, and the patient must make up her +mind to be entirely subservient to the rules laid down by her medical +attendant. Although the chances are against her escaping without premature +expulsion, still we are not to despair, experience showing that cases +every now and then occur where the patient has gone the full term of +pregnancy in safety, in spite of repeated previous abortions. Dr. Young of +Edinburgh, in his lectures on midwifery, describes a case where the +patient actually miscarried thirteen times, and yet bore a living child +the fourteenth time. + +On the other hand, where the condition of the patient evinces a state of +strength considerably below the natural standard, we find a very different +set of symptoms to those which have been just described, requiring +opposite treatment: the face is pale and even sallow; the pulse is soft, +small, and irritable; the tongue pale and flabby; the digestion impaired; +the bowels torpid; and the extremities cold: fatigue, or rather a sense of +exhaustion, is induced by the slightest exertion, and this is attended +with dull, heavy, dragging pain about the pelvis and loins, and a feeling +as if the contents of the abdomen required more support, and were disposed +to prolapse either by the rectum or vagina, on her maintaining an upright +posture for any length of time. + +Even at a very early period of pregnancy, there is the sensation of a +weight in the lower part of the abdomen, falling over to that side which +is lowest, as we described among the signs of the death of the foetus at a +later period, resulting in all probability from a loss of tone and +firmness in the uterus. In this state, if nothing be done to restore the +mother's strength, the embryo will inevitably perish, and expulsion +follow, sooner or later, as a necessary result. + +In all cases where pregnancy occurs, in a weakly delicate woman, measures +should be taken to increase the general tone of health, in order to fit +her for going through this process safely, by removing her to the country, +or to the sea-side, or to some watering place, where she will have the +opportunity of drinking a mild chalybeate, and enjoying a purer air. Where +it is even hazardous to move her, she should be put upon a course of mild +chalybeates. The food should be light and nourishing, and a glass or two +of wine or mild ale, may generally be taken with advantage. Where she can +bear it, tepid salt-water bathing, or sponging, will have the best +effects. + +"For a number of years, (says Mr. White of Manchester,) I have been +convinced of the good effects of cold bathing, not only in preventing +miscarriages when every other method has been likely to fail, but other +disorders which are incident to pregnant women, and generally attendant +upon a weak lax fibre. I don't mean the cold bath in the greatest +extreme, but such as that of Buxton or Matlock, or sea-bathing, or bathing +in a tub in the patient's house, with the water a little warmed. I have +frequently advised my patients to bathe every other day, at a time when +the stomach is not overloaded, and not to stay at all in the water; to +begin this process as early as possible, even before they have conceived, +as there will be then no danger from the surprise, and continue it during +the whole term of pregnancy; and several have bathed till within a few +days of their delivery." (White, _on Lying-in Women_, p. 70.) Where +exercise can be taken without fear, it should be done regularly but +cautiously, so as not to induce fatigue or exhaustion, which is the very +effect we must be so careful to avoid; in fact, every means and +opportunity should be used of recruiting the powers and the vigour of the +system. In proportion as the strength increases, so does the irritability +diminish; the uterus becomes less sensitive to external impressions, and +can, therefore, bear its gradual development without being excited to +contraction; the foetus receives its due supply of nourishment; the +feeling of relaxation and deficient support of weight, and bearing down, +go off as health returns; and by thus keeping up the powers of the system +to the proper standard, it will be enabled to continue the process of +pregnancy to the full term. + +Although some women recover very quickly after an abortion, and appear for +the time to suffer but little from its effects, they seldom escape with +impunity, more especially if it has been repeated more than once: anæmia, +with its varied train of anomalous symptoms and concomitant gastric and +cerebral disturbance, profuse leucorrhoea, menorrhagia, and dismenorrhoea, +are some of the more direct results of repeated abortion; we may also +enumerate prolapsus uteri, inflammation of the cervix, with induration and +scirrhus, as the more remote effects. + +In the treatment of a case where expulsion is threatened, our object will +be either to stop that process in time to save the life of the foetus, or +if this cannot be attained, to carry it through, in such a manner, as to +expose the mother to as little danger and injury as possible.[63] In the +first instance, we must be guided nearly by the same rules as in the +prophylactic treatment: if there be considerable arterial excitement, and +evidence of general plethora, a small bleeding will be useful in restoring +a calm to the circulation; the most perfect quiet of body and mind must be +insisted upon; the patient should lie upon a hard mattress, and be covered +with as little clothing as is consistent with safety; she must refrain +from all exertion, and strictly maintaining the horizontal posture for a +considerable time. The indications for our treatment will be, 1. to remove +every thing which may, in any degree excite the circulation, and, 2. to +prevent the contraction of the uterus. Stimulants of every description, +and animal food must be forbidden; the bowels must be opened by gentle +saline laxatives; and if the pulse still betrays any sharp or resisting +feel to the finger, small doses of nitre may be taken as already +recommended. When the circulation has become perfectly calm, and every +trace of excitement allayed, opiates will prove of inestimable value: they +stop any disposition to uterine contraction, and remove the pain in the +back and loins which this will cause. The form which we prefer is the +Liquor Opii Sedativus, as being more sure in producing a sedative effect +than common laudanum, while at the same time, it produces less irritation +and derangement in the stomach and bowels. + +A moderate discharge of blood from the vagina, although showing that a +separation has taken place between the ovum and the uterus, cannot be +looked upon as an unfavourable sign, for it relieves the pelvic vessels, +diminishes the pain in the back, and makes the patient feel more light and +comfortable; but if it be at all brisk, and continues so after the +employment of the above remedies, if also there be heat and throbbing in +the region of the uterus, it will be necessary to apply cloths wrung out +of cold water to the lower part of the abdomen and vulva, and to the +groins and sacrum; and this treatment must be continued in full force +until the symptoms of congestion have abated, and the discharge lessened +or stopped. + +If the hæmorrhage be really profuse, it shows that the separation of the +ovum from the uterus must be of considerable extent; and as there will be +no chance of preserving the life of the foetus under such circumstances, +the expulsion of the ovum is no longer to be avoided, but rather to be +promoted; our attention therefore must now be directed to assist the +uterus in the evacuation of its contents, with as little injury and danger +to the mother as possible. It is, however, no easy matter to decide with +certainty when we must give up all hope of preserving the ovum, for a +large quantity of blood may be lost without expulsion being a necessary +consequence. Uterine contractions may have even taken place, and yet by +careful management the mischief may be sometimes averted, and the patient +be enabled to go her full time. Even where they have been of sufficient +force and duration to dilate the os uteri, we are not justified in +discontinuing remedial measures unless the flooding has seriously affected +the patient's strength, and the ovum be actually projecting through the os +uteri. "We might often prevent abortion (says Baudelocque) if we were +perfectly acquainted with its cause, even when the labour is already +begun. A very plethoric woman felt the pains of childbirth towards the +seventh month of her pregnancy, and the labour was very far advanced when +I was called to her assistance, since the os uteri was then larger than +half a crown; two little bleedings restored a calm, so much that the next +day the orifice in question was closed again, and the woman went the usual +time. Food of easy digestion prudently administered quieted a labour not +less advanced in another woman, where it was suspected to be the +consequence of a total privation of every species of nourishment for +several successive days. Delivery did not take place till two months and a +half afterwards, and at the full time. Emollient glysters and a very +gentle cathartic procured the same advantage to a third woman, in whom +labour pains came on between the sixth and seventh months of pregnancy, +after a colic of several days' continuance, accompanied with diarrhoea and +tenesmus." (_Baudelocque_,) § 2232. Nor is it always easy to decide +whether it be the ovum or not which we feel protruding through the os +uteri. "When the abortion is in the second or third month, the +practitioner must bear in mind that it may have been retention of the +menses, and, therefore, what he feels in the os uteri may either be an +ovum or a coagulum of blood. To decide this point he must keep his finger +in contact with the substance lying in the os uteri, and wait for the +accession of a pain (for where clots come away, pains like those of labour +are present,) and ascertain whether the presenting mass becomes tense, +advances lower, and increases somewhat in size; this will be the case +where it is the ovum pressing through the os uteri. On the other hand, if +it be a coagulum, which it is well known assumes a fibrous structure, it +will neither become tense nor descend lower, but be rather compressed. +Generally speaking, the ovum feels like a soft bladder, and at its lower +end is rather round than pointed, whereas, a plug of coagulum feels +harder, more solid, and less compressible, and is more or less pointed at +its lower end, becoming broader higher up, so that we generally find that +the coagulum has taken a complete cast of the uterine cavity. If we try to +move the uterus by pressing against this part, it will instantly yield to +the pressure of the finger, if it be the ovum; whereas, the extremity of a +coagulum under these circumstances is so firmly fixed, that when pressed +against by the finger the uterus will move also. When abortion happens at +a later period of pregnancy, we shall be able to feel the different parts +of the child as the os uteri generally dilates, viz. the feet, or perhaps +the sharp edges of bones, although we cannot distinguish the form of the +head from the cranial bones being so compressed and strongly overlapping +each other." (Hohl, _on Obstetric Exploration_.) + +Although expulsion must be looked upon as the only means of placing the +patient in a state of safety, where the symptoms have advanced so far as +to preclude all hopes of preserving the life of the foetus, there are so +many steps of this process to be gone through before it can be entirely +completed, that more or less time must necessarily be required for that +purpose. The ovum must be completely separated from its attachments to the +uterus, and the contractions of that organ must have been of sufficient +strength and duration to produce such a degree of dilatation of its mouth +and neck as to allow the ovum to pass; but before this can be effected, +such a quantity of blood may have been lost as greatly to endanger the +life of the patient. Hence we must use such means as shall enable us to +control the hæmorrhage, whilst we give the os uteri time to dilate +sufficiently: this object will be gained most effectually by plugging the +vagina. The best mode of performing this operation is that recommended by +Dr. Dewees of Philadelphia: a piece of soft sponge, of sufficient size to +fill the vagina without producing uneasiness, must be wrung out of pretty +sharp vinegar, and introduced into the passage up to the os uteri; the +blood, in filling the cells of the sponge, coagulates rapidly, and forms a +firm clot, which completely seals up the vagina without producing any of +those unpleasant effects which are produced by the insertion of a napkin +rolled up for the purpose. A hard unyielding mass of this nature +frequently produces so much tension, pain of back, and irresistible +efforts to bear down, as to render it incapable of being borne for any +length of time. The sponge plug may be borne for hours without +inconvenience; we may either leave it to be expelled with the ovum, or +after awhile remove it for the purpose of ascertaining what progress has +been made. If the os uteri be still undilated, and the hæmorrhage going +on, the plug must be returned. It is however by no means a remedy to be +used in every case of hæmorrhage, for in most instances the treatment +already mentioned will be sufficient to keep it within safe bounds. Where, +however, the flooding has become very alarming, and the os uteri still +remains firm and but little dilated, the plug will prove an invaluable +remedy; and so long as the os uteri remains in this condition, and the +uterus itself shows no disposition to contract, we may safely trust to +perfect rest, cold applications, and the plug. Opium, which in the early +stages of the attack is so useful in keeping off contractions of the +uterus, will now for this very reason be contra-indicated; it will +diminish the power of the uterus, and interfere with the process of +expulsion. + +The acetate of lead has been extolled as a powerful remedy for stopping +hæmorrhage, more especially by Dr. Dewees, who states that "in many cases +it seems to exert a control over the bleeding vessels as prompt as the +ergot of rye does upon the uterine fibre." (_System of Midwifery_, § +1045.) We have never tried this remedy in premature expulsion, having +found the means of treatment above mentioned sufficient; the authority +however of such an author demands respect, the more so as it is known to +be a valuable remedy in certain forms of menorrhagia. + +Where a considerable quantity of blood has been lost, and the patient is +much reduced, we must endeavour not only to excite the contractile power +of the uterus, but also to assist this organ in the expulsion of its +contents: syncope in these cases is a dangerous symptom, because, as the +patient is in the horizontal posture, it will seldom be induced except by +a serious loss of blood; although we must not therefore allow her to flood +until she faints, still, however, when the pulse has become considerably +affected, the os uteri dilates more readily, and in this way facilitates +the expulsion; we must no longer trust to the plug, for the whole system +is beginning to sympathize and grow irritable, the pulse grows quicker and +smaller, and the stomach rejects its contents. Although vomiting as well +as syncope are symptoms which we cannot safely wait for, they are +nevertheless means which nature adopts to relieve herself from the +impending danger: by syncope she not only produces greater dilatability of +the os uteri, but also, by causing a temporary cessation of the heart's +action, she favours the coagulation of blood, and thus checks the +discharge; whereas, by the involuntary effort of muscles which she excites +by the action of vomiting, the ovum is more speedily separated and +expelled. + +Where it becomes evident that expulsion cannot be prevented, it is our +duty to promote this process before nature has had recourse to the means +just mentioned. The ergot of rye is here a valuable remedy, for by +inducing or increasing the contractions of the uterus we shorten the +process and diminish the danger: the powder given in cold water is +decidedly the best form in which it can be given; in infusion its powers +seem to be injured by the heat of the water, and in tincture by the action +of the spirit: the addition of about half its quantity of borax renders +its action more powerful and certain. Borax has been long considered in +Germany to possess a specific power in exciting uterine contraction, but +it was first recommended for that purpose in this country by Dr. Copland. +(_Dict. Pract. Med._ art ABORTION.) A scruple or half a drachm of ergot +powder with ten grains of borax may be given in cinnamon water, and this +repeated every hour for several times. + +In all cases threatening premature expulsion, wherever there has been much +pain and discharge, the napkins which come from the patient should be +carefully examined by her medical attendant, for otherwise the ovum may +escape among the coagula and not be perceived. Where the separation is +nearly complete, a portion of it protrudes at the os uteri; and this we +can sometimes hook down with one or two fingers, and bring away: a still +better mode is recommended by Levret, viz. of throwing up a pretty +powerful stream of warm water by means of a syringe. Dr. Dewees has +recommended a wire crotchet, which he has used with very good effect. +(_Op. cit._ § 1011.)[64] We ought not, however, to be in a hurry to bring +away the ovum, for when the uterine contractions have been of sufficient +strength to dilate the os uteri, it will generally come away of itself. +One objection to the wire crotchet is, that it tears the membranes, and +lets out the liquor amnii, and perhaps the embryo.[65] This is by all +means to be avoided; the larger the body which is to be expelled, the more +powerfully and effectually does the uterus contract upon it: hence, +therefore, if the membranes of a three or four months' ovum be imprudently +pierced with a view of hastening the expulsion, the liquor amnii and +embryo escape, but the secundines remain and require protracted efforts of +the uterus to expel them, during which time the sufferings of the patient +are prolonged, and the hæmorrhage kept up; whereas, if the ovum had +remained whole, it would have been expelled more easily and quickly. On +the other hand, where the foetus has already attained a considerable size +(fifth month,) the plan recommended by Puzos of rupturing the membranes is +very desirable; by this means the size of the uterus is reduced by the +escape of liquor amnii, and thus the hæmorrhage checked; and the foetus +remaining in the uterus is of sufficient weight and bulk to excite +contractions to expel itself and the membranes. + +The treatment after abortion varies considerably: in many cases it will be +merely necessary for the patient to remain in bed for a few days +afterwards; but where she has been much reduced, a mild course of tonics +will be necessary, in order to prevent that disposition to leucorrhoea and +menstrual derangement which is so common a result: this, where it is +possible, should be combined with removal into the country, or to the +sea-side, or, what is still better to a watering place, where there are +mineral springs of chalybeate character. For the treatment of anæmia we +must refer our readers to the chapter on HÆMORRHAGE. + + + + +PART III. + +EUTOCIA, OR NATURAL PARTURITION. + + + + +CHAPTER I. + +STAGES OF LABOUR. + + _Preparatory stage.--Precursory symptoms.--First contractions.--Action + of the pains.--Auscultation during the pains.--Effect of the pains + upon the pulse.--Symptoms to be observed during and between the + pains.--Character of a true pain.--Formation of the bag of liquor + amnii.--Rigour at the end of the first stage.--Show.--Duration of the + first stage.--Description of the second stage.--Straining pains.-- + Dilatation of the perineum.--Expulsion of the child.--Third stage.-- + Expulsion of the placenta.--Twins._ + + +Parturition may be divided into two great orders, _Eutocia_ and +_Dystocia_, the one signifying natural labour which follows a favourable +course both for the mother and her child; the other signifying faulty or +irregular labour, the course of which is unfavourable. + +We may define eutocia to be the safe expulsion of the mature foetus and +its secundines by the natural powers destined for that purpose. No +function exhibits such infinite varieties, within the limits of health and +safety to the mother and her offspring, as that of parturition; no two +labours, even in the same individual are exactly alike; still, however, +the great objects of the process will be the same, viz. 1st. the +preparation of the passages and the foetus for its expulsion; 2dly, the +expulsion of the foetus; and 3dly, the expulsion of the placenta and +membranes. + +That we may form a clearer and more comprehensive view of this process, +labour has usually been divided into stages or periods, marked by the +changes just now alluded to: hence it is generally said to consist of +three stages; the first, or preparatory stage, commencing with the first +perceptible contractions of the uterus, and terminating in the full +dilatation of the os uteri; the second, or stage of expulsion, terminating +with the birth of the child; and the third, consisting of the expulsion of +the placenta. + +_Preparatory stage._--_Precursory symptoms._ For some time before the +commencement of actual labour, a variety of changes are taking place which +must be looked upon as the precursors of this process: during the last +weeks of pregnancy, nature appears, as it were, to be preparing for the +great change which is at hand, and to be making such arrangements as shall +enable it to be completed with the least possible danger both for the +mother and her child. + +One of the earliest warnings which we have of approaching labour is an +alteration in the form of the abdominal tumour; the cervix uteri has by +this time (especially in primiparæ) entirely disappeared; the presenting +part of the child has therefore descended to the lowest part of the +uterus; the fundus has sunk lower and more forwards; and from the +diaphragm being enabled to act with greater freedom, the respiration is +performed with more ease and comfort to the patient; she therefore feels +more capable of moving about, and is in better health and spirits than for +some time previously. Upon examination per vaginam, the head will be found +deep in the cavity of the pelvis, covered by the lower and anterior +segment of the uterus; the os uteri is still closed, and situated in the +upper part of the hollow of the sacrum, forming merely a small circular +depression. In women who have already had children, a portion of the +cervix uteri is still remaining; it is thick and bulky; and in some cases, +where the uterus has been greatly distended in several successive +pregnancies, it is nearly as long as in the unimpregnated state; the os +tincæ or os uteri externum is open, its edge irregular from former +labours; the upper extremity of the canal of the cervix is contracted, and +forms the os uteri internum; it has been closed during the greater part of +pregnancy, but usually is now sufficiently open to admit the finger; the +os uteri is neither so high up nor so far backwards in the pelvis as in +primiparæ, and is reached with greater ease; whereas, the head of the +child, instead of being felt in the cavity of the pelvis, generally +remains at the brim until labour is more advanced. + +_First contractions._ The first contractions of the uterus (in a state of +health) are so slight as scarcely to be noticed by the patient: they +create a sensation of equable pressure and general tightness round the +abdomen, and during the contraction the uterus feels somewhat firmer, but +they are neither attended with pain, nor do they appear at first to have +any effect upon the os uteri; these precursory contractions generally come +on a day or two before actual labour commences, and sometimes are felt at +intervals for one or two weeks. Where the uterus has been exposed to any +source of irritation, and especially where there is a disposition to +rheumatic affection of this organ, they may produce much suffering and +give rise to one form of what are called _false pains_, hereafter to be +described. "The first contractions, says M. Leroux (_Sur les Pertes de +Sang_, § 41.,) are feeble, and communicate no sensation to the patient; in +order to discover them we must hold our hand upon the abdomen, and if we +feel the globe of the uterus raise itself and become hard, this is a true +contraction. These contractions gradually increase until they excite pain: +but pain is not essential to a contraction; it depends on the distension +and compression of the nerves produced by the resistance of the body upon +which the uterus acts, and increases in severity in proportion to the +degree of resistance and contraction." + +In proportion as the lower part of the uterus descends into the cavity of +the pelvis, so does it exert a degree of pressure on the neighbouring +parts; the capacity of the bladder and rectum is diminished; and being +therefore unable to contain the usual quantity of urine and fæces, and +being probably rendered more irritable by the pressure above-mentioned, +the patient experiences frequent calls to pass water and evacuate the +bowels, which is sometimes effected with considerable difficulty: in some +instances she is obliged to lean forward, or support the abdomen, in order +to take the weight of the child off the neck of the bladder before she can +empty it: the same cause occasionally requires the use of the catheter, +and sometimes renders the introduction of it a matter of considerable +difficulty. + +As these various changes make their appearance, the patient becomes +restless and anxious; she cannot remain long in the same posture; the +slight precursory contractions which have been just described, are +becoming stronger, and begin to produce a sensation of pain; the os uteri +(in primiparæ) opens somewhat, its edge at first is exceedingly thin, and +feels almost membranous; by degrees however it swells, grows thick and +cushiony, and is now more dilatable. + +_Action of the pains._ The os uteri does not dilate merely by the +mechanical stretching which the pressure of the membranes and presenting +part exert upon it; it dilates in consequence of its circular fibres being +no longer able to maintain that state of contraction which they had +preserved during pregnancy; they are overpowered by the longitudinal +fibres of the uterus, which, by their contractions, pull open the os uteri +equally in every direction. + +The vagina also swells and grows more cushiony, and this is followed by a +copious secretion of colourless and nearly inodorous mucus. "The more +albuminous it is the better, and it is always a good sign when lumps of +albuminous matter come away from time to time; the thicker, softer, and +more cushiony the os uteri is, the more mucus does it secrete." (Wigand, +_Geburt des Menschen_, vol. ii. p. 292.) The thin hard os uteri does not +dilate, its fibres are all in close contact, and like a well-twisted cord +will not yield; whereas, when they are separated from each other by the +swelling of the os uteri, they easily yield to the dilating force which is +applied to them. Besides serving the purpose of lubricating the passage, +the secretion of mucus is of great importance as a topical depletion, for, +by thus unloading the congested vessels, they diminish the vascularity and +heat of the part, and render it more capable of dilatation. "If, on the +other hand, the entrance of the vagina is small, the neighbouring parts +cool, dry, inelastic, and as if tightly stretched over the bones; if the +finger, in spite of being well oiled and carefully introduced, produces +pain upon the gentlest attempt to examine, we may expect a tedious and +difficult labour." (_Op. cit._ p. 190.) + +The patient is now no longer able to conceal her pains when they come on. +If she be in the act of conversing she stops short, and remains silent +until the severity of the pain is over; if she be walking about her room +she is obliged to stand still for the time, and rest against or hold by +something until the pain has gone off. The true labour pains are situated +in the back and loins; they come on at regular intervals, rise gradually +up to a certain pitch of intensity, and abate as gradually; it is a dull, +heavy, deep sort of pain, producing occasionally a low moan from the +patient: not sharp or twinging, which would elicit a very different +expression of suffering from her. + +_Auscultation during the pains._ "If we direct our attention to the +changes of tone which the uterine pulsations present during auscultation, +we shall find them generally stronger, more distinct and varied in tone +during labour; and this is especially the case just before a pain comes +on. Even if the patient wished to conceal her pains, this phenomenon, and +more especially the rapidity of the beats, would enable us to ascertain +the truth. The moment a pain begins, and even before the patient herself +is aware of it, we hear a sudden short rushing sound, which appears to +proceed from the liquor amnii, and to be partly produced by the movement +of the child, which seems to anticipate the coming on of the contraction: +nearly at the same moment all the tones of the uterine pulsations become +stronger; other tones, which have not been heard before, and which are of +a piping resonant character, now become audible, and seem to vibrate +through the stethoscope, like the sound of a string which has been struck +and drawn tighter while in the act of vibrating. The whole tone of the +uterine circulation rises in point of pitch. Shortly after this, viz. as +the pain becomes stronger and more general, the uterine sound seems as it +were to become more and more distant, until at length it becomes very +dull, or altogether inaudible. But as soon as the pain has reached its +height and gradually declines, the sound is again heard as full as at the +beginning of the pain, and resumes its former tone, which in the intervals +between the pains is as it was during pregnancy, except somewhat louder. +This is the course of things if the pain be a true one, and attain its +full intensity: where the pains are false or irregular it is very +different; the uterine sound either remains unaltered, or increases only +for an instant, or its seeming increase of distance, as above mentioned, +is not observed." (_Die Geburtshülfliche Exploration_, von Dr. A. T. Hohl, +erster theil, s. 105.) + +_Effect of the pains upon the pulse._ It is curious to observe the effect +which a regular pain has upon the rapidity of the mother's pulse; as the +former comes on and goes off, so does the other increase or diminish. "The +increasing rapidity of the pulse announces the commencement of the pain; +it rises and attains its _summum_ with it; and as the pain subsides so +does the pulse gradually resume the rate which it had during the +intervals; a similar ebb and flow may be heard in the uterine souffle. The +more regular the pain is, and the more distinctly it rises to its full +extent, the more marked, regular, and distinct, is this change in it. We +may also invert the order of things, and say, the more distinctly the +rapidity of the pulse comes on and announces the pain, the more regularly +it rises and attains a certain height, which it maintains, and then +gradually subsides; in like proportion will the pain be more perfect, +attain its full extent more completely, and act more efficaciously upon +the regular progress of the labour. Where however the rapidity of the +beats subsides before it had scarcely begun to increase, the pain is too +weak; or where the rapidity rises by sudden starts, the pain is a hurried +one; and in either case its effect will be imperfect." (Hohl, _op. cit._ +vol. i. p. 108.) In order that we may ascertain these changes correctly, +we ought to note the rapidity of the pulse during each successive quarter +of a minute as directed by M. Hohl; thus, in a pain which lasts two +minutes, the increase and diminution in the rapidity of the pulse may be +as follows, 18. 18. 20. 22.; 24. 24. 22. 18. As labour advances it +increases, so that shortly before the birth of the child we shall find +that what was the rate of the pulse during the height of the pains at the +beginning is now the rate of it during the intervals. + +_Symptoms to be observed during and between the pains._ When a pain comes +on, the uterus grows hard and tense; if the fundus be somewhat to one +side, as is not unfrequently the case, it now gradually moves, so that the +median line of the uterus corresponds with that of the patient's body; the +various prominences of the child are no longer to be felt, the whole is +now firm and unyielding; the os uteri is put tightly upon the stretch, the +membranes which were loose become tense and are firmly pressed against it, +and the presenting part is rendered indistinct: as the pain gradually +subsides, the uterus becomes softer, and yields to the pressure of the +hand; the different parts of the child which project, as also its +movements, can now be felt more distinctly; the patient is free from pain, +and feels herself in an agreeable state of tranquillity, which is +frequently attended by a short refreshing doze; the os uteri, which has +become somewhat more dilated during the last pain, is now soft and loose, +so that we can hook the finger into it and move it about; the tight +bladder of membranes becomes relaxed and flaccid, and retracts more or +less into the uterus, so that we shall now be able to introduce the finger +into the os uteri and feel the presenting part through the membranes; +while the presenting part of the child, which during the pain was fixed, +can be moved somewhat by the finger. + +_Characters of a true pain._ In examining the course of a true pain we +shall find that the contractions of the uterus do not begin in the fundus, +but in the os uteri, and pass from the one to the other. (Wigand, _op. +cit._ vol. ii. p. 197.) Every pain which commences in the fundus is +abnormal, and either arises from some derangement in the uterine action, +or is sympathetic with some irritation not immediately connected with the +uterus, as from colic, constipation, &c. We very seldom find that a +contraction of the uterus, which has commenced in the fundus, passes into +the cervix and os uteri, and becomes a genuine effective pain; usually +speaking, the contraction is confined to the circumference of the fundus, +without detruding the foetus at all. When a genuine pain comes on, so far +from the head being pressed against the os uteri, it at first rises +upwards, and sometimes gets even out of reach of the finger, whilst the os +uteri itself is filled with the bladder of membranes: if it had commenced +in the fundus instead of the inferior segment of the uterus, so far from +the head being drawn up at the first coming on of the pain, it would have +been forcibly pushed down against the os uteri. In the course of a few +seconds the contraction gradually spreads over the whole uterus, and is +felt especially in the fundus; the head which had been raised somewhat +from the os uteri is now again pushed downwards to it, and seems to act as +a wedge for the purpose of dilating it; it is not until the whole uterus +is beginning to contract that the patient has a sensation of pain. We may, +therefore, consider that a genuine uterine contraction consists of certain +phenomena which occur in the following order: first, the os uteri grows +tight, and the presenting part rises somewhat from it; then the rest of +the uterus, especially the fundus, becoming hard, the patient has a +sensation of pain, and the presenting part of the child advances. The +period of time necessary for all these changes varies not only in +different individuals, but in the same individual in different labours, +and in different stages of the same labour. + +"The more completely the os uteri is opposite the fundus, and the more +the axis of the uterus corresponds with that of the pelvis, the sooner are +the pains, _cæteris paribus_, capable of dilating the os uteri." +(_Wigand_, vol. ii. p. 273.) The cushiony state of the vagina and os +uteri, and the free secretion of thick albuminous mucus from these parts, +as already mentioned, will be of great importance in ensuring their easy +dilatation. Where this secretion is either absent, or very scanty, the +passages become dry, hot, and tender, from no relief being afforded to the +congested vessels by its effusion; and _vice versâ_, where there is a +febrile state of the circulation and considerable topical excitement, the +secretion is sparing, or, perhaps, stops entirely. This state may arise +from a variety of causes, such as from general plethora, too warm +clothing, bad ventilation, derangement and irritation of the primæ viæ, +and abuse of spirituous and other stimulating liquors: it may arise from +constipation, or may be induced by rough and too frequent examination. The +patient becomes flushed, excited, and feverish, with a hot skin, dry +tongue, thirst, and headach; the uterine contractions become irregular, +they produce much suffering, and but very little advance in the progress +of the labour; the passages are in a state of inflammation, and more +especially the os uteri, which is much swollen and excessively tender. The +process of labour is completely interrupted, and can only be restored to a +healthy condition by bleeding, warm bath, laxatives, and enemata. + +_Formation of the bag of the liquor amnii._ When the os uteri has dilated +more or less, a quantity of liquor amnii begins to collect between the +head and the membranes, so that when a pain comes on they form a tense, +elastic, and conical bag, which presses firmly against the os uteri, and +protrudes through it into the vagina, and from its form and elastic nature +greatly facilitates the speedy dilatation of it. If the edge of the os +uteri be still thin, it will become so tense during the pain, and the bag +of membranes will press so firmly against it, that we shall have some +difficulty for the moment in distinguishing the one from the other. As the +labour advances, the intervals between the pains become shorter, whereas +the pains themselves are of longer duration and more effective. In this +way pain succeeds pain until the os uteri, at length, attains its full +degree of dilatation; if the membranes have not yet ruptured, we may now +expect them to burst with every succeeding pain. + +_Rigour at the end of the first stage._ At this moment the patient is +occasionally seized with a sudden and violent fit of shivering, so much so +as to make the teeth chatter, and even communicate a tremulous motion to +the bed itself; this is not the result of cold, nor is it relieved by the +application of external warmth; and, in many cases, the patient will +express her surprise that she should shiver thus violently, and yet not +feel cold. It appears to be a modification of convulsive action, excited +by sympathy between the os uteri on its becoming fully dilated, and +certain muscles in other parts of the body. + +_Show._ On examination at this stage of the process, streaks of blood will +be found in the mucus which soils the finger, and sometimes it amounts to +a slight discharge of blood: this appearance is called by midwives "_a +show_," as it usually indicates that the os uteri is nearly or fully +dilated. It is produced by a separation of the membranes from the vicinity +of the os uteri, and consequent rupture of any little vascular twigs which +may have passed from the uterus to them. + +The full dilatation of the os uteri terminates the _first stage_ of +labour. During this stage, the action of the pains does not appear to have +been so much for the expulsion of the child, as for preparing it as well +as the passages for this purpose, viz. by so arranging and regulating the +different forces of the uterus, and at the same time by giving the child +such a position (_i. e._ with its long axis parallel to that of the +uterus,) and the os uteri such a degree of dilatation, as shall ensure its +expulsion with the greatest possible ease and safety. + +_Duration of the first stage._ The duration of the first stage of labour +varies exceedingly, both in primiparæ and those who have had several +children; nor is it at all easy to determine with precision the exact +moment when labour commences. The sensation of pain to the patient is no +guide whatever, for what is attended with much suffering in one patient is +scarcely sufficient to excite the notice of another. The dilatation of the +os uteri as marking its commencement, must also be taken with some +caution: in primiparæ, where it generally remains closed until the +contractions are becoming painful, it would obviously be wrong to date the +commencement of labour from the moment that the os uteri opens, as regular +uterine contractions have been evidently present for some hours +previously, although not of sufficient force to produce actual pain. On +the other hand, in women who have already had several children, the os +uteri is found open some days and even weeks before labour comes on. As a +general rule, we may state that regular and genuine contractions of the +uterus, sufficiently powerful to produce pain, seldom require more than +six hours to effect the full dilatation of the os uteri; in many cases a +much shorter time will be sufficient; whereas, in others, the first stage +of labour may last for more than quadruple this period before it is +completed: in neither can it be considered as abnormal; and we usually +find that where the pains of the first stage have been slow and lingering, +they become remarkably quick and active during the second stage. This +agrees with the experience of Dr. Churchill, in his report of the Western +Lying-in Hospital at Dublin, viz. that, "no evil consequences resulted, +and they (the labours where the first stage was so protracted) were +amongst those in whom the remaining stages of labour were shortest." + +The first stage terminates with the full dilatation of the os uteri; the +rupture of the membranes is a change which is necessarily more or less +uncertain, as to the precise period of labour at which it takes place. +Thus, in primiparæ, it frequently occurs before the first stage is +completed; whereas in other cases the membranes sometimes do not give way +until the head approaches or has even passed through the os externum; +generally speaking, however, they burst at this period of the labour, and +usually effect a remarkable change in the whole process. The pains are now +of longer duration and more powerful, the intervals between them are +shorter, and yet, although the suffering is actually more severe, it is +more tolerable to the patient than that of the first stage. During the +first stage they are chiefly confined to one spot in the loins; and as +they must necessarily continue for some hours without any distinct +evidence of the labour being advanced by them, the patient feels +discouraged and gets a little impatient at the endurance of so much +apparently useless suffering: but as soon as the gush of liquor amnii +takes place, she feels that a great alteration has been produced; the +abdomen becomes smaller: the pains assume a very different character, and +every thing combines to assure her that she has made progress, and +encourages her to patience and resolution. + +_Description of second stage._ The os uteri has now disappeared entirely, +so that the vagina and uterus form one continuous canal, and is thus +admirably adapted for the easy passage of the head: the anterior lip, +however, dilates much more slowly than the other parts of it, and this is +especially the case in primiparæ, for, being pressed between the head and +pelvis it becomes oedematous, and swells to a considerable size: if the +pains be strong, it is pushed down more or less before the head, and may +be frequently felt beneath the symphysis pubis, and occasionally it is +detruded so far as to be visible between the labia. According to Wigand, +the swelling of the anterior lip sometimes attains such a size as makes it +liable to be mistaken for the bladder of the membranes (_op. cit._ vol. +ii. p. 308;) it seldom produces much obstacle to the advance of the head, +and with a little patience gradually disappears of itself. All attempts to +push it up above the head are objectionable, because, in the first place, +the finger cannot reach sufficiently high to effect this object, and +therefore the swelling descends again to its former situation; and, +secondly, the efforts to push it up only tend to inflame it and increase +the swelling. Those who imagine that they can push up the anterior lip of +the os uteri above the head deceive themselves; and even if they do +succeed, it merely shows that had they let it alone, it would have gone up +very shortly of itself. + +_Straining pains._ As the head enters the vagina, not only do the +contractions of the uterus become much more powerful, but now another set +of forces are called into action, and the half involuntary efforts of the +abdominal and other muscles come to aid the uterus in expelling its +contents. The sole object of this stage is the expulsion of the child, and +even the vagina by its contractions contributes to effect it. The head is +therefore subjected to considerable pressure; hence we may now feel the +cranial bones overlapping each other at the sutures, and the fontanelles +diminished in size; and, from the tightness with which the head is +embraced by the vagina, the circulation in the scalp is more or less +impeded, and a large oedematous swelling, called _caput succedaneum_, +forms on that part of the head which presents. + +Each pain is attended with a violent and irresistible impulse to bear +down, and every muscle which can assist in effecting this object is now +brought into play. The tone of the patient's voice, the expression of her +face, the hurried breathing and sudden inspiration, stopping short the +moment a pain comes on, in order that she may add still greater power to +the efforts which she is about to make, all betoken a very different +process to that of the first stage, and one which requires a powerful +struggle of muscular strength and energy for its completion. Hence it is +that the sound of the patient's voice during the pain is frequently of +itself sufficient to inform us how far labour is advanced, for "we never +see the really powerful straining pains come on (the head may be never so +low in the pelvis,) so long as the os uteri is not fully dilated." +(Wigand, _op. cit._ vol. ii. p. 310.) This is a wise provision of Nature, +for by this means it prevents the danger of laceration to which the os +uteri would be otherwise exposed, and shows the importance of not +permitting a patient to strain and bear down until the os uteri be fully +dilated. In those cases where a patient has been induced to exert herself +prematurely, the efforts being voluntary are never so powerful, and soon +produce much fatigue. + +Several reasons have been assigned why the straining pains should come on +at this stage. It cannot be owing to the pressure of the head upon the +parts of the pelvis, as has been supposed and especially the rectum, thus +producing the sensation of a violent desire to evacuate the bowels, +because, in almost every case of first labour, the head for several days +before the actual commencement of labour is sufficiently deep in the +pelvis to produce these effects. It evidently arises from a sympathetic +connexion "between the os uteri and vagina on the one hand, and the +abdominal and other muscles on the other. We see this connexion most +distinctly in those difficult labours where the head is pushed down deeply +in the pelvis even to the very outlet, and where the os uteri which is but +little dilated is protruded before it. In such cases we never see the +really powerful and continued action of the abdominal muscles excited, +let the head press never so forcibly upon the rectum; but as soon as the +os uteri (perhaps after much suffering) has retracted over the head, the +whole auxiliary action of the abdominal muscles commences." (_Ibid._ vol. +ii. p. 467.) + +There is the same relation between these muscles and the vagina, as there +is between them and the rectum: the moment the vagina becomes distended, +it begins to contract upon the distending body, and like the rectum +excites them to strong and involuntary action. The tenesmus of dysentery +is a sympathetic action of the same nature; the rectum is highly irritated +by the acrid nature of its contents, and excites an irresistible +disposition to bear down. The patient wishes for the next pain and yet she +dreads it, from the suffering it creates, and the tremendous effort which +it compels her to make; the pulse is quicker, and is not only so during +the intervals, but undergoes a greater increase of rapidity during the +pains themselves than in the first stage; the face becomes red, swollen, +and bathed in perspiration; the breath is hurried; the lips are apart; the +eyes are wild; every thing betokens a state of the highest excitement. +When a pain comes on, she catches hold of whatever she can reach, plants +her feet upon any thing which is firm, and, by thus fixing her +extremities, she is enabled to bear down with greater power and effect. +During the struggle the face often changes its expression surprisingly, so +much so, that even her own attendants would scarcely recognise her. + +_Dilatation of the perineum._ As pain succeeds pain, gradually increasing +both in force as well as duration, the head descends along the vagina, and +begins to press against the perineum; the rectum becomes flattened; the +sphincter ani dilated, and therefore any fæcal matter which may have been +lodging there is unavoidably expelled; the anterior wall of the rectum is +pressed close against the anus, and where the pressure is very great, even +protrudes somewhat through it; the hæmorrhoidal veins are frequently much +distended, and form a roll of cushiony swelling around the anus. A small +quantity of liquor amnii dribbles away from time to time, but is neither +during a pain, nor during the absence of a pain, for in the former case +the pressure of the head acts as a plug and prevents its escape, and in +the latter there is no uterine contraction present to expel it: the liquor +amnii dribbles away only at the moment when a pain is coming on or going +off. + +_Expulsion of the child._ As the head descends farther it begins to press +more powerfully on the perineum, and during each pain pushes it out like a +large ball; and then, as a contraction goes off, and the resiliency of the +soft parts regain their superiority, it retires again. The breadth of the +perineum (viz. from the anus to the vulva) increases, whilst it diminishes +considerably in thickness, especially towards its anterior margin. Whilst +passing through the inferior aperture or outlet of the pelvis, the head +advances more or less forwards under the pubic arch, and begins to distend +the os externum; during a pain it separates the labia, and protrudes +between them, and again retires as the pain goes off; a larger and larger +portion of the head gradually forces itself through the os externum as +this dilates; the perineum becomes still thinner, so that at length it is +scarcely thicker than parchment. When more of the head has passed through, +it does not now recede when the pain goes off; the os externum and +perineum are at their greatest distension, for the largest diameter of the +head, which is presented to the os externum is now encircled by it; the +next pain brings the head into the world. + +This is the moment of greatest pain, and the patient is frequently quite +wild and frantic with suffering; it approaches to a species of insanity, +and shows itself in the most quiet and gentle dispositions. The laws in +Germany have made great allowances for any act of violence committed +during these moments of phrenzy, and wisely and mercifully consider that +the patient at the time was labouring under a species of temporary +insanity. Even the act of child-murder, when satisfactorily proved to have +taken place at this moment, is treated with considerable leniency. This +state of mind is sometimes manifested in a slighter degree by actions and +words so contrary to the general habit and nature of the patient, as to +prove that she could not have been under the proper control of her reason +at the moment. It is a question how far this state of mind may arise from +intense suffering, or how far the circulation of the brain may be affected +by the pressure which is exerted upon the abdominal viscera. + +A short cessation of pain succeeds the birth of the head. The violent +distension of the os externum has ceased for a time, and the patient feels +comparatively easy; but in the course of a few minutes the pains return as +before, although not quite so severe: first, the shoulder, which is turned +forwards, passes under the pubic arch, followed by the other which sweeps +over the perineum. The rest of the child is expelled with comparative +ease, and as soon as its pelvis has passed through the os externum, a gush +of the remaining liquor amnii, which had been retained in the upper +portions of the uterus, follows; the whole abdomen instantly sinks and +becomes flaccid, while the uterus contracts into a firm globe upon the +placenta, which is shortly to be expelled. A most delightful and perfect +calm succeeds, and the sense of freedom from suffering, and joy for the +termination of her trial, are expressed in the liveliest terms of +gratitude. + +_Third stage._--_Expulsion of the placenta._ The period between the birth +of the child and expulsion of the placenta varies considerably. Sometimes +it follows the child very rapidly, so that, apparently, they are both +expelled by the same effort of uterine action; at others, the interval is +more considerable. There is generally an interval of ten or fifteen +minutes, and then pains of a totally different character make their +appearance: these are supposed to denote the separation of the placenta +from the uterus, and, from their being usually attended with discharge of +more or less blood, have been termed _dolores cruenti_ by many of the +foreign writers. The expulsion of the placenta is attended with little or +no suffering; it descends into the vagina inverted, _i. e._ with its +foetal or amniotic surface turned outwards: whether or not this is +produced by pulling at the cord is perhaps a question. + +_Twins._ If there be twins, the placenta of the first child is seldom +expelled until after the birth of the second child. The membranes of the +second ovum become distended with liquor amnii, project into the vagina +and burst as in a common single labour; the passages have been +sufficiently dilated and prepared by the birth of the first child, so +that, when the uterus begins to contract, the expulsion of the second will +be readily and easily effected. The uterus may resume its efforts for this +purpose in twenty minutes after the birth of the first child, or it may +remain quiescent for several hours without at all disturbing the regular +and natural course of the process which will be precisely the same as in +the previous case. + +The placentæ of twins are usually expelled together, forming one large +placentary mass; their vessels, however, are distinct from each other, so +that with care one placenta can be peeled away from the other. In other +cases, they are separated from each other by an intervening space of +membranes; and in one rare instance of triplet placentæ the umbilical +arteries of two placentæ anastomosed with each other, before dividing into +smaller branches. + +Upon the expulsion of the placenta, the uterus, being now emptied of its +contents, contracts into a firm hard ball, which may be felt behind the +symphysis pubes, or sometimes a little to one side, of about the size of a +full grown foetal head. This state of hard contraction gradually +disappears, and a discharge of blood called lochia follows, which having +continued for a few days becomes colourless, and at length ceases +altogether. For a description of the changes which the uterus and passages +undergo in returning to their former condition as in the unimpregnated +state, we refer to the chapter on the FEMALE ORGANS OF GENERATION. + + + + +CHAPTER II. + +TREATMENT OF NATURAL LABOUR. + + _State of the bowels.--Form and size of the uterus.--True and spurious + pains.--Treatment of spurious pains.--Management of the first stage.-- + Examination.--Position of patient during labour.--Prognosis as to the + duration of labour.--Diet during labour.--Supporting the perineum.-- + Treatment of perineal laceration.--Cord round the child's neck.--Birth + of the child, and ligature of the cord.--Importance of ascertaining + that the uterus is contracted after labour.--Management of the + placenta.--Twins.--Treatment after labour.--Lactation.--Milk-fever and + abscess.--Excoriated nipples.--Diet during lactation.--Management of + lochia.--After-pains._ + + +This is a subject of great extent as well as importance, because it +comprehends the whole mass of rules for the management of a woman, not +only just previous to and during, but also after, her confinement. On +nothing does the course of a natural labour depend so much, as upon the +careful removal of every source of irritation which may tend in any way to +derange or interrupt the regular progress of that series of changes or +phenomena which constitutes the great process of normal parturition. It +will be necessary that the reader should have made himself thoroughly +master of the subjects discussed in the last chapter, before commencing +those of the present one. With each change there mentioned, the state of +the system and its functions should be carefully watched, and every slight +deviation from the natural course of things checked by appropriate +dietetic or medical treatment. Hence, therefore, the more a woman can +follow her usual avocations, and take that degree of exercise to which she +has been accustomed at other times, the better; for by so doing the +circulation is equalized, the digestion is kept in full activity, and the +tone and general strength of the system maintained. + +It would almost seem, by rendering a woman more capable of moving about +during the last weeks of pregnancy (which has already been shown to be +produced by the sinking of the fundus, enabling the respiration to act +more freely,) that Nature intended she should use exercise at this period, +and thus prepare her, by increased health and strength, for a process +which requires so much suffering and exertion. + +Her hours should be regular and early, her meals light and moderate, and +by agreeable and cheerful occupation she should fit herself, both in body +and mind, to meet the coming trial. + +_State of the bowels._ Attention to the state of the bowels is of first +importance, and must never be neglected. It is a subject nevertheless upon +which women are remarkably careless, and they will frequently, when not +attended to, allow labour to come on with their bowels in a very loaded +and highly improper condition. + +There is, perhaps, no one circumstance which is found to exert such a +prejudicial influence on the course of a natural labour, in so many +different ways, as deranged and constipated bowels. Where the contents are +of an unhealthy character, the irritation which they produce in the +intestinal canal is quickly transmitted to the uterus, and tends not a +little to pervert and derange the due and healthy action of this organ: +hence arises one of the most fertile sources of spurious pains, a subject +which will shortly come under our consideration. Where the bowels are +loaded, in consequence of the pressure upon the ascending cava, +considerable obstruction to the free return of blood from the pelvic +viscera is produced, the vessels of which become considerably engorged. No +organ feels these effects more than the uterus: from the immensely dilated +condition of its veins, a state of local plethora is engendered, which, +from the congested state of the uterine parietes, considerably interferes +with the free and regular action of its fibres, and not unfrequently +predisposes to hæmorrhage. + +Moreover, the rectum being distended with fæces, diminishes proportionally +the capacity of the pelvis, and prevents the ready descent of the head +into it; occasionally it forms, at the beginning of labour, a solid +cylinder of indurated fæces, so hard, as, at the first touch, almost to +induce the suspicion of a projecting sacrum. As a measure of common +cleanliness, the bowels ought always to be attended to before labour, for, +besides the more serious effects now enumerated, the labour may be +rendered exceedingly filthy for the patient, and not less disgusting for +the practitioner; for, as the sphincter ani loses all power of contraction +when the head advances deeper into the pelvis, it follows that whatever +fæcal matter may have been lodging in the rectum will now be unconsciously +pressed out. + +Hence, therefore, for the last few days of pregnancy, the bowels should be +regularly opened (unless they are so spontaneously, which is seldom the +case) by castor oil or other mild laxatives: and if labour has already +commenced before this measure has been taken, and if, therefore, there is +not sufficient time for the operation of the medicine, an enema should be +given.[66] In Germany it is a rule to throw up some chamomile infusion at +the commencement of every labour, by which means the process is rendered +more cleanly than is frequently the case in this country; and also, for +the reasons already given, the early stage is less apt to be tedious from +spurious and ineffective pains. + +_Form and size of the uterus._ The more regular the first precursory pains +are, the more symmetrical and uniform will be the shape of the uterus; and +again, on the other hand, the more uniform its shape, the more regularly +and effectively will it act. + +It is these slight but early contractions, which, although they produce +little or no effect upon the os uteri, exert a very important influence +over the first half of labour; for it is by their action, in great +measure, that the form of the uterus is determined, as also the correct +position of the child. Hence, therefore, some practitioners lay +considerable stress on ascertaining the precise form of the abdomen as a +means of determining what sort of labour the patient will have. + +In a woman pregnant for the first time, and in a state of perfect health, +the uterus is of an oval or rather elliptical form at the beginning of +labour: when seen in profile, the abdomen presents nearly a uniform degree +of convexity. In this state the child lies with its long axis parallel to +that of the uterus, that is, with its head or inferior extremity turned +towards the brim of the pelvis; and if the fundus has already sunk in the +manner above-mentioned, the practitioner may very confidently +prognosticate that the head presents, even before making an examination +per vaginam. + +In a perfectly healthy primipara there is scarcely any inclination of the +uterus either to one side or forwards, its median line corresponding with +that of the abdomen: whereas, in the multipara, the axis of the uterus is +seldom straight, inclining more or less to one side, or, from the greater +relaxation of the abdominal parietes, being somewhat pendulous. The size +of the uterus should also be taken into consideration, especially in first +pregnancies; a large uterus shows that either its parietes are gorged with +too much blood, or that its cavity is distended with an unusual quantity +of liquor amnii, or that the child is very large, or that there are twins. +Whatever may be the cause of the distension, it interferes with the +regular and effective contractions of the uterus, and tends to make the +labour (at least the first part of it) tedious. A moderate sized uterus is +much more capable of active exertion, for its fibres not being put so much +upon the stretch are enabled to contract better. + +_True and false pains._ If the patient is already beginning to suffer +pains, it is of great importance to ascertain whether they be genuine or +spurious; upon the correct diagnosis of which, the favourable or +unfavourable course of the labour not unfrequently in great measure +depends. + +A genuine labour pain comes on at tolerably regular intervals, rises +gradually to a certain degree of intensity, remains at that point for a +few seconds, and then subsides as gradually; the body and the fundus of +the uterus increase in hardness, and the os uteri in tenseness, in +proportion as the pain rises, and vice versâ; the pain is seated in the +back and loins, and is of a dull aching character: but with the spurious +pains it is quite the reverse; they come on and go off suddenly and +irregularly, the pain is in the abdomen, and produces a sharp twinging +sensation, and the hardness of the uterus and tenseness of its mouth bear +no proportion to the pain. + +Spurious labour pains are the early contractions of the uterus perverted +and rendered irregular, spasmodic, and painful by irritation, congestion, +or inflammatory action; they sometimes come on several days before actual +labour commences, and if not recognised and removed, may expose the +patient to considerable suffering and exhaustion. Derangement of the +stomach and bowels is one of the most frequent causes of spurious pains, +for by the irritation which is thus produced, the uterus is almost sure to +sympathize, and to have its action more or less disordered. This may arise +from unhealthy irritating contents of the bowels producing spasmodic, +griping, and colicky pains, or from diarrhoea with tenesmus arising from +exposure to cold, or from irritation caused by the pressure of the gravid +womb. Spurious labour pains of this character also frequently occur in +patients who are accustomed to indulge in the luxuries of the table, or in +the lower classes, who are addicted to the use of spirituous liquors. +Constipation has been already mentioned as a cause of this condition. The +state of plethora, congestion, or inflammation, acting as a cause of +spurious pains, may arise from various sources: it is frequently observed +in strong healthy young women, especially those pregnant for the first +time; the pains do not assume the proper character of genuine labour +pains, and exhaust the patient by continued but useless suffering. The os +uteri probably dilates somewhat, but its edge remains thin and tense, and +the pains appear to have no effect in dilating it any farther. The mucous +secretion of the vagina is not of the character described at the beginning +of labour in the preceding chapter. The pulse is strong and more or less +excited, and the flushed face, and generally increased heat of skin +indicate the condition upon which those symptoms depend. The inflammatory +form of spurious labour pains is not unfrequently of the rheumatic +character, a condition which has not been much noticed in this country, +but which is capable of exerting a very considerable influence upon the +course and progress of the labour. It is usually produced by exposure to +cold and the other common causes of rheumatism in other parts of the body, +and is generally accompanied with more or less derangement of the stomach +and bowels. In this state each contraction of the uterine fibres is +attended with much suffering, although the contraction itself may be so +slight as to produce little or no effect upon the os uteri. Most of these +conditions, in a severe degree, form that species of dystocia which arises +from a faulty state of the expelling powers, for the farther consideration +of which we must refer to our chapter upon that subject. In a minor degree +they produce these slight derangements of uterine action, which we are now +considering under the name of _spurious pains_. + +_Treatment of spurious pains._ The indications of treatment depend in +great measure upon the cause; and we cannot impress it too strongly on the +young practitioner, as a rule never to be lost sight of, that, whatever is +wrong in the state of the circulation or of the bowels must be first +rectified before having recourse to opiates. Where the stomach is much +deranged at the beginning of labour, nature frequently induces spontaneous +vomiting, with considerable relief to the patient, and mitigation of the +pains; if not a gentle emetic may be administered. Where the bowels are +loaded, the treatment already mentioned must be put into practice, after +which [Symbol: minim] xx of Liquor Opii Sedativus and of antimonial wine +in peppermint water, or gr x of Dover's powder may be given. When there is +diarrhoea with a good deal of griping and tenesmus, a dose of castor oil +with Liquor Opii Sedativus in any aromatic water may be administered; and +if the labour be not yet commenced, gr v of Pil. Hydr. and Dover's powder +may be also given at night. If there be a plethoric or even inflammatory +condition, the lancet will be of the greatest service; it reduces the +temperature of the body, relaxes the soft parts, brings on copious +secretion of mucus, and by relieving the congested state of the uterine +parietes, enables the fibres to contract with more regularity and effect. +In the rheumatic form, laxatives followed by diaphoretics, the warm bath, +and even venesection will be necessary. + +By thus treating the spurious pains according to their cause, they will +usually subside readily enough, and be either followed immediately by +pains of a more genuine and effective character, or leave the patient +perfectly free for several hours, or perhaps even days. It is by +inattention to, or ignorance of, these conditions, that patients have been +allowed to remain for several days in suffering, during which they have +been treated as if they had been in natural labour, until at length they +have become so exhausted that, when labour really made its appearance, +they were incapable of undergoing the exertions which this process +demands. + +_Management of the first stage._ The preparatory pains of labour, which +form the first stage, do not require that the patient should take to her +bed at this early period; and this is especially the case in primiparæ, +where the first stage is usually somewhat tedious. Until nearly the end of +the first stage, she ought rather to be induced to suppose that actual +labour has scarcely yet commenced, and that she may still sit up or walk +about the room as best suits her feelings, taking care at the same time +that every thing is in readiness against the moment when it shall become +necessary for her to lie down. A nurse who understands her business will +of course duly arrange all these matters, but it behoves the accoucheur, +nevertheless, to pay attention to these little details, and to see that +every thing is properly prepared: that the bed is ready, and guarded +either by several folds of sheeting, or by a leather for the purpose, to +prevent the blood and other discharges during labour from soaking into the +bedding beneath; this must be done either on the right side or at the foot +of the bed, in order that the patient may be better within the reach of +the accoucheur: that the patient should be partially undressed, and +covered with her dressing-gown: that all the linen should be well aired: +that there should be towels, napkins, hot and cold water in readiness, and +also a bottle of vinegar, and one of spirit in the room, in case of +hemorrhage, suspended animation in the child, &c. &c. These and many other +arrangements of less importance are by no means beneath his attention, and +require but a moment's glance to assure him that every thing is properly +prepared. + +By encouraging the patient to sit up as long as she can, or even to move +about occasionally, the pains are rendered more tolerable as well as more +effective; the time passes more agreeably and quickly; and by the time +that it has become necessary for her to lie down, the labour has made so +much progress that the rest of its course seems to be much quicker than +was at first expected. On the contrary, where the practitioner at an early +period of the first stage, informs her that she must stay up no longer, +that she must go to bed and remain lying on her left side, her mind is +solely occupied with her pains, which become wearying and irksome; the +time passes heavily away; she becomes impatient and therefore dispirited; +and is much disappointed, that, after remaining in this state for some +time, the termination of the labour appears to be as far off as ever. +Nothing eases the pains of the first stage, or increases their effect, so +much as frequent change of position and moving about; when, however, they +are severe or of long continuance, and the patient becomes fatigued, she +will require rest, and this opportunity, afforded by her lying down, +should be seized for the purpose of making an examination. + +_Examination._ The manner in which this operation should be proposed to +the patient cannot be too delicate: it should, as Dr. Dewees has justly +observed, always if possible be done by means of a third person, such as +the nurse or any elderly female friend who happens to be present. If the +accoucheur has proposed it with that degree of gentleness and good feeling +which it ought to behove every one to show under such circumstances, he +will rarely, if ever, experience the slightest unwillingness to accede to +his request: the better the patient's rank in life is, the more docile +will she prove at these times, and the more resolute to undergo whatever +she is told it is necessary to submit to. The object of an examination is +to determine whether the child presents rightly, whether the labour is far +advanced, and to form some degree of prognosis as to its course and +duration, &c.: these are points which are of such importance as well as +interest to ascertain, that the dread which a patient feels at undergoing +an operation so repugnant to her feelings is generally merged more or less +in the intense anxiety to know if all is right. + +An examination at an early period of labour is important in many respects. +We ascertain the condition of the vagina, whether it be soft, cool, +relaxed, and well lubricated with mucus, as described at the beginning of +the last chapter; whether the os uteri be dilated; whether its edge be +thin and tense, or already becoming soft, cushiony, and yielding; whether +the membranes are ruptured; whether the presentation be a natural one, and +whether the pelvis be rightly formed. In cases where the umbilical cord is +prolapsed, it is particularly desirable to ascertain the existence of this +displacement as early in labour as possible. + +It is usually directed to examine during a pain, because at this moment we +feel the os uteri tense, and therefore more distinct to the finger; but it +is far better to examine during the interval between the pain: the os +uteri being now relaxed, admits the finger more easily; the membranes +being loose are not so liable to be ruptured; and, from their not being +distended, we shall feel the presenting part more distinctly. + +Wherever the os uteri is nearly or fully dilated, or from its condition +and the effect which the pains have upon it shows a disposition to dilate +with rapidity, the patient should go to bed, as we cannot be sure when the +membranes may rupture, more especially in primiparæ, in whom this usually +takes place early. It is equally desirable, also, in those who have +already had children, that the patient should be upon her bed at this +moment; because, if the pains be strong, and the os uteri yielding, the +head is apt to follow the discharge of the liquor amnii, and sudden +expulsion of the child might result at a moment when the patient is +unprepared for such an occurrence. + +The accoucheur should always examine when the membranes give way, because +not only will he be able to feel the presenting part now more distinctly, +but if the cord has prolapsed, a coil of it will come down into the +vagina and cannot escape his notice; in fact, if there is any thing +unusual about the presentation, he will be now able to distinguish it with +greater certainty. In women who have had large families, the head remains +very high in the pelvis until this moment, so that it is frequently +extremely difficult to reach it and to ascertain its position: the same is +observed with presentations of the nates and of the shoulder, which seldom +descend into the pelvis until the liquor amnii escapes. + +_Position of the patient during labour._ The position which the patient +should take during the actual process of labour has been a subject of +considerable discussion, and even at the present day varies exceedingly in +different countries. In the earliest periods of history, women appear to +have been delivered in a sitting posture, as is described in the first +chapter of _Exodus_: this mode was revived in comparatively modern times; +thus Ambrose Paré, in 1573, speaks of a labour chair with an inclined +back, which he preferred to a common bed. Labour chairs were brought into +very general use upon the Continent in the beginning of the last century +by Hendrick van Deventer of Dort in Holland, and although they have been +in great measure discontinued in modern times, there are still some +districts of Germany where they continue to be used. It is a species of +chaise percée furnished with straps, cushions, &c. by which the patient +can fix her extremities, and thus enable the abdominal muscles to act with +the greatest power. This is the very reason which renders labour chairs +objectionable. The presenting part of the child is forced through the soft +passage with great violence, before they have had time to yield and to +dilate sufficiently; hence it has been noticed that lacerations of the +perineum are of very frequent occurrence in those countries where labour +chairs have been in general use. In some remote parts of Ireland, and also +of Germany, the patient sits upon the knees of another person, and this +office of substitute for a labour chair is usually performed by her +husband. Labour chairs, as far as we are acquainted with their history, +were never used in this country, nor have they been used for the last +century in France, where the patients are usually delivered in the supine +posture, on a small bed upon the floor, which has not inaptly been termed +_lit de misére_. A modification of the labour chair is the labour cushion +first used by Nuger, and afterwards by the late Professor von Siebold of +Berlin and Professor Carus of Dresden; it is a species of mattress, with a +hollow beneath the nates of the patient for receiving the discharges which +take place during the labour. The patient is compelled to lie upon her +back during the greater part of labour, and thus maintain the same posture +for some time, which must necessarily become irksome and even painful to +her. In this country and in Germany the patient is delivered upon a common +bed, prepared for the purpose as above mentioned: in England she is placed +upon her left side, the nates projecting to the edge of the bed, for the +greater convenience of the accoucheur: in Germany, except in Vienna and +Heidelberg, where the English midwifery has in great measure been +introduced by Boer and Naegelé, the patient is delivered upon her +back.[67] In former times the supine posture was also used in this +country, but for about a century the position on the left side has been +preferred; the patient lies more comfortably to her own feelings; her face +is turned from the practitioner who sits behind her, and who, from this +posture, is able to examine or to perform any other necessary manipulation +without her feelings being annoyed by seeing what is going forward. It is +decidedly the easiest position during the last moments of tremendous +suffering and exertion; when the presenting part is passing she is not +able to exert an undue degree of violence, and from the knees being kept +together, there is less danger of the perineum being torn. The left side +seems moreover to be the natural position for a woman at the moment of +parturition, for if accidental circumstances have occurred, such as sudden +labour, &c. by which she is deprived of all assistance at this moment, she +will almost invariably be found upon the ground lying on her side +supporting herself with one hand. In some cases she will remain during +these moments upon her knees, into which posture she has gradually dropped +from that of standing: in by far the majority of cases she will take the +position upon her side, as above mentioned. + +So long as the os uteri is not fully dilated, the patient is not +involuntarily compelled to strain and bear down: hence it is important to +caution patients, more especially primiparæ, not to be induced by an +ignorant nurse or friend to exert themselves improperly during the first +stage of labour, for not only is the process of dilatation considerably +impeded, and much exhaustion produced, but frequently severe febrile or +inflammatory action excited, which may lead to serious results after +labour. All attempts to accelerate the course of a natural labour, +especially the first stage, either on the part of the patient by premature +straining, or on the part of the practitioner by attempts to dilate the os +uteri and passages, or by giving her stimuli, &c. cannot be too strictly +forbidden. It is a mode of practice which has long since been strongly +condemned by the highest authorities in midwifery, except in Scotland, and +which may very easily lead to most mischievous results. Quick rapid +labours are by no means desirable, for they are seldom safe; nor is it +possible to limit this or that stage (especially the first) to any given +duration of time. + +No conscientious practitioner, who has clear and enlarged views of the +process and mechanism of natural labour, would feel himself justified in +interfering with its course, merely because some portion of it has +extended beyond a certain fixed period; but would rather guide his conduct +by the habit and strength of the individual, and by the effects which the +labour has upon her. We have before stated, that no two labours are alike; +we may also add, that no two individuals are similarly affected by the +same degree and duration of labour, nor indeed are any two labours exactly +alike in the same person: hence it will be evident, that what to one +patient would prove a protracted and exhausting labour, to another would +be nothing more than a perfectly regular labour, natural both in its +character and progress. Among other injurious effects which premature +efforts on the part of the patient will have, is, that the membranes are +liable to give way too soon--this is by all means to be avoided, for +nothing is so likely to render the first stage protracted as the +occurrence of this accident; the course of the labour frequently undergoes +an immediate change; the pains lose their regular and effective character; +the os uteri remains thin, tense, and unyielding, and the process of +dilatation is greatly retarded. + +_Prognosis as to the duration of labour._ There are few subjects upon +which an accoucheur is so frequently importuned, or about which it is so +difficult to give a decided opinion, as the probable duration of labour. +It is natural enough that both she and her friends should be anxious to +know how long this process of suffering is likely to last: nothing, +however, is more hazardous than a prognosis in these cases; and we would +warn our junior brethren to be cautious how they commit themselves by +venturing an opinion, which the result of the labour may prove to have +been founded upon guess-work or ignorance. The character of the labour +during the second stage, is frequently very different to that of the +first, so that the mode in which the labour commences is by no means a +criterion for its latter part. A labour which has commenced briskly and +regularly, and with every promise of a rapid progress and termination, +frequently becomes exceedingly lingering during the second stage, so that +the expelling powers may, perhaps, even fail altogether in making the head +pass through the os externum; whereas, on the other hand, a labour, the +first stage of which has been slow and protracted, frequently experiences +a complete alteration of character, and advances with a degree of +quickness and energy, which could scarcely have been anticipated from the +manner in which it commenced. In primiparæ, especially, it is particularly +difficult to foretell, with any thing like certainty, the duration of +labour: hence it is, that unguarded assertions in this respect are not +only liable to disappoint the patient, but destroy her confidence in the +practitioner. + +_Wigand's views._ The celebrated Wigand of Hamburgh considered that the +form of the vagina would frequently furnish the means of a pretty certain +prognosis, as to the duration of labour: thus, if it were wide and +yielding throughout its whole length, the labour would be quick, both at +its beginning and termination; if, on the other hand, it were small, +rigid, and contracted throughout, the labour might be expected to be of a +very opposite character. If on examination the vagina is found roomy and +well dilated at its upper part, but contracted and rigid near the os +externum, the labour will be probably quick and easy during the first +half, but slow and difficult afterwards; on the contrary, where the os +externum is yielding and wide, but the upper portion of the vagina narrow, +the labour may be expected to be slow at first, but to be brisk and active +afterwards. We have already stated, that the course of labour varies in +every possible way; in some cases the same peculiar character of labour +shows itself through two or three successive generations: hence it has +been observed, that very tedious or very violent and rapid labours +sometimes seems to be hereditary; the mother, daughters, and +grand-daughters, being all remarkable for their lingering or rapid +labours. + +_Diet during labour._ The diet of the patient during labour should be +simple and unirritating; if every thing is going on naturally and briskly, +some gruel or tea, with or without a little biscuit or bread and butter, +will be quite sufficient; but if the process is becoming tedious and +exhausting, some beef-tea, broth, or any other mild nourishment of this +sort will be required to support the strength. + +During the first stage of labour there is no need for the practitioner to +be constantly in the room, nor even during the early part of the second, +unless the pains are very violent and protrusive; for, by taking frequent +opportunities of quitting the patient for a few minutes, she is left more +free from restraint, and the presence of the practitioner becomes less +irksome when it is really necessary; whereas, if he continues at the +bed-side, she is justified in expecting that the labour must be advancing +rapidly to demand so unremitting an attendance, and, therefore, becomes +disappointed and impatient to find that his presence has been of so little +use to her. The conversation should be light and cheerful, and every means +taken to encourage her and keep up her spirits. + +_Supporting the perineum._ As the head approaches the os externum our +attention must be directed to giving the perineum such a degree of +support, as shall secure it from any serious degree of laceration during +its passage. The greatest danger of ruptured perineum is in primiparæ, for +the soft parts never having been subjected to such a degree of dilatation +before, do not yield so readily as in multiparæ. The anterior margin of +the perineum, called _frænulum_, is, we believe almost invariably ruptured +in every first case; but the laceration ought not to extend farther. The +more gradual the advance of the head is through the os externum, the +better will be the dilatation of the soft parts: hence therefore, when the +pains are violent, and the head is thrust with great force against the +perineum, it will be desirable to restrain it in some degree, until the +parts shall have had sufficient time to yield; on the other hand, where +the pains are more gradual, the perineum and os externum may receive the +whole dilating force of the head, and every succeeding pain will show that +a progressive advance is taking place. + +The increasing thinness of the perineum itself, and the frænulum becoming +tense during the height of a pain, may be looked upon as warnings that the +expulsion of the head is not far distant, and now the support of the hand +will be needed to prevent laceration; for this purpose the position on the +left side is peculiarly convenient, besides having the additional +advantage of relaxing the external parts more completely. If the pains be +violent, and the impulse to strain very considerable, we must desire the +patient to lie as passive as she can, and do her best not to bear down, +for otherwise the head is sometimes driven through the os externum with a +single effort, and the mischief done in spite of all our care. + +The support of the perineum has been variously directed by different +authors; we prefer using the left hand, because then we have the right at +liberty for any manipulations which may be necessary, such as examining if +the cord be round the child's neck, &c. &c. It is awkward at first, +because it requires the hand to be considerably twisted, and makes the +wrist ache a good deal; but a very little practice soon conquers this +slight difficulty, and the superiority of the mode will then be apparent. +As our object is not merely to support the perineum, but to direct the +head as much forwards under the pubic arch as possible, in order that the +anterior portions of the os externum should undergo their share of +dilatation, and thus in some measure spare the perineum, the chief +pressure should be applied near to the sphincter ani, gradually +diminishing it up to the frænulum perinei in front: for this purpose the +left hand protected by a napkin (partly for the sake of cleanliness and +partly for the purpose of having a firmer hold upon the parts, and +preventing it slipping) should now be applied with the palm in the +vicinity of the sphincter ani, so that the tips of the fingers should +project somewhat beyond the frænulum; the whole should be laid as flat and +close to the part as possible. In order that we may be sure of the hand +being applied exactly along the raphe of the perineum, we should guide it +by the examining finger of the right hand, bearing in mind, that when we +place this against the posterior margin of the os externum, and bring the +middle finger of the left hand in contact with it, we shall hold the left +hand in the desired direction. + +It is desirable also to hold the examining finger of the right hand +against the frænulum perinei when a pain comes on, because then we know +exactly when the tension of the perineum is becoming such as to endanger +its integrity, and when the head is about to pass out. Until this moment +the frænulum is seldom on the stretch, although the rest of the perineum +is: hence we need not apply our support until now, and thus give the parts +the full benefit of the dilating force, which the head exerts upon them, +until the very last instant. To relax them still farther, the patient's +knees ought not to be separated by a pillow or cushion placed between +them, as is usually done, although it must be confessed that in some cases +she is relieved by it. + +In applying the left hand to support the perineum, it should be placed +somewhat more backward than the spot which we intend to support: for by +this means we are enabled to push the soft parts somewhat forwards, and +thus relax them. By this means, also, we not only direct the head against +the other parts of the os externum but avoid the danger of its perforating +the perineum. When the moment of greatest distension arrives, the process +cannot be too slow; we must therefore desire the patient not to bear down, +and endeavour, if possible, to make the head remain in the state of +_crowning_ until the next pain comes on: the os externum having been held +for some moments at its utmost dilatation, permits the head to pass with +greater ease and safety. As the globe of the head passes forwards and +emerges through the os externum, we feel the posterior portions of the +perineum become soft and lax, while the forehead, followed by the face, +and lastly the chin glide over the anterior margin of it. + +The passage of the head is not the only moment of danger to the perineum, +for laceration is even still more liable to be produced during the +expulsion of the shoulders; any slight rupture of the anterior edge is now +apt to be converted into a considerable laceration, unless the support be +continued until the thorax be expelled. We have already stated that the +frænulum perinei is generally torn through in the first labour; but the +laceration ought not, if possible, to extend farther, because serious +injury may be produced either to the vagina, or even to the sphincter +rectum. To say, however, that laceration of the perineum need never +happen, would be preposterous; because cases every now and then occur, +where, from the contracted and unyielding state of the os externum, and +from the size of the child, it is nearly impossible that the perineum can +escape without injury; fortunately, although considerable lacerations are +by no means uncommon, they are seldom observed to extend into the +sphincter ani, the direction of the rent being usually to one side. Under +the ordinary circumstances of perineal laceration, little more than mere +attention to cleanliness is required; for the parts contract so +astonishingly after labour, that what was a wide rent of an inch and a +half long, in a couple of days will be scarcely more than two or three +lines in length. Rest, great cleanliness, and gentle-relaxed bowels, +constitute the chief treatment. + +_Treatment of perineal laceration._ Where, however, the laceration extends +into the rectum, the case becomes exceedingly troublesome and difficult to +cure, and the patient is liable to be rendered a miserable object for +life; for the action of the sphincter being entirely destroyed, she is +unable to retain fæces or flatus in the rectum; besides which, from the +injury to the posterior wall of the vagina, prolapsus uteri is an almost +certain consequence. In these cases the slightest movement of the thighs +upon each other alters the position of the lips of the wound, and thus +tears it open afresh, so that at length the edges of the wound become +callous and refuse to heal. A great deal in these cases depends upon the +patience and good conduct of the patient herself; for if she have the +resolution to lie perfectly still for at least a week, she will have every +chance of a perfect cure. If there be much swelling of the edges, and a +disposition to slough, a warm poultice of chamomile flowers should be +applied, and the bowels kept in a nearly liquid state by gentle and +repeated doses of salines, in order to prevent distension of the rectum +when the evacuation is passing; she should preserve the supine posture, +and have her knees confined together by a piece of tape, as is done with +patients after the operation of lithotomy. Straps of adhesive plaster are +seldom or never of any use, but if the rent be very severe a suture or two +may be required. The great fault in applying these means for bringing the +edges of the wound together is the attempting to unite them throughout +their whole length; for by so doing the tension of the parts is increased, +and therefore there is less disposition to unite; and even if we succeed +in effecting complete union of the whole wound, the perineum is so +contracted and unyielding from the cicatrisation, that it can scarcely +escape a repetition of the injury in succeeding labours. It is, therefore, +much better that we should content ourselves with uniting merely the +posterior half of the laceration; the parts heal much more readily, and +the os externum is left of a sufficient size to escape all danger of +laceration on future occasions. + +Where the edges have become callous and refused to unite, they require to +be pared and brought together again; this, however, does not always +succeed, and the case becomes very difficult and protracted: under these +circumstances, the treatment adopted by Dr. Dieffenbach, of Berlin, is +well worthy of attention. Having pared off the callous edges of the wound, +he brings them into the closest opposition by transfixing them with +needles in several places, as is done for the operation of hare-lip; and +in order to isolate the wound as much as possible from the surrounding +parts, and prevent any tension, he makes a free incision through the +integuments, parallel with the wound, at a little distance from it, and +nearly of the same length; by this means, every cause which might tend to +separate the edges is removed; whilst the parallel cuts, being fresh +incised wounds, soon close by granulation.[68] + +It sometimes, although rarely, happens that the perineum, instead of being +torn from before backwards, is perforated through its centre by the head, +so that the child is not born through the os externum, but through a +lacerated opening in the body of the perineum. This accident may arise +from a variety of circumstances: the direction of the pelvic outlet may be +faulty, or the inclined plane formed by the lower part of the sacrum, by +the sacro-sciatic ligaments, &c. may be insufficient to guide the head +forwards under the pubic arch; or the perineum may be unusually broad; in +which cases the power of the uterus being directed against the centre of +it, the head becomes enveloped in a bag of protruded perineum; and if the +pains are violent, and the head not properly supported, it at length +bursts its way through the centre without even injuring the frænulum. The +treatment of this form of ruptured perineum is the same as that of the +more common species; the bowels must be kept open, and a fomentation of +chamomile flowers applied to the wound, which, from the gradual +contraction of the surrounding parts after labour, diminishes remarkably, +so that in the course of a short time it will have entirely or nearly +closed.[69] + +Besides the above-mentioned advantages in supporting the perineum, we may +mention another which is not generally noticed, and which is sometimes of +considerable service. In cases where the head has completely descended +upon the perineum, and begins to protrude somewhat through the os +externum, the pains occasionally fail at this moment, the labour becomes +very lingering, while the advance of the head and state of the parts show +that two or three active pains would bring the child into the world; firm +pressure applied at the lower end of the sacrum, in a direction forwards, +materially adds to the effect of each pain in bringing the head through +the os externum, and seems also to excite the patient to make a more +powerful effort with the abdominal muscles. On several occasions we have +thus assisted the expulsion of the head, when otherwise the labour would +have been very protracted, or would have even required the forceps to +disengage it. Madame La Chappelle is the only authority in midwifery, as +far as we know, that has noticed this fact. + +_Cord round the child's neck._ As soon as the head is born, we must +examine whether the cord be twisted round the child's neck; and here the +advantage of supporting the perineum with the left hand becomes evident: +it is ready to support the shoulders when they begin to pass, while the +right hand is at liberty to perform any manipulations which may be +necessary. If it be important to support the head during its passage over +the perineum, still more so will it be to support the shoulders; for if a +small laceration has already been produced, it is invariably converted +into a wide rent at this moment, if great care be not taken: indeed, we +are justified in saying that most of the cases of severe perineal rupture +are produced by the shoulders, not by the head. + +_Passage of the shoulders._ If the pains cease for a time, or the child be +large, the shoulders do not pass immediately: in this position the face +swells and grows purple from the pressure upon the neck, although it does +not necessarily result from the cord being round it; if, however, we find +that this is the case, we can in most instances loosen it somewhat by the +finger, and as the shoulders advance, slip it first over one and then the +other: we must recollect that the shoulder, which is forwards, passes out +first, and that, therefore, we must slip the cord over it first. + +It is seldom necessary to assist the shoulders by applying any extractive +force to the head, for in the course of a minute or two the uterus +generally resumes its activity and expels it: on the other hand, when the +shoulders pass through the os externum, the right hand should be in +readiness to prevent the body of the child from being born too rapidly: +the uterus can scarcely be emptied of its contents too gradually, for by +this means it contracts equably, powerfully, and permanently, and throws +off the placenta without difficulty; whereas, if suddenly evacuated, it +frequently becomes powerless for a time, or if contraction does take +place, it is so irregular and incomplete as to endanger partial +separation, retention of the placenta, and hæmorrhage.[70] If, however, +the cord be twisted exceedingly tight round the child's neck, and imbedded +so deeply into the skin, as to render it impossible to push the coil over +the shoulder, it may become necessary to divide it in order to let the +child pass, in which case the practitioner must seize the divided ends as +well as he can, and apply a ligature the instant the child is born. We +believe that this is rarely, if ever, necessary; for in proportion as the +child advances, so does the fundus descend, and thus relieves, in some +measure, the tension to which the cord is exposed. This subject, however, +belongs rather to the third species of dystocia, to which we must +therefore refer. + +_Birth of the child and ligature of the cord._ As soon as the child is +born, we must place it in such a position as will enable it to breathe +with ease. The sudden exposure to the external air is generally +sufficient to excite respiration; if not, a gentle pat on the nates, or +blowing suddenly in the face, will usually succeed: if, however, the child +still remains insensible, recourse must be had to those means which are +recommended under the head of _Asphyxia neonatorum_. The cord should not +be tied until it has ceased to beat, for unless the circulation be well +established in its new course, the breathing is apt to stop, and the child +relapse into insensibility: the cord should be tied about three inches +distant from the umbilicus; it should be applied tightly, because +otherwise it is apt to become loose, as the cord grows flaccid. In tying +the ligature, one hand should be supported against the other to prevent +giving the cord any jerk in case the ligature breaks; we are able also by +this means to tie it more firmly. + +The cord should be divided at some little distance from the ligature, so +as to prevent all chance of its slipping off, and it should be done with a +pair of blunt scissors, by which means the vessels of the cord are so +bruised as to be rendered nearly impervious. There is no need to apply two +ligatures; in fact it is better not, for, as Dr. Dewees justly observes, +"the evacuation from the open extremity of the cord will yield two or +three ounces of blood, which favours the contraction of the uterus and +expulsion of the placenta." It has been recommended, in case of twins, to +apply a second ligature, to prevent all chance of the second child +bleeding through the cord of the first. There is, however, no connexion +between the two placentæ, although they usually form what appears to be +one mass. We only know of one case where the umbilical arteries of one +cord anastomosed with those of the other, an anormality of very rare +occurrence: still, however, it is better to apply a second ligature upon +the cord, where we find that twins are present, as a precaution: and also +to prevent it being said, in case the second child is still-born, that it +had died from no ligature having been applied upon the placental extremity +of the cord. It has been questioned whether it was really necessary to tie +the cord before separating the child from the mother, from the well known +fact that nothing of the sort is required in animals; and that, in cases +of rapid labour, where the child has been unexpectedly dashed upon the +floor and the cord broken, no hæmorrhage has resulted. This arises from +the bruised and lacerated condition of the cord under these circumstances: +animals not only bite the cord, but also draw it through their teeth +several times, so as to contuse the vessels for a considerable extent; +whereas, if it was merely divided with a sharp instrument, there is no +doubt but that the new-born animal would quickly bleed to death.[71] + +_Importance of ascertaining that the uterus is contracted._ As soon as the +child is separated from its mother and removed, or even sooner, if this +process has gone on slowly, we ascertain if the uterus has contracted: +this we shall know by its feeling like a large hard ball behind the +symphysis pubis: if there be one rule more important than another, it is +this, for without it we cannot be certain of the patient's safety for a +single minute: so long as we feel the fundus to be hard, we know that the +uterus is contracting, and that it will expel the placenta quickly, and +ensure the patient against hæmorrhage; but if it be soft and relaxed, she +cannot be considered safe even if their be no hæmorrhage; for the placenta +may have been separated, and may be lying across the os uteri, or the os +uteri itself may be contracted, or blocked up with coagula, so as to +prevent the blood from escaping; it therefore collects in the cavity of +the uterus in large quantities, to the imminent danger of the patient. +Even where the uterus has contracted, the patient is not permanently safe, +for it may again relax and grow soft, and hæmorrhage come on. + +_Management of the placenta._ The placenta sometimes follows the child +immediately, and occasionally is expelled by the same pain; usually, +however, a few minutes intervene, during which time the uterus remains +more or less in a state of inaction; it then begins to contract, and the +dull and peculiar pains which characterize the separation of the placenta +are now felt. The interval after the birth of the child varies +considerably, and depends in many cases on the degree of rapidity with +which the uterus has been emptied: hence in some cases we feel the fundus +hard almost immediately, whereas, in others some considerable period +elapses before it resumes its state of activity, a period which, if any +separation of the placenta has already taken place, will be attended with +the greatest danger. The occurrence of pains indicates fresh contractions, +and therefore we should now examine to ascertain if the placenta has been +detached. As a general rule it may be stated, that if we can reach the +insertion of the cord with our finger we may presume that the placenta is +ready to be expelled; if not, that it is still partially or wholly +attached to the uterus. So long as this latter is the case, the less we +meddle with the cord the better, for by pulling at it we only excite the +os uteri to contract, and thus seriously impede its removal. + +Where some time has elapsed without any symptoms of contraction coming on, +we may excite the uterus by circular friction of the abdomen, fanning the +face, or by sprinkling a little water upon it, &c.: if, however, the +uterus is hard and yet the placenta not within reach, we may pull slightly +at the cord, pressing it at the same time back with the fore-finger into +the hollow of the sacrum; we thus bring it down in the direction of the +pelvic axis, and generally succeed in moving it into the vagina. No +violent effort should be made, as this would probably tear it off from its +insertion into the placenta, but, by keeping a gentle pressure upon it, +the placenta will slowly pass through the os uteri, and then come away +without farther difficulty. Following the axis of the vagina, we now guide +it downwards and forwards; and when it approaches the os externum, it +should be seized with the finger and thumb, and rotated several times: the +membranes are thus twisted into a rope, and are less liable to be torn in +separating from the uterus. The uterus being now completely emptied, +contracts into a hard ball of about the size of a child's head. If, +however (whether before or after the expulsion of the placenta) the uterus +grows soft and swells, if the patient becomes pale and restless, and +complains of faintness, sickness, load at the præcordia, darkness before +the eyes, &c. we may be sure that hæmorrhage is going on. We refer to the +chapter upon uterine hæmorrhage for the measures to be adopted. + +_Twins._ Where there are twins, the above rules for ensuring the safe +expulsion of the placenta require to be still more strictly observed: the +uterus has been more distended, the mass of placenta is larger, and is +attached to a much greater extent of surface than where there has been +only one child: hence there is not only a greater liability to hæmorrhage, +but if it does take place, will probably be much more dangerous. We cannot +be too cautious how we extract the placentæ of twins: from the size of the +mass, the uterus remains larger, and therefore less contracted: hence, if +we venture to pull at the cord before being able to reach the placenta +with our finger, we shall feel it yield; but this is not from the placentæ +being detached and coming away, but from the fundus itself being pulled +down with it--a state which would rapidly pass into inversion if the force +were continued. In order to detach the mass more equally, we should twist +the two cords together; by so doing there is less danger of their giving +way. The same rotating movement should be used when the placentæ approach +the os externum; the two bags of membranes are thus twisted together, and +come away entire: if this be not attended to, the membranes are torn, +portions of them are left adherent to the uterus, and come away some days +afterwards in a half putrid state producing a fetid discharge, and +sometimes considerable fever. + +_Treatment after labour._ As soon as the placenta is expelled, the soiled +and wetted sheet should be removed and a warm napkin applied to the +external parts: the patient should remain thus for half an hour or more, +and enjoy a little rest, or even a short sleep: by this time the nurse +will have washed and dressed the child, and be ready to attend to the +mother. The external parts should be sponged with warm water, her linen +changed, and a broad bandage pinned firmly round the abdomen to give it +the necessary degree of support. Where there has been great abdominal +distension and more than one child, it is sometimes advisable to apply the +bandage immediately after the birth of the first, in order to assist the +uterus in expelling the second, and in contracting afterwards. The +bandage, therefore, should be gradually tightened as the abdomen +diminishes in size: without this precaution the removal of so much +pressure from the abdominal circulation will be sometimes attended with +alarming faintings. A similar effect may be produced by the patient +incautiously sitting up in bed to take any refreshment which may be +offered to her at this moment; she should be warned, more especially if +she be a primipara, not to raise herself from the horizontal posture for a +few hours after labour; at any rate, not until the bandage has been +properly applied: from inattention to this point, cases have occurred +where, on the patient's sitting up immediately after labour, she has +fallen back in a faint from which she never recovered; in other cases it +has been attended by profuse hæmorrhage, which has instantly proved fatal. +"The influence of position," says Dr. Meigs, "in determining the momentum +of blood in the vessels is well known to the Profession, but there are few +cases where it is of more consequence to pay a profound regard to this +influence than in the parturient woman. A uterus may be a good deal +relaxed or atonic, and yet not bleed, if the woman lie still with the head +low; whereas, upon sitting up suddenly, such is the rush of blood down the +column of the aorta, the hypogastric and the uterine and spermatic +arteries, that the resistance afforded by a feeble contraction is +instantly overthrown, and volumes of blood escape with an almost +unrestrained impetuosity: the vessels of the brain under such +circumstances become rapidly drained, and the patient falls back in a +state of syncope, which now and then proves immediately fatal." +(_Philadelphia Practice of Midwifery_, by Charles D. Meigs, M. D. p. 192.) +Even if all these directions have been strictly obeyed, if every thing has +gone well, and the uterus is firmly contracted, we are not sure of its +remaining so: after the lapse of many hours it may again relax, and +flooding come on, its power of contraction being impaired either by the +exhaustion of the previous labour, the warmth of the bed, &c. It will, +therefore, be desirable to adopt such measures, as will ensure the +patient against this occurrence: in most cases it will be sufficient to +keep the room moderately cool, and ensure a due degree of ventilation; but +where the uterus has shown a disposition to relax, we know of nothing +which guards the patient so effectually against hæmorrhage after labour, +and enables us to leave her with so much confidence, as putting the child +to her breast. The sympathetic connexion between the breast and the uterus +is now well known; nor are there any means so certain of producing +permanent uterine contraction as this natural act: it is a duty which +nature instinctively prompts the mother to perform, not only for the +preservation of her child, but for the safety of herself. We, therefore, +make it a rule, whenever the patient intends to suckle her child (a duty +which is performed more frequently now than it was a few years ago,) to +have it put to the breast before quitting the house: the first excitement +of the mother's feelings towards her offspring is a favourable moment for +the performance of this act, the erectile tissue of the nipple becomes +turgid, the child takes the breast with ease, and the effect upon the +uterus is not less certain than complete; even if the child sucks fairly +well for only five minutes we feel satisfied, for we cannot call to mind a +single case of hæmorrhage after the effects of this operation. + +_Lactation._ When the wet clothing has been removed, and fresh linen +substituted, the patient should be left to enjoy perfect quiet both of +body and mind, in order that she may have some sleep, for "the refreshment +of sleep seems to be the most powerful natural means of inducing full +contraction of the uterus."[72] After this, the child should be placed at +her side, in order that it may enjoy the warmth of her body, and make +another trial of taking the breast. That new-born animals are not able to +maintain a sufficient degree of warmth, is seen by the care with which a +bird shelters her young beneath her wings, and by the manner in which +kittens, puppies, &c. crawl close to the mother's abdomen to enjoy that +degree of heat which of themselves they are unable to produce. Dr. Edwards +has shown that the animal heat of a new-born infant is several degrees +below that of the adult: the mother's breast is, therefore, the natural +place for it, where it can not only enjoy the necessary warmth, but take +that nourishment which has been destined for its support at this early +period. A child is capable of sucking the moment it is born; indeed, we +would say, better at this moment than later, for the power of instinct in +it is fully as great as in other animals; whereas, if not put to the +breast soon after birth, but fed instead, it quickly loses it. A vigorous +healthy child immediately seeks its mother's breast, and if it does not +find it, sucks at every thing which touches its mouth, even its own little +hand or finger when presented to it: so strong is this instinct, that, on +more than one occasion, we have known the child suck at the finger of the +medical attendant when the head had only just cleared the os externum. + +It has been, and even still is, a very general practice not to apply the +child to the breast until the second or third day, upon the plea that +there is no milk: a more erroneous and mischievous plan of treatment could +not be devised, for it is a fruitful source of much injury as well of +suffering both to the mother and her child. The child should be put to the +breast, "whether there be signs of milk or not." (White, _on Lying-in +Women_.) There is always more or less thin watery fluid called _colostrum_ +which is admirably adapted to form the first nourishment of the infant; it +is slightly purgative, and, therefore, well fitted to unload the bowels of +the viscid green mucus, called _meconium_, which fills them. The colostrum +has been variously described by authors; some speak of it as a thin watery +fluid, others as a thick creamy milk: this difference depends in great +measure upon the interval between the birth of the child and its +application to the breast: where this has taken place early, as we have +just recommended, the colostrum has almost always the thin watery +appearance above mentioned; whereas, if some period of time has been +allowed to pass before the child is applied, the breast begins to secrete +a fluid containing a larger proportion of caseous matter, or, in other +words a more perfect milk, which not being drawn off, the watery part of +it is absorbed, leaving the thicker portion to be removed by the process +of sucking. Instead of giving the child this bland and natural fluid when +in a state best fitted for its delicate digestive organs, it is but too +frequently the practice to make it swallow some soft sugar, or a +tea-spoonful of castor oil, and follow this up with a little gruel. The +effects of such treatment upon a stomach which has never yet received food +may be easily imagined; the digestive function becomes deranged, pain is +excited, acid is secreted, gas is disengaged, flatulence, diarrhoea, &c. +are the result, with all those manifestations of gastric irritation, such +as strophulus, aphthæ, colic, &c. from which new-born children are made to +suffer so severely. + +Besides the above advantages in applying the child thus early to the +breast, there are others of even greater importance which require to be +mentioned. The breast is not yet distended; it is soft and conical, and +therefore in a most favourable condition for being drawn; the child can +seize the nipple and draw it out with ease, and by thus straightening the +lactiferous tubes it commands a ready flow of their contents. By the +gentle irritation of sucking, an earlier secretion of milk is excited, and +being drawn off as fast as it is formed, the breast is never distended by +an accumulation of milk. On the other hand, where some time has elapsed +before putting the child to the breast, it will have in great measure lost +the instinctive desire to suck; the breasts have become distended and +painful; instead of being soft and conical, they are now hard and +flattened, the nipple is shortened, or even sunken in; and if the child +does succeed in drawing it out, it is at the expense of severe suffering +to the mother. The process of sucking in this state of the breast is very +difficult; a considerable effort is required to elongate the nipple, and +the thin delicate skin which covers it is abraded; excoriations and deep +fissures round the base of it are produced, and each application of the +child is one of absolute torture. In many cases, partly from having been +fed, and partly from the difficulty it meets with, the child refuses the +breast altogether; in others, the suffering is so severe as to oblige the +mother to discontinue the attempt. The breasts now increase in size and +hardness, producing great pain from their weight and tension; hard painful +knots from the distended tubes and vessels are felt in different parts, +and the pain and dragging extends to the axillæ, the glands of which are +also swollen and painful. + +_Milk fever and abscess._ By this time, or even earlier, the patient will +in all probability have been attacked with a smart shivering fit followed +by a hot and then a sweating stage, and accompanied with headach and +febrile excitement of the circulation. This is the _febris lactea_, or +_milk fever_, an affection which, at one time, was very generally supposed +to be necessary for establishing the secretion of milk: experience, +however, has shown that it chiefly results from neglect in not putting the +child to the breast sufficiently early; the secreted milk has been in part +absorbed into the system, fever has been induced, and the patient has been +relieved by the natural crisis of a sweating stage. The febrile excitement +will be considerably moderated, and the tension of the breasts relieved, +by the action of saline laxatives: the shoulders which are usually kept +warm for the purpose of promoting the secretion of milk, should now be +clothed more lightly; the relief, however, is but too frequently partial, +the breasts still remain large and painful; the process of suckling is +just as difficult as before, and the indurated spots increase in hardness, +sensibility, and extent; throbbing and darting pain is felt in the part, +the skin over it becomes hot and red, and at length presents that shining +glazy look which but too surely indicates the formation of matter beneath, +a circumstance which is still farther proved by the oedematous feel of the +part, or by the presence of actual fluctuation.[73] + +Where the breast is capable of being drawn, whether by the child or by +artificial means, the application of a cold evaporating lotion, and the +frequent exhibition of saline laxatives, will generally suffice to check +the determination of blood to the breast, and diminish the secretion of +milk; but where these means fail to reduce its size and hardness, it +should be frequently rubbed with volatile liniment, and then enveloped in +a hot linseed-meal poultice: this may be advantageously made with Goulard, +and changed every two or three hours, keeping up a brisk action upon the +bowels, as before-mentioned.[74] + +If there be much febrile excitement of the circulation, bleeding may be +sometimes required: we have rarely, however, found it necessary, having +been almost always able to exert a sufficient effect by means of nitre +with small doses of Vin. Antimonii and Sp. Æth. Nitr. Leeches seldom give +more that temporary relief, and that only when applied in large +quantities; in which case so much irritation and inflammation is produced +by their bites as not unfrequently to counteract the benefit arising from +the loss of blood. The patient should preserve the horizontal posture, or +at least have the breast well supported by a soft handkerchief, as +otherwise its weight will produce much painful dragging. It is not always +easy to detect the fluctuation, particularly when it is seated deep +beneath the fascia, which invests the mammary gland; but wherever it is +tolerably distinct, especially in the upper parts of the gland, the +abscess should be let out early, otherwise it will burrow through a large +extent of the breast, and destroy a considerable portion of the gland; +whereas, if it be felt below the nipple, it may be allowed to approach +nearer to the surface and point, by which means it will not be necessary +to make the incision so large or so deep, a point which is worthy of +attention, as otherwise considerable-sized milk tubes and even +blood-vessels may be divided. Dr. Burns has mentioned a case of fatal +hæmorrhage from this cause. In either case, whether the opening has been +made artificially or spontaneously, the breast should be constantly +enveloped in a hot poultice of linseed meal: if this be made with boiling +water it forms a gelatinous mass, which retains its heat for a very +considerable time, and not only acts as a fomentation, but gives great +relief by softening the indurated portions and diminishing the tension. If +the patient can bear it, the breast ought to be drawn by a glass for that +purpose: this is much better than the breast-pump, being simple and easy +of application. Where little or no milk comes, it is useless to persevere, +as we should only expose the patient to much unnecessary pain, and the +breast to a good deal of irritation. + +It rarely happens that the breast recovers so far as to enable the mother +to nurse with it, and she will therefore be obliged to nourish the child +entirely from the other, which generally bears the double duty without +inconvenience: in some cases, however, there has been so much fever, and +the process of inflammation and its consequences has been so long, that it +is neither possible nor advisable to keep up or recall the secretions. In +succeeding labours great attention must be paid to a breast which has been +thus injured, and every disposition to distension and accumulation of milk +carefully watched. + +By the time a mammary abscess has been fairly opened, the strength of the +patient is considerably lowered, not only from the quantity of discharge, +but also from the nature of the previous symptoms and treatment; her food +should now be more nutritious, she should take a little wine or porter; +and if the appetite be delicate, two pills, consisting of equal parts of +Extr. Gentianæ and Extr. Hyoscyami should be given night and morning; she +will thus be enabled to sleep better, and the general irritability arising +from her state of weakness will be relieved. If, however, the appetite +fail entirely, and she has a pale flabby tongue, or if it is brown and dry +in the centre; if the bowels are deranged, and she has a disposition to +profuse perspiration, with much pain in the front or summit of the head, +and other signs of debility, the Hydr. c. Cretâ and Dover's powder should +be given at night followed by a rhubarb and manna draught the next +morning, and if these have acted sufficiently, she may be put upon the use +of quinine and sulphuric acid with Tinct. of Hyoscyamus two or three times +during the day. + +_Excoriated nipples._ When the nipples are merely excoriated, or there are +fissures in them, they should be bathed with tepid Lotio Plumbi or a +solution of Zinci Sulph. in rose water, which must be carefully washed off +before applying the child to them. If they are too tender to permit being +drawn by the child, they should be covered by the shield, to which is +attached a cow's udder or some form of artificial nipple, through which +the child can draw the milk without pain to the mother; the udder should +be kept very clean, and there should be one or two spare ones soaking in +water, in order that they may be changed from time to time. Excoriation of +the nipples frequently arise from the extreme thinness of the skin which +covers them, and from their unnatural softness. Whatever renders the +nipples soft and tender, makes the operation of sucking difficult, because +the child can draw them out too easily: we should rather be careful to +have them firm, and less sensitive of irritation, just as they would be +if they had not always been covered by the dress from the earliest +childhood, and thus rendered perfectly unfit to perform the office +designed them by nature. The best means of attaining this end is to expose +them frequently to the air during the latter months of pregnancy, and by +dabbing them occasionally with cold water mixed with a little lavender +water or eau de Cologne. (_Boer._)[75] + +It is important that the child should be suckled at regular intervals of +about three hours during the day; and if this be done the last thing at +night, and the first thing in the morning, there will be no need of giving +it the breast during the night. With a little perseverance on the part of +the mother, the child soon learns not to require the breast at this time, +which ensures her a good night, and spares her much trouble and annoyance. +Those mothers who are obliged to suckle their children at all hours of the +night to pacify their screaming, have brought the trouble upon their own +heads, for if, instead of dosing the children with castor oil, and feeding +them for the first day or two after birth, they had put them to the breast +at once, the derangement of stomach and bowels which is the cause of this +restlessness would have been avoided. + +_Diet during lactation._ Attention should be also paid to the diet of the +mother, for upon this subject much erroneous opinion prevails. If she be +strong and healthy, her food should be entirely farinaceous for the first +three or four days, using gruel, tapioca, farinaceous powder, arrow root, +&c. with a due admixture of milk; if there are no symptoms to forbid it, +an egg may now be taken in the morning, and she may gradually proceed from +chicken, &c. to the stronger meats, as her general condition and appetite +point out. Where she is naturally delicate, or has been weakened by a +sickly pregnancy, &c. it will be advisable to allow her chicken broth, and +weak beef-tea from an earlier period. + +"Serious mischief is frequently done by the mother attempting to remedy +every temporary diminution of milk, by increasing the quantity of her +food, or by imagining that some stimulating drink will answer this +valuable end. Owing to some trifling disturbance in the system of a +temporary kind, the secretion of milk may be for the moment suspended or +diminished. An attempt is made to recall it by an increase of food, by +which a slight inconvenience is converted into a permanent derangement of +the system, or a fever of even a dangerous character may be generated; or +owing to a false theory, or imperfect observation, it has been supposed +that certain liquors have a control over the secretion of milk, and hence +the too free use of certain combinations, into which ardent or fermented +spirits too largely enter. We must not, however, be supposed to deny the +influence of certain solid as well as fluid substances upon the secretion +of milk, for we well know, that unless the body be properly supported, +there must soon be a diminution of milk. We only mean to insist that it is +the nutritious, and not the stimulating part of the diet, which is +subservient to the plentiful and healthful formation of this fluid. In +proof of this we need only observe, that we have often been consulted upon +the subject of the failure of milk, where an anxious mother herself, or a +hireling nurse, was concerned, and had been informed by them that they had +tried every thing with a hope of improving it, such as rich food, porter, +ale, beer, &c. without success, or it was followed, perhaps, by a +diminution of it. In such cases we have often succeeded in producing a +plentiful supply of milk, by adopting the opposite plan of treatment, for +it must be borne in mind, as an important truth, that this failure +proceeds more frequently from an over, than from an under, quantity of +food or of drink. It is a fact well-known to all who have paid attention +to the consequences of arterial excitement, that when it amounts to even +moderate fever, the milk almost immediately diminishes in quantity; and +also when this action is diminished by suitable remedies (provided it has +not continued too long,) that the secretion of milk again becomes more +abundant. Upon this principle we have frequently prescribed evacuants and +abstinence to promote the secretion of milk." (Dewees, _on Children_.) + +Where the mother does not intend to nurse her child, a different plan of +treatment must be adopted: the shoulders should be lightly covered, cold +evaporating lotions applied to the breasts, and the bowels freely opened +by saline laxatives, her diet must be abstemious until the fulness of the +breasts subsides, and she ought not to take much fluid: where there is a +disposition to febrile action, an antimonial may be advantageously +combined with the salines. In most instances the milk is thus checked +without any inconvenience, but every now and then much illness and +suffering is produced before this can be effected. Wherever, therefore, it +is possible for the patient to suckle, the practitioner should urge the +importance of it in the strongest terms. + +"A very serious evil from a woman neglecting this imperious duty is the +probability of her becoming more frequently pregnant than the constitution +of most females can sustain without permanent injury. A woman who suckles +her children has generally an interval of a year and a half or two years +between each confinement; but she who without an adequate cause for the +omission does not nurse, must expect to bear a child every twelve months, +and must reconcile her mind to a shattered constitution and early old +age." (Conquest's _Outlines_.) + +_Management of the lochia._ The management of the lochia constitutes also +an important part of the treatment of a natural labour, for the patient's +health will be materially affected by any alteration either in its +quantity or quality. The lochia usually continues to be a sanguineous +discharge for about three days, becoming paler, thin, watery, and of a +brownish hue, and gradually disappears: a free lochial discharge for the +first forty-eight hours, at least, is one of the greatest safeguards +against the different forms of puerperal fever and inflammation which are +so justly dreaded by the practitioner, and nothing tends to ensure this +desirable object so much as the early application of the child to the +breast. It may seem paradoxical to assert, that what prevents hæmorrhage +after labour should promote the lochial discharge: we do not attempt to +explain why such is the case, but merely mention it as a fact repeatedly +observed. As the lochia is secreted from the internal surface of the +uterus, it will continue to accumulate in this cavity and that of the +vagina so long as the patient remains in the horizontal posture, the +direction of the vagina preventing its spontaneous escape: it will, +therefore, be desirable to favour its discharge by occasionally altering +the position of the patient, and thus prevent its becoming offensive, +which it would readily do from the temperature at which it is kept by the +surrounding parts, from being in contact with the external air, and from +its muco-sanguineous character. In the same way it frequently happens that +small coagula of blood lodge in the uterus and rapidly grow putrid. In +either case much irritation and fever are produced by their presence in +the passages, and serious symptoms would soon result if they were allowed +to continue there. Hence we make it a rule, that whenever the patient +requires to evacuate the bladder, she should do it by kneeling: by this +means the position of the vagina is altered, and the accumulated +discharges and coagula readily drain away and produce the greatest relief. +Wherever the patient complains of abdominal pain, and the lochia has +become scanty and somewhat offensive, it will be advisable to wash out the +vagina with a warm water injection: for the farther treatment of these +symptoms, we must refer the reader to the chapter on PUERPERAL FEVER. + +_After-pains._ When coagula have remained or formed in the uterus after +labour, these irritate it by their presence, and excite it to contract: +pains therefore of a crampy spasmodic character are produced, which have +received the name of _after-pains_. Women who have already borne children +are more liable to them than primiparæ. They vary considerably in degree: +in some cases they are scarcely sufficient to excite attention; in others +they rise to great intensity, and may even be mistaken for inflammation; +indeed, they occasionally pass into this condition. During these pains the +uterus is evidently in a state of contraction, for the fundus feels hard, +and for the moment it is more or less painful to the touch: the patient +has also pain in the back like a labour pain. + +After-pains do not only arise from coagula in the cavity of the uterus +irritating it to contraction, but also from little plugs of coagulated +blood, which fill the sinuses opening upon the internal surface of the +uterus. After awhile they excite contractions, by which they are squeezed +out and come away in the discharges: this fact was first pointed out by +Dr. Burton in 1751. Having to introduce his hand into the uterus for the +purpose of removing a portion of the placenta, he felt several of these +little oblong fibrinous masses exuding from the orifices of the uterine +sinuses, whenever he at all stretched the uterus by opening his hand; +these proved to be so many fibrinous casts of the above vessels, the blood +having been retained and coagulated in them, when the uterus contracted +after the birth of the child. When the uterus has been slowly emptied +during labour, it contracts gradually and uniformly, and forces the blood +from its numerous sinuses into the rest of the circulation; but where its +contents have been suddenly removed, the contraction is unequal, and a +portion of the blood is retained, which coagulates as described. This fact +affords an additional argument in favour of putting the child early to the +breast: the active contraction of the uterus, which is thereby induced, +effectually expels the coagula from its sinuses: hence we see that where a +patient suckles shortly after labour, she seldom (_cæteris paribus_) has +severe after-pains; but where this has been delayed until the second or +third day, the first application of the child to the breast is sure to +induce a sharp attack; the truth of the old adage, that "the child brings +after-pains," is thus verified. + +After-pains must be looked upon as an important agent in preventing those +attacks of inflammation and fever which arise from the retention of putrid +coagula and lochia: they ought not therefore to be checked, unless their +severity is such as really demands it: hence the custom of giving an +opiate after _every_ labour cannot be too strongly reprobated, for by this +means those uterine contractions are suspended, by which nature would have +rid herself of the offending cause: nor do we consider ourselves justified +in giving an opiate where after-pains are severe, until by change of +posture, &c. we are satisfied that no accumulation exists in the passages. +"Wherefore," says Burton, "we must not be too forward in giving strong +opiates and other internal medicines, which may take them off while this +grumous blood is lodged within these sinuses. I doubt not but those +patients who die from the eighth to the fourteenth day, whose uterus has +been inflamed with the symptoms above-mentioned, have been injured by the +too free use of opiates." (_Essay towards a complete new System of +Midwifery_, by J. Burton, M. D. p. 342.) We do not deny that a mild +sedative is frequently of great benefit after labour: it calms the +irritability of the system and procures sleep: these effects will be much +better obtained by a little extract of hyoscyamus, lettuce, or hop. Where +an opiate is really necessary, twenty minims of Liq. Opii Sed. in any +aromatic water will be as good a form as any.[76] + + + + +CHAPTER III. + +MECHANISM OF PARTURITION. + + _Cranial presentations--first and second positions.--Face + presentations--first and second positions.--Nates presentations._ + + +If we were asked to point out the basis on which the principles of +practical midwifery should be founded, we would answer, on an accurate +knowledge of the manner in which the child presents, and passes through +the pelvis and soft parts during labour. In confirmation of this remark, +we may observe, that almost every great improvement in midwifery practice +which has taken place during the last century, has resulted from farther +investigation into this difficult field of inquiry, and from the gradual +addition of new facts to our knowledge respecting this interesting +process. + +Unless a practitioner be thoroughly acquainted with every step in the +mechanism of a natural labour, how can he be expected to understand and +detect with certainty any deviation from its usual course, still less make +use of those means which may be required under the particular +circumstances of the case; and yet, strange to say, there are few subjects +which, generally speaking, have excited so little attention, and upon +which such incorrect opinions have prevailed even up to the present time. +The investigation is confessedly one of considerable difficulty, and as it +was more easy to calculate how the head ought to pass in this or that +position through the pelvis than to ascertain how it really did pass, +ingenuity has been taxed, and theories have been invented, and positions +of the child without number have been described, which have never existed +in nature, and which have only added to the difficulty and perplexity of +the subject. + +We consider that to form an accurate diagnosis in these cases, requires +the highest perfection of the _tactus eruditus_, which can only be +acquired by long practice and patient observation: and it is chiefly from +this circumstance that we can explain why such gross errors and vague +notions should have existed about a process of every day occurrence, and +why, with but few exceptions, they should have been transmitted from one +author to another even up to the present time. In the last century, when +it was so much the fashion to resolve every physiological process into a +mathematical problem, it was scarcely deemed necessary to spend much time +in actual observation and examination; the proportions between the head +and pelvis were ascertained, their angles were measured, and their curves +determined, and from these data it was inferred, what must be the course +which nature would follow; few attempted the slow but surer method of +ascertaining by patient research the real facts connected with the process +of parturition. + +When the long axis of the child's body corresponds with that of the +uterus, the child (provided the passages are normal) can be born in that +position: it matters little, as far as the labour is concerned, which +extremity of the child presents, so long as this is the case; but where +the long axis of its body does not correspond with that of the uterus, the +child must evidently lie more or less across, and will present with the +arm or shoulder, a position in which it cannot be born. In stating this, +we wish it to be understood, that we merely refer to the full grown living +foetus, and not to one which is premature, or which has been some time +dead in the uterus, as these follow no rule whatever, hence the positions +of the child at the commencement of labour resolve themselves into two +divisions, viz. where the median line of the child's body is parallel with +that of the uterus, and where it is not; the first we shall call +_natural_, the second _faulty_, presentations of the child. A description +of the natural presentations will form the contents of the present +chapter. + +The reader will almost anticipate us when we state, that the natural +presentations consist of two classes, those where the cephalic, and those +where the pelvic end of the child presents; in the first case, it will be +a presentation of the cranium or of the face; in the second, of the nates, +knees, or feet.[77] + +_Cranial presentations._ The presentation of the cranium, (or _vertex_, as +it has been improperly called,) is of by far the most frequent occurrence; +thus, for instance, of 4042 children which were born in the lying-in +hospital, at Heidelberg, 3834 presented with the head; of these the 3795 +with the cranium, and 39 with the face: in either case, whether it be a +presentation of the cranium or of the face, it will be either with the +right or the left side more or less foremost; the former, from its greater +frequency, has been called the first position of the cranium or face, the +latter the second position. + +_First cranial position._ It will be recollected we have stated, that the +os uteri at the end of pregnancy is turned obliquely backwards, +corresponding to the upper part of the hollow of the sacrum. If we examine +during the first stage of labour, when it is just dilated sufficiently to +allow the finger to pass, we shall feel the sagittal suture of the head +running across it, dividing it into two unequal portions, the os uteri +itself corresponding nearly to the middle of this suture. If the os uteri +be sufficiently dilated to let us trace its course, we shall find that it +corresponds more or less to the direction of the right oblique diameter, +viz. that it runs from the right and backwards, obliquely forwards, and to +the left. If we follow it with our finger in this last-mentioned +direction, we come to a spot where it divides into or meets two other +sutures; these are the right and left lambdoidal sutures, and beyond them +is the hard convex occiput, the point where they meet being the posterior +or occipital fontanelle. If we trace our finger along the suture in the +other direction, viz. backwards and to the right, we shall come to a four +cornered space, where four sutures meet at right angles to each other; +these are the sagittal, the frontal, and right and left coronal sutures; +the open space itself is the great or anterior fontanelle. + +That part of the head which lies lowest or deepest in the pelvis, and +which the finger first touches upon when introduced along the vagina, is +the right parietal protuberance; and if the os uteri be sufficiently +dilated, we distinguish it by its hard and conical feel. In primiparæ, +where the head usually is deep in the pelvis at the commencement of +labour, and where the anterior and inferior segment of the uterus is +closely stretched over it, the parietal protuberance may be felt through +this part. Hence, then, the first position of the cranium, (or more +correctly speaking, parietal bone,) is marked by the following characters: +the sagittal suture crosses the os uteri, and runs parallel with the right +oblique diameter of the pelvis: the vertex is therefore turned towards the +upper part of the hollow of the sacrum, the posterior fontanelle forwards +and to the left: the right perietal protuberance, therefore, is +necessarily that part which is deepest in the pelvis; and the +perpendicular diameter of the head, instead of corresponding to the axis +of the pelvic brim, runs in an oblique direction upwards and forwards. + +If the head at this early stage of labour be high up in the pelvis, viz. +has scarcely entered the brim, as is frequently the case in multiparæ, the +sagittal suture approaches in its direction to that of the transverse +diameter, or to one between the transverse and oblique diameters, the +posterior fontanelle corresponding to about the left acetabulum. The +higher the head is in the pelvis, the nearer does its greater diameter +correspond to the transverse one of the pelvis: the more oblique also is +its perpendicular diameter, from which reason the right ear at this time +can usually be felt without difficulty behind the pubic bones. Sometimes +both fontanelles can be reached with equal ease; most frequently the +posterior one is lowest, but occasionally the reverse is the case, and it +is the anterior fontanelle, without, however, at all influencing the +progress of the labour. + +As the head advances through the brim and begins to enter the cavity of +the pelvis, the sagittal suture corresponds more closely with the right +oblique diameter, so that now the posterior fontanelle is turned towards +the left foramen ovale, and as it approaches the outlet of the pelvis, the +occiput advances still more forwards, although the head entirely quits its +oblique position. At this stage of the labour, the fontanelles can usually +be again reached with equal facility, and we find the anterior one +corresponding to the right sacro-iliac synchondrosis, the occiput is +completely behind the left descending ramus of the pubes, the right +lambdoidal suture running parallel with it. Owing to this slight change in +the position of the head, the occiput having advanced somewhat forwards, +we no longer feel the right parietal protuberance to be lowest and in the +centre of the pelvis, but the finger now touches upon the posterior and +superior quarter of the right parietal bone, for this is the part of the +head which first comes under the pubic arch, and first enters the external +passages. + +If there be but little liquor amnii, or the membranes have been ruptured +prematurely: if the head be firmly pressed against the os uteri, and we +examine when it is not more than two-thirds dilated, we feel a puffy +oedematous swelling upon that part of the head which corresponds to the os +uteri. This will therefore be found to be situated upon the sagittal +suture, nearly equidistant from the anterior and posterior fontanelles; it +arises from the circulation in the scalp being obstructed by the pressure +of the os uteri upon the head. If the remaining portion of the labour be +rapidly completed, this will be the situation of the swelling with which +the cranium is born; if, however, it follows a more gradual course, and +the head passes slowly through the os uteri into the vagina, as it thus +advances deeper into the pelvis, and alters its position more or less, the +swelling upon the sagittal suture disappears in part, and forms on that +portion of the head which is advancing under the pubic arch, and is now +tightly encircled by the external passage: we shall, therefore, find that +this second swelling is situated upon the posterior and superior quarter +of the right parietal bone, and this is precisely the situation of the +swelling of the head, which the child is usually born with. + +From these facts we may deduce the following simple law respecting the +mechanism of parturition, where the head presents: viz. that the head +enters, passes through, and emerges from, the pelvis obliquely; and this +is the case not only as to its transverse diameter, but also as to the +axis of its brim; the side of the head being always lowest or deepest in +the pelvis. This shows the beautiful mechanism of the process, for, on +account of its oblique position, there is no moment during the whole +labour at which the greatest breadth (still less length) of the head is +occupying any of the pelvic diameters; even at the last, when the head is +passing under the pubic arch, the complete obliquity of its position, in +order that it should take up the least possible room, is very remarkable; +for the ring of soft parts, by which the head is now encircled, passes +obliquely across it, running close behind the left, and before the right +parietal protuberance. The head never advances with the occiput, forwards, +under the pubic arch, as is stated in works on midwifery, still less with +the sagittal suture parallel to the antero-posterior diameter of the +pelvis; for the direction of the right lambdoidal suture, as also of the +posterior fontanelle, and the position of the cranial swelling, or _caput +succedaneum_, as it has been called, completely prove the inaccuracy of +such a theory, the sagittal suture crosses the left labium at an acute +angle, the right lambdoidal suture being parallel with the left descending +ramus of the ischium. + +Not less incorrect is the theory (for we can call it nothing else) of the +head presenting with the vertex, and turning with its long diameter, from +the oblique, into the antero-posterior or conjugate diameter, and the face +into the hollow of the sacrum, for it is disproved by all the +above-mentioned facts, which careful examination during labour puts us in +possession of. When the head is born, the face looks backwards and to the +right, viz. to the back part of the mother's right thigh, for the +shoulders are by this time passing through the pelvis in its left oblique +diameter, the right shoulder being forwards and to the right, and lowest +in the pelvis: it is also that which is first expelled. + +Such is the manner in which the head presents in the first or most common +position: a slight modification of it is occasionally observed during the +early stages of labour, without influencing the favourable character of +its progress: the head at first is in the left oblique diameter of the +pelvis, the occiput towards the left sacro-iliac synchondrosis, the +anterior fontanelle towards the right acetabulum; but as the labour +advances, the head turns, so that the occiput corresponds to the left +acetabulum, the anterior fontanelle being turned towards the right +sacro-iliac synchondrosis, the sagittal suture running parallel with the +right oblique diameter of the pelvis. This peculiar commencement of the +labour is probably not detected so frequently as it really occurs, owing +to its changing into the common position at so early a period. + +_Second position of the cranium._ The other or second position of the +cranium is, where the _left_ side of the head presents. It is, in fact, +merely the reverse of the one just described: the sagittal suture crosses +the os uteri at the beginning of labour, as in the former case, only now +the posterior fontanelle is turned to the right instead of to the left; it +is the _left_ parietal protuberance which is deepest in the pelvis, and +which the finger first touches upon. As the labour advances, and the head +approaches the pelvic outlet, it is the posterior and superior quarter of +the _left_ parietal bone which first enters the vagina and protrudes +through the os externum, and upon which the swelling of the scalp or +_caput succedaneum_ is situated. + +The chief peculiarity is, that the change, which we noticed in the first +position as an occasional occurrence at the beginning of labour, is in +this case the regular commencement of it. In the second cranial position, +the head at the beginning of labour, with very few exceptions, is always +with its long diameter parallel with the right oblique diameter of the +pelvis, the posterior fontanelle turned towards the right sacro-iliac +synchondrosis, the anterior one towards the left foramen ovale. During the +early periods of labour, when the head is passing through the brim, both +fontanelles may be reached; and, generally speaking, the posterior one +with greater ease, from its being usually somewhat the lower; but as +labour advances, and the head has fairly engaged in the pelvic cavity, +they may both be reached with equal ease, the anterior fontanelle still +corresponding to the left foramen ovale, or rather to the descending ramus +of the left pubic bone. "As soon as the head experiences the resistance +which the inferior part of the pelvic cavity opposes to it, or, in other +words, the oblique surface which is formed by the lower end of the sacrum, +the os coccygis, the ischiadic ligaments, &c. by which it is compelled to +move from its position backwards in a direction forward, it turns by +degrees with its greater diameter into the left oblique diameter of the +pelvic cavity, viz. the posterior fontanelle is directed to the right +foramen ovale, and as the head approaches nearer and nearer to the +inferior aperture, it is the posterior and superior quarter of the left +parietal bone which is felt in the cavity of the pelvis opposite to the +pubic arch, so that when the point of the finger is introduced under and +almost perpendicular to the symphysis pubis, it touches nearly the middle +of the posterior and superior quarter of the left parietal bone: and this +is precisely the part, as the head advances farther, which first distends +the labia, with which the head first enters the external passages, and the +spot upon which the swelling of the integuments forms itself." (Naegelé, +_Mechanism of Parturition_, transl.) + +The manner in which this change in the position of the head takes place, +varies a good deal in different labours: in primiparæ it usually takes +place slowly, and requires several pains before it is completed; as the +pain comes on, the posterior fontanelle, which was backwards and to the +right, now advances more forward and comes more within reach; the anterior +fontanelle, which was towards the left foramen ovale, retreats, so that +when the pain has reached its maximum the head will for a moment be felt +in the transverse diameter of the pelvis, and again resumes its former +position as the pain goes off: with the recurrence of each pain there is a +repetition of this screw-like motion, but by degrees the head not only +passes from the right oblique into the transverse diameter, but from the +transverse into the left oblique, so that at length the anterior +fontanelle corresponds to the left sacro-iliac synchondrosis, and the +posterior one to the right foramen ovale. + +In women who have already had children, the whole change is frequently +effected during one pain, so that the head, which but a few minutes +previously was presenting in what is called the third position of the +German schools, will now be found to be in the second. + +It is to the celebrated Naegelé of Heidelberg that we are indebted for +having first pointed out the uniform occurrence of this change in the +second position. From his extensive and accurate observations, confirmed +since by ourselves, as well as by many others, the head presents with the +occiput _originally_ forwards and to the right very rarely, but passes +into this position during the course of labour. No one has ever described +the mechanism of parturition so minutely and correctly; and the value of +his investigations is the more enhanced, when we recollect what erroneous +notions have prevailed upon this important subject up to the present time. +"In the former part of my practice," says this distinguished obstetrician, +"not knowing that the head made this turn, I always concluded that my +examinations in the early part of labour were incorrect, and was very +uneasy that I did not find it all exactly as the books described, and +attributed my want of success in ascertaining the position to my own +awkwardness. At length in a private case, in which I was much interested, +I again felt what I thought was the anterior fontanelle towards the left +foramen ovale; and circumstances occurring which rendered it necessary to +apply the forceps and terminate the labour, I found that the head had been +actually in the position which I imagined I had felt. Since this time I +have, in many cases, sat by the bed-side during the whole labour, with my +finger upon the head, and thus come at the truth." (_MS. Lectures._) + +The very circumstance of this change in the position of the occiput from +the sacro-iliac synchondrosis to the foramen ovale of the same side, is of +itself quite sufficient to mislead; nor is it to be wondered at that it +should have been so long unnoticed, when we recollect how difficult the +examination is at this early stage of labour, and how few give themselves +the trouble to attain that degree of dexterity and tact, which, even under +the most favourable circumstances, is required for this species of +investigation. + +The diagnosis of the sutures and fontanelles may be rendered more +difficult by other circumstances: when there is a large quantity of liquor +amnii between the head and membranes, it renders the diagnosis exceedingly +obscure in the early part of labour. In some cases the cranial bones are +remarkably thin and yielding, and communicate a sensation to the finger as +if it were touching a fontanelle; in others, the sutures run an irregular +course, and form ossa triquetra, &c. which may easily mislead. We may +also notice the changes, already mentioned, which are produced by the +death of the child, and the various congenital anormalities of +hydrocephalus, acephalus, &c. &c. In some cases the sagittal suture is +continued backwards through the occipital bone, dividing it into two equal +portions, and thus making the posterior fontanelle four cornered, and not +to be distinguished from the anterior. Nor is it always easy to +distinguish the posterior from the anterior fontanelle under more normal +and favourable circumstances; for it would be hazardous to conclude that +it is the posterior fontanelle merely because we feel three sutures +meeting together, as it may possibly be the anterior one, and we are not +able to reach the sagittal suture beyond. In this case we may ascertain +which it is by the following rule: if it be the posterior fontanelle in +the first position we shall feel a suture running more or less forwards +(the right lambdoidal,) but none backwards; but if it be the anterior +fontanelle forwards and to the left, we shall also feel a suture (the +right coronal) running backwards. Lastly, in the second cranial position +the face when born turns to the posterior surface of the mother's left +thigh. + +Such are the two positions in which the head presents during labour, and +such is the manner in which it passes through the pelvis and external +passages. Slight deviations do occasionally take place, the chief of which +is, that the head in the second position does not always make the quarter +of a turn as above described, but comes out with the anterior fontanelle +forwards and to the left: this is by no means of common occurrence, and, +as far as we have observed, increases the difficulty of labour very +little. + +_Face presentations._ The face, like the cranium, may present in two ways, +either with its right or left side forwards. The former is the most +frequent occurrence, and bears a striking analogy to the first cranial +position; indeed, we cannot too strongly impress upon the minds of our +readers the advantages of accurately knowing the different features of the +two cranial positions just described; for by this means the positions of +the face will be rendered much more simple and easy of comprehension. +Whether the right or the left side of the face presents (first or second +facial position,) the root of the nose crosses the os uteri exactly in the +same manner as the sagittal suture does in the two cranial positions; the +chin is turned to the right acetabulum, and as the face descends through +the pelvis during the progress of the labour, the chin moves somewhat more +forwards, as the occiput does in the cranial positions. + +At an early stage of labour the right eye and zygoma is that part of the +face which is lowest in the pelvis, and which the finger first touches +upon during examination, precisely as it was the right parietal +protuberance in the first cranial position; and as in this case the caput +succedaneum was situated upon the posterior and superior quarter of the +right parietal bone, so here the livid bruise-like swelling, which the +face brings with it into the world, is situated upon the right cheek, this +part being the first which presses through the os externum; the chin +passes under the right branch of the pubic arch, as the occiput in the +first cranial position does under the left, the face during the whole +process preserving a strictly oblique position, both as to the transverse +diameter and axis of the pelvis.[78] + +_Second position of the face._ The second position of the face is merely +the reverse of the first: it is now the left side which is turned +forwards, the left eye and zygomatic process being those parts which are +lowest in the pelvis; the chin is turned to the left side and somewhat +forward, and advances towards the left foramen ovale during the farther +progress of the labour. As the face approaches the inferior aperture of +the pelvis, it is the left cheek which first enters the os externum, and +upon which the swelling is situated: likewise the chin passes beneath the +left branch of the pubic arch. + +It has been supposed by some authors, and we think correctly that the +majority (if not all) of face presentations are originally cranial +presentations: if this be the case, we can easily understand why the right +side of the face presents more frequently than the left, for if the head +in the first cranial position moves round upon its transverse diameter, +and thus allows the face to turn downwards, we shall immediately have a +first position of the face. We are the more inclined to adopt this +opinion, not only from the greater number of cases where the right side of +the face presents, but also from our having more than once met with cases +where so long as the head of the child was moveable above the brim, the +presentation was midway between one of the cranium, and of the face. On +one side of the pelvis we could feel the anterior fontanelle; on the other +we could, with some difficulty, reach the orbital process of the frontal +bone: as the pains increased, and the head advanced lower, the side of the +face came more within reach; so that by the time it had fairly entered the +cavity of the pelvis, it had become a complete presentation of the +face.[79] + +We distinguish the face by the bridge of the nose, which from its crossing +the os uteri may be detected at a very early period of labour: it is far +better than the eye, for not only is this liable to mislead us in our +examination, but it may also receive injury from the finger. Nor is the +malar bone a guide, for this might easily be mistaken for the tuberosity +of the ischium, or even for the shoulder. The nose not only tells us that +the face is presenting but also in which position, for at one end we +shall feel the soft cushiony extremity of it, at the other we shall reach +the broad hard expanse of the forehead. + +It was not until nearly the end of the last century that presentations of +the face ceased to be accounted unnatural, and impossible to be terminated +by natural means. Although the fact had been pointed out by Portal so +early as 1685, that these presentations were very little removed from the +usual one, it seems to have excited but little attention until the time of +Deleurye in 1770. "I have," says Portal, "delivered several women whose +children came with the face foremost, and always without any great +difficulty, it being only observed, _that in such cases no violence must +be used, but nature be left to its own course; which done, there is no +danger either of mother or child_." (Portal's _Midwifery_, transl. obs. +66:) La Motte in 1721, although so accurate an observer, could not divest +himself of the general opinion that these were unfavourable positions, +even although the face was usually expelled by the natural efforts, after +he had fruitlessly endeavoured to rectify it, and although he himself +confesses never to have "seen any that had not done well." + +Giffard has recorded two cases of face presentation (_Cases in Midwifery_, +1734, p. 59, 443.,) both of which he delivered by his extractor, which was +one of the early forms of midwifery forceps; and in both, although the +labour had lasted some time, the child was alive. He describes the +position of the face in the second case, the chin being turned towards the +right side. The only practical observation which he makes is, that turning +is very difficult where the "waters are gone off, and the uterus closely +envelopes the child." This is probably given as an explanation for his +deviating from the usual practice of turning in these cases. Deleurye in +supporting Portal's views observes, "one daily sees similar labours +terminate naturally: it is true they are somewhat longer, but they +terminate without the aid of art." (_Traité des Accouchemens_, 1770, § +736.) + +Lastly, the celebrated Boer of Vienna (1793) placed the matter in a still +more decided point of view when he asserted, that "face presentations +being merely a rare form of natural labour, should be left to be completed +by the natural efforts, since neither the mothers nor their children were +exposed to any more danger in this form of labour than they were in the +most usual forms of all." Having charge of the great lying-in hospital of +Vienna, Boer had ample means of ascertaining the most accurate results on +all points of practical midwifery, and his observations on labours where +the face presented, are, therefore, peculiarly interesting, and tend +strongly to contradict the prevailing opinion respecting the difficulty +and danger of these presentations. + +"Of eighty cases of face presentations which have occurred during a period +of some years, and which I have myself observed and noted down, there +were three, or at the most four, where the children were born dead. None +of the patients suffered in the slightest degree from any of these +labours; and, except one case, all were left entirely to nature: in one +case only, on account of the weakness of the pains and doubtful character +of the symptoms, I deemed it necessary to terminate the labour by the +forceps." (Boer's _Natürliche Geburtshülfe_, erstes buch, p. 137.) In +spite of this valuable practical fact, supported by experience on so great +a scale, the opinion that face presentations were preternatural, continued +to prevail upon the Continent, being supported by the authority of +Baudelocque and Osiander. A similarly unfavourable opinion was entertained +by Dr. Smellie in this country, although Dr. W. Hunter, in his lectures +delivered prior to the publication of his plates on the gravid uterus +(and, therefore, at an early date,) states, "in this case I do not turn +the head round in order to deliver, but nineteen times in twenty leave it +to itself to come as it will." (W. Hunter, _MS. Lectures_.) + +Dr. R. W. Johnson, who dedicated his _New System of Midwifery_, &c. to Dr. +W. Hunter and others, in 1769, and probably attended his lectures, +expresses a similar opinion, and says, that in these cases "nature herself +will do the work." (p. 267.) Dr. Alexander Hamilton, in 1784, also speaks +favourably of these presentations. "The head will, however, in most cases, +advance in that position by the force of the natural pains, though the +delivery will be more slow or painful." (_Outlines of the Theory and +Practice of Midwifery._) + +Farther experience has shown that, so long as the pelvis is of the natural +size, the head can be born in this position without peculiar difficulty, +the soft parts usually require a little more dilatation than where the +cranium presents, and, therefore, this stage of the labour is generally +somewhat slower. Although presentations of the face are not so favourable +for the child as those of the cranium, they stand next to them in point of +safety. Where the cranium presents, a slight misproportion between the +head and pelvis produces little or no increase of difficulty to the +passage of the child; but under similar circumstances, where the face +presents, the difficulty may become very serious, for if the labour is +prolonged, "the brain and vessels of the neck," observes Smellie, "will be +so much compressed and obstructed as to destroy the child." (Explanation +to table 25.) A similar view has been given by Dr. Denman, and still more +recently by Professor Chaussier, of Paris, and Professor Naegelé; the two +latter authorities examined the brain in several still-born children where +the face had presented, and invariably found the cerebral vessels gorged +with blood. + +The presenting side of the face when born is frightfully distorted by the +livid swelling above-mentioned; the mouth is pulled to one side and +upwards; the angle of the eye is drawn downwards, and the corresponding +ala of the nose scarcely discernible amid the purple mass of tumefaction: +the less this is meddled with the better, for in the course of a day or +two the parts will have returned to their condition; whereas, if friction +or hot poultices, &c., be used, ulceration may be the result, and produce +considerable disfigurement.[80] + +_Nates presentations._ "After the presentations of the cranium those of +the nates are the most frequent in point of occurrence, and also the most +natural," says the celebrated Boer, in the work already quoted. Under the +term _nates_ presentations, we include those of the knees and feet, as +these latter presentations can only be looked upon as modifications of the +former. Professor Naegelé, jun., in his new edition of the admirable essay +upon the mechanism of labour, published by his father, in Meckel's +_Archiv. für die Physiologie_, has very properly brought these different +positions under one head, viz. "positions of the pelvic extremity of the +child:" as, however, we possess no word in English to express this, we +shall attain the same object by considering knee and footling births as +mere modifications of breech presentations. + +"As regards the relative situation of the limbs to the body of the child, +the position is the same as in the two genera of head presentations above +described, viz. the knees are usually drawn up to the abdomen, the feet +close to the nates, so that not unfrequently they may both be felt +together at the beginning of labour, and afterwards descend into the +pelvis and are born together. Sometimes the feet (or perhaps only one +foot) are felt higher above the brim than the nates; in which case, as the +nates descend they rise, and are turned upon the abdomen and breast of the +child, and descend with these parts as labour advances. Frequently it is +the reverse: the feet are somewhat lower than the nates; they are felt in +the os uteri at the beginning of labour, and descend before them as labour +advances. It is rare that the knees come down before the nates during the +farther progress of labour, and it is not probable that they are ever +found alone in the os uteri at the commencement of it." (H. F. Naegelé, +_Mechanismus der Geburt_, 1838, p. 57.) + +The nates may present in two ways, either with the back of the child +forwards, or with its abdomen forwards: of these the former occurs most +frequently; thus of 161 cases which were accurately ascertained at the +lying-in hospital of Heidelburg, 121 were observed with the back of the +child forwards, and 40 with it backwards: in either of these positions the +transverse diameter of the child's pelvis always corresponds to one or +other of the oblique diameters. + +"Labours with the nates or feet presenting, follow certain laws quite as +much as those where the head presents, only that one more frequently sees +deviations from them, both with respect to the manner in which the child +presents at the time of labour, and its passage through the pelvis; but +where, under a proper state of the other requisites for healthy +parturition, no prejudicial result occurs." (Naegelé, _on the Mechanism of +Parturition_, transl. § 19. p. 128.) "In every case, whether the nates +have at first a completely transverse or oblique direction, they will be +always found, on pressing lower into the superior aperture of the pelvis, +to have taken an oblique position; and that ischium, which is directed +anteriorly, to stand lowest. They pass through the entrance cavity and +outlet of the pelvis in this position, which is oblique, both as to its +transverse diameter as well as to its axis." + +Thus, if in the first species the left ischium were either originally +directed more or less forward, (which is usually the case,) or had taken +this direction in passing through the superior aperture, the nates descend +in this direction into the pelvic cavity, with the left ischium during the +whole time standing lowest; and this is the part, during the farther +progress of the nates, which first passes between the labia as the os +externum dilates. As they advance, and while the left ischium, which is +directed forwards and always somewhat to the right, comes completely under +the pubic arch and presses against it, the other ischium, which is +situated in the opposite direction, and which has to make a much greater +circuit, passes forwards over the strongly distended perineum, so that, +when the pelvis is born, the abdomen of the child will be directed to the +inner and posterior surface of the mother's right thigh. + +"The rest of the trunk follows in this position, and as the breast +approaches the inferior aperture of the pelvis, the shoulders press +through its superior aperture in the direction of the left oblique +diameter; and during its passage (viz. the breast) through the pelvic +outlet, the arms and elbows which were pressed against it are born at the +some moment. But whilst the shoulders are descending in the +above-mentioned oblique position, the head, which during the whole +progress of the labour rests with its chin upon the breast, presses into +the superior aperture in the direction of the right oblique diameter, +(viz. with the forehead corresponding to the right sacro-iliac +synchondrosis,) and then into the cavity of the pelvis in the same +direction, or one more approaching the conjugate diameter. After this, it +presses through the external passage and the labia, in such a manner, that +whilst the occiput rests against the os pubis, the point of the chin, +followed by the rest of the face, sweeps over the perineum as the head +turns on its lateral axis from below upwards. + +"But it is sometimes the right ischium, which, in this chief division, is +either originally turned forwards, or in the process of time assumes this +direction. In this case the child passes through the pelvis in the same +manner as before, only with the difference, that the surface of the body +takes of course a different position with respect to the pelvic parietes, +viz. its anterior surface, which in the former case corresponded to the +right side of the pelvis, will be directed to the left, and the head will +press through the superior aperture of the pelvis, in the direction of the +left oblique diameter (the forehead passing before the left sacro-iliac +synchondrosis.)" + +"As in positions of the cranium, the swelling of the integuments is +chiefly met with on that parietal bone which during the passage of the +head, is situated lowest, and on that spot with which it enters the +external passage, so in this case the livid coloured swelling appears on +that part which, directed forwards, was situated lowest during the passage +of the nates, and with which the nates were born. + +"In the second chief position, viz. with the anterior surface of the child +corresponding to the anterior abdominal parietes of the mother, it is +chiefly the left ischium which is either originally situated forwards, or +takes this direction as the nates sink through the superior aperture of +the pelvis, which latter preserve this oblique direction during the +farther progress of the labour, both whilst pressing into the pelvic +cavity, and when entering the external passages. + +"If the ischia be already born, the anterior surface of the child turns +itself to the right and backwards, either immediately, or as the rest of +the trunk advances; but the manner in which the head in this case presses +through the entrance cavity and outlet of the pelvis, is the same as has +already been described." (Naegelé, _op. cit._ p. 128, 130.) + +It appears to be a law in nates presentations, that whatever may be the +direction of the child (first or second position) at the beginning of +labour, it will always, if not interfered with, be found with its anterior +surface turned towards one or other of the sacro-iliac synchondroses, when +the thorax or the shoulders are beginning to pass through the outlet of +the pelvis. When the nates have once passed the os externum, the position +of the child frequently varies a good deal, the abdomen turning first to +one side and then to the other. This is especially the case in the second +position, where it is more or less forwards; nevertheless, as labour +advances, it will almost invariably turn obliquely backwards, and be born +in this position. Dr. Collins is, as far as we know, the only English +author who has distinctly noticed this fact. "It is very desirable," he +observes, "the child should be delivered in this position (viz. the back +of the child towards the mother's abdomen,) as it renders the getting away +of the head much less difficult; yet where there has been no interference +by the attendant in the previous part of the labour, he will rarely find +it necessary to alter subsequently the child's position, the breech +naturally making the turn above alluded to in its passage." (_Practical +Treatise on Midwifery_, by Robert Collins, M. D. p. 41.) + +It sometimes, although rarely, happens in these presentations, that the +head does not rest with the chin upon the breast, but the occiput is +pressed against the nape of the neck, as in presentations of the face. The +passage of the trunk through the pelvis follows, as above-mentioned, as +far as the head: this enters the brim with the occiput in advance, and +vertex towards one or other ilium. As it advances through the brim into +the cavity of the pelvis, it gradually turns more and more backwards, so +that when the body is born, the vertex is turned towards the hollow of the +sacrum, and the under surface of the lower jaw behind the symphysis pubis. + +The _diagnosis_ of nates presentations is not difficult. The pointed and +more or less moveable coccyx, bounded at its broader end by the hard +uneven sacrum, and in the contrary direction by the anus, will scarcely +admit of a mistake. The tuberosities of the ischia may easily be mistaken, +for the malar bone of a face presentation, or even a shoulder, can +scarcely be distinguished from them, and the external organs of generation +become too much swollen and pressed together to give any certain +diagnosis; nor indeed can they be examined in this state without +considerable risk of injury. The direction of the sacrum, like that of the +forehead in face cases, points out the exact position of the child. + +Presentations of the nates, although perfectly natural as far as labour is +concerned, are far more dangerous for the child than those of the face, +for when the head enters the pelvis, if every thing be not favourable for +its passing rapidly through it, the cord is so long compressed that the +child is almost certainly lost. + +The natural position of the foetus in utero is admirably adapted for its +safe passage through the pelvis under these circumstances, and is what we +ought to maintain, as far as possible, during labour. The legs are turned +upon the abdomen, the arms are crossed upon the breast, the chin rests +upon it, the head being bent forwards, so that the whole forms an oval +mass. So long as the child advances gradually, the fundus presses firmly +upon the head, and keeps the chin close upon the breast; the head +therefore enters the pelvis in the most favourable position possible, and +the uterus, not having been suddenly emptied of a part of its contents, +continues to act briskly, and presses the head so rapidly through the +pelvis, that the child is born without having suffered from any serious +pressure upon the cord. As however the body of the child diminishes from +its pelvis up to the axillæ, it is very apt to be rapidly expelled as soon +as the nates have passed the os externum; and if not, it is but too +frequently _assisted_, as it is called, at the very moment when it ought +rather to be supported and prevented from advancing too suddenly. When +this is the case, the fundus ceases to press upon the head, the chin quits +the breast, and as a space is thus left between them, the arms slip into +it, and then turn upwards, so that the head not only enters the pelvis in +a most unfavourable position, but, to make matters still worse, it has an +arm on each side of it: at this critical moment the uterus, from having +been suddenly emptied, ceases to contract, and the head remains so long in +the pelvis that the child has no chance of escaping with its life. + +Where the child has descended gradually, and the arms have advanced with +the breast into the pelvis, if the cord be considerably upon the stretch, +a portion should be pulled gently down in order to relax it, and we should +endeavour as far as possible to guide that part of it which is within +reach towards one of the sacro-iliac synchondroses, being less liable +there to suffer from pressure. One or two fingers should be introduced to +bring down the arms, which are now coming into the lower part of the +hollow of the sacrum: they should be hooked down by the bend of the arm, +in order to prevent the humeri from sticking across the passage. When this +has been effected, the shoulders follow as the head descends through the +pelvis. The body of the child should now be wrapped in warm flannel, and +two fingers passed up towards the face: the lower jaw must not be trusted +to in bringing the head through the pelvic outlet and os externum, for it +may easily be broken: the fingers should be applied one on each side the +nose, and the chin depressed as much upon the breast as possible, by which +means the head will come in a much more favourable direction, and pass +readily. + +In no case is so much mischief done by impatient interference as in +presentations of the lower end of the child. This is still more so in +footling cases, for here the soft parts are not so well dilated as in +nates presentations, where the child comes double: hence the fact, that +presentations of the feet are easier to the mother but more dangerous to +the child. In either case, the passage of the head through the pelvis must +ever be attended with considerable hazard, for if it be delayed beyond a +short time, the child's death is certain. "The more gradually the nates +and body of the child are expelled, the quicker will its head pass through +the pelvis, and the better will be its chance of being born alive." +(_Obstet. Memorand._ 2d ed.) Hence, therefore, if the pains are slow at +this moment, it will be desirable to rouse them with a dose of ergot; and +if the child gives a convulsive twitch, the forceps ought instantly to be +applied. The result of Professor Busch's practice in the lying-in hospital +at Berlin shows, that by the timely use of the forceps a large majority of +children may be saved. For the same purpose, the nurse should be +instructed to have a warm bath in readiness, with some spirit, &c. for +resuscitating the child the moment it is born. + +The numbers which we subjoin are taken from the cases in the Dublin +Lying-in-Hospital, under the late Dr. Joseph Clark and Dr. Collins, from +the private practice quoted in Dr. Merriman's _Synopsis_, and from the +General Lying-in-Hospital. + +Of 71,578 labours, the nates presented once in every 78 cases, and the +feet once in every 108-1/2. Of the nates cases the child was born dead in +the proportion of 1 to 3·8, and in the footling births 1 to 2·8. + + + + +PART IV. + +MIDWIFERY OPERATIONS. + + + + +CHAPTER I. + +THE FORCEPS. + + _Description of the straight and curved forceps.--Mode of action.-- + Indications.--Rules for applying the forceps.--History of the + forceps._ + + +Before describing the various species of dystocia, or faulty labour, it +will be necessary to consider the different means with which the +increasing experience of years has furnished us, of giving artificial +assistance in such cases. These may be brought under two heads, first, +where delivery can be effected with safety to the mother and her child; +secondly, where this can only be effected at the expense of the infant's +life. Under the first head come the forceps, turning, the Cæsarean +operation, and artificial premature labour; under the second are +craniotomy or perforation, and embryotomy. + +Of these the forceps is by far the simplest and safest means of artificial +delivery, and is therefore an operation which should always be had +recourse to in preference to any of the others wherever it is possible. + +The forceps is the simplest imitation of nature, for in fact it is nothing +more than a pair of artificial hands introduced one on each side the head. +It is impossible to define any precise limits of pelvic contraction, +within which the forceps can, or beyond which it cannot, be safely +applied, for the difference in the size and hardness of the child's head, +and in the condition of the soft parts, will greatly modify the degree of +resistance to the progress of the labour: hence the attempt to fix the +exact degree of contraction beyond which the forceps becomes inapplicable +is quite impracticable, as in some cases we might be led to make a trial +of it where it would be quite improper, and in others have recourse to the +perforator where a cautious application of the forceps would have been +attended with success. For the farther consideration of this subject we +must refer to the chapter on DYSTOCIA PELVICA. + +The forceps consists of three parts--the blades, the lock, and the +handles. + +The blades of the present forceps are not solid, but are merely elongated +bows of polished metal, by which they are not only rendered much lighter, +but allow the most prominent parts of the head to project between them, +and thereby take up no additional room when introduced into the pelvis. In +the simplest form, viz. the straight forceps, the blades have only one +curvature for adapting them to the convexity of the head. The degree of +curve varies a good deal in different instruments: the greater the curve +the more firmly will the blades hold, because they act more or less as +blunt hooks, and do not require much pressure upon the head for the +purpose, but on the other hand, they are more difficult to introduce; +whereas, blades which are slightly curved can be applied with greater +ease, but require much more pressure upon the head in order to hold fast. + +It has been a general rule with almost every modification of forceps, that +the greatest distance between their blades should not be less than two +inches and a half, for as this is the breadth of the basis cranii in the +foetal head, it would be impossible to compress the head beyond this +extent. The form of the head curvature will determine the situation of the +point where the blades are most distant from each other: in some forceps +it is about one-third the length of the blades from their extremities; in +some it is nearly equidistant; whereas, in others it is nearer to the +lock; the medium between these extremes is the best. The extremities of +the blades ought to be at least half an inch apart: in this country they +are usually somewhat more; on the Continent they are much less, being +rarely more than one or two lines asunder. The fenestræ, or open spaces in +the blades, should be wide and ample, for not only are the projecting +parts of the head allowed to protrude between them, but the pressure of +the blades is diffused over a larger extent of surface: this is remarkably +seen in the forceps of the late Dr. Hopkins and that of Professor Davis, +both of which are extensively used. It is also important that the edge at +the extremities of the blades should be well rounded and not too thin; it +is thus less liable to catch against corrugations either of the vagina or +foetal scalp. The greatest breadth of the fenestræ is generally towards +the extremities of the blades; in some, their edges are parallel; whereas, +in those of Drs. Orme and Lowder the greatest breadth is near the lock: +upon the whole, an oval shaped fenestra is the best, for it can be easily +introduced, and has the advantages of a wide blade. + +In 1751 and the following year another curve was given to the blades of +the forceps by the celebrated M. Levret of Paris, and by the equally +distinguished Dr. Smellie of London, by which the instrument was adapted +to the curve formed by the axes of the brim, cavity, and outlet of the +pelvis, and by which the head could be seized much higher in the pelvis +than by the straight forceps. Each have an equal claim to the merit of +having invented this "pelvic curvature," as it has been called: the +priority of the invention is perhaps due to Levret; but as he made a +secret of it for some years, it is impossible to ascertain the precise +fact. The pelvic curve, as it is called,[81] is especially adapted to the +long forceps, which thus becomes an instrument of very considerable power. +Numerous modifications of these curved forceps have since been made, but +they are merely varieties of the original ones invented by Smellie and +Levret, which have become the national instruments of their respective +countries. + +Perhaps the greatest improvements in the blades of modern times is seen in +the forceps of Dr. Hopkins, above alluded to: the head curvature forms an +elongated oval, admirably adapted to the form of the foetal head when +considerably compressed during a difficult labour; and from the great +breadth of the fenestræ, the pressure of the blades is applied over a +large extent of surface; the pelvic curve is but slight, being greater on +the posterior edge of fenestræ than on the anterior; the blades themselves +are thin, their inner surface flat to ensure a firmer hold, their outer +surface slightly rounded in order to be introduced with greater ease; and +for a similar reason the edges of their extremities are somewhat thicker +and carefully rounded in a peculiar manner. + +[Illustration: Naegelé's forceps.] + +The lock of the modern English forceps consists of two deep grooves, into +which the shank of each blade mutually fits, so that the two blades are +fixed upon each other merely by the pressure exerted upon the handles. In +former times the blades were united together by a pivot, which could screw +and unscrew at pleasure. This was abandoned by Chapman, who published the +first work in English on operative midwifery.[82] He found that the +forceps held better without the pivot than with it; and from what we have +brought forward elsewhere (_Med. Gaz._ Jan. 8, 1831,) there can be little +doubt that he invented the lock which is now generally used in this +country. Chapman's forceps was adopted in France prior to this improvement +in its lock, especially by Gregoire, and has retained the original pivot +lock which now forms one of the most distinguishing marks between the +French and English forceps. Although the pivot forms by far the firmest +lock, for the blades can never slip from each other, still the difficulty +in locking, and also in separating, the blades at a moment's notice, +render it much inferior to the English lock. An ingenious modification was +invented by the late Professor Von Siebold of Berlin, but the most perfect +lock is that of Professor Brüninghausen of Würzburg, first introduced by +ourselves into this country, and commonly known among the +instrument-makers under the name of Professor Naegelé's forceps. The shank +of one blade has a semicircular indentation, which at the moment of +locking fits into a fixed pivot in the other: this, therefore, combines +the advantages of the French and English locks. We can safely affirm, from +extensive experience for many years, that there is even less difficulty in +locking it than with the English lock: the blades are capable of instant +separation, and yet when locked, the firmness of their union is equal to +that of a pivot joint. + +The handles of the English forceps are pieces of wood or ivory fixed upon +each shank below the lock, flat upon the inside, convex externally and +furnished with a depression or groove at the lower end for fixing a +ligature round them. These handles were probably first introduced by Dr. +Smellie, who seems to have borrowed the idea from the forceps of M. +Mesnard, for the earlier English forceps, viz. of Giffard and Chapman, +terminated in blunt hooks, those of the former being curved inwards, those +of the latter outwards, a form of handle which has been retained in the +French forceps up to the present time. + +There are two pieces of forceps, the _long_ and the _short_ forceps; the +former for cases where the head is still high in the pelvis, the latter +when it is at the pelvic outlet and approaching the os externum; the +former with few exceptions being curved, the latter straight.[83] + +The forceps act in three ways, 1. by mere pulling; 2. as a species of +double lever, by moving the handles from side to side; and 3. by +compressing the head, thus still farther disposing it to elongate and +adapt itself to the passage through which it has to be expelled. + +The blades should always, if possible, be applied one on each side of the +head, the position of which must be determined by the direction of the +fontanelles and sutures, not by feeling for the ear, as is usually +recommended in this country. The ear can seldom be reached without causing +a good deal of pain, even under the most favourable circumstances; in +cases, therefore, where the head is so impacted as to be incapable of +advancing by the natural powers, it cannot surely be justifiable to force +up the finger between the head and the pelvis to ascertain this point, the +more so, as the soft parts soon become swollen and more or less inflamed, +and, therefore, little able to bear such rude treatment. No operation +requires such an intimate acquaintance with the mechanism of parturition +as that for applying the forceps: it is simple and generally perfectly +easy when the precise position of the head and its relations to the pelvis +are accurately known; on the other hand, it is not less injurious and +painful to the patient than difficult and unsatisfactory to the +practitioner. + +The most usual circumstances under which the forceps is applied, are where +the head is already deep in the pelvis and approaching the os externum; in +such cases it is generally required not so much for the purpose of +overcoming an unusual degree of resistance, as for assisting the natural +powers, which are becoming exhausted: the head is near the os externum, +and therefore easily reached; and from there being little or no impaction +present, the blades are applied without difficulty. + +The application of the forceps when the head is at the upper part of the +pelvis, and where the greater portion of it has not yet passed the brim, +is rarely practised in this country, because as the necessity for +performing the operation at this stage arises in most instances from +contraction of the brim, the perforator has usually been preferred, +wherever the expelling powers have proved incapable of overcoming the +resistance to the passage of the head. The circumstance also of this +condition requiring the long forceps has been another source of objection, +from the much greater power which this instrument is capable of exerting, +and from its being therefore more liable than the short forceps to prove +mischievous in the hands of the inexperienced. + +Cases however do occur where there is but a very slight want of proportion +between the head and pelvis, where the obstacle is easily overcome, and +where, but for the application of the forceps, the labour would either +have been protracted to a dangerous degree, or have required the use of +the perforator.[84] "On the whole," says Dr. Burns, "I would give it as my +opinion that a well instructed practitioner, who has already had some +experience in the use of the short forceps, is warranted to make a +cautious, steady, but gentle attempt to apply and act with the long +forceps in a case where he is not quite decided that the perforator is +indispensable, and where the head is higher than admits the application of +the short forceps." (_Principles of Midwifery_, 9th ed. p. 493.) + +In applying the forceps, whether short or long, there are two conditions +which, _cæteris paribus_, are requisite in every case; first, that the os +uteri shall be fully dilated; secondly, that the pains are within the +bounds of what are commonly known as moderate pains. In the first case it +will be very difficult and frequently quite impossible to pass the blades +between the head and os uteri when only partly dilated; it will be +difficult to avoid injuring its edge more or less, and if we do succeed in +applying and locking the forceps, on making an extractive effort we shall +find that the uterus descends with the head as we draw it down. + +In the second place we ought never to apply the forceps whilst the pains +are violent, for not only do they render its application difficult and +even dangerous, but we are adding still farther to the force (already too +great) with which the head is pressed against the pelvis. Where the head +remains immoveable under violent exertions of the uterus, it is not a case +for the forceps but for the perforator; nor does it admit of much delay, +for it endangers much injury of the soft parts or even rupture of the +uterus. + +It is exceedingly difficult to assign any precise limits of pelvic +contraction, within which the forceps can, and beyond which they cannot be +applied, for the size and hardness of the foetal head, the nature of the +pains, and the condition of the patient must also be taken into account in +every instance; hence, we frequently meet with cases where the pelvis is +scarcely if at all contracted, and yet where the labour has been +terminated with the greatest difficulty by means of the forceps; whereas, +in others where we know the pelvis to be more or less deformed, the child +has been delivered by the natural powers. This subject will be still +farther considered under DYSTOCIA PELVICA. + +The _general indications_ for the use of the forceps are two: 1. They are +indicated in all labours which are difficult or impossible to complete, +either from deficiency in the expelling powers, or from misproportion +between the head and pelvis, or from the arm coming down with the head. 2. +They are indicated by circumstances or accidental causes, which render +labour dangerous for the mother or child, and where the danger can only be +removed by hastening labour, as in cases of hæmorrhage, convulsions, +syncope, alarming debility, faulty condition of the organs of respiration, +danger of suffocation, obstinate vomiting, unusually severe pains in +nervous irritable habits, hemorrhoids which have burst, hernia, retention +of urine, determination of blood to the head, prolapsus of the cord, (in +certain cases,) inflammation of the uterus, &c. (Naegelé, _MS. Lectures_.) + +We have already stated that an intimate acquaintance with the mechanism of +parturition is of the greatest importance in applying the forceps. Knowing +that the head always presents in one of the two oblique diameters of the +pelvis, and that the blades are applied on each side of the head, it +follows that the forceps must always be applied in the contrary oblique +diameter of the pelvis to that in which the head is. Before speaking of +the operation itself, we must first consider what position of the patient +will be the most convenient. In this country no alteration is made in her +position, beyond bringing her close to the side of the bed, with the nates +projecting as much as possible over the edge, for the greater convenience +of the operator; unless this be attended to, it will be difficult to +depress the handle of the upper blade sufficiently when introducing it. +Upon the continent, and also in America, where the long forceps is more +generally used, the patient is usually delivered on her back; she is +placed in a half-sitting posture upon the edge of the bed, her back +supported by pillows, &c., her feet resting on two chairs, between which +the operator stands or sits, and applies the forceps in this position. +This, in many respects, is the most convenient posture for him, but the +very preparation which it requires cannot but be alarming to the patient, +who is obliged to be a witness of all his manipulations; whereas, when she +lies upon her left side, she is aware of little or no preparation being +made, and if any slight exposure happens to be necessary, viz. at the +moment of locking, it can be done without her knowledge.[85] + +The simplest case for applying the forceps is, where the head has already +descended nearly to the os externum, and has begun to press upon the +perineum: it is for this that the straight forceps is chiefly intended; +and as this is the instrument which is generally used, we shall describe +its application first. + +_Mode of applying the forceps._ Having ascertained that the rectum and +bladder are empty, examined the position of the head, and warmed and +greased the blades, we proceed to introduce the upper or lower blade +first, according as its lock is directed forwards: this precaution is for +the purpose of preventing the locks being turned away from each other when +brought together after the introduction of the second blade. The +trochanter major will guide us as to the precise position of the +patient's pelvis, and is especially useful in pointing out the direction +of the left oblique diameter, in which the forceps (on account of the +first position of the head being in the right oblique diameter) should be +most frequently applied: in this case, we pass the upper blade, as it +were, beneath the trochanter, and the lower one in the opposite +direction.[86] + +Let us suppose that the head is in the first position, with its sagittal +suture parallel with the right oblique diameter of the pelvis, and that in +accordance with the above rule, the upper blade is to be introduced first. +Having passed one or two fingers up to the head, we guide the blade along +them, depressing the handle so as to make the extremity of the blade lie +closely upon the head, neither allowing the point alone to impinge upon +the head, nor _vice versâ_, to protrude against the vagina. The extremity +of the blade, therefore, must be our guide for the direction in which we +hold the handle: we must carefully insinuate this by a gentle vibratory +motion between the head and passage which surrounds it: the convexity of +the head will show the course which it has to take, nor is there any need +of passing the finger farther; for when once the extremity of the blade is +fairly engaged between the head and passage, it will almost guide itself, +and needs little more than to be pushed on gently, the handle gradually +rising according to the curve of the blade. The shank or handle should, +therefore, be held lightly like a pen, by which means the operator will +possess much more feeling with his instrument, than if he grasped it with +his whole hand. As the blade advances, he should keep his eye on the +general form of the pelvis, the curve of the loins, the situation of the +trochanter and symphysis pubis, and thus gain a more accurate idea of the +course which the instrument must take. This will, in great measure, depend +upon the situation of the head: if it be quite down upon the perineum, the +blade should be pointed towards the promontory of the sacrum, and the +handle turned downwards and forwards; if it be still in the cavity of the +pelvis, and only beginning to engage in the outlet, the blade must be +directed upwards towards the centre of the brim, and the handle turned +directly downwards. Having passed the blade to its full extent, we must +press the handle backwards against the perineum, to allow sufficient room +for the introduction of the second blade, and give it to an assistant or +the nurse, with the caution to hold it steadily and firmly, especially +during the pains, when it is apt to slip into the hollow of the sacrum if +held carelessly. + +As we have passed the upper blade behind the right acetabulum or foramen +ovale, so now we must introduce the other in the opposite direction, viz. +before the left sacro-iliac synchondrosis: and, as the blades being +exactly opposite to each other is essential to the easy locking of the +instrument, it will be necessary to guide the course of the second blade, +not so much by the form of the pelvis, as by the direction of the first +blade. It must, therefore, pass up, so that when introduced to its full +extent, the inner surface of its handle shall correspond precisely to that +of the first blade. The easy or difficult locking of the blades is a proof +of their having been correctly or incorrectly introduced. If, therefore, +on bringing the locks together we find that they do not correspond, that +the inner surfaces of the handles are not parallel, but form an angle with +each other, we must endeavour to rectify this, by withdrawing, to a short +extent, that blade which deviates most from the proper direction, and pass +it up again more correctly. All attempts to twist the handles so as to +correspond with each other, are bad and cannot fail to put the patient to +much suffering. + +When we are about to lock the blades, we cannot be too careful in +preventing the soft parts from being pinched between them, for it causes +most intolerable pain, and frequently makes the patient give such an +involuntary start, as to run the risk of altering the position of the +instrument. + +The whole process of introducing and fixing the forceps should be +conducted in as gentle and gradual a manner as possible: no attempt should +be made to proceed with the operation during a pain; and in no case is +force either necessary or justifiable. + +Every thing being now prepared for the extraction, we must endeavour to +make this resemble as far as possible the natural expulsion. When a pain, +therefore, comes on, we should grasp the handle firmly, and pull gently, +at the same time giving them a rotatory motion. The direction of the +handles, as before said, will depend upon the situation of the head in the +pelvis: if it be at the outlet, it will point downwards and forwards; if +in the cavity, nearly directly downwards. If the head makes but little or +no advance with one or two efforts, it will be advisable to tie the +handles firmly together, and thus keep up a continued pressure upon it, +and dispose it the more to elongate and adapt itself to the passages. As +it advances and begins to press upon the perineum, we must be more than +ever cautious not to hurry the expulsion, and give the soft parts time to +dilate sufficiently. At this period it is desirable to make the extractive +effort not so much forwards as the direction of the handles would seem to +indicate: we thus avoid pressing too severely upon the urethra and neck of +the bladder, which might otherwise suffer, and assist the dilatation of +the perineum. When the head is on the point of passing the os externum, +all farther extractive efforts should cease; the perineum must be +supported in the usual manner, and the head should be expelled if possible +by the patient herself.[87] + +In applying the curved forceps we must bear in mind another rule in +addition to the one above-mentioned for selecting the first blade, viz. +the pelvic curvature must correspond with that of the sacrum. As with the +straight, so also with the curved forceps, the extremity of the blade will +be our best guide as to the direction in which we should hold the handle +at the moment of introduction; it must be directed more or less forwards +in proportion to the degree of the pelvic curvature of the blade. If, for +instance, it be the upper blade which is to be introduced first, we pass +it obliquely over the lower thigh or nates of the mother, making it glide +closely round the convexity of the head, between it and the pelvis, +without impinging either on the one or the other. As the position of the +head is still more distinctly oblique at this earlier period of its +progress through the pelvis, so will the blades require a more oblique +direction, and also (as in the former case) they must be introduced in the +contrary oblique diameter to that in which the head is. + +As the blade passes up between the head and pelvis, so does the handle +gradually make a sweep backwards, until at length it approaches to the +edge of the perineum. During the process of introduction, one or two +fingers should press against the posterior edge of the blade to guide it +up to the brim of the pelvis, and prevent its slipping too far backwards +towards the hollow of the sacrum. + +The second blade will be guided in its direction by that of the first: it +must be introduced so that the inner surface of its handle corresponds +exactly with that of the first. The locking must be performed under the +same precautions as with the straight forceps: the more so, as in some +cases it has to take place just within the os externum, and therefore +requires the most careful attention to prevent the soft parts from being +caught and pinched between the blades when they are brought together. In +extracting the head we must bear in mind the part of the pelvis in which +it is impacted, and make our effort in the direction of its axis; we must +also recollect the curved form of the instrument, and that we must not +pull in the direction in which the handles point, but rather hold them +firmly with one hand, and, by pressing against the middle of the forceps +with the other, guide the head downwards and backwards into the cavity of +the pelvis. We shall thus make our extractive effort in the direction of +the upper portion of the blades, or that part which has the chief hold +upon the head: hence, therefore, as it descends, the handles are directed +more and more forwards, so that when it has reached the perineum, the +handles will not only point forwards, but considerably upwards. Whilst +extracting we should, as with the straight forceps, slowly move the +handles from side to side, and even make them describe a circle: we thus +not only use the forceps as a simple extracting instrument, but make it +act as a lever in every direction, and greatly facilitate the advance of +the head, even under circumstances of considerable impaction. It is in +these cases where keeping up a continued pressure upon the head by tying +the handles tightly together, and tightening it after every successive +effort, has such excellent effects in diminishing the degree with which it +is wedged against the pelvis and soft parts, and in disposing it by +gradual elongation to assume a form which is better adapted for advancing +through the passages. + +The slow and gradual pressure of the forceps thus exerted upon the head of +a living foetus will have a very different result to that of the +experiments by Baudelocque and others, in attempting to compress the head +of a dead foetus by the application of a sudden and powerful force. Even +if we were capable of effecting no greater diminution of its lateral +diameter than a quarter, or at the most, three-eighths of an inch, as +stated by Dr. Burns, we should, in most cases of impacted head, where the +forceps is justifiable, find it quite sufficient to remove the obstructing +causes. + +The forceps is also occasionally required in presentations of the face and +nates. In the first case we must pass up the blades on each side of the +face, and along the side of the head, having previously ascertained to +which side of the pelvis the chin is turned. In nates cases, the blades +should also be passed up along the sides of the child's pelvis, and here +the advantages of a broad fenestra will be very evident, for otherwise our +hold will not be firm enough without exerting an improper degree of +pressure. + +Cases every now and then occur, where from convulsions, &c., it is +desirable to apply the forceps whilst the patient is lying upon her back, +as is practised upon the continent. "The patient is placed across the bed, +propped up in a half-sitting posture, by pillows, &c., her pelvis resting +upon the edge, her feet on two chairs, the knees supported by assistants. +Two, and generally three fingers are passed, if possible, up to the os +uteri, on the side where the blade is to be introduced: the index finger, +is held a little behind the middle finger, so that this last, by +projecting somewhat, forms a species of ledge upon which the blade slides, +and which acts as a fulcrum to it. The handle is held at first nearly +perpendicular; but as the blade advances, it gradually approaches the +horizontal direction, being guided by the pelvic curve of the instrument. +The middle finger, along the ulnar surface of which the convex edge of the +blade slides, prevents its extremity from passing too far backwards, and +directs it in the axis of the pelvis. When introduced to the full extent, +the handle is inclined obliquely downwards, and is now grasped by an +assistant passing his hand below the patient's thigh. The other blade is +introduced in the same way on the opposite side of the pelvis; and the +locking, extraction, &c., conducted much in the same manner as in +England." (_British and Foreign Med. Rev._ vol. iii. April 1837, p. 419.) + +_History of the forceps._ We have already mentioned some historical points +connected with the improvements of the present French and English forceps; +it will now be unnecessary to enter more fully into the history of this +instrument. The earliest trace of the midwifery forceps which we possess +is under the form of a secret in the hands of an English family, named +Chamberlen. As to when and by whom it was first invented, this must +probably remain for ever unknown; and at any rate there is no more reason +to suppose that Dr. Hugh Chamberlen was the inventor than his father or +brothers were. He was compelled to quit England on account of being +involved in the political troubles of the time, and went to Paris in the +beginning of the year 1770, and evidently had then been some time in +possession of the secret. He returned to London, in August of the same +year, having in vain attempted to sell it to the French government, after +having entirely failed in a case of difficult labour which he had asserted +he could deliver in a few minutes, although Mauriceau had stated that the +Cæsarean operation would be required. Dr. H. Chamberlen published in 1772, +a translation of Mauriceau's work, which had appeared four years +previously, and in his preface he publicly alludes to this secret, and +says, "My father, brothers, and myself (though none else in Europe, as I +know) have, by God's blessing and our industry, attained to, and long +practised a way to deliver women in this case without any prejudice to +them or their infants: though all others (being obliged, for want of such +an expedient, to use the common way) do or must endanger, if not destroy, +one or both, with hooks." He thus apologizes for not having divulged this +secret: "there being my father and two brothers living, that practice this +art, I cannot esteem it my own to dispose of, nor publish it without +injury to them." + +Whether a work, entitled _Midwife's Practice_, by Hugh Chamberlen, 1665, +was by the translator of Mauriceau's work, or by his father, must now +remain a matter of doubt: it was, however, in all probability by the +latter, from what the translator says in his preface, viz. "I designed a +small manual to that purpose, but meeting some time after in France, with +this treatise of Mauriceau, I changed my resolution into that of +translating him." On account of his being attached to the party of James +II. he was again obliged to quit England, in 1688, and crossed over to +Amsterdam, where he settled, and in five years after succeeded in selling +his secret to three Dutch practitioners, viz. Roger Roonhuysen, Cornelius +Bökelman, and Frederick Ruysch, the celebrated anatomist. In their hands, +and in those of their successors, it remained a profound secret until +1753, when it was purchased by two Dutch physicians, Jacob de Visscher and +Hugo van de Poll, for the purpose of making it generally known. It turned +out to be a flat bar of iron, somewhat curved at each end: this lever was +stated to have been received from Roonhuysen, one of the original +purchasers of the Chamberlen secret; but there is no reason to suppose +that any such instrument had been communicated by Chamberlen either to him +or the others, as we have distinct evidence that both Ruysch and Bökelman +possessed _forceps_, the blades of which united at their lower end by +means of a hinge and pin. It is known also that Roonhuysen used a double +instrument consisting of two blades. The above-mentioned flat bar of iron, +commonly called Roonhuysen's lever, was, without doubt, invented after his +time, by Plaatman, who received the Chamberlen secret from him. (_Edin. +Med. and Surg. Journal_, Oct., 1833.) + +[Illustration: Chamberlen's Forceps.] + +Not many years ago a collection of obstetric instruments were found at +Woodham, Mortimer Hall, near Mildon, in Essex, which formerly belonged to +Dr. Peter Chamberlen, who, having purchased this estate "some time +previous to 1683," was, in all probability, one of the brothers alluded to +by Dr. Hugh Chamberlen, in his preface to the translation of Mauriceau's +work. This collection, (now in the possession of the Medico-Chirurgical +Society, of London,) contains several forceps, two of which appear to have +been used in actual practice: these differ from each other only in size, +and present a great improvement upon the instrument possessed by Hugh +Chamberlen, at Amsterdam. The blades are fenestrated and remarkably well +formed: the locks are the same as of a common pair of scissors, except +that in one case the pivot is riveted into one lock, which passes through +a hole in the other when the blades are brought together. In the smaller +forceps there is merely a hole in each lock through which a cord is +passed, and then wound round the shanks of the blades to fasten them +together, an improvement in which Dr. Peter Chamberlen had evidently +anticipated Chapman, in making the first approach to the present English +lock. + +The earliest professors of the forceps, besides the Chamberlens, were +Drinkwater, who commenced practice at Brentford, in 1668, and died in +1728; Giffard, who has given cases where he used his extractor as early as +1726; and Chapman, who possessed a similar instrument about the same +time. These forceps correspond very nearly with the above-mentioned ones +of Dr. Peter Chamberlen; and as it is well known that from those of +Giffard and Chapman, the forceps of the present day are descended, we +cannot consider ourselves so much indebted to Dr. Hugh Chamberlen for +these instruments, to which his bear so distant a resemblance, as to his +relations, who, from living together in England, had doubtless assisted +each other by their mutual inventions, and thus brought the instrument to +that state of improvement in which it was found as above-mentioned. + +For more detailed information respecting the history of the forceps we may +refer our readers to Mulder's _Historia Forcipum_, &c., particularly, the +German translation by Schlegel, to a similar work brought down to the +present time, by Professor Edward von Siebold, to our own lectures on this +subject, published in the _London Med. and Surg. Journal_, for March 28, +1835, vol. vii., and to the two papers already alluded to in the _London +Med. Gazette_, Jan. 8, 1831, and _Edinburgh Med. and Surg. Journal_, +October, 1833. [Also, _Researches on Operative Midwifery_, &c. By +FLEETWOOD CHURCHILL, M. D., essay iv. on the Forceps. _Dublin_, +1841.--ED.] + + + + +CHAPTER II. + +TURNING. + + _Turning.--Indications.--Circumstances most favourable for this + operation.--Rules for finding the feet.--Extraction with the feet + foremost.--Turning with the nates foremost.--Turning with the head + foremost.--History of turning._ + + +Turning is that operation in midwifery where the feet, which had not +presented at the time of labour, are artificially brought down into the os +uteri and vagina, and in this manner the child delivered. (Naegelé, _MS. +Lectures_.) + +Besides turning with the feet foremost as now described it has also been +proposed, as being safer for the child, to bring down the nates or the +head, but these operations, especially the former, have scarcely ever been +practised, and in most cases are impracticable. + +Turning, in the strict sense of the word, is that operation, by which, +without danger to the mother or her child, the position of the latter is +changed, either for the purpose of rendering the labour more favourable, +or for adapting the position of the child for delivering it artificially. + +The delivery of the child with the feet foremost, by means of the hand +alone, may be looked upon as a second stage of the operation; where, +however, the turning has been undertaken on account of malposition of the +child, it has been very properly recommended by Deleurye, (_Traité des +Accouchemens_, 1770,) Boer, (_Naturliche Geburtshülfe_, 1810,) Wigand, +(_Geburt des Menschen_, 1820,) and other high authorities in midwifery, +that as the position is now converted into a natural one, (viz. of the +feet,) it should be left as much as possible to the natural expelling +powers; hence, therefore, under these circumstances, artificial extraction +of the child with the feet foremost can scarcely be said to exist, the +operation itself being confined to changing the position of the child. + +Where, however, the circumstances of the case require that labour should +be hastened in order to avert the impending danger, the extraction of the +child with the feet foremost, by means of the hand alone, becomes a +distinct operation. + +The artificially changing the child's position into a presentation of the +feet is indicated in cases where, on account of malposition of the child, +the labour cannot be completed, or at least without great difficulty. + +_Indications._ The artificially delivering the child with the hand alone, +or the extraction of it with the feet foremost (which of course presumes +that it has presented with the feet, either originally or has been brought +into that position by interference of art,) is indicated in all cases +where the labour requires to be artificially terminated either on account +of insufficiency of the expelling powers, or from the occurrence of +dangerous symptoms. Under this head, on the part of the mother, are +violent floodings, especially under certain circumstances, convulsions +with total loss of consciousness, great debility, faintings, danger of +suffocation from difficulty of breathing, violent and irrepressible +vomiting, rupture of the uterus, death of the patient, &c.;--on the part +of the child, prolapsus of the cord under certain circumstances. (Naegelé, +_Lehrbuch der Geburtshülfe_, §§ 394, 395. 3d edit.) Hence, therefore, the +general indications of turning are the same as those of the forceps, it +being indicated in all those cases where nature is unable to expel the +foetus, or which demand a hasty delivery of the child, but which cannot be +attained by the application of the forceps. + +Turning is an operation which is far inferior to that of the forceps, both +as regards the safety of the mother and her child, and also the ease with +which it is performed. Whenever the circumstances under which it is +undertaken are unfavourable, it not only becomes a very difficult +operation, but also one of considerable danger: for the child especially +is this the case, as the very circumstance of its being born with the feet +foremost shows that it is necessarily exposed to the same dangers as those +already mentioned in nates presentations, in addition to those of the +first part of the operation, viz. the changing its position. + +The most favourable moment for undertaking the operation of turning is +when the os uteri is fully dilated and the membranes are still unruptured. +In this state, the vagina and os uteri are most capable of admitting the +hand, and the uterus, from being filled with liquor amnii, is prevented +contracting upon the child, the position of which is changed with great +ease and safety; but when the os uteri is only partially dilated, its edge +thin and rigid, the membranes ruptured, and the liquor amnii drained off +for some hours, it becomes a matter of great difficulty and danger either +to introduce the hand into the uterus under such circumstances, or to +attempt changing the child's position: the os uteri tightly encircles the +presenting part, and the uterus contracts upon the child itself so as to +render it nearly, if not altogether immoveable. + +The os uteri ought always if possible to be fully dilated: this however is +not so essential as with the forceps, for when once it has reached the +size of a crown piece, it mostly yields easily to the introduction of the +hand. Where turning is indicated in malposition of the child we may safely +await its full dilatation so long as the membranes remain unruptured. +Where the membranes have been ruptured some hours and the os uteri hard, +thin, and rigid, it will be impossible to turn until, either spontaneously +or by proper treatment, it becomes soft, cushiony, and dilatable. + +In cases which require turning as a means of hastening labour, as for +instance in flooding from placenta prævia and other causes, the hæmorrhage +is seldom so severe as to demand it without at the same time rendering the +os uteri so relaxed as to present little or no obstruction to the hand. +Where convulsions indicate turning, the bleeding and other depleting +measures, which are necessary to control them, will have a similar effect +in preparing the os uteri for this purpose. + +In ordinary cases of turning there will be no need to change the patient's +position, as it will be just as easy to perform it as she lies upon her +left side, merely bringing her pelvis nearer to the side of the bed in +order to reach her with greater facility. Where, however, from the +position of the child or from the state of the uterus, the introduction of +the hand and searching for the feet will probably be attended with +considerable difficulty, it may be advisable to place her across the bed, +sitting upon its edge, her back supported by pillows, her feet resting on +two chairs, in the same way as it is used by the Continental practitioners +for applying the forceps; or if it be really a case of very unusual +difficulty, it will be better to put her upon her knees and elbows, for in +this position we gain the upper and anterior parts of the uterus with +greater ease. + +In choosing which is the best hand for performing the operation, the +practitioner must not only be guided by the position of the child, but +also by the hand with which he possesses most strength and dexterity: many +always use the left hand for turning when the patient lies upon her left +side; for our own part we have always used the right, and have never +failed except in one or two cases of great difficulty, where we judged it +more prudent to put the patient on her knees and elbows than risk any +injury by using too much force. In introducing the hand into the vagina as +the patient lies on her left side, the right is moreover preferable, as we +can pass it more completely in the axis of the vagina, than we can the +left.[88] + +The directions which are usually given to introduce one hand or the other +according to the child's position, are not practical, because cases occur +where it is impossible to ascertain this point without passing the hand +into the uterus, as in placenta prævia, and occasionally in shoulder +presentations; and it would be by no means justifiable to make the patient +undergo the suffering from a repetition of this operation, merely because +the position of the child is such as is stated in books to require the +left hand instead of the right. + +Having evacuated the bladder and rectum, and greased the fore-arm and back +of the hand, we should gently insinuate the four fingers, one after the +other, into the os externum: the whole hand must be contracted into the +form of a cone; the thumb will pass up easily along the palm; the passage +of the knuckles is the most difficult, for as the os externum is the +narrowest part of the vagina, and the hand is widest across the knuckles, +it follows that this is the point of the greatest resistance and +suffering, and that, when once this is overcome, our hand will advance +with greater ease both to ourselves and to our patient. This part of the +operation can scarcely be conducted too gradually or gently, for if we +give the soft parts sufficient time to yield, it is scarcely credible what +an extent of dilatation may be effected by a comparatively moderate degree +of pain; the os externum is also the most sensitive part of the vagina, +and serious nervous affections may even be provoked by the intolerable +agony arising from a rude and hasty attempt to force the hand through it. +We must not advance the hand merely by pushing it onwards, but endeavour +to insinuate it by a writhing movement, alternately straightening and +gently bending the knuckles, so as to make the vagina gradually ride over +this projecting part as the hand advances. + +In passing the os uteri the same precautions must be observed, +particularly when the os uteri is not fully dilated; at the same time we +must fix the uterus itself with the other hand, and rather press the +fundus downwards against the hand which is now advancing through the os +uteri. In every case of turning we should bear in mind the necessity of +duly supporting the uterus with the other hand; for we thus not only +enable the hand to pass the os uteri with greater ease, but we prevent in +great measure the liability there must be to laceration of the vagina from +the uterus, in all cases where the turning is at all difficult. "In those +cases (says Professor Naegelé) where artificial dilatation of the os uteri +is required to let the hand pass, it should be done in the following +manner:--during an interval of the pains, we introduce, according to the +degree of dilatation, first two, then three, and lastly four fingers; and +by gently turning them and gradually expanding them we endeavour to dilate +it sufficiently to let the hand pass. This must only be done under +circumstances of absolute necessity and always with the greatest +caution--in fact, only in those cases where the danger consequent upon +artificial dilatation of the os uteri is evidently less than that, to +avert, which we are compelled to turn before it is sufficiently yielding +or dilated." (_Lehrbuch der Geburtshülfe_, p. 212. 3tte ausgabe.) This +observation from so high an authority evidently applies to those cases +where the os uteri is not only soft and yielding, but also nearly dilated; +the _forcible_ dilatation of the os uteri is justly deprecated by Madame +la Chapelle: "I never attempt to produce this forced dilatation, _not even +in cases of hæmorrhage_. But we may frequently promote the dilatation of +the passages in a remarkable manner by moistening and relaxing them and +diminishing their state of excitement, viz. by the steams of hot water, +tepid injections, and more particularly by warm baths and bleeding." (p. +49.) Her diagnosis of the condition in which the os uteri will yield to +the introduction of the hand is well worthy of attention. "If the inactive +uterus be unable to expel the child, or to make the head clear its orifice +although considerably dilated, if, in this state of affairs, the membranes +give way, we can feel the os uteri retract, from being no longer pressed +upon. How different is this state of passive contraction to the rigidity +of an orifice which has not yet been dilated: in this case, although the +os uteri is contracted and even thick, it is soft, supple, and easily +dilatable; there is no feeling of tightness or resistance; it is little +else than a membranous sac, and the head has not descended sufficiently to +press upon it; or if the head does not present, it is some part of the +child, as for instance the shoulder, which is unable to advance and act +upon the os uteri: in this case operate without fear--in the other wait." +(_Pratique des Accouchemens_, p. 86.) + +If the membranes be not yet ruptured we should use the greatest caution to +preserve them uninjured: the hand must be gently insinuated between them +and the uterus, and should be passed either until the feet are felt, or at +least, until it has gained the upper half of the uterus. Now, and not till +now, ought they to be ruptured. As this is done at the side of the uterus +little or no liquor amnii escapes, for the torn membranes are pressed +closely against the uterine parietes, and the vagina is completely closed +by the presence of the arm in it acting as a plug; the uterus is unable to +contract upon the child on account of the fluid which surrounds it, and +the hand, therefore, passes up with great facility. The uterus is not +diminished by the loss of its liquor amnii; its contractile power is, +therefore, not increased. When the hand has broken the membranes it can +move about in perfect freedom: if the feet have not as yet been reached +they will now be easily found, and the position of the child will be +changed without difficulty. + +The importance of passing in the hand without rupturing the membranes was +first shown by Peu in 1694.[89] But it excited little or no notice at the +time, not even by La Motte, who paid so much attention to improving the +operation of turning. Dr. Smellie appears to have been the first after Peu +who recommended this mode of practice, although he makes no mention of his +name. "Then introducing one hand into the vagina we insinuate it in a +flattened form within the os internum, and push up between the membranes +and the uterus as far as the middle of the womb: having thus obtained +admission, we break the membranes by grasping and squeezing them with our +fingers, slide our hand within them without moving the arm lower down, +then turn and deliver as formerly directed." (_Treatise on the Theory and +Practice of Midwifery_, vol. i. p. 327. 4th edit.) In 1770, Deleurye again +pointed out the value of this mode of introducing the hand, and expressly +directs us "introduire la main dans la matrice _sans_ percer la poche des +eaux, détacher les membranes des parois de ce viscère, et les percer à +l'endroit où l'on juge que les pieds peuvent le plus naturellement se +trouver."[90] Dr. Hamilton, of Edinburgh, five years afterwards +recommended the same method, and in nearly the same terms. Little notice, +however, has been taken of it since, either in this country or upon the +Continent, and the old objectionable mode of rupturing the membranes at +the os uteri is still taught even by the most modern authors. The +celebrated Boer also added his testimony in favour of Deleurye's mode of +practice,[91] and it has still farther been confirmed by Professor +Naegelé. + +Turning under these circumstances is an easy operation, and a very +different affair compared with its performance in cases in which the +membranes have been some time previously ruptured, and the uterus drained +of liquor amnii: the hand is passed up with difficulty, the feet are +quickly found, and the child moved round with a degree of facility which +is scarcely credible. Where, however, the uterus is irritable and closely +contracted upon the child, the liquor amnii having long since escaped, +where the os uteri is not more than two-thirds dilated, its edge thin, +hard, and tight, as is especially seen in a neglected case of arm or +shoulder presentation, every step of the operation is attended with the +greatest difficulty, and in fact is neither possible nor justifiable, +until by bleeding to fainting, by the warm bath and opiates, we have +succeeded in producing such a degree of relaxation as to enable us to +introduce the hand. "Blood-letting is the only remedy with which we are +acquainted that has any decided control over the contracted uterus. It is +one almost certain of rendering turning practicable under such +circumstances, if carried to the extent it should be. A small bleeding in +such cases is of no possible advantage, for unless the practitioner means +to carry the bleeding to its proper limits, which is a disposition to, or +the actual state of syncope, he had better not employ it." (Dewees' +_Compendious System of Midwifery_, § 629.) "The vagina is never so soft, +so dilatable, and capable of admitting the hand as during the presence of +an active hæmorrhage, and this is equally the case in primiparæ as in +those who have had several children: and it is a mistaken kindness in the +medical attendant, who in order to spare his patient's sufferings, under +these circumstances delays to introduce his hand until the hæmorrhage +shall have ceased. The moment this is the case, the vagina regains more +vitality, sensibility and power of contraction, the hand now experiences +much more opposition, and excites far greater pain than during the state +of syncope." (Wigand, _Geburt des Menschen_, vol. ii. p. 428.) + +When once a powerful impression has been made upon the system by an active +bleeding, opiates, which before it, would have only tended to render the +patient feverish, are now of great value: they relax the spasmodic action +of the uterus, allay the general excitement and irritability, and induce +sleep and perspiration. As with bleeding in these cases, they must be +given in decided doses: a grain of hydrochlorate of morphia given at once, +or in two doses quickly repeated, and at the same time from half a drachm +to a drachm of Liquor Opii Sedativus thrown into the rectum with a little +thin starch or gruel, will rarely or never fail to produce the desired +effect. The opiate by the mouth may be advantageously combined with +James's powder, and thus assist its diaphoretic action. The warm bath will +also prove a valuable remedy. + +"If the arm or funis of the child presents and is prolapsed into the +vagina, we must not try to push back these parts into the uterus again, +but we must endeavour to pass our hand along the inner surface of the +presenting arm; or if it be the cord, we must guide it so as to press the +cord as little as possible: if however a coil of it has passed out of the +vagina and is still beating, we had better carry it upon the hand with +which we are about to turn the child." (Boer, _op. cit._ vol. iii. p. 5. +1817.) For farther information on this head we must refer to the +observations on _Malposition of the Child_. + +If the head or nates be occupying the brim of the pelvis it will be +necessary to raise them gently and press them to one side: this however is +usually effected by the very act of passing up the hand, and seldom +produces any difficulty, unless these parts have already advanced deeper +into the pelvis; in which case, as turning under these circumstances can +only be undertaken with a view to hasten labour, it will become a matter +of consideration whether we shall not be able to attain this object better +by the aid of the forceps. + +Although it ought ever to be considered as a rule that turning must not be +attempted whilst the pains are violent, the introduction of the hand into +the uterus always excites it more or less to contraction: the degree of +pressure and impediment which it will produce to the progress of the hand +will in a great measure depend upon the quantity of liquor amnii which it +contains. Where the uterus has been drained of the fluid, every +contraction will be felt in its full force by the operator: his hand is +firmly jammed against the child, and if it happens to be caught in a +constrained posture at the moment, is liable to be attacked with a severe +fit of cramp, which benumbs and renders it powerless. Wherever we find +that the hand is tightly squeezed during a pain, we should lay it flat +with the palm upon the child, and hold it perfectly still: in this posture +it will bear a powerful contraction without inconveniencing ourselves or +injuring the uterus; and by letting it be quite flaccid and motionless we +shall not provoke the uterus to farther exertions. Attempting to turn +during the pain would not only be useless, but we should exhaust the +strength of our hand which cannot be spared too much; we should torture +the patient unnecessarily, and run no small risk of rupturing the uterus. + +In letting the pressure of our hand be upon the child during a pain, +instead of against the uterus, we must select any part rather than its +abdomen, for pressure here seems to act as injuriously as pressure upon +the umbilical cord. + +_Rules for finding the feet._ In searching for the feet we must endeavour +to gain the anterior surface of the child, for (unless its position be +greatly distorted) they are usually turned upon the abdomen: in arm +presentations the position of the hand will also guide us, the palm of it +being mostly turned in the same direction as the abdomen, and therefore +points to the situation of the feet; the rule also, as above given by +Boer, of passing the hand along the inside of the presenting arm, is well +worthy of recollection, for this can scarcely fail to guide us to the +anterior part of the child. Where, either from the pressure of the uterus +or other circumstances, it is difficult to distinguish the precise +position of the child, it will be better to follow Dr. Denman's simple +rule, that the hand "must be conducted into the uterus, on that side of +the pelvis where it can be done with most convenience, because that will +lead most easily to the feet of the child." The soft abdomen, the curved +position of the child, and its extremities crossed in front are so many +reasons why there should be more room in this direction. + +During all this time the other hand placed externally will be of great +service, not only in supporting the uterus, but in fixing the child and +rendering the different parts of it more attainable. Where the feet are at +some distance, we frequently come first to an arm or thigh, which soon +leads us to the elbow or knee; if the introduction of the hand has been +attended with some difficulty, it will not be very easy to distinguish +these joints from each other, without bearing in mind the following +diagnostic points:--the knee present two rounded prominences (condyles of +the femur) with a depression between them, whereas, the elbow presents +also two rounded prominences, but with a sharp projection (olecranon) +between. + +If the foot is not easily reached, there will be no need of forcing up the +hand farther to gain it: it will be much better and safer to hook the +finger into the bend of the knee and hold by it for a pain or two: this +will generally be sufficient to bring it within reach; or during an +interval of the pains, the leg may be gently disengaged and brought down. +Not unfrequently we can only feel the toes with the extremities of our +fingers, and therefore cannot maintain a sufficient hold upon the foot so +as to bring it down: here again the same rule will be applicable, for by +keeping but a slight hold upon it during a pain, it will be found to have +approached nearer when the pain has gone off; in fact our first attempt to +move the child must be done in this cautious manner, and we shall effect +our object with greater certainty by merely holding the feet still during +the pain, not allowing them to recede from that position in which we had +placed them during the intervals, than by using considerable efforts to +bring them to the os uteri. By the time we have got one foot fairly within +grasp, the other is seldom very distant and should always be brought down +if possible: by bringing down both feet we cause the hips of the child to +enter the brim of the pelvis more equally; whereas, if one leg only is +brought down, the pelvis of the child comes more or less awry, and the +ischium of the other side is apt to lodge against the brim of its mother's +pelvis.[92] This practice has been recommended on the grounds that, by +bring down only one leg, we make the presentation rather resemble a breech +case, which is known to be more favourable for reasons already mentioned, +and that by having the other leg turned upon the abdomen it will protect +the cord from undue pressure. As far as the abdomen is concerned this may +possibly be the case, but the pressure of the head upon the cord, which is +the real source of danger to the child in turning, can in no wise be +influenced by this position. + +In bringing down the feet it must be done with the articulation, that is, +the child must be turned forwards; at the same time the hand upon the +abdomen, externally, will be of great service in assisting us to move the +child, and in preventing the change of its position from taking place in +too sudden and violent a manner, a circumstance which is apt to paralyze +the uterus considerably, and even produce alarming symptoms from the shock +it occasions. + +_Extraction._ When once we have brought the feet into the vagina, the +first part of the operation, viz. the changing the position of the child, +is completed: it has now become a presentation of the feet, and as such +ought to be treated, unless some source of danger be present which +requires that the delivery should be hastened. The value of this practice +in footling cases was first pointed out by Deleurye,[93] and particularly +applied to the second act of turning by Wigand. "I have made it," says he, +"a strict rule in turning, from the moment that I have brought a foot of +the child as far into the vagina as I can without force, to do nothing +beyond patiently waiting for the return of the pains, even if this did not +take place for many hours, and leaving the rest of the labour entirely to +nature. I have found by doing so that when the pains at length began to +expel the child, they did it with so much force and activity as was not +even seen in the most natural case of head presentation." (_Geburt des +Menschen_, vol. ii. p. 130.) + +As the feet descend towards the os uteri, the presenting part, +particularly if the arm has been prolapsed into the vagina, begins to +recede, the hand externally will assist in moving the child round, and we +should perform this step of the operation so gradually as to be assured +that the presenting part has quitted the pelvis before the feet have +entered. Without attention to this point, the child may easily be fixed +across the upper part of the pelvis, or even the body brought down, while +the head is wedged into the cavitas iliaca of the ilium, and produce a +serious obstacle to its farther advance. This is a sort of mishap which +can rarely happen except to young practitioners. If the process be slowly +and carefully conducted, we doubt much if it be ever necessary to +disengage the presenting part as has been so frequently recommended: the +uterus in fact will move the child round with very little assistance on +our part, and we shall find that after every pain the advance of the feet +and recession of the part has increased considerably. From our own +observations we would say that in all difficult cases, of turning +especially, it is desirable for the patient to have several pains between +the moment of gaining the feet and bringing them fairly into the vagina: +very little force is required to bring them down, and the uterus does not +appear to suffer; but where the position of the child has been rapidly +changed, its contractile power seems to be injured, and it is ill able to +make those exertions during the last stage, which will be required of it +in order to save the child's life. + +Not less necessary is it that we should proceed with the second stage as +cautiously as possible: the grand principle is the same, viz. to conduct +the expulsion as gradually as possible: there is no use whatever in +hurrying this part of the operation, for if the child be alive, we place +it in imminent danger of its life; and if it be dead, as will easily be +known by the cord not pulsating, we are putting the mother to a great deal +of suffering for no reason. Now that it has become a footling case, it +must be managed according to rules already given for this species of +presentation: the uterus must be emptied as slowly as possible, the +anterior part of the child must be directed more or less backward, and the +funis guided into the vicinity of one or other sacro-iliac synchondroses. +By retarding the advance of the child, we resist the action of the uterus +somewhat, and thus excite it to contract more actively, the head enters +the pelvis in the most favourable position, and as the pains are still +brisk, it passes through so quickly as to subject the child to little or +no danger by pressing upon the cord. Where however the passage of the head +through the pelvis threatens to be delayed, we would strongly recommend +the application of the forceps in order to terminate the delivery before +the child has begun to suffer: it is to this mode of practice that +Professor Busch, of Berlin, attributes the extraordinary success of +turning in his hands; of forty-four cases where turning was deemed +necessary only three children are stated to have lost their lives from the +effects of the operation, a result which is by far the most favourable +known. + +_Turning with the nates foremost._ It has been proposed by several authors +of the last century to turn the child with the breech foremost, as being a +less dangerous operation for it than the common one of bringing down the +feet. Levret has distinctly proposed this mode (_L'Art des Accouchemens_, +§ 767,) and Smellie on more than one occasion has alluded to bringing down +the nates. Dr. W. Hunter has also recommended turning with the breech +foremost: still more recently has this mode of practice been confirmed by +W. J. Schmitt, of Vienna,[94] also by some other continental authors; but +the difficulty in bringing down a part of the child's body, upon which we +can exert so little hold, will always be very considerable, wherever the +circumstances under which the operation is undertaken is at all +unfavourable. Schmitt recommends that as soon as we reach the nates we +should apply the hand flat upon them; while in order to turn the child, +active pressure is kept up from without by the other hand: when once we +have succeeded in moving the breech somewhat downwards, its farther +descent is very easy. + +A still more recent modification of turning the child in arm and shoulder +presentations has been proposed by Dr. v. Deutsch, of Dorpat: it consists +in raising the presenting part, and at the same time turning the child +upon its long axis, as the hand placed in the axilla carries the shoulder +to the upper parts of the uterus, after which, as the hand descends, it +brings the feet along with it into the vagina. + +_Turning with the head foremost._ In former times, as the head was +considered the only natural presentation of the child, every deviation of +its position from this was looked upon as unnatural, and, therefore, the +operation of turning only applied to bringing down the head, which had not +presented: as, however, the difficulties already mentioned, in turning +with the nates, would apply still more forcibly to bringing down the head, +it is plain that this mode of turning would rarely be practicable. "Were +it practicable at all times," says Dr. Smellie, vol. i. book iii. chap. +iv. sect. iv. number v., "to bring the head into the right position, a +great deal of fatigue would be saved to the operator, much pain to the +woman, and imminent danger to the child: he, therefore, ought to attempt +this method, and may succeed when he is called before the membranes are +broke, and feels by the touch that the face, ear, or any of the upper +parts present." Still, however, he confesses that the usual method of +turning by the feet is the safest. In his first volume of cases, +(collection 16, number 6, case 5,) he has given a description of this mode +of turning. Dr. Spence also turned with the head foremost, as is shown by +his thirty-second case, where the hand and cord were prolapsed into the +vagina. "I introduced my hand into the vagina, and in the intervals +between the pains reduced both the arm and the cord: but as I found they +were like to return again upon my withdrawing my hand, I therefore +continued to support them till such time as, by the strength of the pains, +the child's head was so far forced down as to prevent any danger of their +returning, the happy consequence of which, was, that she was delivered of +a live child in about half an hour after: both mother and child did well." +(Spence's _System of Midwifery_, p. 465.) Dr. Merriman has recorded a +similar case in his own practice: "The arm was returned at two o'clock; +there was afterwards no occurrence of pain till six, after which, they +became very strong, and between eight and nine the child was born. This +was the only infant that Mrs. R. has seen alive out of six." (_Synopsis of +Difficult Parturition_, 1838, p. 250.) Still more recently turning with +the head foremost has been tried by Dr. Michaelis, of Kiel, (_Neue +Zeitschrift für Geburtskunde_, vol. iv. 1836.) When once the faulty +position has been altered, the liquor amnii is allowed to drain off, the +uterus contracts and presses the head down into the pelvis, and the child +is born without farther difficulty. + +_History of turning._ Turning, as it is generally practised at the present +day, viz. changing the position of a living child so that the feet are +brought down foremost into the vagina, was unknown to the ancients. There +is little doubt, however, that if they could have been induced to have +looked upon presentations of the nates and feet as natural labours, they +would have been in possession of this valuable means of effecting +artificial delivery; as it is, we meet with detached allusions to it in +their writings, although applying only to cases where the child is dead. +In the writings of Aspasia and Philumenus, which, but for the quotations +of Oetius, would have been entirely lost to us, we find directions for +turning the child. Thus, Philumenus states, "Si caput foetûs locum +obstruxerit ita ut prodire nequeat infans in pedes vertatur atque +educatur." At a still later period, Celsus gave similar directions, but to +all appearance they also merely apply to a dead child. "Medici vero +propositum est, ut infantem manu dirigat, vel in caput vel etiam in pedes +si forte aliter compositus est;" and again he says, "Sed in pedes quoque +conversus infans, non difficulter extrahitur. Quibus apprehensis per ipsas +manus commode educitur." (Celsus, _de Medicinâ_, lib. vii. cap. 29.) + +From this time the whole subject seemed to sink into oblivion, until +Pierre Franco, in his work on surgery[95] proposed the extraction of the +child with the feet foremost: this was put into practice by the celebrated +French surgeon, Ambrose Paré, (Ambr. Paræus, _Opera Chirurgia_, 1594,) +who, nevertheless, recommended turning with the head foremost, where it +was possible. His work was afterwards translated into Latin by Guillemeau, +who, although he still adhered to the old plan of bringing down the head, +showed the value of Paré's mode of turning in hæmorrhages and convulsions. +To Francis Mauriceau, a man of great learning and experience, we are +indebted for this operation being greatly improved, by means of his +valuable work, in 1668; but it is Philip Peu, in 1694, and William +Manquest de la Motte, in 1721, to whom the merit is due of having pointed +out the value of two great laws in turning--the one of not rupturing the +membranes as already mentioned, the other of not attempting to push back +the arm which presents.[96] + + + + +CHAPTER III. + +CÆSAREAN OPERATION. + + _Indications.--Different modes of performing the operation.--History + of the Cæsarean operation._ + + +The next operation in Midwifery for delivering the full-grown foetus alive +is that of _Hysterotomy_, commonly called the Cæsarean operation, viz. +where the foetus is extracted through an artificial opening made through +the parietes of the abdomen and uterus. + +The _indications_ for performing the operation are so different in this +country to what they are elsewhere that they require especial mention: in +England the operation is never performed upon the living subject except +where the child cannot be delivered by the natural passage; under these +circumstances it is scarcely undertaken in this country for the purpose of +saving the child's life, but merely that of the mother, it being +considered preferable to deliver the child by perforation or embryotomy, +even when known to be alive, than to expose the mother to so much +suffering and danger. + +On the Continent and also in America, it has not been considered in so +dangerous a light as in this country, still less as an operation almost +certainly fatal to the mother: therefore, besides being indicated as a +means for preserving the mother's life, it is performed for the purpose of +saving the child's life in cases where, by using the perforator, the child +might be brought through the natural passages. The results of the Cæsarean +operation have been so unfavourable, and the character of the process so +frightful, as to have rendered it a measure of peculiar dread to +practitioners, and in different times and countries the strongest feelings +have been excited against it. By many of the celebrated authors of former +times, viz. Ambrose Paré, Guillemeau, Dionis, &c. it was looked upon as +altogether unjustifiable, and a similar opinion was entertained by many of +our own countrymen at a much more recent period, (Dr. W. Hunter, Dr. +Osborn, &c.) + +There is no doubt that in England it has been peculiarly unsuccessful. Dr. +Merriman has collected the results of 26 cases of Cæsarean operation: of +these only 2 mothers and 11 children survived; thus out of 52 lives only +13 were saved. On the Continent it has been far more successful. Klein has +collected with the greatest care 116 well authenticated cases, of which 90 +terminated favourably; and Dr. Hull, in his _Defence of the Cæsarean +Operation_, has recorded 112 cases, of which 69 were successful. M. Simon +has not only collected a number of cases which were favourable, to the +number of 70 or 72, but which were performed on a few women, "some of them +having submitted to it three or four times, others five or six, and even +as far as seven times, which if they were all true, would superabundantly +prove that it is not essentially mortal." (_Baudelocque_, transl. by +Heath, § 2095.) + +During the last fifteen or twenty years the operation has become +remarkably successful in the hands of the German practitioners, so that +there has been scarcely a journal of late from that part of the Continent +which has not contained favourable cases of it. One of the most +interesting instances of later years is that recorded by Dr. Michaelis, of +Kiel, where the patient, a diminutive and very deformed woman, was +operated upon four times:[97] the second operation was performed by the +celebrated Wiedemann, and is stated to have been completed in less than +five minutes, and without any extraordinary suffering on the part of the +patient, who complained most when sutures were made for bringing the lips +of the wound together. The uterus became adherent to the anterior wall of +the abdomen, so that in the fourth operation the abdominal cavity was not +even opened, the incision being made through the common cicatrix into the +uterus. + +There is every reason to suppose that the chief cause of its want of +success in this country has been the delay in performing it. "In France +and some other nations upon the European Continent," says Dr. Hull, "the +Cæsarean Operation has been and continues to be performed where British +practitioners do not think it indicated; it is also had recourse to early, +before the strength of the mother has been exhausted by the long +continuance and frequent repetition of tormenting, though unavailing +pains, and before her life is endangered by the accession of inflammation +of the abdominal cavity. From this view of the matter we may reasonably +expect that recoveries will be more frequent in France than in England and +Scotland, where the reverse practice obtains. And it is from such cases as +these, in which it is employed in France, that the value of the operation +ought to be appreciated. Who could be sanguine in his expectation of a +recovery under such circumstances as it has generally been resorted to in +this country, namely, where the female has laboured for years under +_malacosteon_ (_mollities ossium_,) a disease hitherto in itself +incurable; where she has been brought into imminent danger by previous +inflammation of the intestines or other contents of the abdominal cavity, +or been exhausted by labour of a week's continuance or even longer." +(Hull's _Defence of the Cæsarean Operation_.)[98] + +The difficulty of deciding upon the operation according to the indications +of the Continental practitioners, is much more perplexing than according +to that which is followed in this country: the question here is, can the +child under any circumstances be made to pass _per vias naturales_ with +safety to the mother? The impossibility of effecting this object is the +sole guide for our decision. In using the operation as a means for +preserving also the life of the child, we must not only feel certain that +the child _is_ alive, but that it is also capable of supporting life, +before we can conscientiously undertake the operation upon such +indications. This uncertainty as to the life or death of the child greatly +increases the difficulty of deciding. Under circumstances where there is +reason to believe that, although the child may be alive, it is +nevertheless unable to prolong its existence for any time, and the pelvis +so narrow that it can only be brought through the natural passage +piecemeal, we are certainly not authorized in putting an adult and +otherwise healthy mother into such imminent danger of her life for the +sake of a child which is too weak to support existence. Circumstances may +nevertheless occur where the pelvis is so narrow that the child cannot be +brought even piecemeal through the natural passage: in this case, even if +the child be dead, the operation becomes unavoidable. + +Under the above-mentioned circumstances, it is the duty of the surgeon to +perform the operation; and he can do it with the more confidence from the +knowledge of many cases upon record where it has succeeded even under very +unfavourable circumstances, and where it has been performed very +awkwardly: moreover, it seems highly probable that the unfavourable +results of this operation cannot often be attributed to the operation +itself, but to other circumstances. Not unfrequently the uterus has been +so bruised, irritated, and injured by the violent and repeated attempts to +deliver by turning or the forceps, and the patient so exhausted, and +brought into such a spasmodic and feverish state by the fruitless pains +and vehement efforts, together with the anxiety and restlessness which +must occur under such circumstances, that it is impossible for the +operation to prove successful. Here it is an important rule that we +should decide as soon as possible, whether she can be delivered by the +natural passages or not: we should allow of no useless or forcible +attempts to deliver her; and if these have been made, we should carefully +examine whether the passages, &c. have been injured, and proceed to the +operation without delay. Moreover, the patient can the more easily make up +her mind to the operation, as she will suffer far less than from the +fruitless efforts and attempts to deliver her by the natural passages. +(Richter, _Anfangsgründe der Wundarztneikunst_, band vii. chap. 5.) + +Although it is so important that we should lose no time, still +nevertheless it does not appear desirable to operate before labour has +commenced to any extent; for unless the os uteri has undergone a certain +degree of dilatation, it will not afford a sufficiently free exit for +liquor amnii, blood, lochia, which, by stagnating in the uterus after the +operation, would soon become irritating and putrid, in which case they +would be apt to drain through the wound into the abdominal cavity and +create much mischief.[99] + +_Different modes of operating._ The incision has been recommended to be +made in different ways by different authors; but the highest authorities, +as also later experience, combine in favour of that in the linea alba. +Richter states, that one great advantage from making it in this direction +is, that when the uterus contracts and sinks down into the pelvis, the +incision in it still corresponds with that through the abdominal parietes, +and therefore admits of a free discharge of pus, &c. through the external +wound; whereas, if it have been made to one side, viz. at the outer edge +of the rectus abdominis muscle, as recommended by Levret for the purpose +of avoiding the placenta, the wound in the uterus when contracted ceases +to correspond with it, and the discharge escapes into the abdominal +cavity. Besides this the abdomen is usually more distended at the linea +alba; the uterus here lies immediately beneath the integuments; the +intestines are usually pressed towards each side; and therefore when the +incision is made on one side they frequently protrude, a circumstance +which rarely happens when it is made in the linea alba, except perhaps +towards the end of the operation. In the linea alba we have only to cut +through the external integuments in order to reach the uterus, while at +the side, we have to cut through considerable layers of muscle. + +Previous to operating, the rectum and the bladder should be emptied, +particularly the latter, because it is desirable to carry the incision of +the abdominal integuments, for reasons just given, as near as possible to +the symphysis pubis (viz. an inch and a half,) which otherwise would +endanger the safety of the bladder. The experience of later years proves +decidedly that three intelligent assistants are necessary, "two to prevent +the protrusion of the intestines, and a third to remove the placenta and +foetus." (_Neue Zeitschrift für Geburtskunde_, band iii. heft 1. 1835.) We +are convinced, that the success of the operation depends more upon +carefully preventing the slightest protrusion of any portion of the +intestines, and excluding all access of the external air than upon any +other cause, for by this means alone can we save the patient from the +dangerous peritonitis which is so apt to follow. The two assistants, whose +duty it is to support the abdominal parietes and keep the edges of the +wound closely pressed against the uterus, should be furnished with napkins +or sponges soaked in oil in order instantly to cover any coil of intestine +which may protrude, and press it back as quickly as possible; it is to +this that the great success of the Cæsarean operation in later years is +chiefly owing. + +The incision in point of length varies from five to six, seven, or more +inches, beginning at about two to four inches below the navel, and +terminating at rather less than that distance above the symphysis pubis. +The peritoneum is usually divided with a bistoury and director, and the +wound through the uterus made an inch or two shorter than that of the +abdominal integuments. If, on dividing the uterine parietes, the placenta +presents, it must be separated, and removed as quickly as possible to one +side, the membranes ruptured, and the child extracted; after which the +uterus rapidly contracts, and thus prevents all fear of hæmorrhage: for +this reason the sooner the child is removed the better, as otherwise the +uterus is apt to contract upon a portion of it when passing through the +wound, and thus retain it. It is desirable to remove the membranes as far +as possible, especially from the os uteri, to allow of a free discharge +from the uterus per vaginam. No sutures are needed for the uterine +incision: the contractions of the organ not only diminish its length, but +generally bring its edges into sufficiently close contact. + +Some discrepancy of opinion has existed respecting the treatment of the +external wound: sutures are of course the most secure means of retaining +the edges in apposition, but they produce great suffering, and, from +taking up a good deal of time, delay the closing of the abdominal wound +more or less; whereas, straps of sticking plaster are applied much quicker +and without any suffering to the patient. To do this most effectually it +will be advisable to arrange them under the loins previous to the +operation: they should be from five to six feet long, and the ends may be +rolled up until wanted; the wound can thus be instantly closed and in the +most secure manner. Where the operator finds it necessary to use sutures, +he must avoid puncturing the peritoneum as far as possible: the lower inch +of the wound should be left open to allow any matter to drain out, and the +whole dressed according to the common rules of surgery. The patient should +be placed upon her side with the knees bent to relax the abdominal +parietes. A grain of the hydrochlorate of morphia has been given in these +cases with the best effects, having procured sleep and allayed the +disposition to spasmodic coughing and vomiting, which so frequently exists +after the operation. + +One of the greatest triumphs of modern surgery is the performance of this +dangerous operation four times successively on the same patient. The first +operation was performed in June 1826, the woman being then in her +twenty-ninth year, the second in January 1830, the third in March 1832, +and the fourth on the 27th June, 1836. The second operation was performed +by Wiedemann, of Kiel, and scarcely lasted five minutes; nor does it +appear that the patient's sufferings were very great, for the application +of sutures on this occasion elicited more complaint than all the +operations put together.[100] + +_History._ Although the early records of the Cæsarean operation are not +very distinct, still we possess sufficient data to pronounce it of very +considerable antiquity. The earliest mention of it shows that it was at +first used merely for the purpose of saving the child by extracting it +from the womb of its dead mother, a law having been made by Numa +Pompilius, the second king of Rome, forbidding the body of any female far +advanced in pregnancy to be buried until the operation had been performed. + +The mythology of the ancients refers to two cases of an exceedingly remote +period where a living child was taken from the dead body of its mother: +these were the birth of Bacchus and Æsculapius; but as these traditions +are so enveloped in allegory and mystery, it is difficult to come to any +other conclusion than a mere inference of the fact: one circumstance, +however, connected with the birth of Bacchus is curious, viz. that his +mother Semele died in the seventh month of her pregnancy. + +The oldest authentic record is the case of Georgius, a celebrated orator +born at Leontium in Sicily, B. C. 508. Scipio Africanus, who lived about +200 years later, is said to have been born in a similar manner. There is +no reason to suppose that Julius Cæsar was born by this operation, or +still less that it derived its name from him, for at the age of thirty, +he speaks of his mother Aurelia as being still alive, which is very +improbable if she had undergone such a mode of delivery. We would rather +prefer the explanation of Professor Naegelé, viz. that one of the Julian +family at Rome had been delivered _ex cæso matris utero_, and had been +named Cæsar from this circumstance, so that the name was derived from the +operation, not the operation from the name. + +"The earliest account of it in any medical work is that in the _Chirurgia +Guidonis de Cauliaco_, published about the middle of the fourteenth +century. Here, however, the practise is only spoken of as proper after the +death of the mother." (Cooper's _Surg. Dict._) Among the Jews, however, it +appears to have been performed on the _living_ mother at a very early +period; a description of it is given in the _Mischnejoth_, "which is the +oldest book of this people, and supposed to have been published 140 years +before the birth of our Saviour, or, according to some, even antecedently +to this period. In the _Talmud_ of the Jews, also, their next book in +point of antiquity, the Cæsarean operation is mentioned in such terms as +to render it extremely probable that it was resorted to before the +commencement of the Christian era. In the _Mischnejoth_ there is the +following passage, 'In the case of twins, neither the first child which +shall be brought into the world by the cut in the abdomen, nor the second, +can receive the rights of primogeniture, either as regards the office of +priest or succession to property.' In a publication called the _Nidda_, an +appendix to the _Talmud_, there is the following remarkable direction: 'It +is not necessary for women to observe the days of purification after the +removal of the child through the parietes of the abdomen.'" (_Introduction +to the Study and Practice of Midwifery_, by W. Campbell, M. D. p. 260.) + +The first authentic operation upon a living woman in later times was the +celebrated one by Jacob Nufer, upon his own wife, in 1500, after which, +owing to its fatal character and the strong feeling against it, it was +performed but rarely: still, however, sufficient evidence existed to mark +its occasional success and urge its repetition in similar cases; and from +what we have already stated, the history of the last twenty years shows +that its results have rapidly become more and more favourable, so that in +the present day it can be no longer looked upon as an operation of such +extreme danger and almost certain fatality, as it was in former +times.[101] + + + + +CHAPTER IV. + +ARTIFICIAL PREMATURE LABOUR. + + _History of the operation.--Period of pregnancy most favourable for + performing it.--Description of the operation._ + + +Perhaps the greatest improvement in operative midwifery since the +invention and gradual improvement of the forceps is the induction of +artificial premature labour for the purpose of delivering a woman of a +living child, under circumstances of pelvic contraction, where either the +one must have been exposed to the dangers and sufferings of the Cæsarean +operation, or the other to the certainty of death by perforation, or at +least where the labour must have been so severe and protracted as to have +more or less endangered the lives of both. It consists in inducing labour +artificially, at such a period of pregnancy that the child has attained a +sufficient degree of development to support its existence after birth, and +yet is still so small, and the bones of its head so soft, as to be capable +of passing through the contracted pelvis of its mother. + +_History._ Few improvements have met with more violent opposition, or have +been more unjustly stigmatized or misrepresented, than artificial +premature labour, and it redounds, not a little, to the credit of the +English practitioners that they have not only had the merit of its first +invention, but with very trifling exceptions, have been the great means of +bringing it into general practice and repute. + +To the late Dr. Denman we are under especial obligations in this respect; +for, although himself not the inventor of this operation, he, +nevertheless, was one of the first who widely recommended it to the +profession, and actively promoted it by the powerful support of his name +and writings. "A great number of instances," says he, "have occurred to my +own observation of women so formed that it was not possible for them to +bring forth a living child at the termination of nine months, who have +been blessed with living children, by the accidental coming on of labour +when they were only seven months advanced in their pregnancy. But the +first account of any artificial method of bringing on premature labour was +given me by Dr. C. Kelly. He informed me that about the year 1756 there +was a consultation of the most eminent men in London, at that time, to +consider of the moral rectitude and advantages which might be expected +from this practice, which met with their general approbation. The first +case in which it was deemed necessary and proper, fell under the care of +the late Dr. Macauley, and it terminated successfully.[102] Dr. Kelly +informed me he himself had practised it, and among other instances +mentioned that the operation had been performed three times on the same +woman, and twice the children had been born living." (Denman's +_Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 174.) +Since this the observations of Mr. Barlow, Dr. Merriman, Mr. Marshall, +Drs. J. Clarke, Ramsbotham, &c. &c., have afforded an ample body of +evidence in its favour, and have, we trust, tended not a little to +diminish the frequency of perforation. On the Continent it experienced a +very different reception, being regarded as immoral, barbarous, and +unjustifiably endangering the life of the mother and her child. In France, +although at first successfully adopted by a few practitioners, (_Sue_,) +its farther progress was completely stopped by the powerful opposition of +Baudelocque, and by the plausible though erroneous objections which he +made against it. A similar course was pursued by Gardien and Capuron, and +even by the celebrated Madame la Chapelle, all of whom have taken a +singularly incorrect view of it and assign it a totally different object +to that which is intended: the very name which they have given to it of +_Avortement artificiel_, plainly shows how little they have understood of +its real character. + +Among his objections, Baudelocque states, that "the neck of the uterus at +seven months has seldom begun to open; it is still very thick and firm. +The pains, or the contractions of that viscus, cannot then be procured but +by a mechanical irritation pretty strong and long continued; but those +pains, being contrary to the intentions of nature, often cease the instant +we leave off exciting them in that manner. If we break the membranes +before the orifice of the uterus be sufficiently open for the passage of +the child, and the action of that viscus strong enough to expel it, the +pains will go off in the same manner for a time, and the labour afterwards +will be very long and fatiguing; the child deprived of the waters which +protected it from the action of the uterus, being then immediately pressed +upon by that organ, will be a victim to its action before things be +favourably disposed for its exit, and the fruit of so much labour and +anxiety will be lost. Premature delivery obtained in this manner is always +so unfavourable to the child, that I think it ought never to be permitted +except in those cases of violent hæmorrhage which leave no chance for the +woman's life without delivery; the nature of the accident also disposes +the parts properly for it." (_Baudelocque_, transl. by Heath, § 1986, +1987.) All this plainly shows that Baudelocque did not rightly understand +the real objects and nature of artificial premature labour, to which, in +fact, his objections do not apply, but to the _accouchement forcé_ of the +French practitioners, where, on account of the sudden accession of +dangerous symptoms, such as hæmorrhage, convulsions, &c. &c., the os uteri +was rapidly and violently dilated by the hand, which was then passed into +the uterus, the feet seized, and the child forcibly delivered, an +operation which is now rarely performed in Germany and never in this +country. + +The celebrated Carl Wenzel, of Frankfort, was the first in Germany who +declared himself in favour of the operation. Kraus and Weidemann followed, +the former two having performed it with complete success. The favourable +results also in the hands of English practitioners and its increasing +reputation quickly silenced the virulent abuse which was levelled at it by +Stein, jun., and some other German authorities; the celebrated Elias von +Siebold, of Berlin, who had first opposed it, candidly confessed his error +and became one of its earliest supporters. Increasing experience showed +that it could scarcely be looked upon as a dangerous operation for the +mother, and that in by far the majority of instances it was also +successful as regarded the child. Professor Kilian, in his work on +operative midwifery, has collected the results of no less than 161 cases +of artificial premature labour. (_Operative Geburtshülfe_, erster band, p. +298.) Of these, 72 occurred in England, 79 in Germany, 7 in Italy, and 3 +in Holland: of these cases, 115 children were born alive and 46 dead; of +the 115 living children, 73 continued alive and healthy; 8 of the mothers +died after the operation, but of these, 5 were evidently from diseases +which had nothing to do with the operation. + +The most unfavourable circumstances under which the operation can be +undertaken are, where the child presents with the arm or shoulder: here it +will require turning, which, in many cases, owing to the faulty form and +inclination of the pelvis, cannot be effected without considerable +difficulty, and greatly diminishing the chances of the child being born +alive. With this exception we cannot see why it should not be as +favourable as labour at the full term of pregnancy; it is far less +dangerous than other species of premature labour, for the hæmorrhages, +which are so apt to attend them, are never known to occur here. + +This mode of delivery has not only been proposed in cases of contracted +pelvis: "There is another situation," says Dr. Denman, "in which I have +proposed and tried with success the method of bringing on premature +labour. Some women who readily conceive, proceed regularly in their +pregnancy till they approach the full period, when, without any apparently +adequate cause, they have been repeatedly seized with rigour and the +child has instantly died, though it may not have been expelled for some +weeks afterwards. In two cases of this kind, I have proposed to bring on +premature labour, when I was certain the child was living, and have +succeeded in preserving the children without hazard to the mothers." +(_Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 180.) + +_Period for performing the operation._ Although under the head of +PREMATURE EXPULSION we have stated that a foetus is capable of maintaining +its existence if born after the twenty-eighth week of pregnancy, we must +not be supposed to recommend the artificial induction of premature labour +at so early a period as this. "Experience has shown that it was not +necessary to induce labour at so early a period as was first imagined, on +account of the very great difference which even one or two weeks are found +to make in the hardness of the foetal skull. Thus, for instance, in cases +where the antero-posterior diameter was only three inches, six weeks +before the full term of utero-gestation were found sufficient, and where +it was three inches and a half, fourteen days made sufficient difference." +(Naegelé, _MS. Lectures_.) Still, however, as it is so difficult to be +quite sure of the data upon which we have made our reckoning, it will be +safer to fix the operation a week or two earlier; and if we lose a little +time by failing in our first endeavours to induce uterine action, it will +be of so much the less consequence: hence, therefore, as a general rule, +the most eligible time will be between the thirty-fourth and thirty-sixth +week; and if the deformity be very considerable, we may commence +operations as early as the thirty-second week or two months before the +full term, short of which it will seldom either be justifiable or +necessary. On the other hand, where the state of the cervix and the +history of her pregnancy combine to make our reckoning nearly a matter of +certainty, the later we can safely delay the operation the better, for by +so doing the process resembles more a natural labour, and the chances in +favour of the child are much increased. + +_Operation._ The original mode of artificially inducing premature labour +was merely by puncturing the membranes and allowing the liquor amnii to +escape; the more gradually this is done the better, for by this means the +uterus is not entirely drained of its fluid contents, and is, therefore, +prevented contracting immediately upon the child; the value of this +precaution was pointed out by the late Dr. Hugh Ley, and also by Wenzel. A +considerable interval may elapse between puncturing the membranes and the +first contractions of the uterus, generally varying from forty to eighty +hours: it should be performed while the patient is in the horizontal +posture, in order to prevent the escape of too much liquor amnii. A +moderately curved male catheter, open at its point and carrying a strong +stilet sharpened at the end, is the best and simplest instrument for the +purpose: on passing it up to the membranes, the stilet should be +protruded, but to a short extent, to avoid injuring the child; and as soon +as the liquor amnii runs from the other end, the instrument should be +withdrawn, and the patient desired to remain quiet. A dose of opium has +been usually given after the operation by the English practitioners, but +its utility appears rather questionable: a brisk purge of calomel and +jalap, some hours previously, is much more important; uterine action comes +on much more regularly and effectively, and there will be much less chance +of those rigours occurring which some practitioners, although erroneously, +have supposed, were connected with the death of the child. + +The practice of dilating the os uteri first, as recommended by +Brüninghausen, Kluge, and others, has, as far as we know, never been +attempted in this country, and resembles much too closely the +_accouchement forcé_ of the French authors ever to be permitted. + +The simplicity of the operation of tapping the membranes has rather led +practitioners to overlook a still greater improvement, viz. the inducing +uterine action first: this was proposed by Dr. Hamilton to be effected by +passing up a catheter, and separating the membranes from the uterus to a +considerable distance above the os uteri. The operation certainly succeeds +in some cases; but our own experience goes to prove, that in the majority +it is not sufficient by itself to provoke uterine contraction, and in +order to ensure success we must combine with it other means. + +The plan of treatment which we have found most certain is first to clear +out the bowels by a full dose of calomel and colocynth, then to give the +patient a warm bath, in which she may remain twenty or more minutes, after +which the abdomen should be well rubbed with stimulating liniment as she +lies in bed, and the secale cornutum given in doses of a scruple of the +powder in cold water, repeated every half hour for five or six times. +Contractions of the uterus rarely fail to follow, and although they +generally require the secale to be renewed after a few hours, they will be +found to have effected several very important changes preparatory to +actual labour;--the abdomen has sunk, the fundus is lower, the cervix is +shorter or has disappeared, and not unfrequently we feel the head has +already passed the brim and is now in the cavity of the pelvis; the vagina +and os uteri are lubricated with a copious secretion of remarkably pure +and albuminous mucus; and in these cases especially, we frequently meet +with those little lumps of inspissated mucus which were formerly called +the _ovula Nabothi_. All these precursory changes are so many preparations +of nature for a natural labour, and contribute not a little to the +successful termination of the case, advantages which cannot be enjoyed +where the membranes have been previously ruptured. If, however, we do not +succeed in producing more than a slight dilatation of the os uteri, if the +repeated exhibition of the ergot only produce vomiting, or constant pains +which have no other effect beyond preventing rest and inducing exhaustion, +the separation of the membranes from the uterus, as proposed by Dr. +Hamilton, will now have the best effects: even if this fail and we are +compelled to puncture the membranes, it will now be performed under so +much more favourable circumstances, from labour having already commenced +to a certain extent. + +A warm bath and the other usual means for recovering the child should be +in readiness. In most cases the secretion of milk follows as after labour +at the full term, which is a great advantage; for the thin watery +secretion of this early period is much better adapted to the weak +digestive organs of the premature child. It is frequently a matter of some +difficulty under these circumstances to make a child take the breast at +first, and this is the chief reason why their digestive organs so soon +become deranged. "In case no milk be present, a good substitute may be +made by beating up fresh eggs and milk, boiling them over a gentle fire +and straining off the thin fluid." (Reisinger, _die künstliche +Frühgeburt_.) + +One great encouragement in cases requiring this operation is the fact that +in every successive pregnancy the uterus is more easily excited to +premature action; and in some cases where it has been induced several +times, it has at length, as it were, got so completely into the habit of +retaining its contents only up to a certain period, that labour has come +on spontaneously exactly at the time at which in the former pregnancies it +had been artificially induced.[103] We have already alluded to this +circumstance in the chapter on PREMATURE EXPULSION OF THE FOETUS.[104] + + + + +CHAPTER V. + +PERFORATION. + + _Variety of perforators.--Indications.--Mode of operating.-- + Extraction.--Crotchet.--Embryulcia._ + + +The perforation is that operation "where we make an opening into the +cranial cavity, and, by allowing the brain to escape, thus diminish the +bulk of the head." (_Obstetric Memoranda._) + +Perforation is one of the most ancient operations in midwifery, for in +former times it was the only means of artificially delivering the child +when the head presented: hence we find that from the age of Hippocrates +down to the last century, midwifery instruments almost entirely consisted +of knives or lancets for piercing the foetal head, and blunt or sharp +hooks for extracting or dismembering the child. + +Thus Hippocrates, Celsus, and Albucasis, and others, have described a +variety of such instruments and given full directions for their use. + +_Variety of perforators._ No instrument has been so greatly modified or +has appeared under such different forms as the perforator; but it is not +our object to enter into any detailed account of its history, for it would +not, like that of the forceps, lead to any useful information; we shall, +therefore, content ourselves with mentioning those few which have been in +general use during the last century. They are chiefly of the scissor kind; +the two most commonly known are the perforators of Dr. Smellie and M. +Levret: the former are merely strong long-handled scissors, the backs of +the blade being neither exactly sharp nor blunt,[105] and furnished each +with a projecting shoulder or rest to prevent them from entering too far. +Levret's perforator, which is extensively used in this country under the +name of Dr. Denman's perforator, and which was originally invented by +Bing, of Copenhagen, is also formed like scissors, but has its cutting +edges outside; the blades are also furnished with rests or shoulders like +the Smellie perforator. + +[Illustration: Naegelé's perforator.] + +A useful modification has been invented by Professor Naegelé, which +supplies a considerable defect in the two above-mentioned instruments, +viz. the necessity of using both hands to open the blades, thereby +requiring that the hand which guides the instrument in the vagina should +be removed at this moment: for this purpose the blades do not cross at the +lock as the others do, by which means the grasp of one hand is sufficient +to squeeze the handles together, and thus make the blades diverge in order +to dilate the opening. A similar one has been invented by the surgical +instrument maker, Mr. Weiss, but it does not appear to be quite so safe. + +The object of these instruments is not merely to bore through the skull, +but to break down the parietal bone to a certain extent, in order to +enlarge the opening: a slight curve of the blades is advantageous, because +their points thus impinge more directly upon the skull, and enter it at +once without running the risk of slipping along the surface. + +_Indications._ "The perforation is indicated, first, in all cases where +the labour is dangerous for the mother, and where the antero-posterior +diameter, although more than two inches and a half, is so small that the +head which presents, cannot be delivered by the forceps. Secondly, it is +indicated where the head is much larger than natural, as in +hydrocephalus." (Naegelé, _MS. Lectures_.) For a more detailed and special +account of the precise circumstances under which it will be required, we +must refer to those different forms of DYSTOCIA, where it is occasionally +required, particularly our fourth species, viz. DYSTOCIA PELVICA. + +Much discrepancy of opinion has existed as to how far the operation itself +was justifiable, and has, therefore, given rise to very different results +in the practice of different schools. The most obstinately prejudiced +against perforation was the late celebrated Benjamin Osiander, of +Göttingen, who asserted, that it was never necessary, for, where others +were obliged to open the head, he would deliver the patient by means of +his forceps, an instrument which, from its great length and the various +hooks &c. for applying additional hands, was capable of exerting a degree +of force which nothing could justify. In France, the predilection for +using exceedingly powerful forceps to a degree, which in this country and +the greater part of Germany would be looked upon as very injurious, if +not dangerous, has tended to render the perforation a comparatively rare +operation: thus out of somewhat more than twenty thousand labours at the +Maternité, of Paris, only sixteen were delivered by this means. Of the +ninety-six cases in whom the forceps was applied, no mention is made as to +the result with respect to the mothers; but, from the description of a +forceps case at the Hôtel Dieu which we have received from an eye-witness, +the force used must have been carried to a most unwarrantable extent. + +The English practitioners have frequently been accused by their +Continental brethren with being too ready in the use of the perforator; +but, with one or two exceptions, the charge is not just, for, as already +stated, we are not justified in subjecting an adult and otherwise healthy +woman to so much suffering and danger for the sake of a child which, after +all, will be probably sacrificed by the severity of the labour.[106] + +_Operation._ In performing the operation we introduce two or three fingers +along the vagina to the presenting part of the foetal head, and carefully +guide up the perforator against it: these fingers will not only protect +the soft parts from injury, but steady the point so firmly upon the skull, +as to enable the other hand to bore through it without difficulty. Having +passed the blades up to the shoulders or rests, we dilate the opening, +first one way and then the other, to form a crucial incision: we now +insert the instrument up to the basis cranii, breaking down the +attachments and structure of the brain, and thus enabling it to come away +with greater facility. To favour this object still farther, and make the +cranial bones collapse more readily, we must pass a long elastic tube +through the opening, and by means of a syringe, throw up a powerful stream +of water into the cavity of the skull: if this be introduced to the base +of it, the water will necessarily drive out the brain before it, so that +with every stroke of the piston, a quantity of brain will be expelled +nearly equal to that of the water injected. + +When the perforation has been made, it will be desirable to wait a few +hours before making any attempt to extract: we thus give the mother an +opportunity of getting a little rest; the attachments of the cranial bones +after a short time become more yielding, the head collapses more readily, +and adapts itself better to the form of the passages. "In all +circumstances," says Dr. Osborn, "which admit and require precision, I +would recommend the delaying all attempts to extract the child till the +head has been opened at least thirty hours: a period sufficient to +complete the putrefaction of the child's body, and yet not sufficient to +produce any danger to the mother. From such conduct, the beneficial +effects of facilitating the extraction of the child, I am firmly +convinced, by frequent experience, will much overbalance any possible +injury which may reasonably be expected from the putrid state of the child +and secundines in so short a time. The propriety, however, of this delay +entirely depends upon the head being opened in the beginning of labour: +for if we do not perform the first part of this operation till the labour +has been protracted so long as that the woman's strength begins to fail, +we must expedite the delivery as speedily as possible, otherwise, the +danger which we wish to avoid, will infallibly be incurred: no woman can +suffer continued labour beyond a certain period without fever, +inflammation, and the most imminent danger, if not death ensuing." +(Osborn's _Essays on the Practice of Midwifery_.) + +It has been recommended to perforate the head at the sutures, on account +of the greater facility in passing the instrument through them: but that +part of the head which is lowest in the pelvis, or which, in other words, +_presents_, must necessarily be the most convenient, not only for the +introduction of an instrument, but also for the evacuation of the brain. +When the perforation is made at a suture, the edges of the bones gradually +overlap as the head diminishes in size, and thus close the opening, a +circumstance which cannot occur when it is made through a bone. +Splintering the bone in making a crucial opening has been objected to on +the ground that the sharp edges and spiculæ are apt to wound the soft +parts of the mother: of this, however, there will be but little danger so +long as they are covered by the scalp, which we should be somewhat +cautious of, and not tear or otherwise destroy the cranial integuments +unnecessarily, for it has long since been remarked by the celebrated Peter +Frank, that inflammation of the uterus produced by wounds from spiculæ of +bone or sharp instruments becoming blunt, &c., usually prove fatal: it is +also desirable to disfigure the head as little as possible. Still, +however, we are far from recommending the trepan-shaped perforators which +have been used by Professors Assalini, Joerg, &c. as they cannot make a +sufficiently free opening, nor break down the skull to the necessary +extent. + +_Extraction._ Where sufficient time has been allowed for the cranial bones +to collapse, the finger inserted into the opening and acting as a blunt +hook will, if assisted by the pains, be enabled to exert a sufficient +degree of force to bring the head down to the pelvic outlet; by which time +the action of the vagina and abdominal muscles in aid of the uterine +efforts will soon succeed in pressing it through the os externum. By +using the finger in this way we pull by that part of the head which is +already lowest in the pelvis, and, therefore, run no risk of altering the +position of the head and bringing it down in an unfavourable direction; +this objection (among others) applies to the hook, whether it be fixed +internally or externally, and thus frequently renders the passage of the +head through the outlet and os externum more tedious, difficult, and +painful, than it otherwise would have been. The craniotomy forceps are +still more objectionable in all ordinary cases of perforation, for they +not only alter the position of the head, but by tearing away portions of +bone from time to time are very liable to wound the soft parts. + +From our own experience, we would recommend the application of the common +curved forceps in all cases where the pelvic deformity is not of a very +unusual degree, for by this means the hand is equally grasped and +compressed, the soft parts to a considerable extent are protected by the +blades, and the whole mass brought down exactly in the position in which +it presented. On several occasions where the craniotomy forceps and +crotchet have failed to move the head, the midwifery forceps has been +applied, and the delivery easily and quickly accomplished. Dr. Smellie +recommends the crotchet to be applied on the outside of the head, and was +evidently aware that its position was liable to be altered by this means. +He directs the practitioner to "introduce it along his right hand with the +point towards the child's head, and fix it above the chin, in the mouth, +back part of the neck, or above the ears, or in any place where it will +take firm hold. Having fixed the instrument, let him withdraw his right +hand, and with it take hold on the end or handle of the crotchet, then +introduce his left to seize the bones at the opening of the skull (as +above directed) _that the head may be kept steady_, and pull along with +both hands." (vol. i. chap. 3. sect. 7. numb. 4.) Where there was +considerable difficulty in bringing down the head, Dr. Smellie used to +introduce a second crotchet opposite to the first, like the second blade +of the forceps, and having locked them together was thus enabled to apply +a greater degree of force. + +_Crotchet._ The usual mode of applying the crotchet at the present day is +to pass it into the cranial cavity, and endeavour to fix it upon some +portion of the skull, which will afford a sufficiently firm hold for the +purpose; the best spot is the petrous portion of one or other of the +temporal bones. The plan of passing up the hook on the outside of the head +is objectionable, for in most cases where there is much impaction of the +head, it will be exceedingly difficult, if not impossible, to push the +hook past it without much suffering and probable injury. Not wishing to +differ from so great an authority as Dr. Smellie without reason, we have +repeatedly tried this mode of using the crotchet, but invariably found +that its introduction on the outside of the head was attended with so much +difficulty and pain as to make us relinquish the attempt. His objections +to passing the hook into the cranial cavity are not valid, for we should +never try to fix it upon the "thin bones," nor should we hold it in such a +manner that, if it did slip or tear through, it would wound either our +hand or the soft parts of the mother. + +The common form of the crotchet in general use is but ill adapted for +taking hold of any part within the skull: it is, in fact, the very +instrument left us by Dr. Smellie for applying on the outside of the +skull: and, therefore, that which was intended to take hold of a convex +surface cannot possibly be also suited for one of the contrary form, viz. +a concavity; for this reason, the shank of the hook requires to be +straight, so that the point may project at a considerable angle, by which +means it will take hold with much greater ease. + +The point of the hook guarded by the finger should be cautiously +introduced up the vagina, and passed into the cranial cavity; having fixed +it, as above directed, the finger should be applied externally, so as to +correspond with the hook inside: by so doing, if the point slips or tears +through the bone, the finger is ready to protect the soft parts from it; +the operator is equally safe from injury, for, by grasping the shank of +the hook with his thumb and other fingers, his whole hand moves with it +and gives him instant warning of its going to slip. Where the deformity of +the pelvis is very great, it may be necessary to break down the bones of +the head still farther, in order to produce greater comminution; but even +here, so long as the bones collapse well together, it will be better not +to displace them from their attachments, the whole mass will come down +better and with less chance of injuring the soft parts. Where, however, +this is admissible, we must give the head sufficient time to undergo that +process of softening which is one of the early stages of putrefaction; the +cranial parietes may be gradually removed, one after the other, until we +have nothing remaining but the base of the skull and the face. Dr. Burns +recommends us now to convert it into a face presentation with the root of +the nose directed to the pubes: "I have carefully measured, (says he,) +these parts placed in different ways, and entirely agree with Dr. Hull, a +practitioner of great judgment and ability, that the smallest diameter +offered, is that which extends from the root of the nose to the chin." + +_Embryulcia._ This is merely a degree farther than the perforation: it +consists in evacuating the chest and abdomen of their contents, and thus +enabling their parietes to collapse. It is chiefly had recourse to in +cases of deformed pelvis, where the arm or shoulder has presented, or +where the distortion is so great as to prevent the trunk from passing +without its bulk being lessened. Dr. Smellie's perforator with its +scissor edges is best suited for this object. Having made an opening into +the most presenting part of the thorax, we enlarge it by cutting away +portions of the ribs and thoracic parietes, and removing the contents of +the chest. The abdominal viscera are brought away in a similar way through +a perforation in the diaphragm; and if this be not sufficient to let the +trunk pass, the crotchet must be inserted into the brim of the child's +pelvis, which must be brought down doubled upon the spine, somewhat like +the process of spontaneous expulsion. + +The success of this operation, will, in a great measure, depend not only +upon its being undertaken sufficiently early before the patient's strength +is exhausted, but upon a sufficient length of time intervening between the +removal of the thoracic and abdominal viscera and the extraction of the +child. The excellent rule of Dr. Osborn, above quoted, is peculiarly +applicable here; for when softened by the effects of incipient +decomposition, the body will sometimes even be expelled by the unassisted +efforts of the uterus. + +In a case of this sort, the perforation of the head is the last part of +the process to be performed. It will be by all means, desirable not to +separate it from the body, but to pass up the curved perforator along the +neck, and make an opening behind the ears: this is effected without much +difficulty, and the head can be brought away whole, or in portions, +according to the nature of the case. + + + + +PART V. + +DYSTOCIA, OR ABNORMAL PARTURITION. + + +_Divisions and species._ By the term Dystocia, we understand those labours +which either cannot be completed by the natural powers destined for that +purpose, or at least, not without injury to the mother or her child.[107] +These will, therefore, consist of the two following classes:-- + +1. Labours that are difficult or impossible to be completed by the natural +powers. + +2. Labours which are rendered faulty without obstruction to their +progress. + +The first division of dystocia may either arise from a faulty condition of +the expelling powers, or, without any anormality in this respect, it may +depend upon the faulty condition either of the child, or of the parts +through which it has to pass. + +As respects the child it may arise from, + +1. Malposition. + +2. Faulty form and size of the child. + +3. Faulty condition of the parts which belong to the child. + +On the part of the mother this division of dystocia may arise from a +faulty condition. + +4. Of the pelvis. + +5. Of the soft passages. + +6. Of the expelling powers. + +The second condition where labour is rendered dangerous for the mother or +her child, without any obstruction to its progress, may arise from, + +1. Following too rapid a course. + +2. Prolapsus, &c. of the umbilical cord. + +3. From accidental circumstances, which render the labour dangerous, viz. +convulsion, syncope, dyspnoea, severe and continued vomiting, hæmorrhage, +&c. + +We propose to consider the different species of dystocia in the order +above enumerated. + + + + +CHAPTER I. + +FIRST SPECIES OF DYSTOCIA. + + _Malposition of the child.--Arm or shoulder the only faulty position + of a full-grown living foetus.--Causes of malposition.--Diagnosis + before and during labour.--Results where no assistance is rendered.-- + Spontaneous expulsion.--Malposition complicated with deformed pelvis + or spasmodically contracted uterus.--Embryulcia.--The prolapsed arm + not to be put back or amputated.--Presentation of the arm and head.-- + Presentation of the hand and feet.--Presentation of the head and + feet.--Rupture of the uterus.--Usual seat of laceration.--Causes.-- + Premonitory symptoms.--Symptoms.--Treatment.--Gastrotomy.--Rupture in + the early months of pregnancy._ + + +We have already stated that the presentations of the full-grown living +foetus may be brought under three classes, viz. those of the head, of the +nates or lower extremities, and of the arm or shoulder: the former two +have already been considered under the head of eutocia or healthy +parturition, and may be distinguished from the latter, by the great +peculiarity that in them the long axis of the child's body is parallel +with that of the uterus, whereas, in arm or shoulder presentations this +cannot be the case, its body lying across the uterus. + +Although malposition of the child, strictly speaking, refers to one +species of presentation only, viz. to that of the arm or shoulder, yet it +has been rendered a matter of great perplexity by the speculations and +theoretical notions of authors. No one has propagated more serious errors +upon this subject than the celebrated Baudelocque, the more so as the +great authority of his name has tended to silence all doubts as to the +accuracy of his views upon this subject. Almost every author since his +time has contented himself with copying more or less from him, without +ascertaining by personal observation how far they corresponded with the +actual course of nature. By forcing a stuffed figure into a pelvis in +every possible direction, he succeeded in making actually ninety-four +presentations of the child, all of which he described as if they had +really occurred in nature. + +Few have taken so simple a view of this subject as the late Dr. Denman. +"The presentations of children at the time of birth," says this +distinguished accoucheur, "may be of three kinds, viz. the head, the +breech or inferior extremities, the shoulder or superior extremities; the +back, belly, breast or sides, properly speaking, never constitute the +presenting part." + +The two greatest Continental authorities of modern times, viz. Madame La +Chapelle and Professor Naegelé, confirm this opinion: the former points +out one of the sources of error which has induced practitioners to suppose +that they had met with other species of faulty presentation besides those +of the arm or shoulder. "In the greater number of shoulder presentations," +says this experienced authoress, "I have very distinctly touched the +chest, in some positions of the nates I have been able to reach the loins, +the hips, or lower part of the abdomen; but it would require no slight +bias from prejudice and theoretical systems to find presentations of the +chest, the back, the abdomen, or the loins, the neck or the ear."[108] + +We would, therefore, limit the term malposition of the child merely to +presentations of the arm or shoulder: other presentations, it is true, +occur, but not of the full-grown living foetus; they are only where the +child is premature, or has been dead in utero some time. Under such +circumstances it will follow no rule whatever; for in the first case it is +too small, and therefore the passages can have no effect in directing its +course through them; and, in the second, a child which has been dead some +time becomes so softened by gradual decomposition, that it may be squeezed +by the pressure of the uterus into almost any shape: it is by this cause +that we occasionally see in still-born children parts in close contact, +which in a living child could not have been brought together. + +We do not deny that such presentations may be made by ignorant and awkward +attempts to deliver, but it is to be hoped that such cases are daily +becoming of rarer occurrence. + +Malposition of the child is fortunately not of very frequent occurrence: +as a general average we would say that it occurs once in 230 cases, as the +following results will show:--At the Westminster General Dispensary (1781) +it occurred to Dr. Bland once in 210 cases: at the Dublin Lying-in +Hospital, to Dr. Joseph Clarke, once in 212: in private practice, to Dr. +Merriman, once in 155: "calculated from a great number of cases," to +Professor Naegelé, once in 180: at the Dublin Lying-in Hospital, to Dr. +Collins, once in 416: at the Maternité, of Paris, to Madame La Chapelle, +once in 230. + +In arm and shoulder presentations the back of the child is turned towards +the anterior part of the uterus more than twice as frequently as it is in +the contrary direction, from which circumstance Professor Naegelé has +called this the first position of the shoulder to distinguish it from the +other, which, as being rarer, he calls the second. + +In investigating the nature of the causes which produce malposition of the +child, which, from the above observations, is evidently a circumstance of +rare occurrence, the question naturally suggests itself, by what means is +the long diameter of the child in so large a majority of cases kept +parallel with that of the uterus? This depends in great measure on the +form and size of the uterus. Where the uterus is not unduly distended with +the liquor amnii, and where it preserves its natural oval figure, it is +scarcely possible that the child should present in any other way than with +its cephalic or pelvic extremity foremost. There can be no doubt that the +first early contractions of the uterus in the commencement of labour have +a great effect in regulating the position of the child; for, by the gentle +and equable pressure which they exert upon it, they not only maintain it +in the proper direction, but tend materially to correct any slight +deviations from the right position. Hence, therefore, we find that where +any cause has existed to impair or derange the action of these precursory +contractions of the uterus, the child is apt to lie across, or, in other +words, to present with the arm or shoulder. Thus, for instance, if the +uterus be much distended with liquor amnii, the contractions of its +parietes can have little influence upon the child's position; this will be +particularly the case where the accumulation is very considerable, for +here the uterus becomes more or less globular, and presents but little +variation as to the length of its diameter in any direction. + +The form of the uterus is no less worthy of attention as a cause of +malposition, and is also in a great measure influenced by the character of +its early contractions. Thus in a uterus for the first time pregnant, they +generally act equally on all sides: hence it is why in primiparæ the +uterus is so exactly oval, and why we so rarely meet with faulty +presentations. Sir Fielding Ould, of Dublin, was the first and almost the +only practitioner in this country who noticed the influence which the +early contractions of the uterus have in determining the position of the +child. "The first labour pains, which are very short, continue their +repetition for two or three hours, or perhaps for more, before there is +the least effect produced upon the os tincæ, which time must certainly be +employed in turning the head towards the orifice." (_Treatise of +Midwifery_, p. 14.) + +Wigand, in reasoning upon the physical impossibility of a child presenting +wrong, where the uterus is of the natural configuration, says that "the +chief cause of faulty position of the child does not depend so much upon +the child itself, as upon the deviation of the uterus from its natural +elliptical or pyriform shape." (Wigand, vol. ii. p. 107.) + +The theory at one time so universally entertained, that the obliquity of +the uterus was the chief cause of malposition of the child, has long since +been disproved, although it continues to find a few adherents to the +present day: the uterus, in fact, towards the end of pregnancy, is +scarcely ever quite straight; the upright posture of the human female +rendering it almost necessary that the fundus should incline somewhat to +one side or to the other, or forwards, and yet we find that it has no +influence upon the position of the child when labour comes on. The moment +a pain commences, the fundus moves towards the median line of the body, so +that its axis corresponds nearly with that of the pelvic brim: as the pain +goes off, so does it return towards its former oblique position. Even in +those cases where it is strongly inclined forwards, and where the abdomen +is quite pendulous, the position of the child is unaffected by it. + +Where, however, the uterus has been altered in point of form, where from +irregular contractions of its fibres it has been pulled down unequally to +one side, while it is quite relaxed in the opposite direction, the +position of the child may be seriously affected, for it will now present +obliquely as regards its long axis, and become a case of malposition. + +We may, therefore, state that the causes of arm or shoulder presentations +are of two kinds, viz. where the uterus has been distended by an unusual +quantity of liquor amnii; or where, from a faulty condition of the early +pains of labour, its form has been altered, and with it the position of +the child. + +It is a well-known fact that cross births, as they have been called, are +frequently preceded by severe spasmodic pains in the abdomen, from which +the patient suffers for some days or even weeks before labour has +commenced: the uterus is more or less the seat of these attacks, which +usually come on towards night-time; and, in some instances, it is felt for +the time hard and uneven from irregular contraction. It was the +circumstance of this symptom having preceded five successive labours of a +patient, in all of which the child had presented with the arm or shoulder, +which induced Professor Naegelé, when attending her in her sixth +pregnancy, to endeavour to allay these cramp-like pains, which had begun +to show themselves as severely as on former occasions. Having tried opium +by itself, and also in combination with ipecacuanha or valerian without +effect, he ordered her a starch injection with twelve drops of Tinct. Opii +every night as long as she continued to suffer from these attacks: the +spasms soon ceased, nor did they appear again during the remainder of her +pregnancy, and he had the satisfaction of delivering her at the proper +time of a living child, which presented in the natural manner. + +Many other causes of malposition have been enumerated by authors, which +evidently exist only in theory and not in reality: thus, shortness of the +umbilical cord, or its being twisted round the child, insertion of the +placenta to one side of the uterus, faulty form or inclination of the +pelvis, obliquity of the uterus, as above-mentioned, violent exertions or +concussions of the body, plurality of children; of all these, we do not +believe that there is one which can exert the slightest influence in +determining the position of the child. There is no doubt that several of +them will render labour difficult or even dangerous, more especially +deformed pelvis; but we constantly meet with it under every degree and +variety without at all altering the child's position. Indeed, if +malformation of the pelvis were to be a cause of malposition of the child +during labour, what difficulties would it not add to the process of +delivery under such circumstances? And yet we find, with very rare +exceptions, that in every case requiring artificial assistance on account +of contracted pelvis, the head is resting upon the brim which is too +narrow to allow it to pass. + +We may also mention another circumstance which has occasionally seemed to +produce a faulty position of the child. It sometimes happens that the +hand, which is frequently felt lying by the side of the face at the +beginning of labour, instead of slipping up out of reach as the head +descends, which is usually the case, advances more and more, until it not +only prevents the head from engaging farther into the pelvis, but pushes +it out, so that the head slips up to one side, and lodges in the cavitas +iliaca, allowing the shoulder with the rest of the arm to descend. + +Where, however, the pelvis is large or the head small, the arm will not +always force it to one side, but the two will come down together and be +born in this position. (See case in our _Midwifery Reports, Med. Gaz._ +April 19, 1834.) + +Sometimes the two hands present (_La Motte_, book iii. ch. 26.,) or a hand +and foot: this, however, does not long continue so, for when the membranes +have ruptured, the liquor amnii flowed away, and the uterus contracted +upon the child, one shoulder and arm descend before the rest, and remain +in this position. + +The complication of two arms presenting with the head we disbelieve +entirely, except where it has been made during some awkward and ignorant +attempts at delivery. + +Although the symptoms of malposition of the child during the last few days +before, or at the commencement of labour, are far from being distinct, +still, however, when taken collectively, they will be sufficient to excite +our suspicion. The abdomen is irregularly distended, and marked with +unequal prominences; anteriorly, it is more or less pointed. It is usually +much increased in breadth, and this is generally in an oblique direction, +forming a globular protuberance at the upper part on one side, and at the +lower part on the other: the former is the pelvic extremity of the child; +the other, from its size, form, and hardness, may easily be recognised as +the head. + +"The movements of the child feel differently to what they did before; +they are no longer exclusively confined either to one side or the other. +Sometimes, as before-mentioned, cramp-like pains are felt in the abdomen, +during which it is more or less distorted with violent movements, +apparently of the child, as if it were trying to force its way through the +abdominal parietes at this spot." (Naegelé, _Lehrbuch_, p. 223.) + +Upon examination _per vaginam_, either no presentation is to be reached at +all, or only small parts can be indistinctly felt, such as the hand, the +arm, or the shoulder. The not being able to feel a presenting part in a +primipara shortly before or at the commencement of labour, is an +unfavourable symptom; for the head at this time ought to be deep in the +cavity of the pelvis; still, however, it does not necessarily prove that +the child is presenting wrong, for it may be a presentation of the nates, +which, as we have before shown, do not descend so low into the pelvis just +before labour, as the head does; or it may arise from the unusual size of +the child's head, especially in cases of congenital hydrocephalus. It may +arise from a large quantity of liquor amnii, and where the head is +nevertheless presenting; it may be a case of twins, or lastly of dystocia +pelvica, where the head is presenting, but unable to pass through the +contracted brim. + +In women who have had several children, it is frequently impossible to +reach the presentation during the early part of the labour: this arises +either from the abdomen in these cases being generally more or less +pendulous, or from the circumstance of the uterus having been distended in +so many previous pregnancies: its lower part does not become so fully +developed as before, but continues more or less funnel-shaped, a +considerable portion of the cervix still remaining. Where this is the +case, the head will not descend so low as usual at first, but remains out +of reach, or nearly so, until the os uteri is fully dilated and the +membranes have given way. + +"If, upon such an examination, it should be ascertained that the os uteri +is considerably dilated, and the child cannot be felt, this affords reason +to suspect that the presentation is preternatural. Should the liquor amnii +be discharged and the child be out of reach of the finger, the probability +of a preternatural position is greater. Should the membranes be found +hanging down in the vagina not of the usual globular form, but rather +conical and small in diameter, this likewise is a presumptive proof of a +cross-birth; especially if there be any part presenting through the +membranes which is smaller, feels lighter, or gives less resistance when +touched than the bulky heavy head."[109] + +The diagnosis of the shoulder is by no means easy: it offers no +distinctive marks, and may readily be mistaken for the nates, or even for +the head. It feels round, but is smaller and softer than the head. The +scapula and clavicle, the neck, the armpit, the arm itself, and the ribs, +assist us in our diagnosis. From the direction of these parts, we shall be +able to ascertain the position of the rest of the body, and which shoulder +presents. If the hand has prolapsed, the direction of the palm and of the +thumb will soon show the position of the child. + +Labours with malposition are always dangerous; when left without +assistance, they are almost always fatal to the child, and generally so to +the mother. + +When a full-grown child has presented with the arm or shoulder, and +nothing has been done to assist the delivery of it, the results are +usually as follow:--After the membranes have burst, and discharged more +liquor amnii than in general where the head or nates presents, the uterus +contracts tighter around the child, and the shoulder is gradually pressed +deeper into the pelvis, while the pains increased considerably in +violence, from the child being unable, from its faulty position, to yield +to the expulsive efforts of nature. Drained of its liquor amnii, the +uterus remains in a state of contraction even during the intervals of the +pains; the consequence of this general and continued pressure is, that the +child is destroyed from the circulation in the placenta being interrupted, +the mother becomes exhausted, and inflammation or rupture of the uterus or +vagina are almost the unavoidable results. + +Another although much rarer consequence of malposition of the child, is +that peculiar mode of expulsion which was first noticed by Dr. Denman in +1772. From the supposition that the shoulder receded and the nates came +down into the pelvis, in which position the child was born, he called it +"_the spontaneous evolution of the foetus_;" but the term _spontaneous +expulsion_, as proposed by Dr. Douglas in 1811, is much better adapted, it +having been shown by that gentleman that the explanation of this process +as given by Dr. Denman was not correct. (_An Explanation of the real +Process of the spontaneous Evolution of the Foetus_, by J. C. Douglas, M. +D. 2nd ed. 1819, p. 28.,) but that whilst the shoulder rested against the +pubes, the side of the thorax and abdomen, followed by the nates, passed +in one enormous sweep over the perineum, leaving the head and other arm +still to be extricated. + +The shoulder and thorax thus low and impacted, instead of receding into +the uterus, are at each successive pain forced still lower, until the ribs +of that side, corresponding with the protruded arm, press on the perineum, +and cause it to assume the same form as it would by the pressure of the +forehead in a natural labour. At this period, not only the entire of the +arm but the shoulder can be perceived externally, with the clavicle lying +under the arch of the pubes. By farther uterine contractions the ribs are +forced more forwards, appearing at the os externum, as the vertex would in +a natural labour, the clavicle having been by degrees forced round on the +anterior part of the pubes with the acromion looking towards the mons +Veneris. "The arm and shoulder are entirely protruded with one side of the +thorax, not only appearing at the os externum, but partly without it: the +lower part of the same side of the trunk presses on the perineum, with the +breech either in the hollow of the sacrum or at the brim of the pelvis, +ready to descend into it, and, by a few farther uterine efforts, the +remainder of the trunk, with the lower extremities, is expelled." +(Douglas, _op. cit._ p. 28. 2nd ed.) + +Farther experience has confirmed the correctness of Dr. Douglas's views +(_Med. Trans. of the Royal Coll. of Physicians_, vol. vi. 1820;) and, +indeed, the original case as related by Dr. Denman himself tends to prove +that nothing like an "evolution" of the foetus takes place. I found the +arm much swelled, and pushed through the external parts in such a manner +that the shoulder nearly reached the perineum. The woman struggled +vehemently with her pains, and during their continuance _I perceived the +shoulder of the child to descend_. + +Some years afterwards, the late Dr. Gooch had the opportunity of observing +a case of spontaneous expulsion with great accuracy, and came to the same +conclusion as Dr. Douglas had done. "Resolved to know what became of the +arm, if this (the spontaneous expulsion) should happen, and thus fit +myself for a witness on this disputed point, I laid hold of it with a +napkin and watched its movements: so far from going up into the uterus +when a pain came on, it advanced, as well as the shoulder, still forwarder +under the arch of the pubes, the side of the thorax pressing more on the +perineum and appearing still more externally; it advanced so rapidly that +in two pains, with a good deal of muscular exertion on the part of the +patient, but apparently with less suffering than attends the birth of the +head in a common first labour, did the side of the chest, of the abdomen, +and of the breech, pass one after the other in an enormous sweep over the +perineum till the nates and legs were completely expelled." (_Ibid._) + +The celebrated Boer, has, however, detailed a case where the arm had +prolapsed into the vagina, the hand appearing externally; and on +introducing his hand for the purpose of turning, he felt the hand +distinctly receding, and the breech beginning to occupy the cavity of the +pelvis. This is very different to a case of spontaneous expulsion: "the +child lay completely across, with its abdomen towards the back of the +mother;"[110] it had, in fact, not yet begun to press against the brim, +or to assume any definite position, there having been as yet but little +uterine contraction, and both rectum and bladder being considerably +distended. When these were evacuated the pains increased: the breech being +nearest to the brim, descended, and the arm in consequence receded. Dr. +Gooch considers it most probable that "it was only a breech presentation, +the hand having accidentally slipt down into the vagina." + +Although in cases of malposition where turning has become excessively +difficult and dangerous, the spontaneous expulsion must be looked upon as +a most fortunate process by which nature effects delivery, still, however, +we must never venture to wait for it without making such attempts to turn +the child as the state of the patient may justify. It is always more or +less dangerous to the mother, and almost certainly fatal to the child. +Indeed, it is our opinion, that the spontaneous expulsion can rarely, if +ever take place, except where the child has been already dead some time, +or where it is premature. "Nor can any event," says Dr. Douglas, "ever be +calculated upon than that of a still-born infant. If the arm of the foetus +should be almost entirely protruded with the shoulder pressing on the +perineum, if a considerable portion of its thorax be in the hollow of the +sacrum with the axilla low in the pelvis, if with this disposition the +uterine efforts be still powerful, and if the thorax be forced sensibly +lower, during the presence of each successive pain, the evolution may with +great confidence be expected." (_Op. cit._ p. 42.) + +On the other hand, if either from the rigidity, &c. of the child or of the +passages, but little material advance is made in the manner +above-mentioned, if the soft parts are become swollen and inflamed, and +the powers of the patient are beginning to flag, and exhaustion coming on, +if turning has been attempted as far as could be done with safety, and +still without success, we have no choice left but that of embryotomy; the +chest and abdomen must be evacuated of their contents as already directed +under the head of PERFORATION, and in this manner the child delivered. + +_Malposition with deformed pelvis, or rigidity of the uterus._--Where the +pelvis is deformed, or the uterus (from the early escape of the liquor +amnii) spasmodically contracted upon the child, and the os uteri in a +state of rigidity, the difficulties and danger of the case are greatly +multiplied: in the former complication the embryotomy must be carried much +farther, in the latter we must have recourse to bleeding, opium, +warm-bath, &c. as recommended under the head of TURNING. + +_The prolapsed arm is not to be put back or amputated._--Where the arm has +been some time prolapsed, and, from the pressure of the soft parts, much +swollen, it fills up the vagina so completely that it would seem almost +impossible to introduce the hand, unless we push up the arm first: +experience however confirms the valuable rule of La Motte, viz. that we +must slide our hand along the arm into the uterus; we shall rarely find, +where the passages are in a proper state for undertaking the operation, +that the prolapsed arm presents any serious obstruction to the passage of +the hand. "An arm presenting," says Chapman, "and advanced as far as the +armpit, is not to be returned, but the hand is to be introduced (which, as +Deventer justly observes, is often found to penetrate with much more ease +when the arm hangs down than when it is thrust back again) and the feet to +be sought for, which, when found, the arm will prove no great hindrance in +turning the child." (Chapman's _Midwifery_, p. 46. 2nd. ed., 1735.) + +In no case is it necessary to separate the arm at the shoulder, "for I +have found it," says Dr. Denman, "a great inconvenience, there being much +difficulty in distinguishing between the lacerated skin of the child and +the parts appertaining to the mother." (_Essay on Preternat. Labours_, p. +32.) + +Dr. Meigs, of Philadelphia, has added another powerful argument against +this practice, viz. that cases have occurred where the arm had been cut +off and where the child was nevertheless born alive. + +As to how far it is possible or advisable so to alter the position of the +child as to make it present with the nates or head, this has already been +considered in the chapter upon TURNING. + +The _presentation of the arm with the head_ is of very rare occurrence, so +much so that some have doubted if it really existed: two cases of this +kind have come under our own notice, in both of which the child was born +in this position, although with some difficulty. + +"Independent of the awkwardness of position which the head may assume, +from the circumstance of the hand or arm descending with it into the +pelvis, there will be so much increase in the bulk of the part as to +render its passage slow and difficult; yet if the case be not interrupted +by mismanagement, it will terminate favourably, for this complication of +presentation seldom happens but in a wide pelvis." (Merriman's _Synopsis_, +p. 48, last ed.) + +It is by no means uncommon to feel the hand lying upon the side of the +head or on the cheek; but this produces no impediment to the labour, for +as the head descends through the brim of the pelvis the hand usually slips +up: in the other case we have felt the arm bent over the head, and +pressing the ear on the opposite side. + +_Presentation of the hand and feet._ We sometimes also meet with cases +where the hand presents with one or two feet; but these complications +merely exist at the commencement of labour, where the uterus has been +greatly distended with liquor amnii, and where its contractions have not +yet begun to press the child into the brim. Cases of this nature sooner +or later are sure to terminate in presentations of the nates or shoulder, +unless the process of labour has been interfered with. + +_Presentation of the head and feet._ Presentations of the head and one or +both feet have also been described: these, however, have only occurred +during the operation of turning, when the feet have been brought down into +the pelvis before the head had left it, and, therefore, must be considered +as having been _made_ by unskilfulness on the part of the practitioner. +Where this is the case it may be necessary to premise blood-letting, &c., +on account of the inflamed condition of the parts from the previous +unsuccessful attempts to turn: after this, a fillet should be passed round +the feet in order to secure them, and then the head may be safely pushed +out of the pelvis. + +_Rupture of the uterus._ Of the injurious results arising from protracted +or neglected cases of arm or shoulder presentation none can compare in +point of danger with those where the uterus has given way or burst. This +state may also be produced by deformity of the pelvis, tumours, and other +causes of obstruction to the passage of the child, by which the uterus is +excited to unusually violent efforts in order to overcome the impediment +during which the laceration is effected. It may also arise from injuries +to the uterine tissue without undue exertions, as from exostosis of the +pelvis, sharp projecting edges of the promontory or brim, and also from +organic disease: thus, "when the rent speedily follows the accession of +labour, before the pains have become severe, or the uterus has scarcely +begun to dilate, its structures will probably be found diseased." (_Facts +and Cases in Obstetric Medicine_, by I. T. Ingleby, p. 176.) + +_Usual seat of the laceration._ The part of the uterus in which laceration +is most frequently observed to occur is near to or at the junction of the +uterus with the vagina: this happens rather more frequently behind than +before, but the difference in this respect is very trifling. Thus in 36 +cases which were collected by Mr. Roberton, of Manchester, "in 1 the +cervix was separated from the vagina except by a thread: in 11 the +laceration was posterior, in 8 it was anterior, in 5 lateral, in 3 +anterior-lateral, and in 3 posterior-lateral." (_Edin. Med. and Surg. +Journal_, vol. xlii. 1834, p. 60.) In 34 cases which occurred at the +Dublin Lying-in Hospital, "in 13 the injury was at the posterior part; in +12 anteriorly; in 2 laterally; in 1 the mouth of the womb was torn, and in +6 the particular seat of the laceration was not described." (_A Practical +Treatise on Midwifery_, &c., by Robert Collins, M. D., 1835, p. 244.) + +The nature and extent of the laceration varies a good deal: in the worst +cases the uterus is torn completely through, and the child escapes either +partly or wholly into the abdominal cavity; whereas, in many, the +peritoneum has not given way, the laceration being confined entirely to +the tissue of the uterus itself. Thus, in 9 of the 34 cases recorded by +Dr. Collins, "the peritoneal coat of the uterus was uninjured, although +the muscular substance of the cervix was extensively ruptured." In other +instances the peritoneum has been cracked or torn in numerous places +without any injury to the subjacent tissue. + +From the greater degree of resistance to the passage of the child, in +cases of first labour, we might naturally suppose that rupture of the +uterus would be more frequently seen among primiparæ: this, however, is +not the case, for of 29 cases mentioned by Mr. Roberton, only one of them +was a primipara; a larger (and as an average probably more correct) +proportion, viz. 7 in 34, has been given by Dr. Collins: of the multiparæ, +5 were in their sixth pregnancy, 2 in their tenth, and 2 also in their +eleventh pregnancy. + +Experience also shows that in a large proportion of these cases, the +duration of the labour has been very far from being longer than usual; +indeed, in a considerable majority, the mischief has taken place very few +hours after the commencement of active labour. Thus, the average duration +of it in the 36 cases recorded by Mr. Roberton, was 15 hours: in 24 of +those by Dr. Collins, it was 17 hours: but if we take merely the +_majority_ of them we shall have a much smaller average: thus, in 20 of +Mr. Roberton's cases it was 9 hours, and in 15 of Dr. Collins's it was +only 6 hours. + +_Causes._ A large proportion of cases where the uterus gives way during +labour, are connected with more or less deformity of the pelvis, and +where, from previous severe and difficult labours, its structure has been +injured, and rendered incapable of bearing that degree of tension, which +even the ordinary exertions of the uterine fibres would require. In many +others, the impediment produced by the contracted pelvis, or malposition +of the child, has roused the uterus to those violent efforts which have +produced the laceration. Organic diseases of the uterus, or cicatrisations +of the soft passages from extensive injuries in former labours, either +render its powers of resistance defective, or, by increasing the +resistance, excite it to unusual violence. "The operation of turning is +not unfrequently a cause of laceration of the vagina or mouth of the +uterus, _particularly_, where it is performed previous to the soft parts +being sufficiently dilated to admit the easy passage of the hand, or where +great haste is employed. The same consequences may ensue from rash or +violent attempts to remove a retained placenta. I have also known the +mouth of the womb to be torn by the imprudent use of the forceps when not +sufficiently dilated." (Dr. Collins, _op. cit._ p. 242.) "The sex of the +infant, it would appear, may also have some share in occasioning this very +distressing occurrence." (_Practical Remarks on Lacerations of the Uterus +and Vagina_, by Thomas M'Keever, M. D., p. 4.) Thus, of 20 cases reported +by Dr. M'Keever, 15 were delivered of boys and 5 of girls; of the 34 cases +described by Dr. Collins, "23 of the children were males. This is +satisfactorily accounted for by the greater size of the male head, as +proved by accurate measurement made by Dr. Joseph Clarke." + +Another circumstance which influences to a certain extent the frequency of +rupture of the uterus, is the rank of the patient: in private practice, +especially among the better classes of society, it is an extremely rare +occurrence; but in the lower grades of life several causes concur to +render it more frequent. They are "much more exposed to falls, bruises, +and other accidental injuries during pregnancy, in consequence of which +the uterus may be either ruptured at the time they have sustained the +violence, or may be so weakened in structure at some particular point, as +readily to give way during its efforts to accomplish delivery. Lastly, +they are more liable to fall into the hands of ignorant inexperienced +midwives, who not unfrequently, with a view of expediting the process of +delivery, rupture the membranes at an early period of the labour; in +consequence of which, the firm unyielding head of the child is prematurely +brought in contact with the passages, exciting by its pressure, swelling, +inflammation, and an interrupted state of the circulation in the uterus +and adjacent parts. In such a case should there unfortunately exist any +disproportion between the parts of the mother and the head of the infant, +or should proper measures not be employed to obviate distressing symptoms, +and that the labour pains continue to recur with extreme violence, there +is great risk of the uterus giving way, the laceration being of course +most likely to occur at that part where the greatest pressure has been +sustained." (M'Keever, _op. cit._ p. 3.) + +The _premonitory symptoms_ of rupture of the uterus are not always +sufficient to warn us of the impending danger, for in many cases nothing +unusual has occurred until the actual injury has been produced, and it has +then been inferred by the alarming change observed in the patient's +appearance. In many cases, especially where the muscular substance only of +the uterus was torn, the pains have continued with a sufficient degree of +power to expel the child; in others the mischief has been attended with so +little suffering at the moment, and for the time with so little +constitutional derangement, as to excite no suspicion, either on the part +of the patient, or her attendant. "Farther, as on some occasions, the +uterus has been known to give way during the very pain which effected the +delivery of the child, instances of which may be found in the works of +Crantz and Guillimeau." (_Ibid._ p. 15.) + +_Symptoms._ "When a rupture of the uterus has really happened, it is +generally marked by symptoms which are decisive; but it being a case which +occurs so very rarely, they do not immediately create suspicions. When +labour has continued violent a considerable time, if a pain expressive of +peculiar agony is followed by a discharge of blood, and an immediate +cessation of the throes, there is reason to apprehend this mischief. If +nausea and languor succeed, with a feeble and irregular pulse, cold sweat, +retching, a difficulty of breathing, an inability to lie in a horizontal +posture, faintness or convulsions, there is still more reason to suspect +the nature of the case. But if the presenting part of the child, which was +before plainly to be distinguished, has receded and can be no longer felt, +and its form and members can be traced through the parietes of the +abdomen, there is evidence sufficient, I believe, to determine that the +uterus is ruptured. The labour pain, in consequence of which the rupture +is supposed to have happened, is often described by the patient, as being +similar to cramp, and as if something was tearing and giving way within +them. It has been said likewise, to have produced a noise which could be +heard by the people present." (_Observations on an extraordinary Case of +ruptured Uterus_, by Andr. Douglas, M. D., 1785, p. 48.) + +Where the peritoneal coat only has been torn, we may have many of the +above-mentioned symptoms resulting from laceration of the uterus, without +any impediment to the progress of labour. This peculiar species of partial +rupture was first noticed by the late Dr. John Clarke, (_Trans. for the +Improvement of Med. and Surg. Knowledge_, vol. iii.,) since which cases +have been recorded by Mr. Partridge (_Med. Chir. Trans._ vol. xix. p. +72.,) Dr. Collins, Dr. Ramsbotham, &c. In Dr. Clarke's case the uterus and +vagina "were found to have sustained no injury whatever; but on turning +down the fundus uteri over the pubes, between forty and fifty transverse +lacerations were discovered in the peritoneal covering of its posterior +surface, none of which were in depth above the twentieth of an inch, and +many were merely fissures in the membrane itself. The edges of the +lacerations were thinly covered with flakes of coagulated blood; and about +an ounce of this fluid was found in the fold of the peritoneum, which dips +down between the uterus and the rectum." + +Where the uterus has been torn quite through, a frequent result is, that +the child passes either wholly, or in part, through the rent into the +abdominal cavity: this occurrence will, in great measure, be influenced by +the situation and extent of the laceration, and also by the degree of the +uterine contractions. It is easily recognised by the presenting part +having receded, and in all probability by the members of the child being +felt with unusual distinctness through the abdominal parietes. + +_Treatment._ Under such an unfortunate complication nothing remains but to +effect the delivery in as speedy and gentle a manner as possible. Where +the os uteri is fully dilated, the head presenting and but little +receded, and the pelvis only slightly contracted, the application of the +forceps will be justifiable; but in many instances the circumstances of +the case will not warrant it, and the attempt must be made to bring down +the feet, which has been most usually had recourse to with success +although it occasionally happens that even this is attended with no slight +difficulties: the rigid and partially dilated os uteri may be a serious +bar to the introduction of the hand; this has been successfully overcome +by incisions into its edge;[111] but it is a remedy which no practitioner +would use if by any means to be avoided. + +_Gastrotomy._ Where the whole child has passed into the abdominal cavity, +and the uterus has evidently contracted, so as to produce a serious, if +not insurmountable obstacle to delivering it through the vagina, or at any +rate without the risk of increasing the extent of the laceration, the +question then remains as to whether we should perform gastrotomy, or leave +the foetus in the abdominal cavity to be gradually discharged, like an +extra-uterine pregnancy, by abscess and sloughing. There can be no doubt +that the former plan is preferable, nor are there wanting upon record +successful cases of gastrotomy after rupture of the uterus; one of which +is doubly interesting from the operation having been twice performed with +a favourable result in consequence of a repetition of the injury in the +patient's succeeding pregnancy.[112] Mr. Ingleby, of Birmingham, gives a +similar opinion in favour of the operation: "The result of two cases of +Cæsarean operation in which I have been engaged, leads me to view the mere +abdominal incision with very different feelings. The operation is not half +so dangerous as the Cæsarean, whilst the celerity with which it is done, +the absence of hæmorrhage, and the facility with which the intestines are +confined within the abdomen, tend to divest it of much of its terror." +(_Op. cit._ p. 201.) + +_Rupture during the early months of pregnancy._ Cases of rupture of the +uterus have occasionally been observed at an early period of pregnancy; in +many of these the foetus has passed into the abdominal cavity, where it +has been enclosed in a species of cyst, and afterwards expelled through +the rectum or abdominal parietes by an abscess. It may be doubted whether +some of these have not been cases of extra-uterine pregnancy. On the other +hand, there is reason to believe that those extraordinary cases of ventral +pregnancy, to which we have alluded, where the foetus has been found in a +sac in the abdomen, which communicated with the uterus, and to which the +placenta was attached, were the results of rupture at an early period of +pregnancy, in all probability the result of ulceration or organic +degeneration of the uterine parietes. In some instances it has been +produced by violence: and it is by no means impossible that it might take +place during a miscarriage, when the uterine contractions are occasionally +very violent. Mr. Ingleby remarks that in a case of premature expulsion at +the fifth month, the violence of the pains seemed quite equal to produce a +breech of surface. + +Dr. Collins has recorded a case of ruptured uterus in about the fifth +month. The laceration appears to have taken place imperceptibly: the child +was very putrid; and as the os uteri was sufficiently dilated, the head +was perforated, and "was brought away almost without any assistance. It +was nothing more than a soft mass, being so completely broken down by +putrefaction."[113] There was no previous history to explain it; the +muscular structure of the uterus at the anterior part of its cervix was +torn, leaving the peritoneum entire. + +Lastly, we may mention a very singular species of laceration of the +uterus, of which we know of but two cases, the one recorded by Mr. P. N. +Scott, of Norwich, (_Med. Chir. Trans._ vol. xi.) the other which occurred +under our own notice, where the whole os uteri separated from the uterus +during labour.[114] In both cases, the os uteri presented a degree of +unnatural rigidity, which was quite peculiar, and which in one case, +defied repeated and active bleeding, as well as opiates. In Mr. Scott's +case, the laceration took place during a violent pain, when the patient +"felt something snap, the noise of which one of the attendants declared +she heard." In the other case, the patient was not aware of any thing +peculiar having happened: it was a first labour in the eighth month of +pregnancy; the os uteri had dilated to nearly the size of half a crown, +but would dilate no farther; the child had evidently been some time dead; +the cranial integuments gave way from putrefaction, the brain escaped, the +bones of the skull collapsed, and the bag of scalp protruded so far that +we could lay hold of it, although the basis cranii had not passed. We were +thus enabled to use more extractive force than we could have ventured upon +with the crotchet: after a little effort, but without even a complaint +from the patient, the head descended and passed through the os externum. +"On the bed lay a disc of fibrous matter with a circular hole in the +middle; in fact, the os uteri separated from the uterus to the extent of +near half an inch, the edge of the laceration being as clean and smooth as +if it had been carefully cut off by a knife." In both instances the +patient recovered. Whether incisions into the os uteri for the purpose of +effecting the necessary degree of dilatation would have been justifiable +under circumstances of such unusual rigidity, does not belong to the +present subject; for the consideration of this, we must refer to the FIFTH +SPECIES OF DYSTOCIA. + + + + +CHAPTER II. + +SECOND SPECIES OF DYSTOCIA. + + _Size and form of the child.--Hydrocephalus.--Cerebral tumours.-- + Accumulation of fluid and tumours in the chest or abdomen.-- + Monsters.--Anchylosis of the joints of the foetus._ + + +In this case the labour is rendered difficult or impossible to be +completed by the natural powers on account of the faulty size, form, or +condition of the child. In the first instance, it is merely a case of +disproportion between the child and the passages, owing to the unusual +size of the former. Where the child is well formed throughout, but larger +than usual, it rarely happens that the head experiences any serious degree +of difficulty in passing through a well-formed pelvis, the greatest +resistance being observed during the dilatation of the external passages. +Even when the head is born, the shoulders may produce a considerable +obstruction to its farther passage, requiring a good deal of careful +manipulation, in order to disengage the foremost shoulder from under the +pubic arch, and thus diminish the pressure of the child against the +parietes of the pelvic cavity. Where the shoulders have been severely +impacted in this position, it has been in great measure owing to the +practitioner having endeavoured to bring down the wrong shoulder first, +viz. that which is directed more or less backwards. + +_Size of the child._ We have already stated that the average weight of the +full grown foetus is between six and seven pounds, and its length about +eighteen inches; but it is frequently found to exceed these proportions +very considerably. Children are not uncommonly observed to weigh 10lbs. at +birth. Dr. Merriman once delivered a still-born child, which weighed +14lbs., and the late Sir Richard Crofts is said to have delivered one +alive which actually weighed 15lbs.; but by far the largest child which we +have yet heard of is recorded by Mr. J. D. Owens, surgeon, at Haymoor near +Ludlow; it was born dead, and the weight and admeasurements ten hours +after birth were as follow:-- + + The long diameter from the occiput to the root of the nose 7-1/4 inches. + The occipito-mental 8-1/2 + From one parietal protuberance to the other 5 + Circumference of the skull 15-1/4 + Circumference of the thorax over the xiphoid cartilage 14-1/2 + Breadth of the shoulders 7-1/4 + Extreme length of the child 24 + Weight of the child 17 lbs. 12 oz. + + (_Lancet_, Dec. 22. 1838.) + +We have already pointed out the difficulty of determining the presence of +twins merely from the appearance of the mother's abdomen; the same will +necessarily hold good with regard to one large child. The size of the +patient must rarely have any influence in forming our prognosis: in most +cases she will have many symptoms, which arise either from pressure or +weight in the pelvis, such as difficulty in passing water, oedema of the +feet and legs, varicose veins of the thighs and labia, or from cramps, the +result of pressure upon the absorbents, veins, or nerves; considerable +expansion of the inferior segment of the uterus: all these will give us +reason to suspect the presence of a large child even although the abdomen +may not be remarkably distended. + +Where the head is very large, the bones are seldom much ossified; they +therefore yield easily, and the head accommodates itself to the shape of +the passage: sometimes, however, it is unusually hard, the bones are well +ossified and very unyielding, so that even if it be not larger than +common, still, from its hardness, it meets with considerable difficulty in +passing through the pelvis. Cases have been described where the cranial +bones were completely ossified, and the sutures perfect; but this latter +is very doubtful. Perfect mentions an instance where the head was "almost +one entire ossification, and where it passed through the pelvis with great +difficulty." (Perfect's _Cases in Midwifery_, vol. ii. p. 370.) We have +also met with cases requiring perforation on account of deformed pelvis, +and where the cranial bones had almost the feel of a hard nut or shell; +still, however, as already observed, we seldom see any serious impediment +to the passage of a large head, so long as it is naturally formed; and +this applies also to the other parts of the child. + +_Form of the child._ On the other hand, where there is an unnatural form +of the child, either from a disproportionate size or anormal configuration +of certain parts, labour may be rendered not only very difficult but +dangerous: thus one of the three great cavities may be distended with an +accumulation of fluid, the most common form of which, is the congenital +hydrocephalus. + +_Hydrocephalus._ In many cases it produces much less resistance than might +be expected from the size of the head; this is, in great measure, owing to +the unusual width of the sutures and fontanelles, but chiefly to the +almost entire want of ossification in the cranial parietes, which are +little else than membranous, and so flexible as to allow the head to be +squeezed into almost any shape. In some very rare cases the head has +burst, a large quantity of fluid has come away suddenly, and this has been +followed almost immediately by the birth of the child:[115] but in the +majority the labour has been tedious and severe, and in some instances +attended with dangerous results to the patient; thus, Dr. Merriman has +"known one hydrocephalic foetus pass entire, the circumference of whose +head was 17 inches; another passed alive and lived nearly an hour, whose +head measured in circumference nearly 22 inches; both the above labours +were long and painful." Perfect relates a case of hydrocephalic head, of +which he has given engraved delineations; the labour was attended with +extreme difficulty, and the woman expired in less than two hours after +delivery; the circumference of this head was 24 inches. (_Cases in +Midwifery_, vol. ii. p. 525.) An interesting case of hydrocephalus, +attended with convulsions and laceration of the vagina, has been recorded +by Dr. Collins: "the perforator was used, upon the introduction of which +into the head fully three half pints of water gushed out; the bones then +collapsed, and the delivery was easily completed." (_Practical +Observations_, p. 205.) + +_Cerebral tumours._ The bulk of the head is sometimes increased by tumours +or sacs of fluid, which arise from a suture or fontanelle: they are of the +same nature as the spina bifida, being formed by a protrusion of the +integuments and cerebral membranes from an accumulation of fluid beneath: +these are of very rare occurrence, and appear to have retarded labour but +little, even although of considerable size. The largest cases on record +are those which have been described by Ruysch, where one was as big as the +head itself, and another where it was nearly as large as the child's +body.[116] A case of fluctuating tumour upon a child's head has been +described by Mauriceau, (Case 544,) but the precise nature of it is not +very apparent. + +_Accumulations of fluid, and tumours in the chest or abdomen._ It is very +rare that the chest is distended by any accumulation of fluid or morbid +growth, although this is not unfrequently met with in the abdomen. La +Motte has given three cases of ascites which, by the distention of the +abdomen, produced considerable obstruction to the delivery of the child. +(Cases 331, 332, and 333.) In other cases the liver or the kidneys have +been enormously enlarged. A case is described by Dr. Hemmer, where the +child was born as far as the shoulders, and there stuck; finding it +impossible to extract the child, he perforated the abdomen in two places, +but could not extract it; in a few minutes after it came away of itself. +The abdomen had been distended with small hydatids; these gradually +escaped, and thus diminished the size of the abdomen. (_Neue Zeitschrift +für Geburtshülfe_, band iv. heft 1, 1836.) Where the child has been dead +some time in the uterus, the abdomen is frequently tympanic, and thus +retards its expulsion. + +_Monsters._ Certain cases of monstrous formation may produce very serious +obstacles to the progress of labour: the most considerable is of twins +united by the breast. It is difficult to conceive how so large a mass can +be forced through the pelvis: we can only suppose it possible where the +children have been dead some time before birth, or where they were +premature: to this latter circumstance only we can attribute the fact of +their having been born alive, as in the celebrated case of the Siamese +twins. Where the children have been united by one pelvis, &c., the chances +here of the foetus being dead before birth would be even still greater. M. +Rath, of Zetterfeld, has lately described a case of extremely difficult +labour, in consequence of twins united by the breast. "The children (two +girls) weighed 15lbs.; they were 17 inches long. The part by which they +were united was 9 inches broad and 3 long, and extended from the upper +extremity of the sternum to the navel, into which one umbilical cord, +which was common to both, entered. The diameter of the two children when +laid together was between 7 and 8 inches from one back to the other. One +child had two thumbs on the right hand. The cord was 19 inches long, and +unusually thick. After suffering some time from peritonitis, &c., the +patient recovered." (Siebold's _Journal_, band xvii. heft 2. 1833.) + +_Anchylosis of the joints of the foetus._ Lastly, we may mention a very +rare cause of this species of dystocia, which has been observed by +Professor Busch, where the obstruction to the passage of the child arose +from anchylosis of its joints. "The head had been delivered by the +forceps, but the body would not follow. As no cause of obstruction could +be discovered, a gentle and then more powerful traction was used: this +was followed by a cracking sound, and the upper part of the trunk passed +through the os externum: here again it stopped, but still, as no cause of +obstruction could be discovered, and as the child was dead, another +traction was made, with a repetition of the cracking sound, and the child +was delivered. On examination it was found that all the joints of the +extremities were anchylosed in the usual position of the foetus in utero, +so that the ossa humeri and then the ossa femoris had given way. The child +had been dead some time." (_Neue Zeitschrift für Geburtskunde_, vol. xv. +1837; and _British and Foreign Med. Rev._ April 1838, p. 579.) + +No precise rules can be given for the treatment of these cases of +malformation of the child; it must be modified according to the +peculiarities of each individual case. Whenever a part has undergone +considerable increase of size from accumulation of fluid, this can be in +most cases removed without much difficulty by perforation, whether it be +of the head or abdomen. With monstrous growths the accoucheur must depend +upon his own resources, ingenuity and knowledge of the mechanism of +parturition. The more careful and correct his diagnosis is, the more +efficient will be the means he adopts for delivering the child. In such +cases the examination can scarcely be made effectually by the finger +alone, but the hand will be required for this purpose. + + + + +CHAPTER III. + +THIRD SPECIES OF DYSTOCIA. + + _Difficult labour from faulty condition of the parts which belong to + the child.--The membranes.--Premature rupture of the membranes.-- + Liquor amnii.--Umbilical cord.--Knots upon the cord.--Placenta._ + + +In describing this species of dystocia, according to the arrangement of +Professor Naegelé, which we have adopted, it will be necessary to observe +that serious obstructions to the passage of the child is seldom produced +by it, although, at the same time, many slight derangements in the +progress of labour are liable to result, which demand the care of the +practitioner. + +The membranes when too thick or tough (Merriman's _Synopsis_, p. 217,) may +retard the labour occasionally, especially during the second stage, when +instead of bursting and allowing the uterus to contract more powerfully +upon the child by the evacuation of the liquor amnii, they are pushed down +into the vagina, forming a large conical sac, which may even protrude +externally. We doubt much, however, if the non-rupture of the membranes at +the proper time during labour is of itself sufficient to retard its +progress, for it is frequently observed that the head will, nevertheless, +advance rapidly and even be born covered by the protruded membranes. Where +labour is rendered tedious by the unusual strength of the membranes, it is +generally connected with considerable distention of the uterus from liquor +amnii; in which case the bag of waters is so spherical that it will not +descend readily into the vagina, even although the os uteri is fully +dilated, and, therefore, prevents the advance of the head: to this we +shall recur immediately. So long as there is no undue accumulation of +liquor amnii, we may safely allow the membranes to descend to the os +externum before we rupture them. In former times a variety of instruments +were employed for this purpose, many of which were dangerous, and all +unnecessary, the finger being in most cases sufficient. The most effectual +way of doing this is to press the thumb and middle finger upon the +membranes during a pain and thus increase their tension, whilst the point +of the fore-finger is pushed against them: scratching them with the nail +during a pain will be sufficient when they are higher up the vagina. + +_Premature rupture of the membranes._ More frequently the membranes +rupture too soon, that is, before the os uteri is fully dilated: this may +arise from their being too thin, a condition, however, which it is not +very easy to prove: in most instances, it is observed where the uterus is +but moderately distended, and where it has that oval or pyriform shape +which we have already pointed out as being best adapted for acting +efficiently upon the os uteri. This, perhaps, is one reason, why too early +rupture of the membranes so frequently occurs in primiparæ; and this may +be one cause, among many others, why first labours are generally so much +more tedious and severe. The membranes may also be prematurely ruptured by +violent exertions, coughing, sneezing, vomiting, &c. by straining +immoderately and too soon, by rough and awkward examination, &c. Where +this is the case, the patient should preserve the horizontal posture, and +keep as quiet as she can until the os uteri has dilated sufficiently and +allowed the head to advance. + +_Liquor amnii._ Where the uterus is distended by an unusual quantity of +liquor amnii, its contractile power is necessarily much impaired; and +until the quantity of its contents be somewhat diminished, the progress of +the labour will be more or less retarded. The average quantity of liquor +amnii at the full period of pregnancy is about eight ounces; but it +frequently exceeds this very considerably, occasionally amounting to +several pints or even quarts. The causes of this extraordinary +accumulation are still but little known. "M. Mercier has, in some cases, +attributed it to an inflammatory condition of the amnion, the foetal +surface of this membrane being stated to have been partially coated with +false membrane, and the amnion itself crowded with blood-vessels of a rose +colour:" in another case "about a quarter of the foetal surface of the +amnion was inflamed, being of a deep red colour and double the natural +thickness."[117] The results of Dr. R. Lee's observations, after having +paid a good deal of attention to the subject, do not tend to confirm this +view: he has described six cases of unusual accumulation of the liquor +amnii, in one amounting actually to sixteen pints. In five of them "there +existed with dropsy of the amnion some malformed or diseased condition of +the foetus or its involucra, which rendered it incapable of supporting +life subsequent to birth." In two only of the preceding cases was "the +formation of an excessive quantity of liquor amnii accompanied with +inflammatory and dropsical symptoms in the mother; and in none did the +amnion, where an opportunity occurred for making an examination, exhibit +those morbid appearances produced by inflammation, which M. Mercier has +described, and which led him to infer that inflammation of the amnion is +the essential cause of the disease." (Lee, _op. cit._) Dr. Merriman has +given a similar opinion, and states, that "when the embryo or foetus is +diseased, the liquor amnii is sometimes immense in quantity. I once saw at +least two gallons evacuated from the uterus: the child was monstrously +formed and much diseased."[118] + +In these cases the size and globular form of the uterus, the tenseness of +its parietes, the more or less distinct feel of fluctuation, the absence +of the child's movements and of any prominences arising from the +projecting portions of its body, the rapid increase which has been +observed in the size of the abdomen, the pain in different parts of the +uterus, especially in the groins and pelvis, the oedema or anasarca of the +lower extremities, serve to mark this condition. On examination per +vaginam we also feel the inferior segment of the uterus much expanded, the +cervix probably shorter than might be expected for the period of +pregnancy; the ballottement is unusually free and distinct. In some +instances the patient has suffered so much, either from the effects of the +retarded circulation in the lower extremities, or from the impeded +respiration as to require the membranes to be punctured in order to reduce +the size of the uterus. The child is usually born dead where the +accumulation has gone to so great an extent: in the three cases recorded +by La Motte, it was dead before birth in the first two, and died +immediately after birth in the third. Many of these cases, which have been +complicated with disease or malformation of the foetus, have appeared to +arise from a syphilitic taint; but in others, of more common occurrence, +where there was merely an unusually large quantity of liquor amnii without +any disease either of the mother or her child, the cause must still remain +a matter of uncertainty. This latter condition is mostly seen in women who +have been frequently pregnant; the os uteri in them is generally yielding, +and when once it has attained its full degree of dilatation, we may safely +rupture the membranes and thus expedite labour considerably. + +There being an unusually small quantity of liquor amnii can scarcely +operate as an obstruction to labour, except where the membranes have been +prematurely ruptured. + +The _umbilical cord_ may obstruct labour, by either being too short, or +rendered so from being twisted round some part of the child. Its length +varies very considerably. Although we have stated it to average about +eighteen or twenty inches,[119] we have met with extreme deviations both +within as well as beyond this medium length. The shortest cord which we +know of occurred some years ago at the General Lying-in Hospital, "where, +after two or three violent pains, the child was suddenly and forcibly +expelled the cord was found ruptured at about two inches from the navel of +the child, which cried stoutly. After removing the child the matron sought +for the other end of the funis, but could not find it; she examined per +vaginam but could not feel it; and on introducing her hand into the +uterus, found the placenta with the remains of the cord ruptured at its +very insertion; so that in this case the cord could not have been much +more than two inches long." (Printed Lectures in Renshaw's _Lond. Med. and +Surg. Journ._ May 1835, p. 426.) + +We quite agree with Professor Naegelé, that unusual shortness of the cord +can rarely if ever retard labour; and that where the cord really produces +an impediment to its progress, it is from being twisted round the neck, or +some other part of the child. (_Lehrbuch_, 2d ed. p. 289.) This generally +arises from its unusual length, and from its having formed several coils +around the child: we have met with it forty-eight inches long, and twisted +four times round the child's neck; but Baudelocque mentions a case where +it actually measured fifty-seven inches, "forming seven turns round the +child's neck." (Heath's _Transl._ vol. i. § 516.) Mauriceau has given an +instance (_Obs._ 401.,) where the cord had "longueur d'une aune et un +tiers de notre mesure de Paris:" which, converted into English measure, +amounts to somewhat more than sixty-one inches. + +Although nothing is of more common occurrence than the cord being twisted +once or twice round the child, it nevertheless, happens, but very rarely, +that its advance is thereby obstructed. In a case of this sort, the labour +usually commences quite favourably; the os uteri dilates, and the head +advances to a certain extent, beyond which it makes no other farther +progress; the uterine contractions are attended with much pain in the +fundus, during which the head advances somewhat, but retires again during +the intervals. Where the head is already near the os externum, this may be +easily attributed to the elasticity of the soft parts, until the delay +which takes place to the farther progress of the labour warns the +practitioner that something more than ordinary is the cause. But where +this takes place, and the head is still in the pelvic cavity; where at the +same time, although it refuses to advance, it is quite moveable, and +allows the finger to be passed freely round it; where any attempt to +extract it with the forceps has not only met with great opposition, but +has greatly aggravated the sense of painful dragging in the upper parts of +the uterus there will be pretty certain evidence of the cord being either +too short, or, what is most probable, of its being twisted round the +child. In each of the three cases recorded by La Motte, the head had +descended to the os externum; whereas, in two others described by Burton, +it was evidently much higher up: he ruptured the cord in both instances; +La Motte succeeded in cutting the cord with a pair of scissors in one +case, in another he appears to have separated the placenta, and in the +other to have delivered by little else than force. Where upon introducing +the hand we find it impossible to undo the coil of the funis, we should +endeavour to slip it first over one and then the other shoulder, as we +have recommended under the more ordinary circumstances: should this fail, +we must try to cut it through either by a finger nail slightly notched for +the purpose, or by the introduction of a Smellie perforator well guarded. + +The cord being twisted round the child's neck may not only retard labour, +it may destroy the child itself by preventing the free return of blood +from the head: this may take place some little time before birth, or +during the actual process of labour. That suffocation cannot possibly be +the cause of death under these circumstances is sufficiently evident. + +_Knots upon the cord_ have been mentioned by some authors as a cause of +danger to the child shortly before and especially during labour; for the +circulation in the umbilical vessels being more or less compressed, the +child would either be born dead or in a very weakly state. Experience has, +however, shown that these effects have been much over-rated, and that +these knots are seldom injurious to the child.[120] Baudelocque has not +only met with single, but even triple and very complicated knots tied +tightly upon the cord, and yet the child was not only born alive, but +remarkably robust and healthy. Circumstances, however, may occur by which +the knot is gradually drawn so tight as to destroy the child. Smellie has +given a case of this kind; but it is to the late Matthew Saxtorph, of +Copenhagen, that we are indebted for an admirable essay on this subject. +The result of his observations coincides with those of Baudelocque, viz. +that it rarely proves fatal to the child.[121] The manner in which these +knots are formed may be easily imagined; when by chance the cord lies in +the form of a ring, and the foetus happens to float through it, a noose is +made, which, when drawn tight by accident, forms a knot. + +The most favourable time for the formation of such knots is in the earlier +months of pregnancy, when the quantity of liquor amnii, in proportion to +the bulk of the foetus, is so much greater than at an after period, and +when its movements are consequently less impeded. The circulation in the +knot will be obstructed in proportion as the knot is drawn closer: if it +be merely somewhat impeded, the vessels on each side of the knot will be +distended and varicose, and the cord itself, where it forms the knot, from +the constant gradual pressure of one fold against the other, will become +more or less flattened.[122] We believe that in every case the cord has +been of unusual length. + +The _placenta_ cannot easily obstruct the birth of the child, although it +may render the labour exceedingly dangerous in a great variety of ways: +these circumstances will be considered under their respective heads. + + + + +CHAPTER IV. + +FOURTH SPECIES OF DYSTOCIA. + + _Abnormal state of the pelvis.--Equally contracted pelvis.--Unequally + contracted pelvis.--Rickets.--Malacosteon, or mollities ossium.-- + Symptoms of deformed pelvis.--Funnel-shaped pelvis.--Obliquely + distorted pelvis.--Exostosis.--Diagnosis of contracted pelvis.-- + Effects of difficult labour from deformed pelvis.--Fracture of the + parietal bone.--Treatment.--Prognosis._ + + +This may arise from there being either too much or too little resistance +to the passage of the child; where, in the one case, labour is rendered +difficult or impossible to be completed by the natural powers; in the +other, it is unnaturally rapid. The latter condition belongs to the second +great division of dystocia, where the faulty character of the labour does +not depend upon its progress being deranged, but upon other circumstances: +we shall, therefore, delay speaking of precipitate or too rapid labour +from unusually large pelvis, until then, and devote the present chapter to +the consideration of those cases where the labour is more or less +obstructed by the faulty condition of the mother's pelvis. + +The pelvis may obstruct the passage of the child in a variety of ways. + +1. It may be merely a diminutive or dwarfish pelvis, viz. well formed but +smaller than usual in every direction--the pelvis simpliciter justo minor +of Continental authors. + +2. It may be distorted and deformed. + +3. It may be of the natural form and size, but the passage through it more +or less obstructed by exostosis. + +_Equally contracted pelvis._ The first species of faulty pelvis (_pelvis +simpliciter justo minor_,) is not of common occurrence, and has received +but little notice in this country. It has been said to resemble the pelvis +of a girl in its general appearance; but this only holds good in point of +size; for, in the relative proportions of its diameter, it presents all +the characters of a well formed adult pelvis. From this circumstance, it +can scarcely be said to be an arrest of development, the necessary changes +in the form of the pelvis having taken place at the time of puberty, as +completely as if it had been of the ordinary size. A pelvis of this sort +may be not more than a quarter of an inch too small in every direction, or +it may be as much as a whole inch: we do not know of any case where the +diminution has exceeded this last degree. + +The pelvis equaliter justo minor is not accompanied with a corresponding +diminutiveness in the rest of the skeleton, most of the patients in whom +it has been observed being well formed and of the usual stature. +Fortunately, as before stated, it is of rare occurrence, for even a small +diminution in the size of the bony passages, which is uniform in _every +direction_, presents a most serious obstacle to the passage of the child. +Thus, in three cases of the sort, which have been described by Professor +Busch in his report of the Berlin Lying-in Hospital, the labour terminated +fatally in two. "The first case was a presentation of the breech; the head +was delivered by the forceps; the child was dead; the pelvis measured half +an inch too small in every direction. In the second case, which was a head +presentation, the delivery was effected by the forceps, but not without +the greatest efforts; the child was still-born, and the mother died in a +day or two after from peritoneal inflammation. The third case required +perforation; this also terminated fatally, the forceps having been +previously applied, and considerable efforts made without success. On +examination after death, every diameter of the pelvis was three quarters +of an inch smaller than usual: in appearance it resembled that of a +child." (_Neue Zeitschrift für Geburtskunde_, vol. xv. 1837.) + +_Unequally contracted pelvis._ The unequally contracted pelvis (_pelvis +inæqualiter justo minor_) may exist under a variety of forms; the most +common is where the antero-posterior diameter is defective, or, in other +words, where the distance between its anterior and posterior parietes is +less than usual. In a slight degree, it is frequently met with among the +poorer classes, and arises from the patient having been compelled to carry +heavy burdens in early childhood, or otherwise subjected to severe labour. +The practice of entrusting a girl of eight or ten years of age with the +care of a heavy infant, which she carries about in her arms for many hours +every day, is a fruitful source of this species of pelvic deformity; the +young and plastic pelvis is unable to bear the additional pressure which +is thrown upon the sacrum by the overloaded trunk, without having the just +proportions of its growth materially influenced and perverted, especially +at a period of life when the whole form of the pelvis is undergoing +considerable changes. The constant pressure and counter-pressure to which +the pelvis is subjected by the undue weight which is applied to the sacrum +above, and supported by the resistance of the femora against the acetabula +below, must necessarily tend at this age, even in an ordinary state of +health, to impair its symmetry, more or less, and gradually to diminish +the distance between its anterior and posterior parietes. Under no +circumstances has this cause of pelvic deformity acted to such an extent +as in the English manufactories, where young children are compelled to +remain standing for twelve or more hours at the machines: the physical +powers are unequal to the endurance of so much unceasing labour, the +skeleton of the child soon suffers in its growth, and the pelvis almost +certainly becomes contracted. + +Similar effects may also be produced by undue pressure on the other parts +of the pelvis. Thus the outlet may become much contracted by sitting many +hours a day on a hard seat, as is frequently the case in schools. The +tubera ischii are pressed together, the pubic arch is thereby contracted, +and the sacrum becomes strongly curved forwards. Much riding on horseback +at an early age is said to be injurious; and it is stated that the females +of those American nations who are constantly on horseback bear but few +children, and are frequently three or four days in severe labour. + +_Rickets._ Similar effects, only in a much more aggravated form, are +produced by rickets in early life; the pelvic bones having become soft +from the loss of their earthy matter, gradually give way under the +pressure of the superincumbent trunk, to the support of which they were +unequal. In this way the sacrum is forced downwards and forwards towards +the symphysis pubis, the acetabula are driven upwards and backwards, the +pubic arch becomes distorted; and if the disease continues for a +considerable period of time, the whole pelvis becomes so squeezed together +as entirely to lose its original proportions. + +The manner in which the distortion takes place varies exceedingly, and +will be more or less influenced by the circumstances under which the child +has been placed. The most constant change is the shortening of the +antero-posterior diameter at the brim. In severe cases the base of the +sacrum has, as it were, sunk down between the illia, so that its +promontory occupies the cavity of the pelvis, the fourth, or third, or +even the second, lumbar vertebræ occupying its former position. The +gradual yielding of the bones seldom takes place with that degree of +uniformity as to allow the sacrum to approach the symphysis pubis in a +straight line: the more common result of rickets is, that the promontory +is, at the same time, wrung more or less to one side. + +"If the superior strait does not constantly present the same figure in +deformed pelvis; if it is sometimes larger on one side than the other; if +one of the acetabula is nearer to the sacrum, while the other approaches +less; if the symphysis of the pubes is removed in many cases from a line +which would divide the body into two equal parts, it is because the +rickets has not equally affected all the bones of the pelvis, nor equally +hurt all their junctions; and because the attitude which the child takes +in walking or sitting may change a little the direction of the compressing +power, which I have just mentioned." (_Baudelocque_, translated by Heath, +vol. i. p. 60.) Nor is it necessary that the degree with which the disease +affects the different parts of the pelvis should vary in order to produce +these inequalities of distortion, for there is no reason to suppose that +the promontory of the sacrum would approach the symphysis pubis in a +straight line, even where the softening of the bones was uniform +throughout; the attitude of the child, as above-mentioned, and the manner +in which it supports itself, will have no inconsiderable influence in +determining the direction in which the distortion takes place. + +In those instances where the promontory is forced low down into the pelvic +cavity, the sacrum becomes bent upon itself, the upper part of it forming +a sharp curve backwards, while its lower portion together with the coccyx +being confined by their attachments, and more or less compressed by +sitting, are directed forwards. This is not seen where the projection of +the promontory is but slight; the curve of the sacrum so far from being +increased is rather lessened; the sacrum is straighter and flatter than +usual, so that, although the brim of the pelvis is contracted, we not +unfrequently find the outlet even larger than natural: in other cases, +where the softening of the bones has gone to a considerable extent, the +outlet is diminished, from the tubera ischii having been forced inwards. + +The degree to which the promontory projects, of course, varies +considerably. The distortion is occasionally so great as not even to leave +an inch of antero-posterior diameter. This excessive deformity, however, +is more frequently the result of mollities ossium coming on after puberty, +for we seldom find children live through this critical period where it has +been the result of rickets. The brim of a deformed pelvis varies +considerably in shape: "sometimes it has the form of a kidney, or that of +the figure eight ([Symbol: infinity]); sometimes it is triangular or +heart-shaped, the sides being curved inwards, from the acetabula having +been pressed backwards or inwards, the ossa pubis are bent forwards and +outwards, and form at their symphysis a sort of beak-like process, which +is the apex of the heart: in this species of deformed pelvis, which is +usually the result of mollities ossium, the outlet also is usually much +distorted: this arises from the tubera ischii being forced nearer to each +other, thus contracting the pubic arch." (Naegelé's _Lehrbuch_, 2te +Ausgabe, p. 247.) + +[Illustration: _From_ Naegelé.] + +[Illustration] + +_Malacosteon_, or _mollities ossium_. An arthritic, rheumatic, or gouty +diathesis is a morbid state, in which softening of the bones may take +place at a much later period of life, and to a most extraordinary extent. +In almost all the cases of extreme pelvic deformity which have been +recorded, the distortion has been owing to this disease, and not to +rickets in early life: in a pathological point of view there is a +considerable analogy between these two diseases. From a variety of causes +there is a superabundant formation of acid in the system, which its +excreting organs are unable to throw off. The effects of this condition +will vary according to circumstances; among them the softened state of the +bones from a deficiency of insoluble bone earth is not the least +remarkable. Mollities ossium seldom attacks women who have had no +children: sometimes it begins shortly after delivery, and very frequently +during pregnancy, during the progress of which it continues to increase. +Hence, it occasionally happens, that a woman has given birth to several +healthy living children without any unusual difficulty in her labours, and +where, after this, the pelvis has gradually become so deformed from +mollities ossium, as to render delivery impossible by the natural +passages, and, therefore, to require the Cæsarean operation. Pelves of +this sort, may be easily distinguished from those which have been deformed +in early life by rickets; they have evidently attained their full adult +growth before the process of softening had commenced: the ilia, for +instance, are of the natural size, but bent across, as if they had been +folded like wet pasteboard; whereas, the bones of the ricketty pelvis have +not attained their full development, they are stunted in growth as well as +distorted in shape, the two processes, viz. of growth and distortion, +having evidently, co-existed. + +The form of the pelvis in mollities ossium necessarily varies with the +peculiar circumstances under which the individual is placed: thus, if her +strength allows her to sit up, or even to get about, as is generally the +case more or less, the promontory and the pubic bones are gradually +pressed towards each other, so that the antero-posterior diameter is +greatly diminished:[123] if, however, she is confined entirely to bed for +a considerable period, the distortion takes a different and much rarer +form. From her lying first on one side and then on the other, the pelvis +is laterally compressed; the transverse diameter becomes even shorter than +the antero-posterior; and if the disease continues long enough, the pelvis +is at length so altered and mis-shapen, that nearly all its original +configuration is obliterated. The weight of such a pelvis varies +considerably: where the disease has ceased some time before death, and +bone earth has been again deposited, there will be little difference in +this respect from a natural healthy pelvis; but if the patient has died +with the disease in full activity, its weight will be greatly diminished, +amounting sometimes only to a few ounces. + +Mollities ossium, to a slight extent, we believe, is not very uncommon, +although cases of extreme deformity from this cause are of rare +occurrence. Mr. Barlow states, that "eight cases of this species of +progressive deformity have fallen under my notice, in one of which the +projection of the last lumbar vertebra at its union with the angle of the +sacrum was so much bent forwards into the cavity of the pelvis, that on +the introduction of the fore-finger up the vagina, a protuberance was +presented to the touch very much resembling the head of the foetus pretty +far advanced into its cavity. On carrying the finger a little anteriorly +past the projection, I could with difficulty ascertain the head of the +child: but on moving it around, the distortion appeared so great, that the +whole circumference did not exceed that of a half-crown piece. This +occurrence was on the 29th of April, 1792, at which time I delivered the +woman with the crotchet, and the bones of the pelvis receded considerably +to the impulsive efforts during the extraction of the head of the foetus; +yet, notwithstanding, the flexibility of the bones of the pelvis, and the +debilitated state of her constitution, she recovered speedily and without +interruption." On the 2d February, 1794, being in the neighbourhood, and +learning that she was still alive, Mr. Barlow visited her and requested an +examination. "I found her unable to walk without assistance, and as she +sat, her breast and knees were almost in contact with each other. The +superior aperture was nearly in the same state as when I delivered her +with the crotchet, but the outlet appeared more contracted, the rami of +the pubes overreached, leaving a small opening under the symphysis barely +sufficient to admit the finger to pass into the vagina by that passage, +and another aperture below, but rather larger, and parallel with the +junction of the tuberosities of the ossa ischii. From what I learned +afterwards respecting this decrepit female, she survived this period about +two years, at which time she was become still more distorted in the spine; +and after her death it was with difficulty she could be put into her +coffin; this woman bore nine children, and died in the thirty-ninth year +of her age." (Barlow's _Essays_, p. 329.) + +Mollities ossium may be feared when, in addition to the general breaking +up of the health and strength, the patient suffers from arthritic pains +and swellings of the limbs, the urine is generally loaded with lithic +secretion: and most of all, where distinct shortening and gradual +distortion of the skeleton is taking place. Where the deformity has been +the result of rickets in early life, a little careful observation of the +patient's external appearance will quickly lead the experienced eye to +suspect the nature of the case. + +_Symptoms of deformed pelvis._ Among the external appearances which would +lead us to suspect a deformed pelvis, are "the lower jaw projecting beyond +the upper; the chin very prominent; the teeth grooved transversely; +unhealthy appearance; pale ashy colour of the face; diminutive statue; +unsteady gait; when the woman walks the chest is held back, the abdomen +projects, and the arms hang behind; there is deformity of the spine and +breast, one hip higher than the other, the joints of the hands and feet +are remarkably thick; curvature of the extremities, especially the +inferior, even without distortion of the spine is a very important sign; +wherever the lower extremities are curved, the pelvis is mostly deformed: +it is well to ascertain also if, when a child, it was a long time before +she could walk alone; whether she had any fall on the sacrum; whether as a +girl she was made to carry heavy weights, or to work in manufactories." +(Naegelé's _Lehrbuch_. § 444.) + +_Funnel-shaped pelvis._ Besides the above-mentioned species of pelvic +deformity, others are occasionally met with, the origin of which is but +little understood. The funnel-shaped pelvis is of this character, where +the brim is perfectly well formed, but where it gradually contracts +towards the inferior aperture. There are no evidences of its having been +produced by any disease; nor in fact can we assign any satisfactory cause +for this peculiar configuration: it appears to have been a congenital +formation. + +[Illustration] + +_Obliquely distorted pelvis._ A still more remarkable species of pelvic +deformity is the _pelvis obliqué ovata_, which, of late years, has been +pointed out by Professor Naegelé. In this case the pelvis appears awry, +the symphysis pubis being pushed over to one side; and the sacrum to the +other; one side of the pelvis is more or less flattened, the other bulges +out, so that one oblique diameter is shorter, the other longer than +natural; and this applies not only to the brim, but to the cavity and +outlet of the pelvis. In most cases the sacro-iliac symphysis on that side +which is flattened, and to which the sacrum is inclined, is completely +anchylosed, not a trace of the division between the ilium and sacrum to be +detected, the two bones being completely united into one. In many, the +sacrum on this side is smaller than on the other, as if a portion of it +had been removed by absorption during the process of anchylosis, or at +least not properly developed. When we consider the form of the pelvis, and +the appearances which the sacro-iliac symphysis and the sacrum present, we +are almost led to conclude that ulcerative absorption must at one time +have existed between the sacrum and ilium at this point, probably at an +earlier period, by which means more or less bone had been destroyed before +the termination of the disease in anchylosis; indeed, we can to a certain +extent imitate this peculiar species of pelvic deformity by sawing off the +surfaces of the sacrum and ilium which had formed the symphysis, and then +putting the bones together again. Still, however, in the various cases +which have been collected by Professor Naegelé, no proofs could be +obtained of disease having existed in the pelvis during early life. + +"In none of the cases, the particulars of which have come to my knowledge, +has there been any trace of rachitis; nor have any of the symptoms, +appearances, and morbid changes been observed which characterize mollities +ossium coming on after puberty. None of these cases have been traced to +the effects of external violence, as falls, blows, &c.; nor has there been +any complaint of pain in the region of the pelvis, inferior extremities, +&c." (_Das Schräg Verengte Becken_, p. 12.) "With respect to the +strength, colour, structure, &c. of the bones of this species of deformed +pelvis, no difference could be observed between them and the bones of +young and perfectly healthy subjects; not a trace either in form or other +respects could be detected of those changes which usually result from +rachitis or mollities ossium; and but for this distortion and some other +slight irregularities, which required close inspection to detect, these +pelves would have been looked upon as well-shaped, and of sufficient +capacity." (Naegelé, _op. cit._ p. 11.) In some specimens no trace of +anchylosis at the sacro-iliac symphysis has been observed; but whether +this was the case throughout the union of the two bones we cannot say. +Professor Naegelé is inclined to look upon them as modifications of the +_pelvis obliqué ovata_, and certainly in the majority of known cases +anchylosis has been found present. + +It is scarcely necessary to do more than enumerate other varieties in the +form of the pelvis, which are occasionally met with: it is sometimes +round, the transverse and antero-posterior diameters being of the same +length; in other cases it possesses many of the characters which +distinguish the male pelvis, being more or less triangular, deep, and with +a contracted angular pubic arch. + +_Exostosis._ Lastly, the pelvis may be perfectly well formed, but the +passage through it more or less interrupted by the exostosis: this is, +perhaps, the rarest species of dystocia pelvica. It may arise from wounds +of the periosteum, from fracture of the bones, callus, &c. and may vary in +size from a small protuberance to a large mass, which completely fills up +the pelvis. + +_Diagnosis of contracted pelvis._ The difficulty of detecting an abnormal +configuration of the pelvis, will depend, in great measure, upon its +extent: where it is but slight, it may easily be passed over unobserved by +a young practitioner, although it may, nevertheless, be quite sufficient +to render labour both difficult and dangerous. In the ordinary form of +contracted pelvis, where the antero-posterior diameter is shorter than +natural, the being able to reach the projecting promontory of the sacrum +with the finger is of itself a sufficient evidence: but the converse of +this is not true, for we frequently meet with cases of contracted pelvis, +without being able to reach the promontory. The numerous instruments which +have been invented at different times for measuring the pelvis are of such +doubtful accuracy, as to be nearly useless; the experienced finger is the +best pelvimeter; and the power of correctly estimating the dimensions of +the pelvis during examination, can only be acquired by constant practice, +based on a thorough knowledge of them in the healthy pelvis. + +The manner in which labour commences is frequently sufficient to make us +suspect the presence of a contracted pelvis. Besides, the general +appearance of the patient, we frequently find that the uterine +contractions are very irregular; that they have but little effect in +dilating the os uteri; the head does not descend against it, but remains +high up; it shows no disposition to enter the pelvic cavity, and rests +upon the symphysis pubis, against which it presses very forcibly, being +pushed forwards by the promontory of the sacrum. It is probably from this +circumstance that the os uteri, more especially its anterior lip, shows so +little disposition to dilate in these cases, for the lower portion of the +uterus being jammed between the head and symphysis pubis in front, and +promontory behind, the contractions of the longitudinal fibres can have +little effect upon the os uteri. Hence we find, that in cases of +diminished antero-posterior diameter requiring perforation, and where the +os uteri in spite of violent pains, bleeding, &c. has refused to dilate +beyond a certain point, on lessening the head, and thus removing its +pressure from the symphysis pubis, it has quickly attained its full degree +of dilatation. + +Where the pains have been active, and a portion of the head has forced +itself through the brim, and now projects to a certain extent into the +cavity of the pelvis, it will be still more difficult to reach the +promontory before delivery; and if, as is frequently the case, the sacrum +is bent strongly backwards, so as to render the cavity and outlet very +spacious, the real cause of impediment to the progress of labour may be +entirely overlooked. It is here that the position of the head upon the +symphysis pubis will prove a valuable means of diagnosis. The straightness +of the sacrum will also be a guide in other cases. + +In that form of the pelvis which has been called the funnel-shaped pelvis, +and where the brim and upper portion of the cavity are of the natural +dimensions, but where it gradually diminishes towards the outlet, the +appearances are frequently very deceptive, the head advances without +impediment, and descends as far as the inferior aperture, with every +promise of speedy delivery; but here its progress is arrested, and even in +the very last stage may require perforation. + +It occasionally happens, also, where the deformity is very considerable, +that the promonotory projects to such an extent as to be even capable of +being mistaken for the head itself; and cases have actually occurred +where, under this impression, the bone has been perforated instead of the +child's head. So gross an error as this may easily be avoided by care in +making the examination; by ascertaining that the projecting mass is +immoveable; that the patient is sensible to the pressure of our finger; +and that the promontory can be traced to be continuous with the adjacent +parts of the pelvis. + +The effects which may result from labour protracted by pelvic deformity +are very various, both as regards the mother and her child. The most +common form of injury which is produced by this cause, is the contusion +and consequent inflammation and sloughing of the soft tissues which line +the pelvis from the long continued pressure of the head against the +symphysis pubis in front, and against the promontory of the sacrum behind. +Not only may sloughing of the vagina and lower part of the uterus be the +result, but the mischief may extend through the posterior wall of the +bladder, and thus render the patient incapable of retaining her urine, and +an object of great, and, generally speaking, incurable suffering. + +The danger from rupture of the uterus will chiefly depend on the degree of +pressure with which the uterine contractions force the head against the +brim. Where the pains are violent, and yet insufficient to overcome the +obstacle which the contracted pelvis presents to the advance of the head, +there is not safety for a minute, and perforation must be immediately had +recourse to. Where the edge of the promontory is very projecting and +sharp, the structure of the uterus may be seriously injured by the +pressure and contusion. In some cases it has evidently been the cause of +ruptures, the fibres having given way first at this spot. + +The constant severe pressure upon the head will be not less injurious to +the child's life; it must inevitably produce a considerable impediment to +the cerebral circulation; and where the liquor amnii has escaped, the +pressure of the uterus upon the body of the child will scarcely be less +prejudicial. The cranial bones frequently become remarkably distorted, so +that after a difficult labour a deep furrow is found on that part of the +head which corresponded to the projecting promontory. + +_Fracture of the parietal bone_ may even be produced, a fact of which +practitioners, till lately, have not been sufficiently aware; and cases +have occurred where children have been born dead, with the head greatly +distorted, and one of the bones fractured, from which circumstances the +mothers have been suspected of infanticide. Dr. Michaelis, of Kiel, has +lately reported an interesting case of this kind, where the fracture seems +to have resulted from the great immobility of the coccyx. The head was +much disfigured, and on examining it the frontal bones were uninjured, but +so flattened that the frontal and parietal portions of the sagittal suture +lay nearly in the same place; the fontanelle and anterior two-thirds of +the sagittal suture projected high up, and the sagittal borders of the +parietal bones were firm and well formed. In the posterior third of the +sagittal suture, where the parietal bones were firm and well formed, and +the suture only two lines in width, were seen small livid portions of the +longitudinal sinus forced between the bones. The occipital bone was +flattened and forced deep under the parietal bones, but not otherwise +injured. The right parietal bone, which during birth had been turned +towards the promontory of the sacrum, was covered anteriorly and +superiorly with effused blood, and on removing the periosteum, was found +fractured in five places. (_Neue Zeitschrift für Geburtskunde_, vol. iv. +part 3. 1836.[124]) + +Where the action of the uterus is not very violent, and the bones +yielding, the head gradually adapts itself to the form of the passage +without destroying the foetus; it elongates itself more and more until it +is enabled to pass, so that after a tedious labour of this sort, we +sometimes find the configuration of the head remarkably altered. +Baudelocque, has mentioned a case recorded by Solayres de Renhac, where +the head was so elongated that the long diameter measured eight inches all +but two lines, the transverse being only two inches and five or six lines. + +_Treatment._ Where the pelvic deformity is very considerable, there can be +little difficulty in deciding upon the line of conduct to be adopted. It +is in those cases where the obstruction is but slight that the indications +for treatment are less distinctly marked: nor must we be satisfied with +merely ascertaining the relative proportions of the head and pelvis; for +the hardness or softness of the cranial bones, the disposition which they +manifest to yield to the pressure of the uterus and surrounding parts, the +state of the cranial integuments, and though last not least, of the soft +tissues which line the pelvis, must all be carefully ascertained before a +correct opinion as to the precise mode of treatment can be formed. Nor, if +the woman has already had children, can we altogether be guided by the +history of her previous labours; for where the above-mentioned +circumstances have been favourable, a slight diminution of the pelvis will +scarcely be attended with any perceptible delay or increase of difficulty +beyond the natural degree; whereas, if the head happens this time to be a +little larger, its bones more ossified, the fontanelles smaller, the scalp +and soft linings of the pelvis more swollen, &c. a serious obstruction to +the progress of labour will be the result. Thus it is that we not +unfrequently meet with patients in whom the first labour has been +tolerably easy, the second has been attended with much difficulty and +required the forceps, in the third, the difficulty was so much increased +as to require perforation, and the fourth where the labour was, like the +first, perfectly easy and natural. + +It is impossible for the head to remain long in the pelvis (except under +unusually favourable circumstances) without more or less obstruction to +the circulation, both in the scalp itself and in the surrounding soft +tissues. The necessary consequence of this is swelling, by which the head +increases while the passage diminishes in size; and this must still be +more remarkably the case where the pelvis is at all contracted. It is in +these cases that we frequently see such relief produced by venesection; +and it is also as a topical depletion to the overloaded vessels, that we +can explain why a free secretion of mucus is so favourable a symptom.[125] + +_Prognosis._ Where the pains are moderate and equable, the os uteri nearly +or quite dilated, the head not large, its bones yielding and overlapping +at the sutures; where the greater portion of it has evidently passed +through the brim, and, although slowly, advances perceptibly with the +pains; where the passages are cool and moist, the pulse good, and the +patient not exhausted, we may safely wait awhile and trust to the efforts +of nature. On the other hand, where the pains are violent, the os uteri +thin and undilatable, the head forced forwards upon the symphysis pubis by +the projecting serum, if the greater part of its bulk has not yet passed +the brim, if the soft parts are much swelled, the vagina hot and dry, the +pulse has become irritable, the abdomen tender, the patient exhausted and +much depressed both in mind and body, the powers of nature are evidently +incompetent to the struggle, and require the assistance of art. + +Such cases seldom permit the application of the forceps; the head is +already pressing too firmly against the brim, and its greatest bulk having +not yet passed, a still farther increase of pressure will be required to +effect this object, which therefore cannot be attained without producing +serious mischief. Where, however, the head has fairly engaged in the +cavity of the pelvis, and the case is rather becoming one of deficient +power, the forceps will be justifiable, and generally quite sufficient to +effect the delivery safely. + +The young practitioner must be cautious not to mistake an increase in the +swelling of the scalp for an actual advance of the head itself--an error +which may very easily be committed if he merely touches the middle of the +presenting portion: he must carefully examine the circumference of the +presenting part, where the head is pressing against the pelvis, and where +there is little or no swelling, and he will frequently find to his +disappointment, that although the cranial swelling may have even nearly +approached the perineum since his last examination, the head itself has +remained unmoved. + +Where the forceps has been determined upon, we should endeavour to render +its action as favourable as possible, viz. by bleeding, by the warm bath, +and by evacuating the bladder and rectum before proceeding to the +operation: we thus improve the condition of the soft parts, and diminish +the chances of its acting injuriously. + +From what has now been stated respecting the various circumstances which +may tend to aggravate or alleviate the existing degree of pelvic +deformity, it will be seen how incorrect and unpractical must be the +attempt to classify the means of treatment merely according to the +dimensions of the pelvis. To assert that within certain limits of pelvic +contraction the child can be delivered by the natural powers, and that +beyond these limits the forceps must be used; and that where it proceeds +to a certain extent farther, it can only be delivered by perforation, &c. +is evidently objectionable: for there are no two cases alike, even +supposing that the degree of pelvic contraction is exactly similar; hence, +on the one hand, we might (under such fallacious guidance) be induced to +trust to the natural powers when they are wholly incompetent to the task, +and on the other, to have recourse to art when the real condition of the +case justified no such interference.[126] + +With regard to the diagnosis and treatment in the case of obliquely +distorted pelvis (pelvis obliqué ovata,) our data are still too scanty to +enable us to give any decided rules: the immobility of the head, although +the antero-posterior diameter appears of its full length, the shortness of +one oblique diameter, and consequent undue pressure upon the head in this +direction, and the unusual length of the other, are the characteristics +which we have observed in the only case of the kind which has come under +our notice during life. In all the cases of labour rendered difficult by +this condition of the pelvis, which have been collected by Professor +Naegelé, the perforation has been strongly indicated; and where the +forceps has been used, it has either failed, as with us, or if the +delivery has been effected by this means, it has been attended with fatal +consequences. + +In _exostosis_ of the pelvis we must be guided by our knowledge of the +healthy pelvis, and by our carefully ascertaining the form and size of the +bony growth, and in what degree it is likely to impede the passage of the +child. As in cases of simple projection of the promontory, the head may be +capable of passing, but in doing so becomes more or less distorted: thus +Dr. Burns quotes a case from Dr. Campbell, where from exostosis within the +pelvis, the left frontal bone was so greatly sunk in, as to make the eye +protrude. Professor Otto, of Breslau, mentions a woman who had pelvic +exostosis being the mother of four children, in each of whom a small +portion of the cranium was depressed and not ossified. + +An interesting case has been described by Dr. Kyll, of Cologne, where the +patient was the mother of seven children; her former labours had been +perfectly natural, except that in the last there had been preternatural +adhesion of the placenta, which had required to be removed by the hand; in +six days after she was seized with feverish symptoms and violent pain at +the spot where the placenta had been attached. The attack yielded to +proper treatment, but she continued feverish at night with perspirations, +frequently deranged bowels, difficulty in passing water, and severe pain +in the abdomen, especially when she tried to stand on the right leg. An +abscess formed in the right groin, which was opened and discharged a large +quantity of pus, from which her recovery was very slow, and in three years +afterwards she became again pregnant. When labour came on, no presenting +part could be reached; after a long time the feet came down one after the +other, but the nates would not advance. Dr. Kyll found the child resting +with the hips on the brim of the pelvis, and completely wedged fast by a +hard immoveable tumour as large as a hen's egg, springing from the upper +part of the right sacro-iliac symphysis, and apparently having been a +result of the pelvic abscess; the child was delivered with great +difficulty by embryotomy. + +[Illustration: Exostosis of the pelvis.] + +Perhaps the most remarkable case of pelvic exostosis is that which has +been described by Dr. Haber of Carlsruhe, and where also the cause was +ascertained to have arisen from a violent fall on the ice when carrying a +heavy load upon the head; on coming to herself the woman found that she +was unable to move, and in this state was conveyed home; she recovered to +all appearances in a few weeks, married, and soon became pregnant. When +labour came on it was found impossible to deliver her, from the pelvis +being entirely filled with a huge exostosis: the Cæsarean section was +performed, but she died, and on examination after death an immense mass of +bony growth was found springing from the sacrum, which had been apparently +fractured, not only filling up the whole cavity of the pelvis, but arising +to a considerable extent above the brim. + +In those cases of funnel-shaped pelvis which we have had the opportunity +of observing, perforation has been ultimately required, although the head +had passed easily through the brim and entered the cavity; in one of +these we have subsequently used the artificial premature labour with +success. + +We have already stated the doubtful utility of arranging cases of deformed +pelvis according to their degree of contraction, and of classifying the +different modes of treatment by such a scale; still, however, there must +be certain limits beyond which it will be impossible to make the child +pass, even when diminished by embryotomy. To draw the precise line of +demarcation, however, will be nearly if not quite impossible; and, as in +cases of slighter deformity, we must take many other circumstances into +consideration which we have already mentioned. An inch and a half from +pubes to sacrum has been mentioned by many as the extreme degree of +contraction through which a full grown child can be delivered by +embryulcia; generally, however, in these cases of unusually deformed +pelvis, there is much more space on each of the sacrum; and on this, in +great measure, will depend the possibility of effecting the delivery. The +celebrated case of Elizabeth Sherwood, which Dr. Osborn has recorded, and +where he succeeded in delivering the child, although the antero-posterior +diameter "could not exceed three-quarters of an inch," has been looked +upon as being of doubtful accuracy, and that Dr. Osborn had +unintentionally deceived himself. When, however, we learn that on the +right side of the sacrum the antero-posterior diameter was an inch and +three-quarters, the incredible nature of the case diminishes considerably, +the more as the patient was examined by Dr. Denman and others who fully +coincided with Dr. Osborn's statements. To assert that in this case the +antero-posterior diameter was only three-quarters of an inch, as many have +done, is evidently incorrect, and tends to throw doubt upon it: the case +was evidently the closest possible approach to the limits requiring the +Cæsarean operation; its success was mainly attributable to the gradual +manner in which it was performed; the child had become completely soft and +flaccid from putrefaction, and was thus more capable of being moulded to +the contracted passage. + + + + +CHAPTER V. + +FIRST SPECIES OF DYSTOCIA. + +_Obstructed Labour from a Faulty Condition of the soft Passages._ + + _Pendulous abdomen.--Rigidity of the os uteri.--Belladonna.--Edges of + the os uteri adherent.--Cicatrices and collosities.--Agglutination of + the os uteri.--Contracted vagina.--Rigidity from age.--Cicatrices in + the vagina.--Hymen.--Fibrous bands.--Perineum.--Varicose and + oedematous swellings of the labia and nymphæ.--Tumours.--Distended or + prolapsed bladder.--Stone in the bladder._ + + +In speaking of the uterus itself as a cause of this species of dystocia, +we only mention it here as one of the soft passages, not as the organ by +the contractions of which the child is expelled; we merely refer to those +faulty conditions of the uterus which produce an impediment to the child's +progress, not to those which interfere with the natural condition of its +expelling powers, as this will be considered under the next division of +dystocia. + +We have already stated our disbelief that an oblique position of the +uterus can have any influence in producing malposition of the child. With +the exception of extreme anterior obliquity, or pendulous belly, we +equally doubt that it can have any effect in retarding the labour when the +child presents naturally. The highest authorities in midwifery during the +last hundred years unite in asserting that this celebrated opinion of +Deventer, was a misconception. + +_Pendulous abdomen._ Where, from great relaxation of the anterior +abdominal wall, (a frequent result of repeated child-bearing,) the fundus +is inclined so forwards as almost to hang over the symphysis pubis, the +child's head does not readily enter the brim of the pelvis, nor can the +uterine contractions act so favourably in dilating the mouth of the womb; +and in this manner the first part of labour may be considerably retarded. +Pendulous abdomen to this great extent is not very common; and in ordinary +cases the horizontal posture, especially upon the back, is quite +sufficient to allow the head to engage in the pelvis. "We have found more +than once," says Dr. Dewees, "in cases of extreme anterior obliquity, that +it is not sufficient for the restoration of the fundus that the woman be +placed simply upon the back; but we are also obliged to lift up and +support by a properly adjusted towel or napkin, the pendulous belly until +the head shall occupy the inferior strait. To illustrate this, we will +relate one of a number of similar cases in which this plan was +successfully employed. Mrs. O., pregnant with her seventh child, was much +afflicted after the seventh month with pain and the other inconveniences +which almost always accompany this hanging condition of the uterus; was +taken with labour pains in the morning of the 10th of October, 1820. We +were sent for about noon. The pains were frequent and distressing, and, +upon examination per vaginam, the mouth of the uterus was found near the +projection of the sacrum, dilated to about the size of a quarter dollar, +but pliant and soft. During the pain, the membranes were found tense +within the os uteri, but did not protrude beyond it. + +As this was the first time we had attended this patient, and from the +history she gave of her former labours, in which she represented her +abdomen being in all equally pendulous, with the exception of the first, +we waited several hours (she being placed upon her side) for the +accomplishment of the labour. During the whole of this period the head did +not advance a single line; nor could it, as the direction of the +parturient efforts carried it against the projection of the sacrum. We had +several times taken occasion to recommend her being placed upon her back, +but to which she constantly objected, until we urged its being absolutely +necessary. She at length reluctantly consented to the change of position; +when upon her back it was found that it did not advance the os uteri +sufficiently towards the centre of the superior strait. The abdomen was +therefore raised, and a long towel placed against it, and kept in the +position we had carried it by the hands, by its extremities being firmly +held by two assistants; at the same time we introduced a finger within the +edge of the os uteri, and drew it towards the symphysis pubis, and then +waited for the effects of a pain. One soon showed itself, and with such +decided efficacy, as to push the head completely into the inferior strait, +and three more delivered it." (_Compendious System of Midwifery_, § 224.) + +This peculiar displacement of the uterus, which has been called by some +anteversion of the gravid womb, has occasionally given rise to the +suspicion that there was no os uteri, from its being tilted upwards and +backwards towards the promontory of the sacrum: it has been said, in some +cases, to have even contracted adhesions with the posterior wall of the +vagina, from the firmness with which it was pressed against it, and thus +tended still farther to increase the deception. "Within our knowledge," +says Dr. Dewees in the paragraph preceding the one just quoted, "this case +has been mistaken for an occlusion of the os uteri, and where upon +consultation it was determined that the uterus should be cut to make an +artificial opening for the foetus to pass through. They thought themselves +justified in this opinion, first, by no os uteri being discoverable by the +most diligent search for it; and, secondly, by the head being about to +engage under the arch of the pubes covered by the womb. Accordingly, the +labia were separated, and the uterine tumour brought into view. An +incision was now made by a scalpel through the whole length of the exposed +tumour down to the head of the child, the liquor amnii was evacuated, and +in due course of time the artificial opening was dilated sufficiently to +give passage to the child. The woman recovered, and, to the disgrace of +the accoucheurs who attended her, was delivered per vias naturales of +several children afterwards, a damning proof that the operation was most +wantonly performed." Where, in addition to the anteversion, strong +adhesions have taken place between the os uteri and posterior wall of the +vagina, no trace of os uteri will be felt, and the operation +above-mentioned does become sometimes necessary. + +_Rigidity of the os uteri._ The chief way in which the uterus can obstruct +the passage of the child, is, by an undilatable state of its mouth: this +may arise from a variety of causes, which may be chiefly brought under the +two heads of functional and mechanical. Under the first head comes +rigidity of the os uteri, either from a spasmodic contraction of its +circular fibres, or from irregularity or deficiency in the contractions of +the longitudinal fibres of the whole organ. In a slight degree this is +frequently met with, especially in first labours, where the patient is +young, delicate, and irritable, and where, in all probability, there is +some source of irritation in the primæ viæ which tends to disturb and +divert the proper and healthy action of the uterus. We see it also in +robust plethoric primiparæ; the os uteri dilates to a certain degree, +perhaps an inch in diameter, and remains tense and firm, with its edge +thin; the contractions of the uterus produce much suffering, and to all +appearances are very violent; but they are chiefly in front, and produce +little or no effect upon its mouth; the vagina is hot and dry, the patient +becomes exhausted with fruitless pains, and fever or inflammation would +quickly follow, if nothing be done to relieve this state. As this subject, +however, belongs rather to the next species of dystocia, viz. that arising +from a faulty condition of the expelling powers, we shall delay the +consideration of the treatment. + +_Belladonna._ It has been recommended, and not very judiciously, to apply +belladonna to the os uteri in cases of great rigidity: it was repeatedly +tried by the celebrated Chaussier in the Maternité, at Paris, and, +according to his observations, it produced a considerable effect upon it. +"The knowledge of the extraordinary powers which this drug possesses in +causing dilatation of the iris, led to its employment for the object of +enlarging the aperture of the uterus; but there is certainly no similarity +in the structure and office of the two organs, and no analogy can be drawn +between their functions. It is not likely that this means will produce the +relaxation we require; and if no good results from its use, it must be +injurious; not in consequence of the poisonous quality resident in the +drug itself, but in the friction which is necessary for its efficient +application. The mucus which naturally lubricates the part must be wiped +away, and this irritation must predispose the tender organ to take upon +itself inflammatory action." (_Dr. F. H. Ramsbotham's Lectures, in Med. +Gaz._ May 3, 1834.) + +For our own part we must confess, that, although we have seen this +application tried repeatedly, it has never produced the desired effects, +but has invariably brought on very troublesome and distressing symptoms, +such as sickness, faintness, headach, vertigo, &c. + +There is a condition of the os uteri which is occasionally met with, and +which presents a degree of rigidity which we have never seen except where +there have been adhesions and callous cicatrices from former injuries. It +has nothing of the thin edge put strongly on the stretch during the pains; +but it is thick and firm, presenting nothing of the elastic cushiony +softness of the os uteri in a favourable state for dilatation; it dilates +to about an inch across, tolerably regularly, and without much apparent +difficulty, but no efforts of the uterus can dilate it farther. We have +already alluded to two extreme cases of this when speaking of ruptured +uterus, and where in each instance the os uteri entirely separated from +the uterus and came away. Whether there is something peculiar in the +structure of the part which renders it thus undilatable, or whether it +required even still more powerful measures than those employed, is not +very easy to decide. + +_Edges of the os uteri adherent._--_Cicatrices_, &c. A serious impediment +to the passage of the child may be produced by adhesions of the sides of +the os uteri to each other; by hard callous cicatrices resulting from +ulcerations, lacerations, &c. in former labours; by abnormal bands, or +bridles, as they have been called; and by tumours and other morbid +growths. Where the structure of the os uteri has been much injured by +previous injuries of this character, the resistance will probably be so +great as to require artificial dilatation with the knife. Generally +speaking, however, the whole circle of the uterine opening is not +involved, portions still remaining of natural structure, and, therefore, +capable of dilatation. On examination, it feels irregular both in shape +and hardness; a part being soft, cushiony, yielding, and forming the +segment of a well-defined circle, the rest of it uneven, knobby, and hard, +being evidently puckered up by cicatrisation. + +In many cases, these callous contractions give way more or less when the +head begins to press powerfully against them; but even where this is not +the case, the healthy portion of the os uteri is so dilatable as to yield +sufficiently. It would be difficult to estimate how far an os uteri in +this state, with perhaps, not more than half, or even a third, of its +circle in a healthy condition is capable of dilating. But from cases which +have come under our own observation, and others which have been recorded +by authors in whom we place the greatest reliance, we are quite confident +that with proper treatment a sufficient degree of dilatation can be +effected without resorting to artificial means. + +Bleeding to fainting, the warm bath, laxatives, and enemata, will assist +greatly in promoting our object. Where, however, the contracted portion +shows no disposition to yield to this treatment, or to the pressure of +powerful pains, but forms a hard resisting bridle or band, which +effectually impedes the farther advance of the head, it must be divided by +the knife in order to prevent dangerous laceration of the part on the one +hand, or protraction of labour on the other. The mode of doing this will +be described when these conditions as effecting the vagina are considered. + +Artificial dilatation of the os uteri by incision has been practised very +rarely, the chief of these operations having had reference to the vagina. +F. Ould considered that mere contraction of the os uteri from former +lacerations did not require this operation; but that where it was in a +state of schirrus, there would be "no chance for saving either mother or +child but by making an incision through the affected part." + +We have quoted, on a former occasion, a case of cicatrised os uteri +recorded by Moscati, and where, in consequence of injury in a former +labour, the opening was nearly closed; fearing the laceration which had +occurred in a similar case under his father's care, in consequence of +making merely one incision, he made a number of small incisions round the +whole of the orifice until a sufficient dilatation was produced. + +_Agglutination of the os uteri._ Another condition of the os uteri which +may produce very considerable impediment to the passage of the child, is +that which has been called _agglutination_, where by some adhesive +process, apparently that of inflammation, the lips of the opening adhere +and completely close it. These species of imperforate os uteri may occur +in primiparæ as well as in those who have borne children: the +agglutination of its edges takes place during pregnancy, probably shortly +after conception. Upon examination we find no traces of hardness, +rigidity, or any other morbid condition, either in the os uteri itself, or +the parts immediately surrounding it; the os uteri is closed by a +superficial cohesion of its edges, and which in some cases seem to adhere +by means of an interstitial fibrous substance; this when of a firmer +consistence forms a species of false membrane, which in some cases is +capable of resisting the most powerful uterine contractions, and in others +it appears to cover the os uteri so completely as to conceal it most +effectually, and give rise to the erroneous conclusion that the os uteri +is altogether wanting. Baudelocque describes this condition (_Op. cit._ § +1961;) but from the brief mention which he makes of it, as also from the +treatment recommended, it is plain that he had no very distinct notions +about it, for he advises that "in all cases the orifice must be restored +to its original state, and be opened with a cutting instrument as soon as +the labour shall be certainly begun." + +In by far the majority of cases which have been recorded, the pains have +after a time been sufficient to dilate the os uteri. Dr. Campbell has +described two of these cases, where no os uteri could be traced for some +time after the commencement of labour: both were first pregnancies: in the +former, uterine action continued about twelve hours before the os uteri +could be distinguished, when it felt like a minute cicatrix; the other +patient had regular pains for two nights and a day before the os uteri +could be perceived, and she suffered so much as to require three persons +to keep her in bed; both these patients were largely bled, gave birth to +living children, and had a good recovery. + +We may suspect that the protraction of labour arises from agglutinated os +uteri, when at an early period of it we can discover no vestige of the +opening in the globular mass formed by the inferior segment of the uterus, +which is forced down deeply into the pelvis, or at any rate, where we can +only detect a small fold or fossa, or merely a concavity, at the bottom of +which, is a slight indentation, and which is usually a considerable +distance from the median line of the pelvis. The pains come on regularly +and powerfully; the lower segment of the uterus is pushed deeper into the +cavity of the pelvis, even to its outlet, and becomes so tense as to +threaten rupture; at the same time it becomes so thin, that a practitioner +who sees such a case for the first time would be induced to suppose the +head was presenting merely covered by the membranes. After a time, by the +increasing severity of the pains, the os uteri at length opens, or it +becomes necessary that this should be effected by art: when once this is +attained, the os uteri goes on to dilate, and the labour proceeds +naturally, unless the patient is too much exhausted by the severity of her +labour. Although the obstacle in some cases is capable of resisting the +most powerful efforts of the uterus, a moderate degree of pressure +against it whilst in a state of strong distention, either by the tip of +the finger, or a female catheter, is quite sufficient to overcome it; +little or no pain is produced, and the appearance of a slight discharge of +blood will show that the structure has given way. Two interesting cases of +this kind have been described by the late W. J. Schmitt, of Vienna, under +the title of two cases of closed os uteri which had resisted the efforts +of labour, and where it was easily dilated by means of the finger.[127] + +_Contracted vagina._ The vagina may be naturally very small, or unusually +rigid and unyielding: in the first case serious obstruction to the +progress of labour is rarely produced, the expelling powers being +generally sufficient ultimately to effect the necessary degree of +dilatation; the proper precautions must be taken to avoid every species of +irritation and excitement of the circulation; the bowels must be duly +evacuated; the circulation controlled either by sedatives, or, if +necessary, bleeding, and where it is at hand, a warm bath; if this latter +cannot be easily procured, a common hip bath, or sitting over the steam of +warm water will be of great service; the great object will be to ensure a +soft and cool state of the passage with a plentiful supply of that mucous +secretion which is so essential to the favourable dilatation of the soft +passages. + +Nauseating remedies, and even tobacco injections, have been tried to a +considerable extent for the purpose of relaxing the mouth of the uterus; +but they produce little or no good effects, and cause much suffering to +the patient. In Dr. Dewees' second case of obstructed labour from the +above causes, a sufficient trial of this remedy was used to satisfy all +doubts as to its effects. "It produced great sickness, vomiting, and +fainting, but the desired relaxation did not take place: we waited some +time longer and with no better success. In the course of an hour, or an +hour and a half, the more distressing effects of the infusion wore off; +and resolving to give the remedy every chance in our power, we prevailed +on our patient with some difficulty to consent to another trial of it: its +effects were the same as before,--great distress without the smallest +benefit, the soft parts remaining as rigid as before its exhibition." +Bleeding was now proposed; the patient became faint after losing ten +ounces, and the most complete relaxation followed: the forceps were +applied, and a living child delivered. + +_Rigidity from age._ In women pregnant for the first time at an advanced +period of life, the vagina and os externum are said to oppose considerable +resistance to the passage of the child from their rigid condition, the +parts having lost the suppleness and elasticity of youth; the vessels also +convey less blood to the mucous membrane and adjacent tissues: hence the +secretion of mucus is more sparing; the cellular tissue is more condensed +and firm; still nevertheless, although it is constantly mentioned by +authors as a cause of this species of dystocia, we cannot help declaring +that it exists to a much less degree than has been generally supposed, and +that primiparæ at a very early age are much more liable to have tedious +and difficult labours than those at an advanced age. Still, however, the +circumstance is well worthy of notice; and in such cases we may produce +much relief by the warm bath, or hip bath, by sitting over the steam of +hot water, by warm water enemata, and great attention to the state of the +intestinal canal and of the circulation. Mucilaginous or oleaginous +injections into the vagina have been recommended; but we have no +experience of their effects: we have frequently used lard, &c. to the +edges of the os externum when the head was beginning to distend it, and we +think with relief; at any rate it produces a feeling of comfort to the +patient, being soft and cooling. + +_Cicatrices in the vagina._ The most serious impediments to the progress +of labour connected with the vagina are the contractions of this canal +from callous cicatrices, the results of sloughing and other injuries in +former labours. The vagina may be contracted throughout its whole length, +its parietes hard, gristly, and uneven, and so small as not to admit even +the tip of the little finger; the course of the canal from the +irregularity of the contractions and adhesions is frequently much +distorted; in other cases it is obstructed in different places by bands or +septa, which have been produced by similar causes. + +Where the condition of the vagina has been ascertained before labour, much +may be done to ameliorate the condition of the parts, not only by the +treatment already mentioned for rigidity of the vagina under other +circumstances, but also by the judicious application of tents, bougies, +and other means for dilating the passage. A case of this kind came under +our notice some years ago; the patient had been married many years without +being pregnant, and was considerably beyond the age of forty. The deranged +health and enlargement of the abdomen which took place excited no +suspicions of pregnancy either in her mind or that of her medical +attendant: the case was suspected to be ovarian dropsy, and a variety of +medicines under this supposition were administered, both internally and +externally: the commencement of actual labour appears to have been equally +mistaken; nor was it until labour had advanced considerably that the real +nature of the case was discovered; from its length and severity, violent +inflammation and sloughing of the vagina was the result, the canal became +much contracted, and was rendered still farther impervious by the +formation of strong bands or septa which were stretched across it, and +which effectually prevented the os uteri from being reached; sponge tents, +and oval gum elastic pessaries of different sizes were introduced, and by +degrees such a state of dilatation was produced as not only permitted the +os uteri to be reached, but restored the vagina in great measure to its +natural size. + +The action of labour forcing the head of the child against these +contractions and adhesions is frequently sufficient ultimately, to effect +the necessary degree of dilatation; where, however, this is not the case, +they require to be divided by the knife. The proper moment for doing this +is during a pain, when the parts are put strongly on the stretch: we can +now feel exactly where there is the greatest resistance, and where an +incision will produce the most effect. In this state also the incision can +be effected with most ease, for the stricture being firmly distended, the +knife will more readily divide it than where it is relaxed; the patient +also at this moment is not sensible to the cutting of the knife. The lower +part of the blade well armed with lint or tow should be cautiously +introduced along the side of the finger during an interval of the pains: +in this way the necessary number of incisions may be made: this is usually +followed by a good deal of bleeding, which tends still farther to relax +the parts; and when the head has advanced low enough, a cautious attempt +may be made with the forceps to deliver it. + +In recommending dilatation by means of the knife, it must be distinctly +understood, that a sufficient time should be allowed in order to see how +much can be effected by the uterine efforts, for in many of these cases +the stricture has at length yielded after severe and protracted +suffering.[128] In cases of this kind, also, the effects of bleeding are +by no means inconsiderable, and must not be neglected. + +The _unruptured hymen_ has been said to be capable of impeding the +progress of the head, but this can only be where the membrane is of +unnatural strength and thickness. It has more than once occurred to us at +the commencement of labour, to find the hymen uninjured; but it has broken +down under the finger, even during examination, and we are convinced would +have produced no obstacle whatever to the child. Where its structure is +abnormal, and the advance of the labour is evidently retarded by it, +division is the simplest and easiest remedy. + +Bands of firm fibrous or almost ligamentous tissue are sometimes found +stretched across the vagina or os externum. We described a remarkable case +of this sort in the _Medical Gazette_, Sep. 26, 1835, where it extended +from the symphysis pubis backwards to the perineum; it had resisted the +pressure of the child's head so powerfully as to produce a deep +indentation along the cranial bones; it was divided by a bistouri, and the +head was immediately expelled. + +The _perineum_ can rarely, if ever, prove a serious hindrance to the +labour in primiparæ so long as its structure is healthy, even although it +may be unusually broad. With patience and due management the necessary +degree of dilatation may be obtained by the pressure of the head; and +proposals to dilate it artificially, or even to make a slight incision +into it, do not deserve a moment's consideration. Where, however, it has +been extensively lacerated in a previous labour, and has healed again +throughout its entire length (by no means a common occurrence) or when +there has been much sloughing, the cicatrix thus formed may render it +incapable of relaxation, and thus produce much resistance to the passage +of the head. Even here we may do a great deal by warm hip baths, +fomentations, and especially by bleeding; an incision through the callous +portion is by no means desirable where it can be possibly avoided, as it +only endangers a farther laceration during the expulsion of the head. +Cases nevertheless, occur where the contracted ring of the os externum is +so unyielding and gristly as to make this operation necessary.[129] In all +these cases, where, either the adhesion and contractions have given away, +or have been divided during labour, great care should be taken to prevent +them forming again during the process of healing, by using sponge tents +well greased, and other appropriate means. + +_Varicose and oedematous swellings of the labia and nymphæ_ also deserve +mention, although they rarely interfere with the progress of labour to any +great extent. Varicose labia seldom annoy the patient during her +pregnancy; the veins of the part may have become somewhat dilated and the +labium swollen; but it is generally not until the commencement of labour, +that they become hard and knotty: at first they feel like a bunch of +currants imbedded in the cellular tissue of the labium, and as labour +advances, and the return of blood from the part is still more impeded, the +swelling continues to increase in size, and frequently obstructs the os +externum very considerably. The danger here is not so much from its acting +as an obstacle to the passage of the child, as from its bursting during +labour and causing loss of blood and other serious consequences. The +tumour seldom bursts directly externally, but first gives way beneath the +skin, producing extravasation, after which, in consequence of still +farther distention, the labium itself ruptures. In some cases the +hæmorrhage is not very profuse externally, while the extravasation +internally, amounts to some pounds, extending not only to the vagina and +perineum, but also to the groin; and instances have occurred where it has +spread to a great distance over the glutæus muscles. + +"The extravasation," says Mr. Ingleby, "usually happens during the pain +which expels the child; but sometimes at an early period of labour, as in +the example of severe hæmorrhage here annexed. I had just left a patient +to whom I had been called, in consequence of the difficult transmission of +the child's head through a distorted pelvis, in connexion with an +inordinate varicose enlargement of the labia pudendi (especially the +left,) when a messenger overtook me urging my immediate return. It +appeared that during the violence of the straining, the tumour on the left +side had suddenly burst at the edge of the vagina posteriorly. The patient +lay in a little lake of blood; and as the bleeding recurred in gushes with +the return of every pain, it became essential to complete delivery, and a +child weighing fifteen pounds was extracted with the forceps. A large +slough separated at the end of the third week." p. 109. + +Where no laceration has taken place externally, it is seldom that an +opening for the purpose of removing the effused blood will be of use; on +the contrary, the access of external air cannot but be prejudicial in many +cases. The action of the absorbents is generally sufficient for this +purpose, and may be increased by friction with stimulating liniments, and +most remarkably of all by the application of electricity. Where the +extravasation extends beneath the lining membrane of the vagina, so much +swelling may be produced as nearly to close the passage; this, however, +generally takes place after the birth of the child, the rupture of the +varicose vessel having occurred whilst it was passing. + +On perceiving, at the commencement of a labour, that there are varicose +veins in the labium, which are beginning to increase in size and hardness +as the head advances, it will be as well to compress them as much as +possible during the intervals of the pains, when there is less impediment +to the blood returning from them: we can, by thus squeezing out their +contents to a certain degree, lessen the size of the swelling, and thus +prevent it from gaining that extent which might endanger laceration. We +may instantly know when this injury has taken place, by the livid +tumefaction of the parts, and our being no longer able to feel the knotty +portions of the varix. In order to check the effusion of blood as much as +possible, we must apply cold, and thus favour its speedy coagulation +beneath the skin. Where the distention is very great, it may become +necessary to evacuate the effused fluid; but, generally speaking, it is +deeper beneath the surface than might, at first sight, be expected. "It +has been proposed," says Mr. Ingleby, "that the swelling should be +punctured, provided there has been no delay, and the puncture is made +whilst the blood is still liquid. On one occasion I promptly carried this +suggestion into effect, but without success; and, considering the +structure of the labium, it is probable that the greater part of the blood +will coagulate almost as rapidly as it is effused." (Ingleby, _op. cit._ +p. 109.) + +A considerable degree of suffering and annoyance to the patient may arise +from oedematous swelling of the labia and nymphæ, both previous to and +during her labour. The labia are occasionally so distended as not only to +close the os externum, but to require that the legs should be kept as wide +asunder as possible, to prevent the swollen parts being crushed: the +patient is thus rendered very unwieldy and helpless, if she were not +already so previously by an anasarcous state of the lower extremities, +which frequently accompanies this condition. + +Oedema of the labia is of less consequence where the patient has had +several children than where she is a primipara, and seldom either retards +labour to any serious extent, or is attended with any troublesome +consequences afterwards: where, however, it is her first labour, and the +swelling is very considerable, laceration may be produced, the results of +which may be sloughing and gangrene: a fatal case of this kind has been +described by Burton. + +Where the labia are much swollen, they not only render the patient +incapable of moving, but are apt to become inflamed and excoriated, from +being in such close contact, and constantly moistened by the trickling of +the urine over them. By preserving the horizontal posture, and thus taking +off the pressure of the child from the soft parts of the pelvis, by +keeping the bowels open by saline laxatives, and by using saturnine and +evaporating lotions to the part, a good deal may be done for the patient's +relief. Where there is no disposition to inflammation, and the parts +appear somewhat flabby, warm and gently stimulating applications will be +preferable. Mr. Ingleby remarks that, "if the swollen parts are punctured +(and a particularly fine curved needle answers best,) a load of serum is +drained off, and relief is rapidly obtained. I have not observed any of +the reported bad effects (sloughing and gangrene for instance) succeed +this little operation; nor are they likely to occur in an unimpaired +constitution." The celebrated Wigand of Hamburgh, who strongly opposed +making incisions into the dropsical structure, does not appear to have +tried the plan recommended above. He considered that, as these swellings +are the result of pressure, the less we do with them the better, merely +taking care to keep up the action of the skin. + +Oedema, or rather dropsy, of the nymphæ, is not of common occurrence, and, +when it takes place to a considerable extent, produces a singular +alteration in the appearance of the external organs. The nymphæ protrude +beyond the labia, and depend so much as to rest upon the bed on which the +patient lies, forming a soft membranous bag, fluctuating with the fluid +which it contains. If labour has not actually commenced, we would prefer +endeavouring to excite the absorbents of the part, and thus remove the +effused fluid, to its evacuation by puncture: we have perfectly succeeded, +by the use of warm aromatic stimulating fomentations. The "_species +aromaticæ_" of the Continental pharmacopeiæ may be used with much +advantage in these cases: the mode of its application is, to tie some up +in a loose muslin bag, and soak it in hot wine; this forms an excellent +warm stimulating application, and appears to excite the absorbents very +briskly. A very good imitation of this, is to scald some chamomile +flowers, and having squeezed them tolerably dry, to sprinkle some port +wine over, and then apply them as a poultice. A swelling of this sort can +offer but little obstruction to the passage of the head; and if labour +commence before we have been able to reduce its size sufficiently, we may +at the last let off the fluid by puncture, should the pressure of the head +be such as to threaten laceration. + +_Tumours_ of different sorts may obstruct the passage of the child, and, +in some cases, produce an impediment of the most serious character. +Fibrous polypi and hard tubercles of the subcartilaginous character +(commonly called the fleshy tubercle) are those which may present the +greatest resistance, while fungoid growths of malignant disease, whether +cephaloma (brain-like tumour,) hæmatoma (fungus hæmatodes,) or carcinoma, +rarely oppose much obstruction. Their structure is soft and spongy, they +therefore yield to the gradual pressure of the head, become more or less +flattened, and thus allow it to pass. But fibrous or chondromatous tumours +are of too firm a structure to admit of this, and are capable of rendering +the labour not only difficult, but very dangerous. The mass being situated +at the lower part of the uterus, or attached to it by means of a pedicle, +is perhaps forced down into the cavity of the pelvis, beyond which its +attachments do not allow it to advance; if it be a fleshy tubercle +imbedded in the structure of the uterus, it will not be able to advance so +far, but will obstruct the brim of the pelvis, and thus prevent the head +descending into it. In many cases, these tumours are merely covered by the +lining membrane of the uterus, which sometimes forms a species of pedicle. +In either case, an early diagnosis is of great importance, as we may thus +have the opportunity of removing the mass either by the scissors or +ligature. + +Dr. Merriman has recorded an interesting case of this kind, where the +polypus which arose from the inner surface of the right lip of the os +uteri was tied, and removed rather more than three weeks before labour +came on. A fatal case, communicated to him by the late Dr. Gooch, is +equally valuable, inasmuch as it shows the results of a contrary +practice.[130] + +"The class of tumours which most frequently obstruct labour comprise +follicular enlargements and the prolapsed ovarium. The former disease +originates in the vagina, and has been shown by Mr. Heming to consist in a +dilated state of one of the mucous follicles, which acquires a cyst, and +secretes a fluid of varying colour and consistence, from a dark to a +straw-coloured serum, or a deposition purely gelatinous. Owing to the +density of its walls, and its general tension, the fluid contents of the +tumour are not easily distinguished; but the flaccidity which succeeds a +free puncture is very striking." + +"There are two forms of ovarian tumour which obstruct the passage of the +child; in the one, a small cyst in connexion with a very bulky cyst; or +else a portion of a large cyst passes into the recto-vaginal septum, and +bulges through the posterior part of the vagina: in the other, and that +which occurs by far the most frequently, the whole ovary, moderately +enlarged, prolapses within the septum. The descent is peculiarly liable to +happen at two periods; the first near the end of gestation, the second +during labour, the prolapsus being promoted by the relaxation of the soft +parts. The changes which the ovary undergoes when long detained in the +septum, will chiefly depend upon the capacity and yielding state of the +parts. If the woman has not previously borne children, it may remain +small, and scarcely retard delivery; but under contrary circumstances, it +acquires a large size, and nearly fills the vagina. In rare instances, the +bulging is said to have appeared at the anterior part of the pelvis." +(Ingleby, _op. cit._ p. 118.) + +The contents of these tumours vary a good deal; the hard ones are usually +lipomatous or fatty tumours, not unfrequently containing hair and +rudiments of teeth. Numerous cases have been recorded where ovarian +tumours, which had been pushed down before the child, have at length +burst, discharging their contents, and thus ceasing to act as an obstacle +to the labour. We quite agree with Mr. Ingleby in recommending puncture +under such circumstances; for, independent of pregnancy, it is a +well-known fact, that there is a much better chance of successfully +tapping an ovarian dropsy per vaginam, than through the abdominal +parietes. The same holds good in operating through the rectum; and he has +described two highly interesting cases where this mode of treatment was +completely successful; one in his own practice, the other in that of our +friend Mr. W. Birch. + +_Distended or prolapsed bladder_, &c. Lastly, the urinary bladder may +obstruct the passage of the child, from being prolapsed and distended with +water, or from containing a calculus which is forced down below the head. +In the first case, a prolapsus of the distended bladder can scarcely take +place without much inattention on the part of the practitioner, not having +ascertained whether the bladder had been lately evacuated. In case we +find, upon examination, that there is a disposition to this displacement, +the elastic catheter will enable the tumour of the prolapsed bladder to +collapse, and thus remove all farther trouble. The examination in these +cases must be conducted with care; for an elastic fluctuating tumour of +this kind may be mistaken for the distended membranes, or a hydrocephalic +head; and Dr. Merriman has given a melancholy case where, in consequence +of such an error, the bladder was punctured. + +_A stone in the bladder_ is sometimes more difficult to manage. If the +head is only just beginning to enter the brim, the stone may be pushed up +above it; but if it has already engaged completely in the pelvic cavity, +it becomes a question whether it will not be necessary to cut down upon +it, and thus remove it. These cases are, however, of very rare occurrence, +and we must be entirely guided by circumstances, it being impossible to +lay down any precise rules for their treatment. + + + + +CHAPTER VI. + +SIXTH SPECIES OF DYSTOCIA. + +_Faulty Labour from a faulty Condition of the expelling Powers._ + + I. _Where the uterine activity is at fault--functionally or + mechanically--from debility--derangement of the digestive organs-- + mental affections--the age and temperament of the patient--plethora-- + rheumatism of the uterus--inflammation of the uterus--stricture of the + uterus.--Treatment._ II. _Where the action of the abdominal and other + muscles is at fault.--Faulty state of the expelling powers after the + birth of the child.--Hæmorrhage.--Treatment._ + + +Although this species includes that condition of the expelling powers, +where their action is excessive, we shall defer this portion of the +subject until we treat of _precipitate labour_, with which it is +essentially connected. + +The agency by which the child is expelled during labour is of two kinds: +1st, involuntary action of the uterus, assisted, _secondly_, by the partly +voluntary and partly involuntary action of the abdominal muscles. + +On the approach of labour, the uterus, which hitherto had been merely +performing the office of a receptacle and a means of conveying nourishment +to the foetus, now assumes a totally different character; from being in a +nearly passive state, it assumes an entirely opposite condition, viz. of +high irritability and powerful action. We might almost suppose that its +connexion with the nervous system was become more close and intimate; for +it is now sensible to the influence of impressions which had before +produced no effect upon it. Thus, we see, that affections of the mind, +even but of moderate intensity, and to which it was, before labour, +nearly, if not quite, insensible, are now capable either of rousing its +efforts to the utmost violence, or of arresting them in the midst of full +activity; and, on the other hand, we see that where its action has been +deranged or interrupted, it gives rise to serious affections of the +nervous system, or even convulsions. + +With all this, it now displays peculiarities of function, which strikingly +distinguish it from all other organs of the body; in some cases it appears +to annihilate or to absorb, by its all-pervading influence, the functional +energies of other organs; and, in spite of its increased nervous power and +susceptibility to various impressions, it seems to possess the faculty of +continuing its efforts uninfluenced by general disease, unimpaired by +exhaustion, and, for a time, almost independent of the life itself of the +mother. In convulsions and paralysis, in general fever and inflammation of +vital organs, its powers appear to be undiminished: on the contrary, where +the patient, from whatever cause, is rendered incapable of assisting its +efforts by the abdominal muscles, the uterus will take upon itself the +whole task of expelling the child, which will be born apparently without a +single effort upon the part of the mother. + +We also observe, that organs, the various conditions and derangements of +which have exerted little or no influence upon the uterus in its state of +quiescence during pregnancy, now affect it powerfully, and are capable of +modifying its action very considerably. The stomach, the intestinal canal, +and the skin, are remarkable instances of this, and seldom fail to disturb +or pervert the natural efforts of the uterus, whenever these organs +deviate from a healthy condition. It will be, therefore, of the highest +importance to watch their functions narrowly, in order that we may form a +correct estimate of their effects upon the uterus. + +Derangements in the contractile power of the uterus may arise from a +variety of causes, which may be chiefly brought under two heads, viz. +_functional_ and _mechanical_. + +The functional derangements may arise from insufficient activity, the +result of general or local debility; from a deranged condition of the +digestive organs; from passions or affections of the mind; from hereditary +temperament, constitution, or peculiarity; from the patient's age, being +either very young or considerably advanced in years, and pregnant for the +first time; from plethora, general or local; from rheumatic affection of +the uterus; and from uterine inflammation. + +The contractions of the uterus may be _mechanically_ impeded, by tumours +imbedded in its substance; by organic diseases, as schirrus, cephaloma, +and hæmatoma; cicatrices from former ulcerations or rupture, or by any +other circumstances which interrupt the action of the longitudinal fibres +upon the os uteri. + +_From debility._ Where uterine action is insufficient from debility, the +pains are feeble, and do not appear to act in the right direction; they +are frequently attended with much greater suffering than might be +expected from their inefficiency; the intervals between the pains are +unusually long, the pains themselves are very short, or, after a while, +cease altogether. + +This condition, when depending on _general_ debility, may be the result of +previous disease, loss of blood, or other debilitating evacuations, +poverty, with its attendant miseries, depressing passions of the mind, and +health broken down by intemperance. + +The contractile power of the uterus itself may be injured by previous +leucorrhoea or menorrhagia, by abortions, or by attacks of hæmorrhage +during the latter part of pregnancy; it may be weakened by over-distention +of the uterus, either from plurality of children or too much liquor amnii, +by the patient exerting herself improperly at the commencement of labour, +straining violently, and endeavouring to bear down before she is +involuntarily compelled to do so by the presence of the head in the +vagina. It may also be produced by the membranes giving way too soon, as +is so frequently observed in first labours. + +_From derangement of the digestive organs._ We have already described the +change which takes place in the relation between the uterus and other +organs, as soon as it passes into a state of action. The intestinal canal +stands foremost in the influence which it exerts upon the uterus; whether +it be from constipation or diarrhoea, irritation from acrid contents, &c., +it will greatly modify, and even derange, its contractile power; the pains +cease to be genuine uterine contractions, and assume a spasmodic +character, producing much painful griping and pinching about the front and +lower part of the abdomen, without any of that regularity of interval and +duration, and gradual accession and recession, which mark the presence of +real labour pains, and, we need scarcely add, with little or no effect +upon the progress of the labour itself. These griping colicky pains appear +to supersede the true process of parturition, and either to prevent the +uterus acting with due regularity and effect so long as they last, or so +to pervert its action as to produce a species of metastasis towards other +organs. The pains lose their peculiar character as the expelling powers of +the uterus; they cease entirely, and the patient is suddenly attacked with +dyspnoea, cramps in the extremities, violent shivering, great +restlessness, intense headach, delirium, convulsions, or even mania. + +Wherever the action of the uterus is deranged by gastric or intestinal +irritation, the abdomen is generally more or less tender in front, +particularly over the symphysis pubis; the os uteri is thin, tense, and +rigid; the vagina is hotter than natural; the secretion of mucus is +sparing; and both os uteri and vagina are more than usually tender to the +touch. + +_From mental affections._ The mind is capable of influencing the action of +the uterus during labour in a remarkable manner, not only where it is +suffering from depressing emotions, as grief, great anxiety, or painful +anticipations as to the result, but from causes of a much slighter +character, which are nevertheless well worthy the attention of the +practitioner: his sudden appearance in the room, without the patient +having been properly warned of his arrival: the dread of an examination; +or annoyances of a much slighter character, as regards his manner, or that +of the nurse, &c., will not unfrequently be quite sufficient to stop the +progress of the pains. + +The _age and general temperament of the patient_ will also affect the +character of the pains. When pregnancy occurs for the first time, either +at a very early age, or considerably advanced in life, labour is apt to be +protracted, from defective uterine contraction; in the first case, she has +not yet attained that degree of adult strength which is requisite to +undergo a process requiring so much exertion; the pains are weak, of short +duration, and inefficient, but very exhausting to the patient. From the +irritability both of the nervous and vascular systems, so peculiar to +youth, arises a long train of troublesome symptoms, such as congestion of +blood to the head, spasms, syncope, convulsions, &c. In the other case, +the condition of the system is the reverse, the irritability is +diminished, the uterus is sluggish in its action, the pains are weak and +inefficient, follow each other very slowly, and the course of the labour +is much protracted; besides this, the short passages through which the +child advances are now less capable of dilatation, from having that +elasticity and suppleness peculiar to youth, and therefore oppose a much +greater resistance. + +Where the patient is of a slothful phlegmatic habit, the uterus generally +indicates a corresponding state, by the slowness of its action and want of +excitability during labour. The same condition is manifested during the +catamenial periods in the unimpregnated state, by the absence of pain, +weight, throbbing, and other symptoms of local congestion, which are +usually observed at these times; so that, but for the discharge, the +patient has scarcely any guide to mark their recurrence. On the contrary, +where the appearance of the menses is preceded and accompanied by severe +pain in the back and loins, throbbing, heat, weight, &c., indicating +considerable excitement in the uterine system, we usually observe a +similar condition in the uterus during labour, the pains being quick, +energetic, and efficient. It is probably from some peculiarity of +temperament that we can explain the hereditary disposition which some +women show in the unusually lingering or rapid character of their labours. + +_From plethora._ A congested or overloaded state of the uterine +circulation, whether from general plethora or from other causes, is not an +uncommon cause of feeble contractions. The spongy tissue of the uterine +parietes is so gorged with blood, as to prevent, in a great measure, the +free action of the pains, and may thus seriously impede the progress of +labour. We have already pointed out, when speaking of the signs of +pregnancy, the disposition which the system manifests for forming a larger +quantity of blood than before; the pulse is stronger and more full, the +animal heat is increased; this is especially observed in the uterus, and +continues so during the whole process. Whilst in the state of inaction +which belongs to pregnancy, but little inconvenience, comparatively, is +felt; but when labour commences, and it contracts, the blood is driven +from its engorged veins and sinuses into the general circulation; if, +however, it cannot do this, from the general state of plethora, its +contractions are rendered very imperfect and inefficient. + +Besides the appearances of general plethora, we shall easily recognise +this condition by the following symptoms: "the patient has much heat of +surface and yet but little thirst; the face, eyes, and skin, are red and +considerably swollen; we can feel vessels pulsating in every direction; +she gets but little sleep, and finds the bed and the bedclothes +uncomfortable to her; the uterus is large, thick, tense, and very warm: +the os uteri swollen and cushiony, and the vagina also warm and spacious; +the foetus is very restless, and causes a good deal of pain by its +movements. The pains are short and ineffective, and accompanied with a +peculiar sensation of painful stretching or tension, without any symptoms +of rheumatism, cramp, or other morbid conditions of the uterus being +present." (Wigand, _Geburt des Menschen_, vol. i. p. 138.) This condition +is not unfrequently accompanied with tendency to hæmorrhoids, inactivity, +constipation, varicose veins of the lower extremities, &c. + +_Rheumatism of the gravid uterus_ is an affection which, although it has +received but little or no notice in this country, has been long known and +described by the continental authors. It appears to be a similar condition +of the uterine fibres, when developed by pregnancy, to rheumatism in other +muscular tissues, arising from the same causes, connected with the same +conditions of the system, and producing similar effects; hence, therefore, +it must interfere considerably with the healthy action of the uterus, and +greatly diminish or entirely destroy, the efficiency of the pains. + +The whole uterus is unusually tender to the touch; the contractions are +excessively painful from their very commencement, the slightest excitement +of the uterus producing a sensation of pain; they come on with a sudden +twinge or dragging pain about the pelvis and loins, and where the +contractions are still powerful, they sometimes rise to an intolerable +degree of intensity. This condition is frequently observed to a slight +extent at the commencement of labour; the mild precursory pains which, in +a healthy state, are merely attended with a sensation of equable pressure +and tightness round the abdomen, now produce much suffering and give rise +to one form of spurious pains, to which we have already, under that head, +alluded. Where the symptoms are of considerable severity and have been +aggravated by improper treatment, this state may easily pass into that of +actual inflammation. + +On examining into the history of the case, we shall frequently find that +for several days, or even more than a week, the patient has remarked the +uterus to be unusually tender to the touch, scarcely bearing the pressure +of the clothes; and at night-time the uneasiness has increased to such a +degree that she could scarcely remain in bed. There is a frequent desire +to pass water, which is highly acid, and deposites much red sediment; and +in all probability she complains of rheumatic pains in other parts of her +body. + +The causes of this condition are the same as those of rheumatism under +ordinary circumstances: exposure to cold, and alternations of temperature, +particularly when heated; derangement of the stomach, with much prevalence +of acid, &c.: insufficient clothing, and, upon the Continent, especially +in Holland, where it is said to be very frequent, by the use of +chauffe-pieds. + +_Inflammation of the uterus_ is another condition which can not only +greatly impair, but entirely suspend, the activity of the uterus. It is +usually brought on by improper treatment during labour, where the real +cause of the lingering ineffective pains at the commencement has been +entirely overlooked, and a state of uterine irritation aggravated into one +of actual inflammation by the abuse of stimuli and other heating drinks, +given with the view to increase the pains; it may be produced by external +violence, improper attempts to dilate the os uteri, rough and too frequent +examination, endeavouring to turn the child or to apply the forceps before +the soft passages were in a fit condition for that purpose. + +The whole abdomen becomes extremely tender, and even the slightest +contractions of the uterus produce intense suffering; the vagina is hot +and dry, and very tender to the touch--its mucous secretion suppressed; +the os uteri is swollen, tense, and painful, and the anterior lip is +sometimes so distended as to have been actually mistaken for the bladder +of membranes; the bowels are confined; the urine is suppressed; the +abdomen becomes distended from tympanitis; and general, and probably +fatal, inflammation of its contents follows. + +_Treatment._ The causes of insufficient uterine action are so numerous +that the modifications to which they give rise are almost endless, and +demand no little variety of treatment. A great deal may be done to avoid +this state by attention to the patient's health shortly before labour; and +by so carefully regulating it as to ensure a healthy condition of the +whole system. Lingering labour from feeble uterine activity is seen most +frequently in young primiparæ of delicate form and nervous irritable +habit; the pains produce much fruitless suffering, and greatly exhaust the +patient. If the cause continues, the case becomes much protracted, and +serious consequences may ensue; such as hysterical symptoms, or even +convulsions, inflammation of some organ, general fever, or complete and +dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass +contraction of the uterus. In a slight degree this condition is not of +unfrequent occurrence, whether from an enfeebled uterus or general +debility, and requires general, rather than special treatment for its +removal. Change of posture, walking about the room, gentle friction of the +abdomen, and occasionally taking some refreshing or mildly nutrient drink, +as tea, wine and water, or beef-tea, &c., prove serviceable in such cases; +friction of the abdomen, if well applied, frequently produces a great +alteration in the character of the pains, and greatly assist the progress +of labour: if it be still in the first stage (the os uteri not yet fully +dilated,) an enema will not only clear the rectum of any fæcal matter +which may be lodging there, but assist in rousing the uterus to greater +activity. + +Where we can satisfy ourselves that none of the above-mentioned causes are +present to protract the labour, we may proceed to the use of those +remedies which are considered to have the power of exciting the uterine +contractions, such as secale cornutum, borax, cinnamon, and the several +diffusible stimulants. This state of uterine inactivity is, however, rare; +and we would earnestly warn young practitioners against too readily +concluding that it is present. They will find that the more carefully they +investigate such cases, the less frequently will they require these +remedies. In using the secale cornutum, we give the preference to the +powder: it should be carefully kept from moisture, air, or light: from +twenty to thirty grains, mixed in cold water, will be the proper dose, and +this may be repeated two or three times, at intervals of half an hour, or +rather more. Borax is also another remedy which appears to possess a +peculiar power in exciting the activity of the uterus: although it is +scarcely ever used for such a purpose in this country, its effects upon +the uterus have been long known in Germany; and in former times, both it +and the secale cornutum entered largely into the composition of the +different nostrums which were used for the purpose of assisting labour. We +have combined these two medicines with the best effects, and generally +give them in the following manner:--[Symbol: Recipe] Secalis Cornuti +[Symbol: scruple] i--ij; Sodæ Subborat. gr x; Aq. Cinnamomi [Symbol: +ounce] jss. M. Fiat haust. Cinnamon, which is a remedy of considerable +antiquity, has also a similar action upon the uterus, although to a less +degree. + +Our own conviction with regard to the use of these remedies is, that they +are seldom required _during_ labour, except in nates, or footling +presentations, or in cases of turning, where the head is about to enter +the pelvis, and where, at this critical moment, the action of the uterus +is apt to fail, when it is important to the safety of the child that +there should be brisk pains to force the head through the pelvis and +internal parts with sufficient rapidity. The chief value of these remedies +is for the purpose of exciting uterine contraction _after_ labour, and +thus to promote the safe expulsion of the placenta, where there is a +disposition to inertia uteri, and ensure the patient against hæmorrhage. + +Where the contractile power of the uterus is so enfeebled that it becomes +nearly powerless, we deem it much safer and better to apply extractive +force to the head by means of the forceps, and thus overcome the natural +resistance of the soft parts, to using medicines which excite uterine +action, and thus stimulate the exhausted organ to still farther efforts. +The mere cessation of uterine action, however, where the labour has been +tedious and fatiguing, is no proof that the uterus is exhausted, and +incapable of farther efforts: so far from its sinking into a state of +quiescence, being a symptom of exhaustion, experience shows that, in +labours of this character, it indicates a very opposite condition, being +nothing more than a state of temporary repose, during which nature affords +it an opportunity of recruiting its own powers, as also those of the whole +system. The interval of ease which is thus given to the patient is +accompanied by refreshing sleep; the skin grows moist; a gentle +diaphoresis creeps over her; the circulation becomes calm; and after a +time, the uterus awakes again to renewed and astonishing exertions; thus, +Wigand has remarked, "the pains during the same labour may cease once, +twice, or even oftener, and yet after a little rest will return with +renewed strength." (_Geburt des Menschen_, vol. ii. p. 242.) On the other +hand, where the pains, in spite of their becoming more and more +ineffective, continue to exhaust the patient with fruitless suffering, and +prevent her from enjoying that repose which is so desirable under such +circumstances; when the uterus, from increasing irritability, scarcely +ceases to contract even for a moment, but continues tense and more or less +tender during the intervals of the pains, we can have little or no +reasonable expectation that such a labour can be terminated by the natural +powers. If the head be not far advanced in the pelvis, or the passages +fully dilated, if the bowels have been relieved before labour, and there +is no febrile excitement of the circulation, a mild diaphoretic sedative, +like Dover's powder, will be of great service: it calms the irritability +of the system, and induces that state of quiet or actual repose to which +we have just alluded. If, on the other hand, the labour be much farther +advanced, the head approaching the pelvic outlet, and the soft parts well +dilated, a little assistance, by means of the forceps, will quickly +terminate the case, and free the mother and her child from farther +suffering and danger. + +Where the uterus is enfeebled by lesion or change of structure, it becomes +very difficult to decide as to what course ought to be pursued: in some +cases, the soft passages partake in the loss of tone, and offer but little +resistance to the advance of the child; in others, however, the uterus is +so powerless as to give us no choice but of employing artificial delivery. + +We have already pointed out the importance of paying the strictest +attention to the bowels shortly before and during labour, and how +frequently a neglect of this precaution acts as a means of perverting the +due action of the pains, and giving them that character, already described +under the head of _False Pains_. "After the labour has made much progress, +the rectum, if loaded, should be emptied by clysters; indeed, the utility +of clysters in almost every stage of labour is so apparent that it is to +be lamented they are not more frequently employed." (_Synopsis of +difficult Parturition_, p. 19.) We have seen cases where, although the +bowels had been opened at the commencement of labour, after a time, the +pains have gradually lost their dilating effect upon the os uteri, +although they have increased in severity; the os uteri has remained tense +and hard, and the labour has become very tedious and exhausting; the +administration of an enema, and removal of a quantity of fæcal matter from +the rectum, has been followed by an instantaneous change in all the +symptoms; the pains have become powerful and effective, the os uteri has +quickly dilated, and the whole labour has been completed in a very short +space of time. In like manner, vomiting during the early part of labour +produces the best effects; for it not only assists to relax the parts, by +the nausea which usually precedes it, but, by emptying the stomach of +unhealthy contents, it tends not a little to restore the uterus to its +natural activity. + +Where the bowels are distended with flatus, and loaded with acrid and +unhealthy contents; we rarely see the pains become regular and effective +until these sources of irritation are removed: the abdomen is painful with +spasmodic colicky griping, and excites the uterus to partial and very +painful contractions of a cramp-like character, which entirely supersede +the regular pains, and thus exhaust the patient with protracted suffering +without at all advancing the labour itself. If this condition be allowed +to continue uninterfered with, the tenderness of the abdomen increases, +the circulation becomes excited, and inflammation, and fever of a most +serious kind will be the result. + +In the management of primiparæ, who are pregnant either at a very early +age or considerably advanced in life, our chief attention must be directed +to the management of them for some little time before labour is expected, +in order that we may place them in as favourable a state of health as +possible, and thus enable them to meet the coming trial with safety. + +Where the patient is very young, we should endeavour, by early hours, +regular exercise, good air, and simple nourishing diet, &c., to increase +her strength, and the general tone of health, and thus diminish that +irritability of the nervous system peculiar to females of this early age. +She should lead a country life, be as much as possible in the open air, +enjoy the absence of restraint and excitement, which are almost necessary +consequences of a residence in town, and, by agreeable occupation and +cheerful society, train herself, as it were, to that state of moral as +well as bodily health best adapted to ensure a favourable result. It is in +cases of this kind where the bodily powers have not yet ripened into adult +womanhood, that so much good may be effected by using the tepid or (if the +season permit) cold salt water bath; and we would beg to refer our readers +to our observations on this subject in the chapter on PREMATURE EXPULSION. +In a case which has recently come under our notice, we have had reason to +attribute the remarkably healthy and favourable labour of a young and +delicate primipara solely to the invigorating effects of regular exercise +and the daily use of sea-bathing, which she continued to within a very few +days of her confinement. + +It is commonly supposed that women pregnant for the first time, and +advanced in years, always have severe labours: this is not necessarily the +case, although, at the same time, the greater rigidity of the soft parts +considerably increases the resistance to the expelling powers. It will be +equally important in this case, also, to improve her health and strength +as far as possible, and, by exercise, warm hip baths, &c., to give the +parts a greater degree of suppleness and elasticity. + +Where the labour is protracted by a state of general plethora or local +congestion, the expelling powers are not only enfeebled by the engorged +state of the uterine circulation preventing effective pains, but the +resistance to the passage of the child is increased by a similar condition +of the soft passages, which are swollen and turgid with blood. It is in +these cases that bleeding effects such a sudden and complete change; the +pulse loses its oppressed character, and rises in point of strength, the +uterus loses the thick solid feel which it had before; its contractions +become active and powerful, the os uteri dilates, the passages become soft +and yielding, and the whole process assumes a different character. By +careful observation, this state can easily be discovered before labour has +actually commenced; in which case much useless suffering may be prevented +by previously reducing the circulation to a proper standard, and thus +fitting the uterus for the exertions it has to undergo: besides bleeding, +mild saline laxatives, with or without antimonials, will be of great +service. The nitrate of potass in these cases has the best effects, either +in farthering the effects of the bleeding, or removing the necessity of +using so powerful a remedy. + +In treating rheumatism of the gravid uterus, our practice will differ but +little from that in cases of ordinary rheumatism in other parts: this +condition, we believe, is rarely excited, until the system had been +already predisposed to it by deranged digestion, and that general +prevalence of acid diathesis, which manifests itself in different +individuals and under different circumstances so variously; hence, +therefore, it will always be important to unload the primæ viæ effectually +by an active dose of calomel or some other mercurial, before prescribing +for the immediate symptoms of the complaint: beyond producing a little +occasional nausea, five grains of calomel will act much more comfortably +to the patient's feelings than a smaller dose; there will be less griping +and intestinal irritation, but the effect will be more complete and +general; not only will the bowels be thoroughly evacuated, but the liver +relieved of a large quantity of unhealthy acrid bile, the removal of which +cannot but be highly advantageous. We may now proceed to the use of +diaphoretics and opiates: of these, Dover's powder stands foremost; and if +given in doses of from ten to fifteen grains, accompanied with warm +diluent drinks, rarely fails to induce sleep and a pretty active +perspiration, which gives great relief. As the abdomen is usually more or +less tender on pressure, it should be covered with a piece of soft +flannel, or, still farther to ensure the full diaphoretic effect of the +remedies, a warm bath may be had recourse to. Where calomel in the above +dose has been premised, we seldom fail in procuring a free action of the +skin, and, according to our own experience, with far greater relief to the +system than where the perspiration has been induced merely by diaphoretics +and external warmth. + +If this condition of the uterus has been neglected, and the contractions +are beginning to produce intense suffering; if the abdomen is rapidly +becoming more tender to the touch, it should be covered with a hot +poultice of linseed meal, made more stimulating by the addition of mustard +flour, and this should be continued until the skin is considerably +reddened. In the slighter cases of this affection, where the bowels have +been opened, friction upon the abdomen frequently produces the happiest +effects. We presume it is to these cases that Dr. Power alludes when he +says, "in some, the improper action will be removed almost instantly, and, +as it were, by a miracle; so that a case which has been protracted for the +greater part of a week, under the most intense suffering, without the +least progress, has been happily terminated in fifteen or twenty minutes +from the first commencement of the friction." (Power's _Midwifery_, 1819.) + +Where inflammation of the uterus takes place during labour, the case +becomes one of the most serious character; for not only is the suffering, +which is produced by every contraction, of the most intense description, +but the presence of the child aggravates the state of inflammatory action, +and excites the uterus to still more violent efforts, while the swollen +and unyielding state of the os uteri, &c., precludes the chance of speedy +delivery. Under such circumstances, we must trust almost entirely to the +lancet in aiding this important object; for, until the circulation has +received an effectual check by fainting, the dilatation of the parts +cannot proceed, nor can any attempt be made to give artificial assistance. +The abdomen should be covered with a hot linseed meal poultice, as above +described, in the treatment of rheumatism of the uterus; warm decoction of +poppies should be thrown up the vagina, or, if this cannot be procured at +the moment, some thin gruel mixed with a little laudanum, or in which a +few grains of Extr. Conii or Hyoscyami have been suspended; the bowels +should be opened by a simple enema, after which a small opiate injection +will be desirable, in order still farther to allay irritation. + +_Stricture of the uterus._ We have already had occasion to allude more +than once to that species of violent and continued contraction which we +have denominated stricture of the uterus, but have chiefly considered it +where it affects the os uteri; a somewhat similar condition of spastic +rigidity is occasionally, though rarely, seen in other parts of this +organ, and is capable of producing a most serious obstacle to delivery. +The uniform and regular action of the uterus disappears; its contractions +become partial, both in extent and effect, one part alone contracts whilst +the rest of the uterus is relaxed; its shape thus becomes altered; for, by +these partial contractions of its fibres, it may become elongated, +shortened, flattened, &c.: the spasmodic action frequently varies its +seat, and successively attacks different portions; thus, where it affects +the body of the uterus, it becomes contracted almost like an hour-glass, +having a transverse circular indentation, as if it had been tied with a +cord. Where the contraction affects one side of the organ, it alters the +shape of it materially; the fundus is pulled down equally, and the +position of the child, as we have shown in the first species of dystocia, +may be seriously affected. If the stricture has its seat in the os uteri, +this becomes tightly contracted, hard, unyielding, and painful upon +pressure: it does not dilate sufficiently, and the inferior segment of the +uterus is generally pushed downwards, whilst the os uteri itself is drawn +upwards. In cases of this kind, we find that although the uterus +contracts, the child does not advance, but rather retracts, during a pain; +the contractions are never general, but partial, and even where they are +general, the fundus does not attain its due preponderance over the os +uteri, so that the one contracts as much as the other does; in severe +cases, also, the uterus continues in a state of spasmodic action during +the intervals of the pains: this is frequently accompanied with a painful +and harassing sensation of tension and stretching, very different to that +produced by the action of regular pains upon the os uteri; and in the +worst cases we occasionally observe a peculiar state of the brain, which +manifests itself by attacks of insensibility, faintings, or even +convulsions. + +Although the head does not advance in spite of the strongest pains, yet, +upon examination, we find no want of proportion between it and the pelvis; +if the intervals of uterine action be of sufficient duration to allow it, +we shall feel the head quite moveable in the pelvis, or, at any rate, with +plenty of room for the finger to pass round it, and yet when a pain comes +on, the head remains fixed, or if it does descend somewhat, it returns +again to its former situation as soon as the pain is over. This state of +things is usually seen where the body of the uterus is the seat of the +stricture, and is contracted transversely upon that of the child, which it +tightly encircles, and renders all farther advance impossible. + +This state of spasmodic action is produced by whatever tends to irritate +the uterus and excite it to irregular action; thus, premature rupture of +the membranes, especially when it has been suddenly drained of a large +quantity of liquor amnii; the irritation arising from acrid matter in the +intestines, or from their being loaded with accumulations of fæces; +improper examination, and more especially, attempts to dilate the os uteri +by the fingers or hand; endeavouring to strain and bear down during the +early part of labour, and when the patient is not involuntarily compelled +to do so; attempting to apply the forceps when the os uteri is not fully +dilated, or whilst the instrument is very cold: malposition of the child, +especially after rupture of the membranes; and lastly, anxiety, fear, and +other affections of the mind. The circulation is generally in an irritable +state, the patient is of a delicate excitable habit, and is apt to be +nervous and hysterical. + +The treatment in these cases will be precisely on the same general rules +as we have above described; the bowels must be relieved by a laxative or +by an enema; if necessary, the circulation must be reduced to the proper +standard by bleeding, and the irregular uterine action controlled by +opiates. Besides these means, the warm bath is of the utmost service, and +seldom fails to produce a favourable change. Where the action of the +uterus is impeded, or otherwise rendered faulty by organic disease, +lesions of its structure, &c., we shall in all probability be compelled to +use artificial assistance. + +II. _Where the action of the abdominal and other muscles is at fault._ +Where the faulty character of the labour arises from a faulty state of the +partly voluntary, partly involuntary, action of the abdominal muscles +which is destined to aid the uterus in expelling the child, this may +equally be a result of general debility from previous disease, exhaustion +from the long duration of the labour, from the abuse of spirituous +liquors, &c. It may also arise from various causes which tend to impede +the respiration; such as excessive corpulence, great deformity of the +spine, bronchocele, spasmodic asthma, rheumatism of the diaphragm, +ascites, hydrothorax, phthisis, pneumonia, aneurism of the aorta, +dilatation of the heart, &c. + +Where the size is such as renders the patient very unwieldy, or the spine +is much deformed, we must place her in that position in which she can +exert herself with greatest effect, and at the same time experience the +least possible obstruction to her breathing: with deformed people, this is +of great importance; she should be propped up with pillows, &c. into +whatever posture she can lie with most comfort, and the practitioner must +manage to deliver her in this position. Patients suffering from pluerisy +or pneumonia are unable to bear the continued strong inflation of the +lungs which is necessary during the second stage: under these +circumstances, the pain and inflammation are greatly aggravated; +venesection must be used with great promptness, but it does not always +bring relief or remove the danger; for the disease is kept up by the +presence of labour, which, therefore, in all probability, will require to +be terminated by art. In some cases, however, as we have already +mentioned, especially where the disease is of an acute character, the +uterus appears to take upon itself the whole exertion of the labour, so +that the child is born apparently without any effort on the part of the +mother. + +_Faulty state of the expelling powers after the birth of the child._ The +last stage of labour, which comprehends the expulsion of the placenta, may +also be retarded by a faulty state of the expelling powers. This not only +arises from the causes which we have already mentioned, but from those +connected with the labour itself; as from premature and immoderate +straining during the pains, misuse of medicines given to increase the +pains; also, where the uterus has been exhausted by the length and +severity of the labour, or where it has been thrown into a state of +inertia by the sudden evacuation of its contents, especially when +previously much distended. This condition is frequently induced by not +supporting the child sufficiently when the shoulders are about to pass +through the os externum; the main bulk of the child is therefore suddenly +expelled, and the uterus is at once thrown into irregular action by the +sudden shock of so great a change, or falls into a state of inertia. The +separation and expulsion of the placenta may be also retarded where the +labour has required the forceps, turning, or perforation, especially the +latter, on account of considerable pelvic deformity; the more so if there +has been considerable delay in giving assistance. Irregular and partial +action of the uterine fibres, after the expulsion of the child, may easily +render the last stage of labour dangerous; for, under such circumstances, +the portion of the uterus to which the placenta is attached may be in a +state of firm contraction in one part, while the other is quite relaxed, +so that incomplete separation of the placenta will be the result, and +hæmorrhage follow: hence we cannot be too cautious in avoiding every cause +which may at all influence the regular action of the uterus during the +last stage of labour, which is far more dangerous than the two others put +together. + +In a case of this kind, we do not feel the uterus contracting into the +firm globular mass above the symphysis pubis, as might have been expected; +but if inertia uteri be present, it remains soft and large, the peculiar +pains of the last stage which indicate the speedy separation and expulsion +of the placenta do not make their appearance, or only in a very +insufficient degree. If it be contracting irregularly and only in part, we +shall feel this distinctly, from the unequal shape and hardness of the +uterus, which in some cases will have almost a lobulated feel; in others, +it presents a considerable depression either upon the fundus or anterior +wall. + +_Hæmorrhage._ The danger here, chiefly depends upon the occurrence of +hæmorrhage: if the placenta be still attached by its whole surface to the +uterus, no hæmorrhage can ensue; but if the contractions have been of +sufficient power to detach more or less of it from the uterus, large +trunks, which have hitherto conveyed maternal blood into the placental +cells, are torn through, and a profuse discharge must be the result. The +degree of the hæmorrhage will in most instances furnish us with a +tolerable estimate of the extent to which the separation has taken place; +but it is far from easy to ascertain correctly the quantity of blood which +has been lost, and we must rather try to ascertain what are the effects +produced upon the system of the patient. The pulse becomes smaller and +quicker, the column of blood is evidently diminished, and the heart for a +time drives on its contents more rapidly; but as the loss increases, so +does it become enfeebled, and although beating with a very frequent +stroke, it now becomes so weak as to be scarcely or no longer capable at +the wrist of producing such a resistance to the finger as will give the +sensation of a pulse; the necessary consequence of this is, that the +patient at first complains of great weakness, the face becomes pale, the +lips white, the breathing anxious; this is followed by a sense of great +prostration, the perspiration breaks out upon the face and forehead, +tinnitus aurium, confusion of ideas, and sense of darkness before the eyes +succeed; the load at the præcordia, and the oppression of breathing, +become more insupportable; she tosses her arms about, and in some +instances has a sensation that the room is going round with her, or that +she is sinking through the bed; in other cases, the breathing becomes +gradually more feeble, until it is almost imperceptible; she every now and +then takes a deep sobbing grasp, which seems to rouse her to consciousness +for a moment, and then she relapses into a state verging upon +insensibility; the pulse is probably now no longer perceptible at the +wrist, the face is undergoing a rapid change, the features are +contracting, and there is a general expression of death-like collapse +which shows too truly the urgency of the danger. The alterations which are +taking place in the state of the brain and nervous system, vary in +different individuals: in some, there is strabismus; in others, temporary +mania, or at least, delirium; and in more unfavourable cases, even +convulsions; these last are especially formidable, as they not only show +that the system has been severely affected by the loss of blood, but are +apt, from their violence, to extinguish the little spark of life which is +left, or, in other words, to be followed by sudden death. + +These are some of the many symptoms indicating a sudden and extensive loss +of blood; others also occur, depending on the external or internal +character of the hæmorrhage. The want of contraction and general +flaccidity of the uterus, as felt through the abdominal parietes, have +been already noticed; if the blood be prevented escaping by the contracted +state of the os uteri, by coagula, or the detached placenta, it begins to +collect in the cavity of the uterus, which therefore swells as the +accumulation continues to increase, so that it may even equal the size +which it had before labour, containing many quarts of blood, and the +patient may be in the most imminent danger of dying from hæmorrhage, +perhaps, without any blood having issued externally: this is the _internal +uterine hæmorrhage_, a form which is justly looked upon as peculiarly to +be dreaded, from the insidious character of its attack. In most cases, the +uterus fills to a certain extent only, and then, as if excited to +contraction by the distention of its parietes, or any slight concussion, +produced by coughing, &c. it expels a large quantity of coagula and half +coagulated blood, and returning to its former state of atony, again begins +to swell from fresh accumulation of blood in its cavity. + +_Treatment._ So long as the inertia or atony of the uterus continues +without any symptoms either of external or internal hæmorrhage, we are not +justified in interfering directly, either for the purpose of exciting the +uterus, or still less of removing the placenta. This condition chiefly +occurs where the uterus has been previously much distended, or suddenly +emptied of its contents, where it has been exhausted by long and difficult +parturition, and also, as Leroux has observed, "in women of a phlegmatic +temperament and lax fibre, who, during pregnancy, have suffered much +ill-health, by which the tone of the solids has been weakened; who have +very large pelves, and a soft dilatable os uteri." (_Sur les Pertes de +Sang_, 1776.) + +We must therefore give the uterus time to recover from the great and +sudden change which it has undergone, to collect its strength, to remodel +and arrange its forces, until it is at length able, not only to resume its +efforts, but to contract to that extent which shall both ensure the +expulsion of the placenta and the safety of the patient. Whilst this state +of inertia lasts, the patient should be kept as quiet as possible; she +should be placed in a comfortable posture, take a little cool drink from +time to time (as cold tea, toast and water, &c.,) in order to refresh +her;[131] or, if she has been much exhausted by her labour, a glass of +wine may be given with good effect. If, however, hæmorrhage appears, this +shows that a separation of the placenta from the uterus must have taken +place: our great object should now be to excite contraction of the uterus, +for by this means alone can we stop the discharge. + +In ordinary cases, a little circular friction with the tips of the fingers +over the fundus will generally be sufficient. If the uterus begins to +swell, we may grasp it with a sudden but moderate degree of force; or we +may give the fundus every now and then a smart jog with our hand. Whilst +these measures are pursuing, a dose of secale cornutum (see DYSTOCIA, p. +330,) will be of great service; for even if it does not act soon enough to +aid the expulsion of the placenta, it contributes greatly to ensure the +contraction of the uterus afterwards. If the hæmorrhage nevertheless +continues profuse, it will be necessary to introduce the hand into the +uterus and remove the half-separated placenta: its contractions are too +feeble for that purpose of itself, and the presence of the hand in its +cavity, and the artificial separation of the placenta, act as a stimulus, +and rouse it to greater activity. The opinion that we only increase the +danger by thus increasing the bleeding surface does not hold good, when, +from the profuseness of the hæmorrhage, it has become evident that the +greater part of the placenta is already separated from the uterus; on the +other hand, where there is but a slight discharge, the case is very +different, and would not justify our having recourse to so strong a +measure. + +If the contraction which has been excited by the artificial removal of the +placenta be but temporary, we must proceed to the use of other means for +the purpose of rousing the activity of the uterus. The sudden application +of cold is a most valuable means; it acts here solely by the _shock_ which +it produces at the moment, and not by lowering the circulation and +favouring coagulation. Thus we find that a cold wet napkin suddenly +flapped upon the abdomen has an immediate effect upon the uterus; but it +ought not to remain on long, and the skin should be dried with a warm +towel, in order that a fresh application of the cold may produce the +greater effect. A series of such _shocks_ may be produced by using another +wet napkin to the vulva, and a third to the sacrum and loins; an +assistant should remove them in the order in which they have been applied, +and dry the skin, for a repetition of the remedy, if necessary. + +A still more powerful mode of producing a sudden shock, and thus rousing +the uterus to activity, is by a douche of cold water upon the abdomen. +This may easily be effected by a teapot or kettle held at some height +above, and slowly emptied upon the lower part of the abdomen; the uterus +will seldom refuse to obey such a stimulus as this, however great may be +the inertia into which it has fallen. The inefficiency of a prolonged +application of cold to the abdomen, however severe, and the efficiency of +the contrary practice, is admirably expressed by Dr. Gooch, in his +description of a dangerous case of hæmorrhage:--"Finding the ice so +inefficient, I swept it off, and taking an ewer of cold water, I let its +contents fall from a height of several feet upon the belly: the effect was +instantaneous; the uterus, which, the moment before, had been so soft and +indistinct as not to be felt within the abdomen, became small and hard; +the bleeding stopped, and the faintness ceased--a striking proof of the +important principle that cold applied with a shock is a more powerful +means of producing contraction of the uterus than a greater degree of cold +without the shock." (_An Account of some of the more important Diseases +belonging to women_, by Robert Gooch, M. D.) + +Another mode of applying cold to induce uterine contraction, and little, +if at all, inferior to that above-mentioned, is the injection of cold +water into the uterus itself: this can only be effectually employed after +the removal of the placenta and membranes, and frequently proves of the +greatest assistance, being capable of rousing the uterus when many other +means have failed. If, from the sultriness of the weather, water cannot be +procured of sufficient coldness, or if the case be very urgent, vinegar +and water in equal parts may be used; but the injections of spirit and +water, which some have recommended, can scarcely be considered as a safe +proceeding. + +These various means frequently require to be repeated several times before +the contraction of the uterus becomes permanent, nor must we be +discouraged by finding the uterus becoming soft again in a minute or two +after ceasing to use them; for we may feel assured, with few exceptions, +that if we can only keep the uterus, by this means, in a state of +tolerable contraction for half an hour, it will ultimately become +permanent, and remain so of itself.[132] + +It is, in these cases, where pressure is of so much importance, not for +the purpose of producing uterine contraction, as of maintaining it when +once excited. By pressure applied at this moment, we may frequently keep +the enfeebled uterus in a state of contraction, which, but for this +support, would have yielded to the general force of the circulation, and +have again expanded. For the same reason, whenever the uterus begins to +swell again from internal hæmorrhage, and by the renewal of the above +remedies, it becomes hard, but does not diminish in size: this shows that +the contraction has not been powerful enough to expel the blood, which, in +all probability, has already begun to coagulate in its cavity: where this +is the case, the hand, or at least two fingers, should be passed, to +dislodge the clots, and assist in their expulsion; after which, a cloth +folded into a thick compress should be placed over the fundus, and firmly +bandaged upon the abdomen by a broad towel. + +Where every means has failed to induce a sufficient or permanent degree of +contraction, we believe that the only certain means which remains, is +putting the child to its mother's breast. Under no circumstances do we see +the sympathy between the uterus and the breast so beautifully displayed as +here, and we may most truly affirm that we have never known it fail where +the mother was sufficiently conscious to know that it was her own child. +To a by-stander, ignorant of what was taking place, the sudden gush of +blood mixed with coagula, which follows the application of the child, +would be nothing less than a sign of renewed danger, while, in fact, it is +a proof that the uterus is beginning to contract and expel its contents. + +If the pulse has been seriously reduced by the loss of blood which the +patient has sustained, a glass of wine, or a spoonful or two of brandy, +will be of great service in rousing the vital powers; and this must be +repeated or increased, according to the urgency of the circumstances; a +little weak beef-tea, given from time to time, frequently appears to rouse +the system, even more than the brandy, and is more refreshing to the +patient; it can also be taken in larger quantities, for when the +exhaustion is very great, stimuli appear to excite vomiting, which is by +all means to be avoided. Where, however, it occurs spontaneously, it need +not be looked upon in so formidable a light: thus Dr. Denman observes, +"when patients have suffered much from loss of blood, a vomiting is often +brought on, and sometimes under circumstances of such extreme debility +that I have shrunk with apprehension lest they should have been destroyed +by a return or increase of the hæmorrhage, which I concluded was +inevitable, after so violent an effort: but there is no reason for this +apprehension; for, though vomiting may be considered as a proof of the +injury which the constitution has suffered by the hæmorrhage, yet the +action of vomiting contributes to its suppression, perhaps by some +revulsion, and certainly by exciting a more vigorous action of the +remaining powers of the constitution, as is proved by the amendment of the +pulse, and of all other appearances immediately after the vomiting." + +When a slight trickling of blood continues, although the uterus is +tolerably hard and contracted, it will be desirable to make an +examination, for we shall frequently find a long slender coagulum hanging +through the os uteri into the vagina, upon the removal of which, the +discharge will cease. + +The application of the child to the breast is not less valuable for +preventing any return of the hæmorrhage than for stopping it in the first +instance: we are _never_ perfectly secure against hæmorrhage coming on +during the first few hours after delivery, even where every thing has +turned out as favourably as possible: the exhaustion from the length or +severity of the labour, the warmth of the bed, and in some cases, it would +even seem, the relaxing effects of deep sleep, are all liable to be +followed by inertia uteri and hæmorrhage. In no way can we ensure our +patient so completely against this kind of danger as by putting the child +to the breast; the uterine contraction which it excites is not only +powerful, but permanent; nor do we consider that a practitioner is +justified in leaving a patient in whom the uterus has shown a disposition +to inertia without having ensured her safety by this simple but effectual +safeguard. + +There is a form of hæmorrhage after the birth of the child, which seems to +depend upon an over-distended state of the circulation, and where its +activity appears too great for the contractile power of the uterus; so +that, in spite of the uterus being tolerably firm and hard, a profuse +hæmorrhage is almost sure to follow the separation of the placenta. This +condition has been described by the late Dr. Gooch, and still more +recently by Professor Michaelis, of Kiel; to the former, especially, we +are indebted, not only for having first pointed out this important fact, +but for having placed it before us in the simplest and clearest light. "I +had now witnessed," says Dr. Gooch, "two labours in the same person, in +which, though the uterus contracted in the ordinary degree, profuse +hæmorrhage had nevertheless occurred: let me be understood--after the +birth of the child, I laid my hand on the abdomen, and felt the uterus +within, of that size and hardness, which is generally unattended by, and +precludes hæmorrhage; in both instances, the labour had been attended by +an excessively full and rapid circulation. I could easily understand that +a contraction of the uterus, which would preclude hæmorrhage in the +ordinary state of circulation, might be insufficient to prevent it, during +this violent action of the blood-vessels; and the inference I drew was, +that, in this case, the hæmorrhage depended not on a want of contraction +of the uterus, but on a want of tranquillity of the circulation; and that +if ever she became pregnant again, a mode of treatment which would cause +her to fall in labour with a cool skin and a quiet pulse, would be the +best means of preventing a recurrence of the accident." This will be +effected by an occasional venesection during the last weeks of pregnancy, +by the use of saline laxatives; and if there be still much disposition to +heat the surface, and excitement of circulation, by doses of nitre three +times a day, and by strict antiphlogistic regimen. + + + + +CHAPTER VII. + +INVERSION OF THE UTERUS. + + _Partial and complete.--Causes.--Diagnosis and symptoms.--Treatment.-- + Chronic inversion.--Extirpation of the uterus._ + + +The uterus is liable, although rarely, to a peculiar displacement called +inversion, where the fundus is forced down into the cavity of the uterus, +and so through the os uteri into the vagina; or where the whole uterus is +turned wrong side outwards, the fundus appearing at the os externum, the +former being the _partial_, the latter the _complete_ inversion: in the +latter it is not only the entire uterus which is inverted, but it is also +the vagina, so that the whole mass which the uterus forms at the os +externum is attached to the inverted vagina as by a hollow pedicle, and is +encircled by the os uteri close to the labia; the external surface of the +mass is the inner surface of the uterus. + +As it is impossible for the fundus to descend through the os uteri when +this is not dilated and open, it is evident that, except in certain cases +of polypus, inversion of the uterus can only take place immediately after +delivery. If, at this moment, especially when the uterus has been too +suddenly emptied of its contents, any force be applied to the fundus, it +may be easily pushed down into the cavity, or, by the continued action of +that force, the fundus may be carried through the os uteri or even through +the os externum. + +_Causes._ Where this force has been applied externally, it may be produced +by violent straining during the last pains, violent efforts, as coughing, +vomiting, sneezing, &c., or by sudden attempts to rise in bed, by which +the abdominal muscles are put into powerful action. Where, on the other +hand, it has been applied from within, it may arise from improper attempts +to extract the placenta before the uterus was sufficiently contracted; +where the cord has been unusually short, or twisted round the child, or +where the patient has been suddenly surprised with violent pains, and the +child dashed upon the floor before she could reach her bed, by which means +the cord has received a violent jerk, or has been even broken. + +It has been very much the habit to attribute inversion almost solely to +these latter causes, and that, except where it takes place from the +shortness of the cord, or the sudden expulsion of the child whilst the +mother is in the erect posture, it must almost necessarily be a result of +improper pulling at the cord on the part of the practitioner: the cases on +record, however, go to prove that, in by far the majority of instances, no +force of this sort had been applied to the fundus; and in those instances +where the child has been dashed upon the floor and the cord broken (some +six or seven of which have at different times occurred under our own +notice,) the fundus has not once been pulled down, although the force +applied to it must have been very considerable, since the very cord which +had thus given way to the weight of the child resisted afterwards, on more +than one occasion, a considerable effort which we made to break it. In by +far the majority of these cases, the cord has given way nearly at the same +spot, viz. about three inches distance from the umbilicus, apparently +justifying the inference, that it was weaker here than elsewhere. Another +reason why the fundus should not have been pulled down by the weight of +the child might be stated, viz. that the placenta being at that moment +above the brim of the pelvis, the direction in which the strain was made +upon the cord (viz. in that of the outlet, or downwards and forwards,) was +not much calculated to affect the fundus. + +"The practice of pulling too early and violently at the cord," says Dr. +Radford, "after the expulsion of the child, before the uterus has +contracted, so as to detach and expel the placenta, has been generally +considered as the cause of inversion; but we know that the accident +happens before any force has been applied to the funis. In case fourth, +the descent was so rapid and forcible through the os externum, that it +would have been quite impossible to have resisted the unnatural action by +which the organ was carried down. It has occurred when the patient was +delivered of a dead child, the funis so putrid as to break with a slight +effort. It has been found before the cord was separated, and the child +given to the nurse. In the practice of Ruysch, this circumstance took +place after he had extracted a dead child."[133] + +Still, however, it is not the less important to recommend caution, +especially to young beginners, against pulling at the cord with too much +force, in their hurry to bring the placenta away; the condition of the +uterus at this moment is highly favourable if in a state of inertia. + +_Diagnosis and Symptoms._ In cases of _partial_ inversion of the uterus, +we distinguish the disease by the absence of the hard spherical tumour of +the fundus above the pubes, and by the presence of a globular fleshy body +in the os uteri, which is sensible to the touch. This tumour will be found +broader at the base than at its extremity; and surrounded by the os and +cervix uteri, forming, as it were, a tight ring round it. The patient +complains of a sense of dragging amounting to severe pain in the groins +and lumbar region, and which compelling her to strain violently, often +forces the uterus farther down, and sometimes induces complete inversion; +hæmorrhage more or less considerable accompanies it; the pain is more +acute in this than in the complete inversion, and the hæmorrhage more +violent; the patient suffers under an oppressive sense of sinking, with +nausea or vomiting, cold clammy sweats, feeble fluttering or nearly +extinct pulse, faintings or even convulsions. + +In the _complete_ form we have neither the hæmorrhage nor that frightful +train of symptoms produced by the strangulated condition of the inverted +uterus; for now that it is fairly turned inside out, it is just, or nearly +as capable of contracting as in its natural state, which it is prevented +from doing when only partially inverted: complete inversion, however, is +not the less to be dreaded, for death may suddenly follow from the shock +which the nervous system has sustained, or from dangerous fainting in +consequence of the sudden evacuation of the abdominal cavity; this latter +circumstance will be aggravated by the inversion of the vagina which is +apt to accompany the complete form, and thus give rise to considerable +displacement of the intestine. + +_Treatment._ The sooner we endeavour to return the uterus the better, for +we shall seldom experience much difficulty in effecting our object, if +done immediately upon the occurrence of the accident; indeed, we know of a +case where, under these circumstances, it was successfully returned by a +midwife. If, on the other hand, some hours are permitted to elapse before +the attempt at reduction is made, it will be attended with great +difficulty, or even prove entirely abortive; the os uteri contracts +powerfully, the uterus swells from the obstructed return of the +circulation, inflammation rapidly follows, and diminishes still farther +our chances of success. Dr. Denman says, "The impossibility of replacing +it, if not done soon after the accident, has been proved in several +instances, to which I have been called so early as within four hours, and +the difficulty will be increased at the expiration of a longer time." +Still, however, we must not despair of success, for numerous cases have +been recorded by different authors where the reduction has been effected +after a much longer period. + +There has been a considerable discrepancy of opinion as to the management +of those cases where the placenta is still adhering to the uterus, viz. +whether it is not safer to reduce the fundus _with_ the placenta, and +excite the uterus to throw it off afterwards in the usual way, or whether +we ought not to separate the placenta before making the attempt at +reduction. Mr. Newnham, the author of almost the only monograph upon this +subject, recommends the former mode of practice. "It has been recommended +by several respectable authorities to remove first the placenta, in order +to diminish the bulk of the inverted fundus, and thus facilitate the +reduction. But it is surely impossible that this proceeding can be +attended with any beneficial consequences, whilst the irritation of the +uterus will necessarily tend to bring on those bearing down efforts, which +would present a material obstacle to its reduction; and would increase the +hæmorrhage at a period when every ounce of blood is of infinite +importance, besides returning the placenta while it remains attached to +the uterus; and its subsequent _judicious_ treatment as a simply retained +placenta will have a good effect in bringing on that regular and natural +uterine contraction, which is the hope of the practitioner and the safety +of the patient." (_Essay on the Symptoms, Causes, and Treatment of +Inversion of the Uterus_, by W. Newnham, Esq. p. 14.) + +On the other hand, many authorities, especially of modern times, advocate +a very opposite practice, and recommend that the placenta should be +removed _before_ attempting to reduce the fundus; as by so doing it will +pass back much more easily than where the bulk of the placenta is added to +it. There can be no doubt that this practice is correct in cases of +complete inversion, where, as we have already observed, there is little or +no danger from hæmorrhage, and where it is of the greatest importance to +avail ourselves of every advantage by lessening the size of the inverted +uterus as much as possible: where, however, it is a case of partial +inversion, it is generally accompanied with hæmorrhage; and here, +therefore, it becomes a question how far we are justified in detaching the +placenta, and therefore increasing the flooding, either before we are +certain that we are able to reduce the fundus, or before we have placed +the uterus in a condition in which it is capable of contracting. In Mr. +Mann's case, quoted by Dr. Radford (_op. cit._,) the inversion was +evidently complete, for the uterus was found to have "passed externally +from the vagina, and the placenta attached to it." "I first peeled the +placenta from the fundus uteri, and then grasping the extruded part with +my hand, I did not find it very difficult to re-introduce it into the +vagina, and to carry it through the os uteri. I followed with my hand, or +rather pushed it forward, when I observed it suddenly start from me as a +piece of India rubber would." + +Dr. Merriman, who candidly owns that he has altered his opinion on this +point, since the last edition of his work on difficult parturition, in +favour of removing the placenta, distinctly proves that the presence of +this mass was the chief cause of the difficulty. "I tried," says he, "to +effect the reduction without removing the placenta, but could, by no +possibility, accomplish it till I had first separated the placenta: this +being effected, I succeeded to my entire satisfaction in re-inverting the +fundus." (_Synopsis of Difficult Parturition._) + +In reducing the fundus, we must not thrust our fingers collected into a +cone against the tumour, as has been recommended by most authors; for, by +so doing, we only produce a depression in it, and, as it were, re-invert +or double the uterus upon itself, and thus add considerably to the bulk of +the mass, and the difficulty of the reduction. We should grasp the tumour +firmly, and push it bodily upwards in the direction of the pelvic outlet: +at first little or no change is produced, until it has ascended so far, +that the vagina which had been dragged down is returned again to its +natural situation; the hand must follow the tumour, and now that the lower +part of the uterus is fixed, by the vagina being put upon the stretch, the +pressure which is applied to the fundus will act with so much greater +effect. We should endeavour to "return, first, that portion of the uterus +which was expelled last from the os uteri." (Newnham, _op. cit._ p. 616.) +As the hand rises into the cavity of the pelvis, and is no longer able to +grasp the tumour, so far from contracting the points of our fingers into a +cone, it will be desirable to spread them at equal distances round it, and +thus apply the pressure over a larger space: it was to attain this object +that Leroux recommended the application of a cloth to the fundus, as by +this means the force applied to it was more equally divided. (_Sur les +Pertes de Sang_, § 218.) The hand, however, will be far preferable. We +must gradually alter the direction in which we press up the tumour as it +ascends, guiding our hand in the axis of the pelvic cavity, and lastly +bringing it upwards and forwards in that of the superior aperture. When +once the fundus has repassed the os uteri, it usually recedes suddenly +from the hand, as already described in Mr. Mann's case: if we feel the +uterus through the abdominal parietes well contracted, there will be no +need of passing the hand into its cavity; but if it be still flaccid and +soft, the hand should be introduced, not only for the purpose of guarding +against any return of the inversion, but of exciting more active +contractions by its presence. The patient should avoid making any sudden +efforts to raise herself, or to cough, strain, or by any means excite the +abdominal muscles to exert pressure upon the fundus, for it is +occasionally observed, that the disposition to inversion continues some +time after the reduction has been effected. + +Where some little time has elapsed before any attempt is made to reduce +the fundus, the inverted portion begins to swell from obstruction to the +return of blood, especially where the inversion is partial, and, +therefore, tightly girded by the os uteri; the passages grow hot and dry, +and the chances of reducing the tumour diminish in proportion. "Is it not +reasonable," as Mr. Newnham observes, "to suppose that the first effect of +the accident will be to bring on inflammatory action and tension of the +parts, and this very state will in itself be a sufficient obstacle to +success." (_Op. cit._ p. 18.) If, under these circumstances, we find that +the attempts at reduction is attended with considerable difficulty, or is +evidently impossible, it will be necessary to wait until the excitement of +the circulation, and the congestion and swelling of the parts are reduced, +and the passages duly relaxed by bleeding; besides this, the external +parts should be well fomented, the patient should use the warm hip bath, +or sit over the steam of hot water, and throw up emollient and sedative +enemata as recommended in our treatment of inflammation of the uterus; the +operation, which was during the state of inflammation and feverish +excitement in which the patient was, strongly contra-indicated, now +becomes practicable and safe, and the difficulties, which before would +have rendered it nearly or quite impossible, are now in a great measure +removed. + +Wherever the uterus is completely inverted, and there is reason to expect +considerable difficulty in reducing it, we shall find great benefit in +adopting the mode of practice recommended by Mr. C. White, of Manchester, +viz. of firmly grasping the tumour until we have succeeded in considerably +diminishing its size, and thus removing the chief obstacle to its +reduction. "I grasped the body of it in my hand," says Mr. W., "and held +it there for some time, in order to lessen its bulk by compression. As I +soon perceived that it began to diminish, I persevered, and soon after +made another attempt to reduce it, by thrusting at its fundus; it began to +give way. I continued the force till I had perfectly returned it, and had +insinuated my hand into its body: it was no sooner reduced, than the pulse +in her wrist began to beat: she recovered as fast as we could wish." +(White, _on Lying-in Women_, case, 19. Appendix, p. 429, 2d edit.) + +Where the fundus is partially inverted, and the os uteri girds it very +tightly, so as not only to produce very frightful symptoms arising from +the strangulated condition of the organ, but also to render its reduction +a matter of great difficulty, or even impossibility, Dr. Dewees has +advised that, so far from attempting to push up the fundus, we should +rather try to bring it down, and thus render the inversion complete; by +this means, the "pain, faintness, vomiting, delirium, cold sweats, +convulsions, extinct pulse," &c. will not only be relieved, but the +farther danger from hæmorrhage prevented. + +"The propriety and safety of this plan is, it must be confessed, +predicated upon the happy result of a solitary case, but, from its entire +and speedy success in this instance, it is rendered more than probable +that it will be of equal advantage if employed in others; "all reasoning +upon the subject" is certainly in its favour; and experience, so far as a +single case may be entitled such, is equally so. The patient is to be +placed upon her back near the edge of the bed, and have her legs supported +by proper assistants; the hand is to be introduced along the interior +part of the vagina, but sufficiently high to seize the uterus pretty +firmly; it is then to be drawn gently and steadily downward and outward, +until the inversion is completed: this will be known by a kind of jerk, +announcing the passing of the confined part through the stricture. +Traction should now cease, and the part be carefully examined; if the +inversion be complete, the mouth of the uterus will no longer be felt, and +there will be an immediate cessation of pain and other distressing +sensations." (Dewees, _Compendious System of Midwifery_, § 1318.) + +_Chronic inversion._ Where some time has already elapsed since the +occurrence of the accident, and the more distressing symptoms have +subsided, the inversion now passes into a chronic state, which, although +not immediately dangerous to life, will ultimately be not less fatal. The +form of the tumour gradually alters; it assumes a more polypoid shape, +from the increasing contraction of its mouth narrowing the upper part of +it; and now the diagnosis from polypus sometimes becomes exceedingly +difficult, the more so as the pressure produced by the os uteri diminishes +the sensibility of the fundus. Hence, as Mr. Newnham observes, we may +conclude, "that it is _always difficult_ and _sometimes impossible_, with +our present knowledge, to distinguish _partial and chronic inversion of +the uterus from polypus_; since, in both diseases, the os uteri will be +found encircling the summit of the tumour, and, in either case, the finger +may be passed readily around it. And if, in order to remove this +uncertainty, the entire hand be introduced into the vagina, so as to allow +the finger to pass by the side of the tumour to the extremity of the space +remaining between it and the os uteri; and if we find that the finger +_soon arrives_ at this point, it will be impossible to ascertain whether +it rests against a portion of the uterus which has been inverted in the +_usual way_, or by the long-continued dragging of the polypus upon its +fundus. And if, under these embarrassing circumstances, we call to our +assistance our ideas concerning the _form of polypus_, its enlarged base +and narrow peduncle, we must also recollect the abundant evidence to prove +that the neck of such a tumour is often as large, and sometimes larger, +than its inferior extremity, and we shall still be left in inexplicable +uncertainty." + +The periodical hæmorrhages, with profuse leucorrhoea during the intervals +are too common, both to chronic partial inversion and to polypus, to +afford any certain means of diagnosis; and the gradually increasing +debility, from the constant drain upon the system and ultimate breaking up +of the general health, may be as much the result of the one as of the +other. The rugged uneven surface of the inverted uterus, the smoothness of +a polypus, are distinctions not of long continuance; for, after awhile, +the uterus gradually becomes smoother, whereas, a polypus rarely +continues long in the vagina without its surface becoming irregular from +ulceration. + +It might be a question whether it would not be possible to detect the +menstrual fluid at the catamenial periods oozing from the surface of the +inverted uterus: that this is quite possible in cases of complete +inversion, is a well-known fact, but how far it can be detected in the +partial form is not so certain, as the position of the tumour pretty high +up in the vagina would prevent our ascertaining it, especially when there +is more or less hæmorrhage going on. In most cases, the history of the +case, and our not being able to pass up a catheter far beyond the os +uteri, which completely surrounds the neck of the tumour without adhering +to it, are the chief points upon which we must found our diagnosis. + +"Whilst the inverted uterus remains in the vagina, the discharge +(excepting at the periods of menstruation) will be of a mucous kind; but +if the uterus falls lower, so as to protrude beyond the external parts, +the exposure of that surface, which in a natural state lined the cavity, +to air, as well as to occasional injuries, may induce inflammation and +ulceration over a part or the whole of its surface; and the mucous +discharge may be changed to one of a purulent kind, so considerable in +quantity as to debilitate the constitution, and to cause all the common +symptoms of weakness." (Sir C. M. Clarke, _on the Diseases of Females_, +part i. p. 155.) + +Although such a length of time has elapsed since the inversion, that it +has become of the chronic kind, still we are not justified in giving up +all hopes as to the possibility of returning it. Dr. Churchill has given +an interesting summary of cases where many days, and in one case even +twelve weeks, had intervened, and yet, nevertheless, where the reduction +was successfully effected. (_On the Principal Diseases of Females_, p. +331.) We may also add two very remarkable cases related by Boyer (quoted +by Kilian,) viz. where the uterus had resisted every endeavour to reduce +the inversion, which in one case had remained fourteen days, in the other +more than eight years, and where, in consequence of a sudden and violent +fall upon the nates, reduction followed spontaneously and permanently. + +_Extirpation of the uterus._ Where, however, the powers of the system are +rapidly breaking, from the profuse hæmorrhages at each menstrual period, +and not less profuse discharge during the intervals, the only means of +saving the patient is by treating the case as one of polypus, or in other +words, removing the uterus by ligature. Numerous cases are on record where +this has succeeded perfectly, although during the process the patient +suffered from several attacks of pain and even inflammation, occasionally +requiring the ligature to be loosened for awhile. In the case recorded by +Mr. Newnham, rather more than three weeks were required before the +separation of the tumour was effected. When once this source of irritation +is removed, the hæmorrhage and other discharges which had so greatly +reduced the patient cease, and, as in cases of polypus, a most striking +and favourable change is produced, the health and strength return, and the +recovery of the patient is complete. + + + + +CHAPTER VIII. + +ENCYSTED PLACENTA. + + _Situation in the uterus.--Adherent placenta.--Prognosis and + treatment.--Placenta left in the uterus.--Absorption of retained + placenta._ + + +By the term _encysted_ placenta, we mean that state of irregular uterine +action after the expulsion of the child, where the lower portion of the +uterus, particularly the os uteri internum, is closely contracted, while +the fundus contains the placenta enclosed in a species of _cyst_ or cavity +formed by itself and the body of the uterus. + +Upon examination externally, we find the fundus pretty firmly contracted, +but probably somewhat higher up the abdomen than usual; the vagina and os +uteri externum, or os tincæ, are usually found dilated, the passage +gradually tapering like a funnel to the os uteri internum, or upper end of +the canal of the cervix. + +_Situation in the uterus._ This state has been very generally considered +to arise from a spasmodic contraction in the circular fibres of the body +of the uterus, by which it was as if tightly girded by a cord at its +middle, and, from the form it was supposed to take, was called _hour-glass +contraction of the uterus_. + +From the observations of later years there is much reason to suppose that +the true hour-glass contraction, as now described, is of very rare +occurrence, even if it does take place at all; and that, in by far the +majority of cases, the stricture is either produced by the upper part of +the cervix, as we have already mentioned, or resides in the os uteri +externum or inferior portion of the cervix. + +Baudelocque was the first who pointed out the neck of the uterus as the +real seat of the stricture in these cases: "that circle (says he) of the +uterus which is round the child's neck, according to the general laws of +its contraction, must narrow itself much quicker after delivery than the +other circles which compose that viscus, because it is already narrower, +and its forced dilatation at the instant of the expulsion of the child's +trunk is only momentary, and because it has naturally more tendency to +close than the other circles have, since it is that which constitutes the +neck of the uterus in its natural state." (Baudelocque, _Heath's Trans._ +vol. ii. § 969.) + +Dr. Douglas, of Dublin, also investigated this subject, and came to a +similar conclusion: he considered that encysted or incarcerated placenta +from hour-glass contraction, resulted either from morbid adhesion of the +placenta, or from inactivity of the uterus, and does not occur as a +primary affection; his observations lead to the conclusion that the +stricture in hour-glass contraction "does not form from the middle +circumference of the uterus; it is formed by the lowest verge of its +thickly muscular substance, at the line of demarcation of its body and +cervix." "Thus, then, it would appear that the upper chamber comprises in +its formation the entire of the body of the fundus; whilst the lower +chamber engages only the cervix uteri and the vagina." (_Medical +Transactions of the Col. of Phys._ vol. vi. p. 393.) + +The late W. J. Schmitt of Vienna considered that the stricture was +produced by the os tincæ, or os uteri externum. + +From our own experience we would say that the seat of the stricture varies +considerably in different cases; that in the simplest form it is nothing +more than a contracted state of the os uteri externum; that in others it +is formed by the upper portion of the cervix uteri, or os uteri internum; +but in other instances it appears to be formed by the inferior segment of +the uterus itself. The contraction in this part of the uterus, which, +according to the observations of Professor Michaelis, comes on when the os +uteri is fully developed, and, by closely surrounding the head, is one +chief means by which prolapsus of the cord is prevented, may easily +produce a state of stricture after the birth of the child, and thus retain +the placenta; it may, however, be questioned whether this portion of the +uterus, when fully dilated by pregnancy, and which then forms its inferior +segment, would not become the os uteri internum when the uterus is empty +and contracted. + +Hour-glass contraction of the uterus is liable to occur where the action +of the uterus has been much deranged or exhausted, either by the unusual +rapidity or excessive protraction of the labour. In all cases where the +child has been rapidly expelled before the uterus has had time to contract +regularly and uniformly, the disposition in the os uteri to contract, as +pointed out by Baudelocque, will manifest itself. This state may also be +induced by great previous distention, as from twins, or too much liquor +amnii; by irritation, as by improperly pulling at the cord, by having used +too much force in artificially delivering the child, by the introduction +of the hand or instruments too cold, &c. The most frequent cause, however, +is over anxiety to remove the placenta; the cord is frequently pulled at, +and at length the os uteri is excited to contract; in this case we +generally find the stricture at the os tincæ, which yields without much +difficulty, either by gentle friction with the hand over the fundus, and +cautiously pulling the placenta in the axis of the superior aperture, or +by introducing the hand and bringing it away. + +_Adherent placenta._ When the placenta is still attached either wholly or +in part, there are generally some preternatural adhesions to the uterus, +which, by keeping its upper portion distended, give rise to partial +contractions below. This condition of the placenta is observed to attend +nearly every severe case of hour-glass contraction; in some instances its +whole surface appears as if grown to the uterus, forming an adhesion so +close and intimate as to be overcome with the greatest difficulty: we have +met with cases where the placenta tore up into shreds which still adhered +to the uterus as strongly as before; in others, however, the adhesions are +of smaller extent, varying from the size of a shilling to that of a crown +piece, sometimes there being only one, sometimes two or three in the same +placenta. + +The nature of these adhesions is but little understood; it is generally +considered that they have been produced by some inflammatory process +taking place between the uterus and placenta; and certainly the firm feel +and lighter colour of the part which has been adherent might, perhaps, +justify such a conclusion. Cases have occurred where the inflammatory +action has extended in the contrary direction (outwards,) producing +mischief in the neighbouring parts, viz. abscess and injury of the pelvic +periosteum with subsequent pelvic exostosis. (_Neue Zeitschrift für +Geburtskunde_, band v. heft 1.) We may also observe, that these adhesions +of the placenta usually occur several times in the same individual. + +_Prognosis and treatment._ The danger in these cases depends chiefly on +the presence or absence of hæmorrhage; in the latter case, we may wait +safely, and give the uterus the opportunity of contracting upon the +placenta, so as ultimately to dilate the stricture and expel it. In most +instances, where the os tincæ is the seat of the contraction, and the +placenta (as is usually the case here) already detached, a little +patience, aided by gentle friction of the fundus, and carefully abstaining +from all irritation of the os uteri, will be sufficient to attain this +object; the os uteri will gradually relax and the placenta slowly exude +into the vagina. Where, from the feel of the fundus, the uterus appears +still unable to exert such a degree of contraction as shall overpower the +os uteri, we may follow the plan of Dr. Dewees, in his section "On the +enclosed and partially protruded Placenta," and rouse its activity by some +doses of ergot: "should this not succeed within an hour, the uterus must +be gently entered, by slowly dilating the os uteri, and the placenta +removed." One finger after the other must be passed through the os uteri, +until it has yielded sufficiently: if the placenta be quite detached, two +fingers will generally be sufficient for this purpose, by which means it +may be gradually brought down into the palm of the hand, and then removed. + +Where more or less of it is morbidly adherent, which may be presumed when +it continues for some time at the upper part of the uterus without any +disposition to descend, we must carefully introduce the whole hand, and +endeavour to find the edge of the placenta at which we should begin the +process of separation. Where, however, the edge is very thin, and the +attachment firm, it is not easy to effect this without risk of injuring +the structure of the uterus itself with the nails, nor can we always +distinguish the thin and closely adherent edge of the placenta from the +uterus itself: in these cases it will be safer to plunge the fingers into +the central and thicker portions of the mass, and gradually separate it +towards the circumference. Wherever this close adhesion prevails over a +considerable extent, it becomes nearly impossible to prevent portions +being left adhering to the uterus; thus it not unfrequently happens, where +a placenta under these circumstances has been artificially removed, that +there are one or more large irregular cavities on its uterine surface, +from a portion of its mass having been torn from it, and left adhering. +Cases have occurred to us,[134] where the whole central portion has thus +remained, the amniotic surface of the placenta having come away entire +with the larger umbilical vessels attached to it, and merely a narrow +margin of parenchyma at its edge; in others, the whole mass has broken up, +the cord, the larger branches of the umbilical vessels, and the membranes +have come away, but the greater part of the placenta has remained closely +adhering to the uterus. In such a case it becomes a question, whether it +be safe to persist in our efforts to remove the remains of the placenta, +or whether it will not be better to leave the case to nature: experience +shows that the latter plan is the safer, and that a practitioner is not +justified in running the risk of severely injuring the uterus by repeated +and violent efforts to effect his object. + +_Placenta left in the uterus._ Where a portion of placenta has been thus +left in the uterus, the case may terminate in one of three ways: either it +may be expelled in the course of from twelve to twenty-four hours, without +any perceptible marks of putrefaction, and with but little or no +disturbance to the system; or where, after a longer interval, the +discharges have become very offensive, and the placenta has been expelled +in a putrid state, with serious disturbance of the health; or lastly, +where the lochia has been sparing but natural, and where no trace +whatever of the placenta has appeared. + +In the first mode of termination it may be presumed that the attachment of +the placenta has yielded either to the continued contraction of the +uterus, or from a slight degree of incipient putrefaction, by which its +union with the uterus was weakened; in the second case, from contact with +the external air, and being constantly kept at a considerable temperature +by the heat of the surrounding parts, the lacerated placenta rapidly +putrefies, putrid matter is carried into the system, producing all the +effects of a deadly poison, and the patient is placed in a state of the +greatest danger; the pulse becomes quick and small, the tongue red and +dry, accompanied with great depression of the vital powers, the uterus +frequently swells, grows hard, and excessively painful, followed by +general peritonitis; it is not, however, the inflammation which +necessarily destroys the patient, but the prostrating effects upon the +nervous system, produced by the introduction of an animal poison into the +circulation. + +_Absorption of retained placenta._ Where the placenta has not been much +lacerated, or at any rate where every portion has been removed which could +be separated without violence, where also the uterus has contracted firmly +and closely, the part which is retained does _not_ pass into putrefaction, +little or no inconvenience is experienced by the patient; the lochia, as +we before observed, is sparing but natural, and ceases after the usual +time, but not a trace of the placenta comes away. This fact has been +repeatedly noticed, especially in later years; but the attention of +medical men was first called to the subject by Professor Naegelé, of +Heidelberg, in 1828. In 1802, and again in 1811, cases of premature +expulsion of the foetus occurred to him where the membranes and placenta +did not come away, and where no trace whatever of them appeared +afterwards. In 1828[135] his assistance was required in a case of +unusually firm adhesion of the placenta, and where, from this as well as +other circumstances, the extraction was so difficult that he was compelled +to leave considerably more than one-third in the uterus. (_Med. Gaz._ Jan. +10, 1829.) About the same time, a most interesting case was published by +Professor Salomon, of Leyden, where the _whole_ placenta of a child only +three weeks short of the full time was retained by the firm contraction of +the uterus, and, according to Dr. Salomon's view of it, removed by the +process of absorption. About the end of the third week, the uterus, which +had hitherto been larger than is natural under ordinary circumstances +after labour, and more globular, now diminished considerably, and began to +assume the usual form as in the unimpregnated state. Besides the cases +already alluded to, which we have described in our Midwifery Hospital +Reports, we may again refer to one which was mentioned by Dr. Young, +formerly professor of Midwifery at Edinburgh: "I could get my hand to the +placenta, but no farther, the uterus having formed a kind of pouch for it, +so that I at last was obliged to trust to nature; _what was very +remarkable, the placenta never came away_, yet the woman recovered." + +Cases have also occurred where the placenta, after having been retained +many days in the uterus, has been expelled quite fresh, the edges worn or +rather dissolved away by the process of absorption; thus Dr. Denman +mentions one where the whole placenta was retained till the fifteenth day +after labour, and was then expelled with little signs of putrefaction +except upon the membranes, the whole surface which had adhered exhibiting +fresh marks of separation. Cases of abortion have occasionally been +observed where the embryo has escaped, but the secundines have never come +away, although the discharges, &c., have been watched with the greatest +attention; after a time the menses have returned, the patient has again +become pregnant, and has passed through her labour at the full term +without any thing unusual occurring. + +The subject has recently been considered very fully, and much interesting +knowledge added, by Dr. Villeneuve, of Marseilles. Besides putting the +fact beyond all doubt, he shows that cases of total adhesion are rarely if +ever fatal; and that, where cases have terminated fatally, the placenta +has only partially adhered, and the patient has been either destroyed by +hæmorrhage, or by the effects arising from the absorption of putrid +matter, or from injury of the uterus in attempting to remove the placenta. +He considers that a placenta which is not fixed to the uterus by organic +and intimate adhesions cannot be absorbed, though it may perhaps be +retained for several days without danger, if there is contraction of the +uterus. (_Gazette Médicale de Paris_, July 8, 1840.) It may, however, be +doubted whether this last observation be correct, as it is a +well-established fact that cows which had been supposed with calf, and in +which the symptoms of pregnancy had again subsided, have afterwards been +killed and nothing but the bones of the calf found in the uterus, the soft +parts having been removed by absorption. The same fact has been observed +also in sheep and other animals; and knowing how abundantly the human +uterus is supplied with absorbents, coupled with what has been already +stated, there can be little or no doubt but that the placenta in these +cases had been acted upon by a similar process. Although we strongly +deprecate repeated attempts to remove the adherent portions of placenta, +especially where we have brought away a considerable quantity of its +foetal part, still we would warn our readers against leaving any loose +ragged pieces in the uterus, for these rapidly pass into putrefaction, and +produce the alarming symptoms above-mentioned. The safety of our patient +mainly depends on the firm contraction of the uterus preventing the access +of air, and on our constantly removing, by means of injections, any putrid +discharge which may have collected. The sparing quantity of lochia which +has generally been observed, especially where the _whole_ surface of the +placenta has adhered, can easily be accounted for, the greater portion of +the vessels which ordinarily furnish this discharge being closed up by the +adherent mass: from the same reason we can explain why cases of total +attachment of the placenta are rarely or never attended with hæmorrhage. + +Lastly, should any symptoms of fever or abdominal inflammation supervene, +they must be treated according to the rules which we have given under +these heads.[136] + + + + +CHAPTER IX. + +PRECIPITATE LABOUR. + + _Violent uterine action.--Causes.--Deficient resistance.--Effects of + precipitate labour.--Rupture of the cord.--Treatment.--Connexion of + precipitate labour with mania._ + + +The second division of Dystocia comprises those species of labour where it +becomes dangerous for the mother or child, without obstruction to its +progress. Of these we shall first consider precipitate or too rapid +labour, not only because it is liable to be followed by a great variety of +injurious results, but also because it has received little or no notice by +the obstetric authors of this country. + +Precipitate labour depends on one of two conditions; either the expelling +powers exceed their ordinary degree of activity, or the resistance to the +passage of the child is less than usual. "Every normal labour has a +certain course, which is neither too slow nor too quick. The passages are +thus dilated gradually and without excessive suffering; the uterus is felt +alternately hard and soft; and the pains have certain and regular +intervals, which become very gradually shorter, during which both mother +and child are enabled to recover themselves." (Wigand, _Geburt des +Menschen_, vol. i. p. 68.) + +_Violent uterine action._ In the present case the pains are extremely +violent from the very commencement of the labour; they produce great +suffering; each pain lasts a considerable time, and the intervals between +them are very short. During their presence, the patient is irresistibly +compelled to bear down and strain with all her force; the whole body +partakes of the general excitement: the patient is more restless and less +manageable than usual, her manner is altered and becomes strange; the head +is hot, the face flushed, and the pulse quick and full. + +In some cases the intervals between the pains are scarcely perceptible, +for one pain has scarcely left off before the next has already commenced; +or the uterus falls into a state of continued violent contraction, which +does not cease until the child is driven into the world. The abdomen is +very hard during the pain, the whole body stiff and rigid; the patient +expresses her sufferings very loudly, or actually raves with pain. From +the constant and irresistible effort to strain, it seems as if she has +scarcely time to get her breath, for she continues to hold it so long that +respiration might be almost supposed to have stopped altogether. "As long +as consciousness remains, the impulse to lay hold of any object within +reach and pull by it is extraordinarily strong, until at length, in the +midst of a violent scream, or grinding of the teeth, covered with sweat +and with simultaneous evacuation of the rectum and bladder, she is +suddenly delivered." (Wigand, _op. cit._ vol. i. p. 71.) + +_Causes._ This storm of uncontrollable uterine action "appears to depend +upon an unusually powerful influence of the nervous system upon the +contractile fibres of the uterus or upon a morbid degree of irritability." +(_Ibid._) In some cases it appears as an individual peculiarity, every +successive labour of the patient being remarkable for its violence and +rapidity. Precipitate labours of this kind are frequently observed to be +hereditary, and like an opposite and equally faulty condition of the +expelling powers, viz. slow and lingering uterine action, are sometimes +peculiar to certain families, the mother and the sisters of the patient +having had all their labours peculiarly rapid and violent. + +The character of the catamenial periods before pregnancy is frequently +observed to bear a considerable relation to that of the labours in the +same individual; thus, if she has always suffered much pain and other +symptoms of uterine excitement just before or during these times, so much +so as even to require slight medical treatment to allay the periodical +suffering, the uterus almost invariably manifests a similar degree of +energy and irritability during labour. On the other hand, where the +menstrual periods produce so little suffering or derangement that, but for +the appearance of the discharge itself, the patient has scarcely any means +of determining their recurrence, the uterus betrays a similar want of +activity when labour comes on, which may therefore, _cæteris paribus_, be +expected to be slow and lingering. + +Mental affections, which we have already shown to be capable of retarding +labour, occasionally have the opposite effect, and rouse the uterus to +violent action. It is well known that the dread of the forceps, which the +practitioner has declared would be required, has frequently been followed +by so much activity of the uterus as to render its application +unnecessary. + +Where the patient is stout, robust, and plethoric, or of a nervous +hysterical habit, this state of unruly uterine action is frequently +attended with great cerebral excitement; during the pains she raves +wildly, and for some time becomes quite unmanageable, or in other cases +this state passes into actual convulsions. + +In febrile diseases, especially of the eruptive kind, the labour is +usually of this character; the exertions of the uterus in such cases, +especially in scarlet fever, are sometimes quite extraordinary, so that +the child seems to be born without any effort on the part of the mother. +This is of great importance in inflammation of the lungs, &c. where the +patient would be unable to inflate the lungs to that extent which is +necessary for any violent efforts. + +_Deficient resistance._ Where the rapidity of the labour arises from want +of that degree of resistance to the expelling powers which is natural, it +may depend on circumstances connected with the mother or the child; thus, +it may arise from too large a pelvis; the head, covered by the inferior +portion of the uterus, is forced down deeper into the pelvis than usual, +especially if, as is not unfrequently the case, this state be accompanied +with violent and powerful pains; the head may thus be actually forced +through the os externum before it has passed the os uteri: cases have been +recorded where nearly the whole uterus, has been thus protruded. In an +"extraordinary case," as Deventer justly terms it, "the head of the child +had passed the os externum as far as the shoulders, and only the summit of +it was visible, three-quarters at least of the head being still enclosed +in the uterus, although the head and neck had already passed." (_Novum +Lumen_, part. ii. chap. 3.) + +In other cases the sudden expulsion of the child appears to depend merely +upon the great dilatability of the soft parts, and may occur quite +independently of any disease. We recollect a case of this sort where the +patient, a healthy woman, had only two pains--the first awoke her out of a +sound sleep and ruptured the membranes, the next drove the child with +great violence into the bed. Where the patient is weakened by previous +disease, and the soft parts are very relaxed and flaccid, they produce no +resistance to the advance of the head: this condition is very +unfavourable, "as it implies a greater state of relaxation, or want of +tone, than is compatible with the welfare of the patient: hence it is +seldom found to take place except when the unfortunate subject is sinking +under the last stage of debility, as in phthisis," &c. (Power's +_Midwifery_, p. 138.) + +The want of due resistance to the expelling powers may depend upon the +size and hardness of the head; it is either smaller than usual, from the +child being premature, or, if of the full size, the cranial bones are +imperfectly ossified, the sutures are wide, the fontanelles large, and the +whole head very yielding and soft; or it may depend on some congenital +defect, in which the brain and cranial coverings are more or less +imperfect. + +In the ordinary cases of precipitate labour the case depends generally on +a complication of violent pains, wide pelvis, and small child. + +_Effects of precipitate labour._ Besides the mischief which may result +from the rapid expulsion of the child causing prolapsus uteri, laceration +of the vagina, perineum, and hæmorrhage from inertia coming on in +consequence of the uterus being so suddenly emptied, dangerous syncope, +or even asphyxia, may follow from the shock which the nervous system has +sustained, or in consequence of the sudden removal of that degree of +pressure which the gravid uterus had exerted upon the abdominal +circulation during pregnancy. Where the patient has been very unruly, and +has exerted herself with great violence, "emphysema of the face and neck +(says Dr. Reid) may suddenly occur during labour, and cause great alarm to +a young practitioner, as it alters and disfigures the countenance in an +extraordinary manner. Great straining or screaming may produce it, and it +probably depends on some partial rupture of the lining membrane of the +larynx. I have seen two or three cases of this description, and one which +occurred to a great extent in the case of an out-patient of the General +Lying-in Hospital, in whom this tumefaction spread to the shoulders and +chest." (_Manual of Pract. Midwifery_, by James Reid, M. D. p. 231.) + +The _child_ also may suffer from a precipitate labour, where the pains are +excessively violent and run into each other, so that the whole labour is +effected during one continued storm of uterine action. If the membranes +have given way at an early period, so that the body of the child is +exposed to the immediate pressure of the pains, the abdominal circulation +suffers, and the child is destroyed in the same way as by pressure on the +cord itself; or it may be suddenly dashed upon the floor before the mother +has had time to reach her bed, or even put herself in a recumbent posture +upon the floor: in this way it may receive a severe injury upon the head, +or the cord may be lacerated, and the child die from hæmorrhage before +assistance can arrive: such accidents, however, are not so dangerous to +the child as have been supposed, a fact which has been proved by +medico-legal investigations. The direction of the pelvic outlet and vagina +is such as to expel the child obliquely downwards and forwards when the +mother is in the upright posture, so that the force of the blow is in a +great measure broken by this circumstance; the head also, as well as the +other parts of the body, are soft and yielding, and nearly preclude the +chances of injury taking place; the violence of the fall is generally +diminished in some measure by the patient being almost always compelled to +drop upon her knees at the moment of great suffering, whilst the child is +passing; her clothes also surround it more or less, and thus shield it +from any severe injury. + +_Rupture of the cord._ The cord is liable to be torn in these cases, +showing that a considerable jerk had been applied to it, but neither the +child nor its mother have suffered from it. Ten or twelve cases of +ruptured cord have come to our own immediate knowledge, and in none of +them were any unfavourable effects produced. It can scarcely be imagined +possible that so much force could be applied to the cord, at the moment +when the uterus is so suddenly evacuated, without inversion or prolapsus +being the almost unavoidable result, the more so when we recollect that +the cord at the moment of birth requires considerable force to break it. +This circumstance may be partly attributed to the firmness with which the +uterus contracts at the moment that the child is expelled, but chiefly to +the fact that the axis of the brim is nearly at right angles with that of +the outlet, more especially if the fundus, as is usually the case, is +inclined somewhat forwards; the cord passes round the posterior part of +the symphysis pubis as upon a pulley, so that a considerable portion of +the force which is applied to it, is spent here before reaching the fundus +uteri. It is however remarkable, that the umbilicus of the child should +receive no injury from a jerk which breaks the cord, when, if we try +afterwards to break the remaining pieces of the cord, we find that it will +resist very powerful efforts: this fact, and the circumstance that the +cord usually ruptures at about two or three inches from the umbilicus, as +in some animals, seems to imply that this part is weaker than elsewhere, +as if intended by nature to give way with a moderate degree of force. + +Wigand considers that patients are particularly disposed to have quick +labours, who are of a scrofulous, rheumatic, or arthritic diathesis; that +such patients are very liable to have adhesion of the placenta after the +birth of the child, with hour-glass contraction: the observation, however, +has not been confirmed by the experience of others, and certainly not by +the cases which have come under our own notice. + +_Treatment._ Where, from the smallness of the child or unusual size of the +pelvis, the pains are forcing the lower portion of the uterus down to, or +through, the os externum, it will be necessary to support it carefully, +until the os uteri is sufficiently dilated to let the head pass. A case of +this kind occurred to Professor Naegelé, of Heidelberg, where, during the +patient's former labour, the pains had been so violent, and the uterus had +been detruded to such an extent, that actually the lower half of it +appeared between the labia: to prevent a similar accident occurring this +time, (as the pains were beginning to show the same disposition to violent +action as before,) he applied a broad T bandage very firmly upon her, +coming over the os externum, so as to prevent the uterus being prolapsed +beyond the labia; he cut a hole in it corresponding to the vagina, and the +child was born through this with perfect safety to the mother. + +Where we have sufficient warning, opium in effective doses will probably +assist in lulling the irritability of the uterus: if the bowels have been +previously well opened, an opiate enema will be desirable; if not, a large +emollient enema should be premised. + +The patient should be made to lie upon her side, and not only strictly +forbidden to resist to her very utmost, the urgent impulse which she feels +to strain and bear down, but must carefully avoid even holding by or +pushing against any fixed body with her hands or feet. Still farther, to +quiet the turbulence of the abdominal muscles, a broad bandage should be +fastened firmly round the abdomen; it not only gives the patient a +comfortable feeling of support, but tends greatly to calm the spasmodic +irritability of these muscles. These precautions will be of so much more +service if they can be used early, as in cases where we have been already +warned by the character of her previous labours: we can thus avoid the +premature rupture of the membranes, which is a thing by all means to be +avoided; the uterus acts with increased power where its bulk has been +diminished by the escape of the liquor amnii, and at the same time becomes +still more irritable and unruly from contracting immediately upon the +child; and not only is there imminent danger of its giving way in some +part, but the child is almost inevitably destroyed by the violence of the +pressure to which it is exposed. + +In cases where the vehemence of the expelling powers appears to be quite +beyond our control, Wigand has recommended a copious bleeding to complete +syncope as the only means; in which suggestion, he has been followed by +Froreip: neither of these authors, however, appear to have had any +experience of this mode of treatment, and knowing how much more active the +uterus becomes after a smart bleeding in ordinary cases, and how +powerfully the state of syncope promotes the dilatability of the soft +parts, we should hesitate exceedingly to employ so doubtful a remedy. +Wigand also proposes, in cases of this desperate nature, to use effusion +with ice-cold water to the abdomen and lower extremities, and by this +powerful species of counter-irritation, produce a temporary calm for a few +minutes--a measure we should fear of as doubtful a character as bleeding. + +_Connexion of precipitate labour with mania._ Lastly, we may observe, that +the subject of precipitate labour involves a medico-legal question of +great importance and interest, which has as yet excited little or no +notice in this country, viz. as regards acts of child-murder after labours +of this character. The state of mental excitement and frenzy into which a +patient is brought, by a labour of such violence and suffering, in many +cases falls little short of actual mania. We now and then meet with +instances, where, for the first half hour or so after a severe and rapid +labour, the patient takes a most insurmountable antipathy to her child, +and expresses herself towards it in so unnatural a manner, as to contrast +strangely with the tender and affectionate feelings which she had a short +time previously expressed for it. Cases have occurred where the patient +has been without assistance, during labour, and where, in a state of +temporary madness from mental excitement and pain at the moment of the +child's birth, she has committed an act of violence upon it, which has +proved fatal; a circumstance, which, from obvious reasons, would be more +liable to occur with single than with married women. These cases have been +very carefully investigated in Germany of late, and in many of them the +patient has been, we think, very properly acquitted, on the grounds of +temporary insanity, having herself voluntarily confessed the act with the +deepest remorse, at the same time declaring her utter incapacity to +account for the wild and savage fury which seized her at the moment of +delivery. + + + + +CHAPTER X. + +PROLAPSUS OF THE UMBILICAL CORD. + + _Diagnosis.--Causes.--Treatment.--Reposition of the cord._ + + +Although by no means a common occurrence, it every now and then happens +that a portion of the umbilical cord falls down between the presenting +part of the child and the mother's pelvis either just before or during +labour; so that, as the child advances through the passages, its life is +placed in imminent danger from the pressure to which the cord is exposed, +obstructing the circulation in it. + +There is probably no disappointment, which the accoucheur has to meet with +more annoying than a case of this kind; every thing has seemed to promise +a favourable labour; the presentation is natural, the pains are regular, +the os uteri is dilating readily, the mother, and, as far as we can +ascertain, her child, are in perfect health, and yet because a minute loop +of the cord has fallen down by the side of its head, the labour, unless +interfered with by art, will almost necessarily prove fatal to it. + +_Diagnosis._ If the membranes be not yet ruptured, we shall probably be +able to feel a small projecting mass like a finger, close to the +presenting part, and possessing a distinct pulsation, which, from not +being synchronous with the mother's pulse, instantly declares its real +nature. When the membranes give way, more of the cord comes within reach, +and probably forms a large coil, which passes through the os uteri into +the vagina, or even appears at the os externum. + +_Causes._ The earliest writer that we know of who has given a detailed +account of cord presention was Mauriceau; few, even in hospital practice, +and certainly none in private practice, have exceeded him in the number of +cases described, and very few have surpassed him in the success of his +treatment. He mentions chiefly three conditions as being liable to produce +prolapsus of the cord, viz. a large quantity of liquor amnii, an unusually +long cord, and malposition of the child: later authors have enumerated +several other causes, many of which are imaginary; of these, by far the +most correct list has been given by Boer, of Vienna, who has justly +ridiculed the theoretical views which were maintained by his +cotemporaries. + +"If there be a large quantity of liquor amnii present, and especially, as +is not unfrequently the case, the child is at the same time under the +usual size; if the head be not firmly pressed against the brim, and does +not enter it sufficiently, or when the child's position is faulty, +especially if, at the same time, the cord is unusually long; if, under +such circumstances, a large bag of membranes has formed, and the brim of +the pelvis itself is very spacious; if perchance, the rupture of the +membranes takes place at a moment when the patient is moving briskly on in +some unfavourable posture, the cord will be very liable to prolapse. +Nevertheless, cases are occasionally seen which arise without these +predisposing circumstances." (Boer, _von Geburten unter welchen die +Nabelschnur vorfällt_.) + +The uterus is the chief means by which the cord is prevented from falling +down between the presenting part of the child and the passages, from the +closeness with which its inferior portion encircles it: without this, from +the erect posture of the human female, there would be a liability to +prolapsus of the arm or cord in every labour. + +"The contraction of the uterus, which comes on with the rupture of the +membranes, and sometimes, where they protrude very much, even before, is +of great importance. This contraction takes place in the inferior segment +of the uterus; it surrounds the head, and when fully developed extends +over the whole head of the child. Thus, for instance, if we attempt to +operate at an early stage, it feels more like a hard ring round the head, +of about a finger's breadth, and it may be felt to extend itself higher +up, in proportion as the stimulus of the hand excites the activity of the +uterus." (Michaelis, _Neue Zeiteschrift für Geburtskunde_, band iii. heft. +1.) + +Hence, therefore, whatever prevents the uterus from contracting with its +inferior segment upon the presenting part of the child, deprives the cord +of its natural support, and, therefore, renders it liable to prolapse. +Many of the causes enumerated by Boer act in this way; thus, where the +uterus is distended by an unusual accumulation of liquor amnii; where the +contractions at the beginning of labour have been exceedingly irregular; +where the arm, or shoulder, or feet present; or where a large bladder of +membranes is formed, the lower part of the uterus will either not contract +at all upon the head, or so imperfectly as to endanger the descent of the +cord. + +Malposition of the child has been mentioned by many authors as a cause of +prolapsus of the cord, and in some cases it may possibly act thus from the +inferior segment of the uterus being unable to surround sufficiently close +so irregular a mass as the shoulder. In the majority of cases, however, +the coincidence of these two circumstances depends upon their being +produced by the same causes; thus an unusually large quantity of liquor +amnii, or irregular contractions of the uterus, will just as much dispose +to the one as the other. + +The form or size of the pelvis can have, we think, but little effect upon +the cord, so long as the uterine action is of the right character and the +child alive. Most authors enumerate a large pelvis or small foetal head as +a cause, why should we not, therefore, have prolapsus of the cord in every +case of precipitate labour which arises from such circumstances? Nor are +we at all disposed to consider deformed pelvis as capable of producing it, +so long as the uterus is not immoderately distended and acting naturally: +we do not deny that the cord is occasionally found prolapsed in cases of +dystocia pelvica, but this is chiefly where the child has died from the +severity of the labour, and where the flaccid pulseless cord has gradually +slipped down during the intervals of the pains. + +So long as the uterus exerts but a moderate degree of pressure round the +head, it is impossible for the cord of a living child to descend, +particularly as, according to Dr. Michaelis, the circular contraction of +the portio vaginalis commences from below upwards, and would rather push +back the cord if a portion of it had descended during the moments of +uterine relaxation. The pulsating turgor of the cord when the child is +alive will also assist much in preventing its descent, even where the +uterus does not surround the presenting part so closely as usual. + +The unusual length of the cord is also a very doubtful cause of its +prolapsus, and will evidently, in great measure, depend upon the causes we +have already alluded to. + +We may also allude to another cause of prolapsus of the cord, which, +although noticed nearly a century ago by Levret, and also by two or three +authors after him, had nearly fallen into oblivion until lately, when it +excited the attention of Professor Naegelé, junior. Levret, from the +result of numerous observations on the insertion of the cord into the +placenta, was led to suppose that the lower the situation of the placenta +in the uterus, the lower also was the insertion of the cord into the +placenta, so that if the edge of the placenta touched upon the os uteri, +the cord was usually inserted into that part of its edge which +corresponded with the os uteri. + +Although it is certain that the situation of the placenta close to the os +uteri, is by no means necessarily attended by insertion of the cord into +its edge, and, therefore, by prolapsus of it when the membranes give way, +inasmuch, as under such circumstances we ought to have every case of +partial placenta prævia accompanied with the cord presenting: still, +however, there is no doubt that cases of the above-mentioned complication +do every now and then occur, and must necessarily incur no inconsiderable +danger of prolapsus. + +"There is no doubt that the situation of the placenta in the vicinity of +the os uteri, may be looked upon as one of the predisposing causes of the +cord presenting during labour; an accident which is the more to be feared, +the nearer the cord is inserted into the inferior edge of the placenta. If +its edge extends quite down to the os uteri, and the cord is inserted into +it, or the umbilical vessels divide, as in the cases we have described, at +some little distance from it, viz. in the membranes, the cord will present +as a necessary result, and prolapse as soon as the membranes give way." +(_Die Geburtshülfliche Auscultation_, von Dr. H. F. Naegelé, p. 114.) The +two cases referred to by Professor Naegelé, jun., of prolapsus of the cord +from this cause, occurred so near after each other, as to render the +circumstance the more remarkable. The fact was noticed by Giffard as early +as in 1728, in a case of flooding from partial placenta prævia; but he +does not appear then to have drawn any inferences from the position of the +placenta, which he did not consider was attached, but was "in part, if not +wholly, separated from the uterus."[137] + +Prolapsus of the cord is fortunately not a circumstance of frequent +occurrence. Dr. Churchill, of Dublin, in a valuable paper, (_Edin. Med. +and Surg. Journal_, Oct., 1838,) has collected the results of no less than +90,983 deliveries, amongst which the cord presented in 322 cases, being in +the proportion of one in 282-1/4.[138] That prolapsus of the cord occurs +most frequently in foot presentations, as supposed by Professor Naegelé, +senior, is disproved by the results of Mauriceau's large experience, as +well as of many others since; thus, out of 33 cases which occurred in +labour at the full term, (or nearly so,) 17 presented with the head, 1 +with the face, 1 with the feet, 9 with the hand or arm, 3 with the hand or +foot, 1 with the hand and breech, and 1 with the hand and head. In the +16,652 births which have been recorded by Dr. Collins, at the Dublin +Lying-in Hospital, the cord prolapsed in 97 instances. "_Twelve_ of the 97 +occurred in twin cases, and in seven of the 12 it was the cord of the +second child. _Nine_ occurred where the feet presented, (not including two +met with in twin children,) which was in the proportion of _one_ in every +_fourteen_ of such presentations. _Two_ only where the breech presented, +which was in the proportion of _one_ in every 121 of such presentations: +this approaches nearly the proportional average in all deliveries, which +is _one_ in 171-1/2. _Four_ occurred where the shoulder or arm presented: +this is in the proportion of _one_ in _nine_ of such presentations. +_Seven_ occurred where the hand came down with the head. _Seven_ of the +children were born _putrid_; _three_ of the 97 were premature, viz. _two_ +at the seventh and _one_ at the eighth month." (Collins's _Practical +Treatise on Midwifery_, p. 346.) We may, therefore, conclude with safety, +that presentations of the head are by far the most common. + +_Treatment._ Left to itself prolapsus of the cord is almost certain +destruction to the child, for unless the labour comes on very briskly, and +the head passes rapidly through the pelvis, the cord is pressed upon so +long as to render it impossible for the child to be born alive. Still, +however, where the passages are yielding, and the pains active; where the +head is of a moderate size, the pelvis spacious, and the cord in a +favourable part of it, viz. towards one of the sacro-iliac synchondroses; +where also the membranes remain unruptured until the last moment, there +will be a very fair chance of the child being born alive. Under no +circumstances is it of such paramount importance to avoid rupturing the +membranes as in these cases, for the bag of fluid which they form dilates +the soft passages and protects the cord from pressure. + +"Many methods of relief have been recommended, such as turning, delivering +with the forceps, pushing up the funis through the os uteri with the hand, +and endeavouring to suspend it on some limb of the child, collecting the +prolapsed cord into a bag, and then pushing it up beyond the head, pushing +up, the funis with instruments of various kinds, endeavouring to keep it +secured above the head by means of a piece of sponge introduced; these and +many other similar expedients have been resorted to." (Collins, _op. cit._ +p. 344.) + +The first two of these means have been chiefly used in cases of prolapsed +funis, the others having, for the most part, been found entirely +inefficient. Thus Mauriceau, in the 33 cases which he has recorded, turned +19 times: the children were all born alive, except one, which was dead, +but required turning as it presented with the arm. In later times, turning +or the forceps have been preferred, according to the period of labour at +which the prolapsus was discovered or occurred. Thus Madame Boivin has +recorded 38 cases, 25 of which occurred at the commencement of, and 13 +during labour, the former were all turned; in the latter the forceps was +used; 29 children were saved, seven were lost, and the two others were +putrid. + +Our practice must be in great measure guided by the circumstances of the +case: where the os uteri is not fully dilated, where the head is still +high and not much engaged in the pelvis, the liquor drained away, and the +cord beginning to suffer pressure during the pains, we dare not wait until +the case be sufficiently advanced to admit the application of the forceps, +but must proceed as soon as possible to turn the child. The operation +should be performed with the greatest possible caution; the cord should +be guided to one of the sacro-iliac symphyses; the expulsion of the trunk +must be very gradual; a dose of secale should be given to ensure the +requisite activity of the uterus when the head enters the pelvis, and the +forceps kept in readiness to apply the instant that its advance is not +sufficiently rapid. On the other hand, where the labour has made +considerable progress before the membranes give way, and the head has +fairly engaged in the cavity of the pelvis, if the os uteri is fully +dilated, it will be no longer advisable to attempt turning; the head is +within reach of the forceps, which should be immediately applied, taking +care that the cord does not get squeezed between the blades and the head. +Where the arm or shoulder presents, this will of itself require that the +child should be turned. + +_Reposition of the cord._ Although the reposition of the cord has been +recommended from the time of Mauriceau, and by the majority of authors +since, it has nevertheless met with so little success as to have fallen +into complete disuse until the last few years; one of its strongest +opposers was the celebrated La Motte. "The delivery ought to be attempted +as soon as we find that the string presents before the head, it being to +no purpose to try to reduce it behind the head, which at that time fills +up the whole passage, and can only admit you to push it back into the +vagina, and it will fall down again at every pain; and if you have done so +much as to reduce it into the uterus, what hinders you from finishing the +delivery at once, by seeking for the feet? the chief difficulty is then +over." (_La Motte_, English translation, p. 304.) This mode of delivery +(turning) has been more adopted by practitioners in such cases than any +other, especially in former times, when the forceps was either not at all +or imperfectly known; by none has it been so with more success than by +Mauriceau himself, having saved every living child in which he attempted +the operation. Still, however, he recommended that the attempt should be +made to return the cord wherever it was possible, and has recorded four +cases of this mode of treatment, all of which proved successful, although +one of the children was born so feeble as to die shortly afterwards. +Giffard seems to have attempted the reposition of the cord only once, and +failed, apparently from the unusual size of the child. In later years Sir +R. Croft, "has related two cases in which he succeeded, by carrying the +prolapsed funis through the os uteri, and suspending it over one of the +legs of the child. In both these cases the children were born alive." +(Merriman's _Synopsis_, p. 99.) It is to Dr. Michaelis of Kiel that we are +indebted for much recent and valuable information on the subject of +replacing the prolapsed cord. Having pointed out the fact that it is the +uterus alone which prevents the cord from prolapsing, he shows that, in +order to replace the cord, we must carry it "above that circular portion +of the uterus which is contracted over the presenting part." The +reposition of the cord may be effected by the hand, or by means of an +elastic catheter and ligature. In replacing the cord by means of the hand +alone, Dr. Michaelis remarks that we shall effect this more readily by +merely insinuating the hand between the head and the uterus, and gradually +passing it farther round the head, pushing the cord before it. In this +manner we do not require to rupture the membranes when we have felt the +cord before the liquor amnii has escaped; a point of considerable +importance. + +The reposition, by means of the catheter, is effected by passing a silk +ligature, doubled, along a stout thick elastic catheter, from twelve to +sixteen inches in length, so that the loop comes out at the upper +extremity; the catheter is introduced into the vagina, and the ligature is +passed through the coil of the umbilical cord, and again brought down to +the os externum. A stilet with a wooden handle is introduced into the +catheter, the point passed out at its upper orifice, and the loop of the +ligature hung upon it; it is then drawn back into the catheter and pushed +up to the end. The operator has now only to pull the ends of the ligature, +so as to tighten it slightly, passing the catheter up to the cord, which +now becomes securely fixed to its extremity. When the reposition has been +effected, he has merely to withdraw the stilet; the cord is instantly +disengaged.[139] To prevent any injury, the ligature should be brought +away first, and then the catheter. + +"Dr. Michaelis has recorded eleven cases of prolapsus of the cord, where +it has been returned by the above means, in nine of which the child was +born alive. In three cases the arm presented also, which was replaced, and +the head brought down; in two of these the child was born alive." +(_British and Foreign Med. Review_, vol. i. p. 588.) A similar plan of +replacing the cord by means of an elastic catheter has been tried by Dr. +Collins, but he had not tried it sufficiently often at the time of +publishing his _Practical Treatise_ to be able to give a decided opinion +about it. + +The plan of introducing a piece of sponge after replacing the cord, in +order to prevent its coming down again, is of no use whatever. Dr. Collins +tried it in several instances, and considers that "it is quite impossible, +however, in the great majority of cases, to succeed in this way in +protecting the funis from pressure, as it is no sooner returned, than we +find it forced down in another direction." The plan has been recommended +by several modern authors, but it is by no means a new invention, having +been proposed by Mauriceau; it does not appear, however, that he ever put +it in practice. + +Where no pulsation can be felt in the prolapsed funis, which is flabby and +evidently empty, no interference will be required; the child is dead, and +therefore the labour may be permitted to take its course. We should, +however, be cautious in examining the cord where it is without pulsation, +and yet feels tolerably full and turgid, for a slight degree of +circulation may go on nevertheless, sufficient to keep life enough in the +foetus, even for it to recover if the labour be hastened. We should +especially examine the cord during the intervals of the pains, and after +we have guided it into a more favourable part of the pelvis, where it will +not be exposed to so much pressure, for then the pulsation will become +more sensible to our touch, and prove that the child is still alive. + +The following case by Dr. Evory Kennedy is an excellent illustration of +what we have now stated:--"The midwife informed me that there was no +pulsation in the funis, which had been protruding for an hour; on +examination made during a pain, a fold of the funis was found protruding +from the vagina, at its lateral part, and devoid of pulsation. As the pain +subsided, I drew the funis backwards towards the sacro-iliac symphysis, +and thought I could observe a very indistinct and irregular pulsation; I +now applied the stethoscope, and distinguished a slight foetal pulsation +over the pubes. Fortunately on learning the nature of the case, I had +brought the forceps, which were now instantly applied, and the patient +delivered of a still-born child, which, with perseverance, was brought to +breathe, and is now a living and healthy boy, four years of age. Had I not +in this case ascertained by the means mentioned, that the child still +lived, I should not have felt justified in interfering; but, supposing the +child dead, would have left the case to nature, and five minutes, in all +likelihood, would have decided the child's fate." (Dr. Evory Kennedy, _on +Pregnancy and Auscultation_, p. 241.) + + + + +CHAPTER XI. + +PUERPERAL CONVULSIONS. + + _Epileptic convulsions with cerebral congestion.--Causes.--Symptoms.-- + Tetanic species.--Diagnosis of labour during convulsions.-- + Prophylactic treatment.--Treatment.--Bleeding.--Purgatives.-- + Apoplectic species.--Anæmic convulsions.--Symptoms.--Treatment.-- + Hysterical convulsions.--Symptoms._ + + +Women are liable, both before, during, and after labour to attacks of +convulsions, not only of variable intensity, but differing considerably in +point of character. We shall consider them under three separate heads, +viz. epileptic convulsions with cerebral congestion; epileptic convulsions +from collapse or anæmia; and hysterical convulsions. Other species have +been enumerated by authors, but they are either varieties of, or +intimately connected with, those of the first species. + +No author has more distinctly pointed out the fact that epilepsy may arise +from diametrically opposite causes than Dr. Cullen; a circumstance which, +in a practical point of view, is of the greatest importance. "The +occasional causes," says he, "may, I think, be properly referred to two +general heads; the first, being those which seem to act by directly +stimulating and exciting the energies of the brain, and the second, of +those which seem to act by weakening the same." "A certain fulness and +tension of the vessels of the brain is necessary to the support of its +ordinary and constant energy in the distribution of the nervous power" +(_Practice of Physic_;) and hence it may be inferred that, on the one +hand, an over-distention, and, on the other, a collapsed state of these +vessels, will be liable to be attended with so much cerebral disturbance +as to produce epilepsy. + +_Epileptic convulsions with cerebral congestion._ Epileptic convulsions +connected with pregnancy or parturition, and which are preceded and +attended with cerebral congestion, alone deserve, strictly speaking, the +name of _Eclampsia parturientium_ (which, in fact, signifies nothing more +than the epilepsy of parturient females,) being peculiar to this +condition; whereas, the anæmic and hysterical convulsions may occur at any +other time quite independent of the pregnant or parturient state. + +The term "puerperal convulsions" is employed in a much more vague and +extended sense, and applies generally to every sort of convulsive +affection which may occur at this period, and as such, it therefore, forms +the title of the present chapter. + +_Causes._ The exciting cause of eclampsia parturientium is the irritation +arising from the presence of the child in the uterus or passages, or from +a state of irritation thus produced, continuing to exist after labour. The +predisposing causes are, general plethora, the pressure of the gravid +uterus upon the abdominal aorta, the contractions of that organ during +labour, by which a large quantity of the blood circulating in its spongy +parietes is driven into the rest of the system, constipation, deranged +bowels, retention of urine, previous injuries of the head or cerebral +disease, and much mental excitement, early youth: also "in persons of +hereditary predisposition, spare habit, irritable temperament, high mental +refinement, and in whom the excitability of the nervous, and subsequently +the sanguiferous system is called forth by causes apparently trivial." +(_Facts and cases in Obstetric Medicine_, by I. T. Ingleby, p. 5.) + +_Symptoms._ From the above-mentioned list of causes it will be evident, +that these convulsions will be invariably attended and preceded by +symptoms of strong determination of blood to the head. Previous to the +attack the patient has "drowsiness, a sense of weight in the head, +especially in stooping; beating and pain in the head; redness of the +conjunctiva; numbness of the hands; flushing of the face, and twitching of +its muscles; irregular and slow pulse; ringing in the ears, heat in the +scalp, transient but frequent attacks of vertigo, with muscæ volitantes, +or temporary blindness; derangement of the auditory nerve; embarrassment +of mind and speech; an unsteady gait; constipation and oedematous +swellings." (Ingleby, _op. cit._ p. 12.) + +As the attack approaches, the patient frequently complains of a peculiar +dragging pain and sense of oppression about the præcordia, which comes on +and again abates at short intervals, and is attended with much +restlessness and anxiety: this is followed by intense pain, which usually +attacks the back of the head, and upon the accession of which the +præcordial affection apparently ceases; the pulse now becomes smaller and +more contracted. If the convulsions do not make their appearance by this +time, and the headach continues one or more hours, a slight degree of coma +supervenes, the patient loses her consciousness more and more, and wanders +now and then; after a time she becomes restless and evidently uneasy, the +eye becomes fixed and staring, the countenance changes, and the outbreak +of convulsive movements follows. + +Sometimes the premonitory symptoms are much less marked; indeed, in some +cases, there is scarcely a sign to warn us of the impending danger; in the +midst of a conversation the patient becomes suddenly silent, and, on +looking to see the cause, we find the expression altered, the muscles of +the face are twitching, the features beginning to be distorted, and the +next moment she falls down in general convulsions. + +Wigand (_Geburt des Menschen_, vol. i. § 102,) considers that the two +symptoms which usher in the attack are, the frightful staring followed by +rolling of the eyes, with sudden starts from right to left, and twisting +of the head to the same side by the same sudden movements; as soon as the +convulsions have commenced, the head generally returns to its former +position, or rather is pulled more or less backwards; "the eyes are wide +open, staring, and very prominent, the eyelids twitch violently, the iris +is rapidly convulsed with alternate contractions and dilatations; the face +begins to swell and grow purple, the mouth is open and distorted, through +which the tongue is protruded, brown, and covered with froth; the lips +swell and become purple: in fact, it is the complete picture of one who is +strangled." (_Op. cit._) + +These convulsions, as in common epilepsy under other circumstances, +usually if not always commence about the head and face, gradually passing +down to the chest and abdomen, and then attacking the extremities. After +the above-mentioned changes, they pass into the throat and neck, by which +a state of trismus is produced, and the protruded tongue is not +unfrequently caught between the teeth and severely wounded. The neck is +violently pulled on one side, and from the pressure to which the trachea +is subjected, severe dyspnoea is produced. The respiration is nearly +suspended, and from the violent rushing of the air as it is forced through +the contracted rima glottidis, the breathing is performed with a peculiar +hissing sound. The muscles of the chest now become affected, and the +thorax is convulsively heaved and depressed with great vehemence; those of +the abdomen succeed, and the convulsive efforts are here, if possible, +still more violent: such are the contractions of the abdominal muscles, +and so powerfully do they compress the contents of the abdomen, that a +person who had not previously seen the patient would scarcely believe she +was pregnant; the next moment the abdomen is as much protruded as it was +before compressed. From the same cause, the contents of the rectum and +bladder are expelled unconsciously, the extremities become violently +convulsed, and the patient is bedewed with a cold clammy sweat. The +duration of such a fit is variable; it seldom lasts more than five +minutes, and frequently not more than two, and then a gradual subsidence +of the convulsions and other symptoms follow; the swollen and livid face +returns to its natural size and colour, the eyes become less prominent, +the lips less turgid, the breathing is easier and more calm, the viscid +saliva ceases to be blown into foam from the mouth, and the patient is +left in a state of comatose insensibility or deep stertorous sleep, from +which, in the course of a quarter of an hour or twenty minutes, she +suddenly awakes, quite unconscious of what has been the matter; she stares +about with a vacant expression of surprise; she feels stiff and sore as if +she were bruised: this will be especially the case if it has been +attempted to hold her during the fit. The convulsive efforts of the +muscles of the body and extremities are not easily resisted, and thus it +is that we hear of a delicate woman under these circumstances requiring +several strong men to hold her: the result of such treatment is, that her +muscles and joints are severely strained, and continue painful for some +time after. Patients, on recovering their senses, frequently complain of +pain and soreness in the mouth, arising from the tongue having been +bitten; in some cases where the tongue has been much protruded, the injury +is very severe, the tongue being bitten completely across, and hanging +only by a small portion. + +The woman may suffer but one attack, and have no return of the fit, or in +half an hour, an hour, or longer, the convulsions again appear as at +first. If this happens several times, she does not recover her +consciousness during the intervals, but remains in a continued state of +coma from one fit to another. Although it rarely happens, that the patient +dies during a fit, still nevertheless, one fit will in some cases be +sufficient to throw her into a state of coma from which she does not +recover; in others, the patient may lie for even twenty-four hours in +strong convulsions and yet recover. + +The character of these attacks appears to vary a good deal with the cause; +thus, where plethora has been the predisposing cause, and the fits +frequently repeated, they take on more or less of an apoplectic character, +the coma is more profound and of longer duration, and is frequently +attended with paralysis; the cerebral affection is more severe, the +patient does not recover her senses even where the intervals between the +attacks have been of considerable duration; and when the fits have ceased +and the coma abated, she is occasionally left in a state of imbecility and +blindness, which lasts for several hours or even days. + +Where it is connected with constipation or deranged bowels, we think that +we have seen it more frequently attended with delirium or even temporary +mania; the fits are numerous, the convulsions as severe, but the cerebral +congestion is not so intense, the coma less profound; instead of being +left in a state of torpid stupor, the patient is very restless and at +times unmanageable, and when we consider the identity of the causes which +produce these convulsions and one form of purerperal mania, it will be +easily understood why the symptoms should assume this character. The +degree also of determination to the head, will in no slight measure +influence the character of the symptoms which attend these attacks. "One +circumstance," says Dr. Parry, "of increased impetus deserves to be +noticed. The delirium is preceded by a pain in the head, but as the +delirium comes on, the pain ceases, though the impetus remains as before, +or perhaps increases. Diminish in a slight degree the impetus, and you +remove the delirium and renew the pain; diminish the impetus in a greater +degree, and the frown on the forehead is relaxed, the features seem to +open, and the pain entirely ceases." (_Posthumous Medical Writings_, vol. +i. p. 263.) + +By far the majority of cases of eclampsia parturientium occur in +primiparæ: thus in thirty cases which occurred to Dr. Collins, during his +mastership at the Dublin Lying-in Hospital, "twenty-nine were in women +with their first children, and the other single case was a second +pregnancy, but in a woman who had suffered a similar attack with her first +child." In two instances, under our own notice, where the disease occurred +in multiparæ, the fits did not appear until _after_ delivery; the patients +were plethoric, and in one especially, the bowels were excessively +deranged; in the other, the attack had much of the apoplectic character, +and the coma did not at once abate until the fatal termination. + +Convulsions usually make their appearance towards evening; and if pains +are coming on, they return with every uterine contraction. The patient's +danger will, in great measure, depend upon the severity, frequency, and +duration of the fits; and although they must ever be looked upon as a +disease of the most dangerous character, yet we are justified in saying +that in the majority of instances the patient recovers: thus, of the +forty-eight cases recorded by Dr. Merriman, thirty-seven recovered; and of +the thirty by Dr. Collins, only five died, "three of which were +complicated with laceration of the vagina, one with twins, and one with +peritoneal inflammation. It is thus evident that the fatal result in these +cases, with the exception of the twin birth, was not immediately connected +with the convulsions; and the danger in all twin deliveries, _no matter +what the attack may be_, is in every instance greatly increased." +(_Practical Treatise_, p. 210.) + +Although puerperal convulsions usually occur at the commencement of +labour, it not unfrequently happens that they do not come on until after +the child is born; whereas, in other cases they occur several months +before the full period: these varieties depend entirely upon the +circumstances under which the attack has appeared. "With respect to their +occurrence in the last month of gestation, although the paroxysm mostly +appears during the actual dilatation of the os uteri, or on the first +approach of labour, still when we recollect that in the last week or two +of pregnancy the neck of the uterus is fully developed, the subsequent +changes being confined to the os internum (the most sensitive part of the +organ,) it cannot be surprising that, in very irritable persons, a +serious impression should be made upon the brain at those periods." +(Ingleby, _op. cit._ p. 11.) + +Dr. Merriman has called it _dystocia epileptica_: there is, in fact, no +difference between this disease and common epilepsy, beyond that, under +ordinary circumstances, epilepsy is a chronic affection, and, generally +speaking, not attended with much danger, whereas, in the present case, it +is an acute attack, and of a highly dangerous character. + +Many phenomena connected with uterine irritation, both in the +unimpregnated state and during pregnancy, prove the intimate nature of the +consent existing between the brain and uterus. Thus it is well known that +menstrual irritation is accompanied with a great variety of nervous and +hysterical symptoms, which are merely a part of the same series of results +to which epilepsy itself belongs: it is occasionally attended with +delirium, spasms, and even coma, and preceded by the oppression at the pit +of the stomach and pain of head, which we have already noticed among the +immediate precursors of puerperal epilepsy; on the other hand, as Dr. +Parry has well remarked, "the beginning and end of each epileptic fit, +before total insensibility begins and after it ceases, is often delirium, +screaming, false impressions, attempt to annoy others under these +impressions," &c. (_Op. cit._ vol. i. p. 396. &c.) Thus also during +labour, either at the termination of the first stage, when the os uteri +has attained its full degree of dilatation, or immediately after the birth +of the child, the patient is frequently seized with a sudden convulsive +rigour so violent as to make her teeth chatter and agitate the whole bed, +and which is nothing more than a harmless modification of convulsive +action arising from uterine irritation; the surface is perfectly warm, and +the patient frequently expresses her surprise to find herself shivering +thus violently and yet not feel cold. + +It has been a common opinion that epileptic puerperal convulsions are +almost certainly fatal to the child, especially if they continue for any +length of time: experience, however, proves the contrary, as cases +continually occur where the mother has laid for many hours in a constant +succession of severe convulsions, and yet has been ultimately delivered of +a living child. Still, however, it must be owned, that barely an equal +number of the children are born alive under these circumstances. Thus, in +Dr. Merriman's 48 cases, as already mentioned, only 17 children were born +alive (including the 6 born before the mothers were attacked with +convulsions;) in the 30 cases recorded by Dr. Collins, 18 of the 32 +children (two of the women having had twins) were born dead; of these, +however, it must be observed, that 8 were delivered with the perforator, +and two were born putrid. + +_Tetanic species._ There is one modification of eclampsia parturientium, +which, from the spastic rigidity of the uterus which accompanies it, is +peculiarly dangerous to the child's life: it has been called the tetanic +form: the convulsions are incessant, without any apparent interval, and +the uterus actively participates in the state of general spasms: under +such circumstances, the pressure which it exerts upon the body of the +foetus will seriously obstruct the abdominal circulation, and produce the +same effects as pressure on the cord. + +In most cases, however, the convulsions have no effect upon the process of +labour, which continues its course uninterrupted; so that, where there has +been no return of consciousness during the intervals between the fits, and +the patient has laid in a continued state of coma for some time, the child +may actually be born before there has even been a suspicion that labour +was present. It is, therefore, of great importance that the practitioner +should be on the watch to detect any symptoms of its coming on, not only +for the purpose of giving her the necessary support at the moment of +expulsion, but also such assistance as may tend to shorten that process. + +"By attentively observing what passes in cases of convulsions, we remark +that they do not always interrupt the course of the labour pains, whether +they had excited those pains, or the pains had preceded them. All authors +relate examples of women who have been delivered without help after +several fits of strong convulsions; and others while they were actually +convulsed, whether there were lucid intervals between, or that the loss of +understanding was permanent. The progress of labour in most of these cases +seems even more rapid than in others, since we have often found the child +between its mother's thighs, though an instant before we could discover no +disposition for delivery." (_Baudelocque_, trans. by Heath, § 1109.) + +_Diagnosis of labour during convulsions._ Where the patient is in a state +of insensibility, we may infer the presence of labour by a variety of +symptoms; every now and then, from a state of torpor, she becomes +restless, and evidently uneasy; she pushes the bed-clothes from the +abdomen, and gropes about it as if trying to remove something that is +heavy or uncomfortable; she writhes her body, and moans as if in pain; +after awhile, she again relapses into her former state of coma. A little +attention will soon show us that these exacerbations of restlessness are +periodical; and if we examine the abdomen at the moment, we feel the +uterus evidently contracting; the os uteri also will be found tense and +more or less dilated: if the head has already advanced into the vagina, +these contractions will be accompanied by a distinct effort to strain. + +It is rare to find convulsions complicated with malposition of the child; +indeed, so uncommon is the occurrence of it under these circumstances, +that we may feel almost certain, on being summoned to a case of +convulsions, that there will be little chance of this additional +difficulty being superadded. "There was but one case," says Dr. Collins, +"of convulsions during my residence in the hospital, where the child +presented preternaturally; there was not one case with a preternatural +presentation during Dr. Clarke's residence; and Dr. Labatt has stated the +same fact in his lectures while master of the hospital. In these three +different periods there were 48,379 women delivered, so that from this we +may infer, where the presentation is preternatural, there is little cause +to dread the attack." (_Practical Treatise_, p. 200.) + +_Prophylactic treatment._ Under no circumstances is the old saying of +"Prevention is better than the cure," so well illustrated as in the +prophylactic treatment of puerperal epilepsy: it is only by carefully +watching for and recognising those symptoms which we have already +enumerated as threatening an attack, that we are able to adopt such +measures as shall either keep it off entirely, or at any rate considerably +diminish its violence. + +The treatment which we have recommended during the last weeks of +pregnancy, is particularly valuable in keeping off any disposition to +these attacks: regular, and for her condition even tolerably active, +exercise and strict attention to the bowels, should be required, +especially in primiparæ. If any distinct symptoms of cerebral congestion +make their appearance, such as flushed face, headach, or slight wandering; +if, moreover, the pulse be slow and labouring, we must at once relieve the +circulation by bleeding; and by an active dose of calomel and James's +powder at night with a warm pediluvium, and a brisk laxative the next +morning, endeavour to ward off the dreaded attack. Not unfrequently, +however, we have no warning of the danger until the fits burst out, and +are thus debarred the opportunity of preparing against them. + +_Treatment._ During the fit itself little can be done beyond placing the +patient in such a situation that she should not injure herself by her +exertions. If she happens to be upon a chair when the attack begins, it +will be as well to let her sink gently upon the floor, and lie there until +the fit is over; if she is in bed when it comes on, we have merely to +watch that she does not roll off during her struggles; her movements +should be restrained as little as possible, and by so doing we shall spare +her the suffering after the fit from strained muscles and half-wrenched +joints, which is so severe where the assistants, from mistaken kindness, +have endeavoured to hold her. + +It has been recommended by Dr. Denman to have the patient's face +frequently dashed with cold water during the fit, a remedy which, as Dr. +Merriman observes, is very effectual in ordinary hysterical paroxysms, and +which possibly may have a slight effect in moderating the violence of the +epileptic convulsions; but from what we have seen we are not inclined to +consider it of much use. + +_Bleeding._ As soon as the fit is sufficiently over to render the +operation possible, the patient ought to be placed in a half-sitting +posture, and bled from a large orifice in the arm; the quantity of blood +abstracted must be determined by the appearance of the patient, the +severity of the cerebral symptoms, and the condition of the pulse; this +latter will usually be found labouring, and even small, but will rise +considerably in fulness and volume as we gradually relieve the +circulation. Syncope is an effect which, under these circumstances, it +would neither be easy nor safe to produce; but at the same time it will be +highly desirable to produce a powerful effect upon the circulation by so +large and speedy an abstraction of blood as shall be certain of +alleviating the cerebral congestion: this is not often attained until +after a loss of twenty, or five and twenty ounces. She should be supported +in the half-sitting posture by means of a chair turned against the head of +the bed, so that its back forms an inclined plane, which should be covered +with pillows for her to lean upon. + +_Purgatives._ An active dose of purgative medicine should be given the +moment the patient is able to swallow; for in case of the fit returning, +it will be sometimes very difficult to make her take any thing. Eight or +ten grains of calomel, with fifteen or twenty of jalap, should be mixed +into a paste with a little thin gruel and laid upon the back of the +tongue, and a few spoonfuls more of gruel, &c. given to carry it down. If +this cannot be taken, a few drops of croton oil will seldom fail to +produce the necessary effect. + +It is of the greatest importance to do this as early as possible, not only +for the reason we have just assigned, but also because we find that +purgative medicines frequently take a longer time to operate in these +cases than they do under ordinary circumstances, and require the +repetition of even a powerful dose before the bowels can be made to act. +Where the convulsions appear to depend in great measure upon the deranged +state of the bowels, the indications for the immediate employment of +purgatives become still more urgent, for although we may control the +cerebral congestion by means of the lancet, we shall not remove the source +of irritation; but when once the bowels have been freely evacuated, the +chain of morbid actions is broken, and the disease ceases: hence, in some +cases, we observe much more striking relief produced by purgatives than +even by bleeding. In order, therefore, to ensure a certain and speedy +effect upon the bowels, she should take, about two hours after the powder, +repeated doses of salts and senna, and if necessary, have their action +still farther assisted by a purgative injection. + +In the mean time, the hair must be closely shaven from the crown and back +of the head, leaving the front bands, that she may be disfigured as little +as possible, and a large bullock's bladder half filled with pounded ice, +applied to the bare scalp; in lieu of which, an evaporating lotion of +vinegar spirit and water, may be applied until the ice is procured. +Sinapisms to the calves of the legs and soles of the feet will also be +required, so that, on coming into a room where a patient is lying in +puerperal convulsions, the practitioner may quickly find employment for +the numerous friends or assistants, who generally crowd round her on such +occasions, and convert their officiousness into real utility. The air of +the room must be kept as fresh as possible, and no more people allowed to +remain in it than are absolutely necessary. + +If she be tolerably conscious during the interval, a hot foot bath, +rendered still more stimulating by some mustard flour, will be of great +service; flannels wrung out of a hot decoction of mustard, and wrapped +round the feet and legs, are also useful, and tend still farther to +diminish the cerebral congestion. + +In all cases of convulsions, especially if the patient be near her full +time, it will be necessary to ascertain the state of the bladder; for the +pressure of the head frequently produces much difficulty in evacuating it, +and sometimes causes so much distention and irritation as to be itself +quite capable of exciting the convulsions. Lamotte has given two instances +where the fits had been evidently brought on by retention of urine, and +where relief was immediately given by evacuating the bladder. + +Where the patient has still some time to go, and no appearance of uterine +action has been excited, the probability is, that the above-mentioned +treatment, will be sufficient to prevent a return of the attack; and, if +we have succeeded in calming the circulation, we may combine a little +henbane with her medicine to allay irritability. But if she be near her +full time, and labour has distinctly commenced, there will be little +chance of the convulsions permanently ceasing until she is delivered, as +the contractions of the uterus frequently appear to excite a return of +them. + +The practice in former times of dilating the os uteri, introducing the +hand and turning the child, has been long since justly discarded, for the +irritation produced by such improper violence would run great risk of +aggravating the convulsions to a fatal degree. + +"No cases require more prudence, attention, and sagacity, than the +accident of convulsions in women, with their first children especially. +The state of the os uteri is of immense importance, and when it will admit +of your delivering the woman without violence, trouble, or irritation, no +doubt it ought to be performed with all prudent expedition, as you never +can be sure of her being restored without delivery." (M'Kenzie's +_Lectures_, MS. 1764, quoted by Dr. Merriman.) + +Where we are called to a patient, who has been some little time in +convulsions, and where bleeding and other necessary measures have been +already had recourse to, we may, with a tolerable degree of certainty, +expect to find the os uteri fully dilated, and the head in a favourable +state for the application of the forceps. The practitioner should be able +to apply the forceps whether the patient be lying upon her back or her +side, as it is not always possible to choose her position; the former, +will generally be the safest, as she will not only lie more quietly upon +her back, but can be kept with most facility in this posture. Generally +speaking the fits subside immediately after the child is delivered, +although not unfrequently they recur during the first twelve or sixteen +hours after labour, coming on at increasing intervals. + +If, however, the state of the os uteri forbids our interfering with art, +we must be content to follow out that plan of antiphlogistic treatment +which has been just laid down, bearing in mind, that in proportion as we +reduce the power of the circulation we increase the disposition of the os +uteri to dilate, and, as Baudelocque justly observes, "while we wait the +favourable moment for operating, we should only employ those means which +we could use after delivery, if the convulsions should continue." (_Op. +cit._ § 1110.) + +By the time that the medicine has begun to operate, a considerable change +will usually be observed in all the symptoms--the violence of the +convulsions abates, the coma is less profound, and if the child be not yet +born, the process of labour much more speedy and favourable; but if we +find that the convulsions assume a tetanic character, and that the uterus +actively participates in this state of spasmodic rigidity, we must not +expect any very favourable change until delivery is effected; and there +will be little chance for the child of its being born alive for reasons +already mentioned. Under such circumstances, which are fortunately of rare +occurrence, it will be our duty to perforate rather than run the risk of +losing the mother as well as her child; but before proceeding to this +extremity we must satisfy our minds that the state of the os uteri forbids +the forceps, and that, from the tetanic action of the uterus, there is +little chance of its farther dilatation. + +"It does not always happen that the convulsions cease upon the termination +of the labour; on the contrary, they often continue after the birth of the +child, and sometimes increase in violence, and at length produce death. +If, however, the intervals between the fits become longer, a more +favourable prognosis may be formed, but it will be expedient to continue +our exertions in relieving the symptoms." (Merriman's _Synopsis_.) + +The after treatment will be little more than a continuation of that which +has been described during the attack, only in a much milder form: the head +must be kept cool by a proper lotion, and the bowels sufficiently open by +gentle laxatives; a little gruel, with or without milk, may be given +occasionally; and if the child be alive, it should by all means be applied +early to the breast, in order to establish a flow of milk as soon as +possible. Where the breasts have been very flaccid, and there were little +or no signs of milk, we have now and then applied a sinapism over them +with very good effect, for the mammary excitement thus produced has been +attended with a copious lochial discharge, which has evidently produced +much relief. + +_Apoplectic species._ Dr. Dewees has described a species of convulsions by +the term "apoplectic," but it is perhaps questionable how far he is +correct in calling them "puerperal convulsions;" for, from the cases which +have come under our own notice, the disease has been nothing else than +genuine apoplexy occurring in the pregnant, parturient, or puerperal +state: he justly observes, that "it may be brought on by causes +independent of pregnancy, though this process may with propriety be +regarded as an exciting cause; for it sometimes takes place when this +process is at its height, but is no otherwise accessary to this end, than +increasing by its efforts the determination of blood to the head." (_Op. +cit._ § 1238.) + +The treatment will in no respect differ from that of the genuine puerperal +convulsions, except that, as the danger is still greater, so, if possible, +must the treatment be more prompt; indeed, it can scarcely be said that +there is a convulsion, for there is merely loss of motion with +insensibility. It is fortunately of rare occurrence, as the patient seldom +recovers. + +_Anæmic convulsions._ The next form of epiplectic puerperal convulsions is +the anæmic form, where, in consequence of serious loss of blood or +debility otherwise induced, the due balance of the nervous system has been +disturbed, and irregular and convulsive actions have been the result. + +We have already shown that cerebral congestion is favourable to that state +of irritability, which, by the help of any exciting cause, may easily pass +into a state of epilepsy; an opposite condition, viz. that of exhaustion, +is capable of acting in a similar way, and thus confirms Dr. Cullen's +assertion, "that there are certain powers of collapse, which, in effect, +prove stimulants and produce epilepsy." + +"That there are such powers which may be termed indirect stimulants, I +conclude from hence, that several of the causes of epilepsy are such as +frequently produce syncope, which, we suppose, always to depend upon +causes weakening the energy of the brain." "The first to be mentioned, +which I suppose to be of this kind, is hæmorrhage, whether spontaneous or +artificial. That the same hæmorrhage which produces syncope, often at the +same time produces epilepsy, is well known; and from many experiments and +observations it appears, that hæmorrhages occurring to such a degree as +to prove mortal, seldom do so without first producing epilepsy." (_Op. +cit._) It is a well-known fact, that when once a state of exhaustion or +collapse has been carried beyond a certain point, the irritability of the +nervous system increases in proportion: the due balance of its various +actions becomes more and more unsteady; their equilibrium is disturbed by +the slightest impressions, and losing the state of well-adjusted repose +which belongs to health, they continually vibrate between the extremes of +excitement or collapse, which seldom fail to produce some serious +derangement. + +"The symptoms of reaction from loss of blood," says Dr. Marshall Hall, +"accurately resemble those of power in the system, and of morbidly +increased action of the encephalon; and, from these causes, the case is +very apt to be mistaken and mistreated by the farther abstraction of +blood. The result of this treatment is, in itself, again apt farther to +mislead us; for all the previous symptoms are promptly and completely +relieved, and this relief, in its turn, again suggests the renewed use of +the lancet. In this manner the last blood-letting may prove suddenly and +unexpectedly fatal." + +_Symptoms._ A very little attention, however, will discover the real +features of the disease; the pale face, the glazy eye, the shrunken +features and colourless lip, the cold moist skin, the heaving chest, the +quick, weak, small, and irritable pulse, all betoken a condition of +exhaustion and collapse. The history of the case will also show that the +patient has suffered from profuse hæmorrhage, or some other debilitating +evacuation; and the intense pain on the summit of the head, verging into +actual delirium, the rambling thoughts and confused mental associations, +the restlessness or absolute insomnia, the tinnitus aurium, disposition to +strabismus or other derangements of vision, indicate the defective +condition of the cerebral circulation. + +We have already mentioned, in the congestive form of epilepsy, that where +the irritation from gastric derangement is conjoined to a state of body +already predisposed to the disease, that this is frequently sufficient to +excite it into action; still more will this be the case where the system +is rendered irritable by exhaustion; and it will occur under more +formidable circumstances, from our means of treatment being confined +within still narrower limits. Dr. M. Hall justly observes, that +"exhaustion is sooner induced under circumstances of intestinal +irritation:" and again, "paralysis has occurred in a state of exhaustion +from other causes, as undue lactation; and in various circumstances of +debility, as in cases of disorder of the general health, with sallowness +and pallor, and a loaded tongue and breath." + +_Treatment._ Our treatment of these cases will not vary essentially from +that of exhaustion from hæmorrhage under the ordinary circumstances; the +patient must be placed with her head low, and as soon as she is able to +swallow, a little hot brandy and water, or ammonia, should be given to +rouse the circulation to a sufficient degree of activity. If the uterus be +still flaccid and disinclined to contract effectively, a dose of ergot +will be advisable, and the abdomen should be tightly bandaged with a broad +towel. When the powers of the circulation have rallied somewhat, a little +plain beef-tea will frequently prove very grateful and appear to revive +her more powerfully than even the stimulants above-mentioned; and now, as +it is of the greatest importance to calm the irritability of the brain and +nervous system, we must proceed to the use of sedatives. Of these, opium +and hyoscyamus have the preference, the latter especially so, from its not +being liable, like opium, to derange the stomach, or contract the bowels. +Moreover, where the exhaustion is very alarming, it is not always easy to +control the sedative action of opium within due bounds; and in such cases +we are sometimes apt to produce so much sopor, as to render it even +difficult to rouse the patient. For this reason, the combination with a +diffusible stimulant is always desirable: five grains of camphor and of +extr. hyosc. in two pills, form, perhaps, the best and safest sedative +which can be given; these may be repeated every hour, and then at longer +intervals of two or more hours, until sleep has been produced. Sleep, in +cases of this kind, is of the greatest importance, and produces the most +favourable change in the patient's condition; the intense headach and +irritability of the mind, of the sight, and of the hearing, all abate; the +circulation becomes calmer, the pulse more full and soft, the heat of the +body more equable; in short, the whole nervous system is returning to a +more natural and regular state of action, the stomach is more capable of +receiving and digesting its food, the bowels are more manageable, and we +may now venture to remove a state of constipation, if present, or any +morbid intestinal contents without running the risk of bringing on +diarrhoea and increasing the debility. + +We rarely find that the convulsions return when once the patient has +enjoyed the calm of a sound and refreshing sleep, and consider the victory +as more than half gained when this favourable state has been produced. The +laxative should be of the mildest form, such as will merely excite the +peristaltic action of the intestines without increasing their secretions; +for this purpose a warm draught of rhubarb manna with hyoscyamus, or +castor oil guarded by a little liq. opii. sed., will be the safest. Food +of the blandest and most nutritious quality should be given in small and +frequently repeated doses; it is important not to load the stomach much or +suddenly, for vomiting is easily produced, and when once excited, the +stomach becomes so irritable as to be scarcely capable of retaining any +food whatever. + +Where, on the other hand, several hours have passed, not only without +sleep but without even a temporary state of quiet; where the headach +alternates with restless delirium; where the medicines and nourishment +have produced little or no effect, or have been rejected by vomiting; +where the pulse becomes quicker, and the debility increases, we have not +only to dread a return of the fits, but that the stage of actual sinking +is at hand. + +"It would perhaps," says Dr. Marshall Hall, "be difficult to offer any +observations on the nature and cause of excessive reaction; but it is +plain that the state of sinking involves a greatly impaired state of the +functions of all the vital organs, and especially of the brain from +defective stimulus. The tendency to dozing, the snoring and stertor, the +imperfect respiration, the impaired action of the sphincters, the +defective action of the lungs, and the accumulation of the secretions of +the bronchia, the feeble and hurried beat of the heart and pulse, the +disordered state of the secretions of the stomach and bowels, and the +evolution of flatus, all denote an impaired condition of the nervous +energy." (_On the Morbid and Curative Effects of Loss of Blood_, p. 54.) + +_Hysterical convulsions_ scarcely deserve the name of puerperal +convulsions, being liable to occur under circumstances quite independent +of the puerperal state; they rarely occur during the process of labour +itself, but are chiefly observed during the last few weeks of pregnancy, +and the first week or so after labour, especially when the milk is coming +on. + +_Symptoms._ The patient is of a nervous hysterical habit; "she is either +still very young, or is of a slim and delicate make; the face is pale and +interesting; she has full blue eyes and light hair, and was always of a +highly sensitive constitution; the pulse is quick, small, and contracted; +the temperature of the skin is rather cool than otherwise; her spirits are +variable, fretful, and anxious; she starts at the slightest noise, cannot +bear much or loud talking, and misunderstands or takes every thing amiss. +During her slumbers, which are short, there are slight twitchings of the +eyes and mouth, and in her sleep the eyes are in constant restless motion, +and she frequently starts. She complains of sickness, and has frequent +calls to pass water, which is very pale; slight rigours alternate every +now and then with flushing, and she is easily tired, even by trifling +pains, and dozes a good deal during the intervals. She is excessively +sensitive, even to the most gentle and cautious examination; the os uteri +remains thin, hard, tense, and painful to the touch longer than is usually +the case. The ordinary tension and stretching of the os uteri at the +termination of a regular contraction is attended with much more pain, and +with a peculiar feeling of lassitude, although uncomplicated with any +rheumatic affection. The pains follow no regular course, being sometimes +stronger, at others weaker, and frequently cease entirely for +considerable periods. The uterus has a great disposition from the +slightest irritation, to partial and spasmodic contractions." (Wigand, +_Geburt des Menschen_, vol. i. p. 164.) + +Before the fit the patient usually passes a large quantity of colourless +and limpid urine; she has oppression at the stomach, anxiety, difficulty +of breathing and palpitation, with globus, sobbing, and other hysterical +symptoms. There are not those precursory symptoms of cerebral congestion +as mark genuine epileptic puerperal convulsions; the headach is neither so +severe, nor is it in the same place, being usually at the temples and +across the forehead; the face is rather pale than flushed, and when the +fit begins, we see little or none of the convulsive twitching among the +small muscles, as is the case with an epileptic attack; the face is less +distorted, but the large muscles of the trunk and extremities are much +more violently affected; the patient struggles furiously, and in severe +cases has more or less of opisthotonos; she screams, and never appears to +lose her senses so entirely as in the epileptic form; her raving may +generally be controlled to a certain extent by suddenly dashing cold water +in her face, and speaking loudly and sharply to her; at any rate it +instantly produces a deep and sudden inspiration, which is frequently +attended with a prolonged hooping sound; this is followed by sobbing, +gasping, choking, and the ordinary phenomena of an hysteric fit, but the +convulsions themselves are usually arrested more or less by this +application: we hold the effects of cold water to be one of the best +diagnostics of the disease from epilepsy, in which the patient is entirely +insensible to such impressions. + +A similar fact is observed during vaginal examination; the patient seems +aware of our intention, and resists in every possible way. + +"The patient, after the fit, can for the most part be roused to attention +or will frequently become coherent so soon as she recovers from the +fatigue or exhaustion occasioned by her violent struggles; and though she +may lie apparently stupid, she will nevertheless sometimes talk or +indistinctly mutter. After the convulsion has passed over, she will often +open her eyes and vacantly look about, and then, as if suddenly seized by +a sense of shame, will sink lower in the bed, and attempt to hide her head +in the clothes." (Dewees's _Compend. Syst. of Midwifery_, § 1240.) + +When sufficiently recovered to be capable of swallowing, she should sip +some cold water, or what is still better, take a dose of spiritus ammoniæ +foetidus in water; this soon produces copious eructations from the +stomach, which are followed with much relief. Where there is a disposition +to vomiting, and other evidences of a deranged stomach, it should be +encouraged by some warm water, chamomile tea, &c. The bowels are almost +always in an unhealthy state, which frequently produces much irritation, +and in plethoric habits so much tendency to cerebral congestion as to +endanger even an attack of the epileptic convulsions. One or two doses of +a pretty brisk purgative should, therefore, be given, and if there be +still heat or pain of head, a bleeding may be required. + +Under ordinary circumstances hysterical convulsions are by no means +dangerous, and beyond a little fatigue and exhaustion, the patient +recovers from them almost immediately. + + + + +CHAPTER XII. + +PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA. + + _History.--Dr. Rigby's division of hæmorrhages before labour into + accidental and unavoidable.--Causes.--Symptoms.--Treatment.--Plug.-- + Turning.--Partial presentation of the placenta.--Treatment._ + + +There are few dangers connected with the practice of midwifery which are +more deservedly dreaded, and which are wont to come more unexpectedly, +both to the patient as well as to the practitioner, than that species of +hæmorrhage which occurs in cases where the placenta is implanted either +_centrally_ or _partially_ over the os uteri. Well has a celebrated +teacher observed, that "there is no error in nature to be compared with +this, for the very action which she uses to bring the child into the world +is that by which she destroys both it and its mother." (Naegelé, _MS. +Lectures_.) In other words, where there is this peculiar situation of the +placenta it becomes gradually detached, either in proportion as the cervix +expands during the latter months of pregnancy, or as the os uteri dilates +with commencing labour, and is thus unavoidably attended with a profuse +discharge of blood, which generally increases as the dilatation proceeds. + +The peculiar feature of this species of hæmorrhage, necessarily +accompanying the commencement of every labour where the placenta is +implanted over the os uteri, was first fully described in this country in +1775, by the late Dr. Rigby, in his classical _Essay on the Uterine +Hæmorrhage which precedes the Delivery of the full-grown Foetus_, a work +which has been justly looked upon, both in England and the Continent, as +the great source to which we are indebted for our practical knowledge in +the management of these dangerous cases. + +_History._ There is abundant evidence to prove the sudden attacks of +hæmorrhage during pregnancy, attended with circumstances of great danger +to the life of the mother and her child, were known from the earliest +times, and especially noticed by Hippocrates where he says, "that the +after-burden should come forth after the child, for if it come first, the +child cannot live, because he takes his life from it, as a plant doth from +the earth." (_De Morbis Mulierum_, lib. i. quoted by Guillemeau.) + +Hippocrates, therefore, evidently supposed that this presentation of the +placenta at the os uteri was owing to its having been separated from its +usual situation in the uterus, and fallen down to the lower part of it. + +This view has been closely adopted by Guillemeau, to whom we are indebted +for having called our attention to the above passage. He has devoted his +fifteenth chapter[140] to the management of a case where the placenta +presents, and shows that "the most certain and expedient method is to +deliver the patient promptly, in order that she may not suffer from the +hæmorrhage which issues from the uncovered mouths of the uterine veins, to +which the placenta had been attached; that, on the other hand, the child +being enclosed in the uterus, the orifice of which is plugged up by the +placenta, and unable to breathe any more by the arteries of its mother, +will be suffocated for want of assistance, and also enveloped in the blood +which fills the uterus and escapes from the veins in it which are open." + +The operation of turning, which had been newly practised by his teacher, +Ambrose Paré, and still farther brought into notice by himself, at that +time formed a great æra in midwifery, for it furnished practitioners with +a new and successful means of delivering the child in cases where urgent +danger could only be avoided by hastening labour; hence, therefore, in all +cases of profuse hæmorrhage coming on before delivery, it was a general +rule, if the case became at all dangerous, to turn the child. + +Guillemeau's explanation of the nature of placental presentations was +still more explicitly adopted by Mauriceau, La Motte, and many others. +Mauriceau invariably speaks of the placenta, when at the os uteri, as +"entirely detached;" and adds that "even a short delay will always cause +the sudden death of the child if it be not quickly delivered; for it +cannot remain any time without being suffocated, as it is now obliged to +breathe by its mouth, for its blood is no longer vivified by the +preparation which it undergoes in the placenta, the function and use of +which cease the moment it is detached from the uterine vessels with which +it was connected: the result of this is the profuse flooding which is so +dangerous for the mother; for if it be not promptly remedied she will +quickly loose her life by this unfortunate accident." (Vol. i. p. 332, 6th +ed.) He also adds, "it must be observed that the placenta, which presents, +is nothing more than a foreign body in the uterus when it is entirely +separated," (p. 333,) "for when it comes into the passage before the +infant, it is then totally divided from the womb." (_Chamberlen's Transl._ +p. 221. 8th ed.) In the sixteen cases which he has detailed, he has +distinctly mentioned the fact in thirteen that the placenta was _entirely +separated_ from the uterus, and presented at the os uteri. In two of +these he has expressly stated his conviction that the placenta had been +detached from the uterus, by the mother having been exposed to a violent +shock, when the cord was shortened from being twisted round the child. + +These facts prove that Mauriceau, considered presentations of the placenta +to arise solely from its having been separated by some _accident_ from the +fundus, and fallen down to the os uteri. + +Dr. Robert Lee, in his "Historical Account of Uterine Hæmorrhage in the +latter Months of Pregnancy," (_Edin. Med. and Surg. Journal_, April 1839,) +has omitted all mention of this circumstance, and from the account which +he has given of Mauriceau's observations, would infallibly lead his +readers to suppose that Mauriceau was fully acquainted with the real +nature of these peculiar cases. Thus, he commences with saying, "The +symptoms and treatment of cases of placental presentation are here +accurately described, and in all cases of hæmorrhage from this cause he +recommends immediate delivery;" and again, he observes, "The rules for the +treatment of these cases are laid down with the greatest precision. When +the placenta was entirely separated, then only did he consider it as a +foreign body, and recommend its extraction before the child." The student +would be led by such a statement to suppose that Mauriceau did not +consider the _entire separation of the placenta_ as the most usual +occurrence in these cases, and will therefore naturally infer that in the +majority of cases of placental presentation, he recognised the +implantation of the placenta upon the os uteri. That such was very far +from the case, we have already shown by quotations from various editions +of his work. Dr. Lee has collected sixteen, (not seventeen,) cases of +placenta prævia from Mauriceau, and has given a short summary of them. Out +of the thirteen cases in which Mauriceau has distinctly mentioned that the +flooding had been caused by the entire separation of the placenta which +presented, Dr. Lee has noticed it in only three; and in one of these he +has reversed the expression by saying, "placenta presenting and entirely +detached:" thus leading his reader to infer that the placenta had +presented at the os uteri, but had become detached from it. Nor is the +case (No. 423,) to which Dr. Lee has referred "as a proof that Mauriceau, +was aware of the fact, that the placenta had not been wholly detached from +the uterus," at all tend to show that he had any idea of the placenta +being implanted upon the os uteri. + +By stating that "Mauriceau has also recorded the histories of thirty-seven +cases of uterine hæmorrhage in which the placenta did not present, but had +adhered to the upper part of the uterus and been accidentally detached," +Dr. Lee has confirmed the erroneous inference that the implantation of the +placenta upon the os uteri was known to this valuable author; whereas, we +have proved by numerous quotations, that Mauriceau distinctly supposed +that in _all_ cases of hæmorrhage before labour, _whether the placenta was +found presenting or not_, it had been originally attached "to the upper +part of the uterus." + +Paul Portal was the first, as far as we are acquainted, who describes the +placenta as _adhering_ to the os uteri. He has recorded eight cases, "in +which," as Dr. Rigby observes, "he was under the necessity of delivering +by art, on account of dangerous hæmorrhages, and in all of them he found +the placenta at the mouth of the womb." (_Essay on Uterine Hæmorrhage_, p. +22, 6th ed.) In these he distinctly mentions the placenta adhering to the +os uteri. In several of these he separated it from the os uteri and +brought it away; and in seven he turned the child. In the other (Case 39,) +the head burst its way through the placenta. In one case only (51,) does +he attempt to make any practical inference whatever, having in all the +others contented himself with merely stating the fact of the placenta +adhering to the os uteri. In this instance, however, he has described the +real nature of the case, and pointed out the cause of the hæmorrhage. On +introducing his hand he "found the after-burden placed just before and +quite across the whole inner orifice, which had actually been the occasion +of the flux of blood; for by the opening of the orifice the said +after-burden then being loosed from that part where it adhered to before, +and the vessels containing the blood torn and opened, produced this +flooding, which sometimes is so excessive as proves fatal to the woman +unless it be speedily prevented." (_Portal's Midwifery_, transl. p. 167.) + +There is no doubt, as Dr. Renton has very justly observed, "that Portal in +1672 (not 1683) knew as much on the subject of uterine hæmorrhage +occasioned by the displacement of the placenta from the os uteri, and the +practice necessary for its suppression, as we do at the present time." +(_Edin. Med. and Surg. Journ._ July, 1837.) But we cannot coincide with +him in the passage which follows, viz. "It is to him unquestionably that +we are indebted for our knowledge on the subject," because, as Dr. Renton +himself has shown, all the authors in midwifery up to the time of Roederer +and Levret (1753) were ignorant of Portal's explanation. We do not even +except Giffard, as there is sufficient evidence to show that he, for some +time, entertained the prevailing erroneous opinions of Mauriceau, until he +at last discovered the real nature of the case himself. We attribute the +omission solely to the above observation of Portal being so short and +isolated, and to its having been entirely unaccompanied by any other +practical remarks or inferences which might have been expected from so +remarkable a fact. To this reason _alone_ can we attribute the +circumstance of its not having been expressly mentioned by Dr. Rigby when +alluding to Portal's cases. In a similar way we can explain why Portal has +not had the merit of a valuable improvement in the operation of turning +which has been attributed to Peu, viz. the passing the hand between the +membranes and uterus up to the fundus before rupturing them, solely +because he mentions it as a cursory observation, without any farther +notice or practical inference. + +The next author who has at all alluded to the real nature of placenta +prævia is Giffard, whose posthumous work was published in 1734. The value +of his evidence on this subject is considerably modified by his having +made no allusion to the implantation of the placenta upon the os uteri in +the first ten cases of flooding, where he found the placenta presenting, +but repeatedly describes the placenta as being wholly separated and lying +in the passage, and in some, he expressly mentions that the placenta had +fallen down to the os uteri. In cases 115, 116. and 224. he gives a +perfectly correct explanation of the cause of flooding, but the opinion is +expressed with such a degree of hesitation, and so cursorily, that we +doubt much if it attracted more notice than the observations of Portal, +above alluded to, more especially as in the six cases of placenta prævia, +which occur between the last two above-mentioned (viz. 120, 121. 158. 160. +185. and 209.,) he returns again to his former mode of describing them. +We, therefore, regret that Dr. Renton has not mentioned this circumstance, +and that in quoting from "two of the numerous cases which he relates," he +has not stated that these were two out of the only three cases which +Giffard had described correctly.[141] + +It is, therefore, to the above-mentioned circumstances of Giffard having +given what is now recognised as the correct explanation, in only three out +of nineteen cases, that we can explain why so little notice was taken of +the subject at that time; why Dr. Smellie, when speaking of it, makes no +allusion to Giffard; and why Dr. Rigby, in his _Essay on Uterine +Hæmorrhage_, was led to suppose that he was ignorant of the real nature of +these cases: certain it is that his opinion could scarcely be called a +decided one. + +Smellie mentions that "the edge or middle of the placenta sometimes +adheres over the inside of the os internum, which frequently begins to +open several weeks before the full time; and if this be the case, a +flooding begins at the same time, and seldom ceases entirely until the +woman is delivered; the discharge may, indeed, be intermitted by coagulums +that stop up the passage, but when these are removed it returns with its +former violence, and demands the same treatment that is recommended +above." His cases contain no observation beyond the recital that a +considerable hæmorrhage had occurred, the placenta had been found +presenting, and that he had turned the child. In his sixth case (Collect. +33, No. 2.) which is dated 1752, it is evident that he was ignorant of +what had been said on the same subject by Giffard and Portal; for he +observes, "This case being uncommon, I was uncertain at first how to +proceed; but at last considering with myself, if I broke the membranes to +evacuate the contained waters, so as to allow the uterus to contract and +restrain the flooding, the foetus would be lost by the pressure of the +head against the funis (which presented) in the time of delivery. I +resolved in order to prevent this misfortune to turn the child, and bring +it along in the preternatural way, which would give it a better chance to +restrain the one, and save the other, if the operation could be performed +in a slow cautious manner." This forms the amount of his observations on +this important subject, and, therefore, justifies the observation which +Dr. Rigby has made, viz. that there are no practical inferences drawn from +the cases; nor in his directions about the management of floodings, are +there any rules given relative to this situation of the placenta. + +Roederer decidedly stands pre-eminent, as being the first author who gave +a distinct and complete description of this species of hæmorrhage; he +points out the cause of it, and accurately describes its symptoms and mode +of attack; he shows that the placenta may be entirely or partially +attached to the os uteri; that in the one case the hæmorrhage will be very +profuse, and artificial assistance will be required; in the other it will +be slighter, and in many cases it may be left to nature.[142] + +Levret cotemporaneously with the first edition of Roederer's work, +published at Paris, a valuable paper on placental presentation, which, +with the above-mentioned chapter of Roederer, must be looked upon as the +first observations in which this form of hæmorrhage was made a distinct +subject of consideration. Although Levret has in no wise claimed the merit +of being the first who had noticed the fact of the placenta being +implanted upon the os uteri, still there can be no doubt that to him and +Roederer we are indebted for having first investigated the subject and +called the attention of the profession to its peculiar characters. + +Levret has reduced his observations under three heads, viz. that the +placenta is occasionally implanted over the os uteri, that hæmorrhage +under such circumstances is inevitable, and that the safest mode of +remedying this accident is the _accouchement forcé_. He has also added a +few valuable remarks, but by far the greater part of the essay is occupied +with theoretical arguments to prove that it is impossible for the +placenta, which had been attached to the fundus, to sink down to the os +uteri. Indeed, beyond stating the three above-mentioned positions, which +are undeniably of great practical value (although by no means original,) +Levret has added but little which is not contained in Giffard, his chief +merit being that of making it a subject of distinct consideration, and +establishing it as a matter beyond doubt. + +Levret cannot, however, be looked upon as the first who considered that +the flooding, in cases of placenta prævia, was "inevitable," although, +from his not having quoted Giffard, we willingly concede to him the merit +of originality, as far as he himself was concerned: it was Giffard, +however, as far as we know, who first pointed out that hæmorrhage was the +necessary consequence of placental presentation, as is shown from what we +have already quoted from him, although, to a certain extent, it was hinted +at by Portal, in his fifty-first case. Levret's memoir was afterwards +reprinted in his large work, entitled _L'Art des Accouchemens_: the third +edition, which appeared in 1766, was quoted by Dr. Rigby in the first +edition of his _Essay on Uterine Hæmorrhage_, 1775,[143] in farther proof +of the placenta being implanted over the os uteri, and being the cause of +hæmorrhage. + +We are chiefly indebted to Dr. Rigby for a complete exposition of this +important and interesting subject. His well-known essay on the uterine +hæmorrhage which precedes the delivery of the full-grown foetus has stood +the test of time, and will ever remain, not less remarkable for its +practical value, than "for the perspicuity and simplicity of its style." +(Renton, _op. cit._) To Dr. Rigby, without doubt, is due the merit of +having first distinguished hæmorrhages, which occur before delivery, into +_accidental_ and _unavoidable_, a division so truly practical and +appropriate, as to have placed this subject in the clearest and simplest +possible light. "He was," as Dr. Collins has justly observed, "the first +English author who fully established this most important practical +distinction in the treatment of uterine hæmorrhages, although Levret had +many years before published a somewhat similar statement." Dr. Rigby's +arrangement has been adopted by Dr. Merriman, Dewees, and every other +modern author of any note; and the medical world have amply testified +their sense of its value, as well as of the work itself in general, by the +numerous editions which it has undergone in this, and translations and +reprints in other countries. + +We have entered into an historical detail of the literature of this +subject, from its having been asserted that Dr. Rigby "published an +abstract of the doctrines of Puzos and Levret with the addition of some +cases from his own practice," (Burns, _Principles of Midwifery_, 9th ed., +1837, p. 364;) that he availed himself of the discoveries of Dr. Smellie +and M. Levret, while he contrived to make the profession believe that his +doctrines were original, (Hamilton, _Practical Observations_, &c., 1836, +vol. ii. p. 238;) and that "no fact of the slightest importance has since +(Smellie) been discovered relating to the causes and treatment of uterine +hæmorrhage in the latter months of pregnancy." (Dr. R. Lee, _Edin. Med. +and Surg. Journ._, 1839, vol. li. p. 389.) We, therefore, deem it only +just to our readers, and also to the author, to lay before them his own +account of what, at the time, he supposed to be a discovery, and how far +he considered himself justified in laying claim to its originality. + +"A case of hæmorrhage, in which I found the placenta attached to the os +uteri, occurred at a very early period of my practice; but not finding +such a circumstance recorded in the lectures which I had attended, or +taken notice of in the common elementary treatises on midwifery, I +considered it at first merely as a casual and rare deviation from nature. +In a few years, however, so many similar instances fell under my notice, +as to convince me, that it was a circumstance necessary to be inquired +after in every case of hæmorrhage: and this conviction was confirmed by +the perusal of cases in midwifery; for I then found that the fact of the +placenta being thus situated had been recorded by many writers, though in +no instance which had then reached me, had any practical inferences been +deduced from it. It appeared to me, indeed, most extraordinary that such a +fact, known to so many celebrated practitioners, should not long before +have led to its practical application, and in consequence to more fixed +principles in the treatment of hæmorrhages from the gravid uterus; and I +may, perhaps, be allowed to say, that I congratulated myself, young in +years and practice as I was, in being, probably, the first to suggest an +important improvement in the treatment of one of the most perplexing and +dangerous cases in midwifery; and that I committed my observations on the +subject to paper, not only under a conviction of their practical utility, +but certainly also under an impression that my suggestions were original. + +"Not long after the first edition was at press, indeed before the first +sheet was printed, Levret's dissertation on this subject fell into my +hands, and in a note I referred to it as additional testimony in proof of +the placenta, in these cases, being originally attached to the os uteri. + +"I have been led into this little detail, because it has been suggested +that I have borrowed my theory from Levret. After remarking the gross +folly I should have been guilty of in quoting Levret, had I furtively +adopted his opinions, it will, I trust, be sufficient for me unequivocally +to declare that my original ideas on the subject were derived solely from +my own personal observation and experience; and that having previously +neither read nor heard of the placenta being ever fixed to the os uteri, +the knowledge of such a circumstance, derived as before observed, came to +me and impressed me as a discovery. + +"I was, certainly, afterwards struck with the coincidence of the +sentiments of Levret and myself on the subject, with the similarity of our +practical deductions, and, allowing for the difference of language, even +with the sameness of our expressions. I am farther not reluctant to +acknowledge, that after reading Levret's dissertation, I felt less +entitled to the claim of absolute originality on the subject; and I now +rest perfectly satisfied to divide with him the credit arising from the +mere circumstance of communicating a new physiological fact. But were I +even denied all claim to originality, I should still not be without the +satisfaction of having, at least, materially contributed to diffuse the +knowledge of an important fact, and of having established its practical +utility on the unequivocal testimony of experience; for, had I seen +Levret's dissertation sooner, or had even my attention been first directed +to the subject by its perusal, ought it to have superseded my publication? +Was the practice in this country, at that time, at all influenced by +Levret's dissertation? or has it even since been translated into the +English language? Was it, at that time, generally known that the +attachment of the placenta to the os uteri was a frequent cause of +hæmorrhage? and were any directions for our conduct in these cases, +founded on the knowledge of the fact, given by those who there lectured on +the art of midwifery? + +"Levret's facts, moreover, though they proved that the placenta might be +originally attached to the os uteri, (and a single instance would +establish this,) were scarcely sufficient to prove the frequency of its +occurrence, from which alone arises the necessity of practically +attending to it in every case of hæmorrhage. His observations (perhaps +even more creditable to him for being founded on such scanty materials) +were derived from four cases only, and of these, but two were under his +own immediate cognizance; whereas, in the first edition of this essay my +opinions were supported by 36 detailed cases, in 13 of which the placenta +was found at the os uteri; and in the fourth edition the number was +increased to 106, 43 of which were produced by this peculiar original +situation of the placenta." (Preface to the 5th ed.) + +The _causes_ of this peculiar deviation from the usual situation of the +placenta are little if at all known. The condition of the decidua shortly +after the entrance of the ovum into the cavity of the uterus, will +probably influence the situation of the placenta considerably. Under the +ordinary circumstances, this effusion of plastic lymph has already +attained such a degree of firmness and coherence as to prevent the ovum +from passing beyond the uterine extremity of the Fallopian tube from which +it has emerged; but in cases of placental presentation it may be presumed +that at this period the decidua was still in a semi-fluid state, had +formed little or no attachment to the walls of the uterus, and had, +therefore, no effect in preventing the ovum gravitating to the lower part, +or even to the mouth of the uterus itself. We state this, of course, as a +mere matter of theory, since the difficulty of investigation at such early +periods, and the comparative rarity of placental presentations, will +probably ever prevent our ascertaining the real cause. + +_Symptoms._ The first symptom which warns us that the placenta is +presenting, is the sudden appearance of hæmorrhage, which is usually more +copious than ordinary hæmorrhage, and apparently comes on without any +assignable reason: it is usually the more profuse the nearer the patient +is to the full term of pregnancy, for not only now are the ruptured +vessels larger, but the separation of the placenta is generally greater. +If she has still some time to go, the discharge will be probably slight, +and with rest and quiet, &c., will cease, to return again in ten days or a +fortnight with increased violence: this usually happens at what would have +been a catamenial period. The suddenness of its attack, the profuseness of +the discharge, and its coming on without any evident cause, are peculiarly +suspicious. + +It has been stated that the abdomen is less distended in these cases than +usual, from the placenta not being in the upper parts of the uterus: it is +an observation, however, which requires to be confirmed, and certainly our +own experience, as yet, has not led us to such a conclusion. + +On examination, the os uteri is found to be larger and thicker than +ordinary: it has a loose spongy feel, for its vessels are now as immensely +distended as those of the fundus, when the placenta has its usual +situation. If the placenta be partially attached over the os uteri, it is +generally upon the anterior lip, which is much thicker. In this case we +shall feel the edge of the placenta projecting at one side of the os +uteri, and the bladder of membranes, and probably the presenting part of +the child at the other. Whereas, if the placenta be centrally attached, we +shall find it attached to the whole circumference, except perhaps where +the separation is, from which the hæmorrhage proceeds. We shall +distinguish the placenta by its spongy mass, by its soft irregular +surface, and by the stringy feel which it communicates where it has been +torn. + +The character of the hæmorrhage is also different from that of common +hæmorrhage, inasmuch as it increases during a pain, and diminishes or +ceases during the intervals, whereas, in hæmorrhage under ordinary +circumstances it is the reverse. + +Where the hæmorrhage takes place at some distance of time from the full +period of utero-gestation, it probably arises from the gradual development +of the cervix during the latter months of pregnancy: where, on the other +hand, it does not appear till just before labour, the separation of the +placenta will have been produced by the incipient dilatation of the os +uteri itself. It might therefore be supposed, that the period of the +attack would, in great measure, depend upon whether the placenta was +centrally, or only partially, attached to the os uteri; that in the former +case the placenta would be more liable to be separated by the gradual +development of the inferior segment of the uterus; and that, therefore, +hæmorrhage would come on several weeks before the full term; whereas, if +only a portion of it cover the edge of the os uteri, the patient would +probably go to the very end of pregnancy before any flooding appeared. +Although this view is supported by the high authority of Professor +Naegelé, still we can scarcely agree with it, since not only do a +considerable majority of recorded cases show that a patient with central +presentation of the placenta may go to the full time without an attack of +flooding, but also several of those which have come under our own +observation lead to a similar conclusion. + +The most alarming attacks of hæmorrhage are doubtless at the full term, +when the os uteri is beginning to dilate from commencing uterine +contractions, and the placenta is centrally attached over it: in these +cases the discharge experiences little or no abatement beyond an +occasional short remission, but returns with the pains, increasing in +profuseness as the gradually dilating os uteri produces a still farther +separation of the placenta. Such cases, if left to themselves, would +almost necessarily prove fatal. The first fainting fit or two would +probably produce a temporary cessation of the discharge, and favour the +formation of coagula in the upper part of the vagina; but with returning +contractions of the uterus, the hæmorrhage would be renewed with +increased violence, and quickly reduce the vital powers. In such cases +the patient will probably die undelivered, or soon after the birth of a +dead child. In some rare instances, the pains have been sufficiently +powerful to force the head through the placenta, and thus enable the +mother to be delivered by the natural means, although with little chance +of the child being born alive, from the injury which the foetal vessels in +the placenta have received. Portal's twenty-ninth case terminated in this +way. A similar and very interesting case was lately communicated to us by +Mr. W. White, of Heathfield, in Sussex, where the placenta appears to have +been centrally attached to the os uteri, and where, in consequence of two +or three powerful pains, the head was forced _through_, tearing it quite +across. The child was born dead, but the mother did well. + +In a few rare cases the placenta has been entirely separated and expelled +before the child, but these have usually been attended with a most +alarming loss of blood. In almost all the cases related by Mauriceau, and +in the majority of those by Giffard, the placenta is stated to have been +entirely detached from the uterus, but this was evidently under the +mistaken supposition of the placenta having been originally separated from +the fundus. "It is extremely rare to meet with a total separation of the +placenta. Dr. Clarke informed me that he met with but one case of total +separation; the patient dying before he reached the house." (Collin's +_Pract. Treatise_, p. 92.) A still more remarkable instance is recorded by +Dr. Collins, where the placenta had been expelled many hours (probably +about 18) before the birth of the child. "The membranes had ruptured, and +the waters been discharged a fortnight previous to admission, from which +time, until the evening before she was brought to the hospital, she had +more or less hæmorrhage. It was now ascertained that the placenta had been +expelled the evening before her admission, and separated by the midwife in +attendance. She left the hospital well on the thirteenth day."[144] (_Op. +cit._ p. 103.) In all these cases the child has been born dead, and must +ever be so, where any period of time has elapsed between the expulsion of +the placenta and that of the child. The only case we know of where a +living child was born after the expulsion of the placenta is recorded by +F. Ould. "I found this woman in imminent danger, being seized with +faintings and hiccough, having her face pale and Hippocratic. Upon +examination, I found the placenta presented to the orifice of the womb, +which I immediately extracted; and although the head was far advanced in +the passage, I put it back into the womb, and taking hold of the feet +brought a living though very weakly child into the world. The mother also +recovered, though with much difficulty." (_Treatise on Midwifery_, p. 77.) +La Motte has described a similar case, but where the child died +immediately after birth. (_Obs._ 238.) + +The irregularity with which cases of placental presentation have appeared +at different times, have more than once excited notice: thus it frequently +happens to ourselves that several years have elapsed without our meeting +with a single case, although connected with a large lying-in hospital; +whereas, at other times two or three cases have followed each other at +comparatively short intervals. In selecting ten successive years from the +period during which Dr. Rigby observed the numerous cases recorded in his +essay, we see this irregularity remarkably exemplified. + + In 1779 three cases. + In 1780 four cases. + In 1781 none. + In 1782 five cases. + In 1783 one case. + In 1784 five cases. + In 1785 two cases. + In 1786 two cases. + In 1787 one case. + In 1788 two cases. + +A still more remarkable variation has been described by the celebrated +Matthias Saxtorph, of Copenhagen. Having stated that placental +presentation had occurred only once in 3600 cases, he adds, "the reader +will be astonished when I assure him that this case, which is so rare that +I had only seen it twice in so many years, and that I had met with it but +once out of so many thousand labours at our lying-in hospital, occurred to +me in the last six months, _eight times_." (_Collect. Soc. Med._ Havn. +1774, vol. i. p. 310.) Professor Naegelé has made a similar remark in his +lectures, and states, that in some years placental presentation was so +frequent that it seemed as if it were almost epidemic. + +Experience proves beyond doubt, that, of the serious floodings which occur +during the last weeks of pregnancy, the majority arise from the attachment +of the placenta to the os uteri. Dr. Rigby also states "that this +attachment of the placenta to the os uteri is much oftener a cause of +floodings than authors and practitioners are aware of, I am from +experience fully satisfied; and so far am I convinced of its frequent +occurrence, that I am ready to believe that most, if not all, of those +cases which require turning the child, are produced by this unfortunate +situation of it." + +The period of pregnancy at which hæmorrhage may come on from placental +presentation, varies very considerably. Although, in by far the majority +of these cases, it does not come on until the last four or six weeks, it +now and then occurs at a much earlier period, viz. the sixth or even the +fifth month, and sometimes even earlier. Where this is the case, it must +rather be looked upon as one of "accidental" hæmorrhage or abortion, for +it can scarcely be supposed that any changes about the os or cervix uteri +could have been sufficient to have produced an "unavoidable" separation of +the placenta at this time. Thus, for instance, in Dr. Rigby's +seventy-fifth case, the first attack of hæmorrhage had appeared when the +patient "was about three months gone with child;" and at that early period +could hardly have been attributed to the peculiar situation of the +placenta, but to the more common causes of hæmorrhage connected with +abortion. In his forty-third case, the hæmorrhage, which came on about the +twenty-sixth week, appears at first to have been purely "accidental," +although it was afterwards produced by "unavoidable" attachment of the +placenta. "We very seldom meet with unavoidable hæmorrhage before the +sixth month of pregnancy; it is not until the cervix uteri begins to +distend freely, and the changes that take place previous to the approach +of labour commence, any suspicions are observed; consequently, it will be +in the last three months of utero-gestation that hæmorrhage of this nature +is found to occur." (Collins, _op. cit._ p. 93.) + +The examination of a case where the placenta presents is not always easy; +the natural position of the os uteri during the latter months of pregnancy +in the upper part of the hollow of the sacrum makes it very difficult for +the finger to reach so completely as to afford us the means of +ascertaining satisfactorily whether the placenta be attached to it or not. +"For this purpose, however, the usual method with one finger will not +always suffice, but the hand must be introduced into the vagina, and one +finger insinuated into the uterus; for in several of the following cases +it will appear, that though the women were frequently examined in the +usual way, the placenta was not discovered till the hand was admitted for +the purpose of turning the child." (_Essay_, 6th ed. p. 35.) + +_Treatment._ We have already stated that the earlier the period at which +the flooding comes on, the less profuse it will be; the treatment, +therefore, where the hæmorrhage is inconsiderable, differs but little from +that in an ordinary case of abortion or miscarriage. The indications, in +fact, are the same, viz. to stop the discharge, and allay any disposition +to uterine contraction. + +The patient must be placed upon a mattress, and covered as lightly as +possible with safety and tolerable comfort to herself. If the circulation +be active, the pulse strong, with more or less heat of surface, it may +even be desirable to reduce this by means of the lancet. "Under any kind +of active hæmorrhage, when the pulse is vigorous, the taking away blood +from the arm has uniformly been found useful, by producing contraction by +the mere unloading of the vessels, and more especially in diminishing the +velocity of blood within them." (Dewees, _Compend. Syst. of Midw._ p. +441.) Cold cloths must be applied to the vulva, loins, and over the +symphisis pubis; gentle saline laxatives with nitrate of potass should be +given if the bowels are confined; and if there be the slightest appearance +of the pains, an injection of twenty or thirty drops of Liq. Opii Sedat. +into the rectum will be necessary. This may be given immediately where the +bowels are not confined, or, if they are, after the rectum has been washed +out by a large domestic enema. If necessary, she should also take an +opiate by the mouth. Her food must consist of little else than plain +drinks, as tea, milk and water, &c., all of which must be taken cold; and +she must preserve the most perfect quiet of body as well as mind. We +cannot agree with Dr. Dewees in permitting "our patients, under treatment +for uterine hæmorrhage, to be five or six days without a discharge from +the bowels;" as a loaded state of the lower bowels cannot fail in our +opinion to obstruct seriously the free return of the circulation from the +pelvic viscera, and thus greatly increase the disposition to congestion +and hæmorrhage. + +The longer the patient has still to go, the more desirable is it that we +should, if possible, control the symptoms, and prevent them from +proceeding to such extent as to require artificial delivery. It is of the +utmost consequence that we should take such measures as will enable the +pregnancy to go on safely, if not to the full time, at least to a later +period, for by this means the uterus will have attained such a degree of +development as will enable the turning to be undertaken with ease to the +practitioner and with safety to the mother; the child also will have so +far advanced towards maturity as to give it a better chance of surviving +the operation. + +Wherever hæmorrhage has occurred during the last three months of +pregnancy, which has come on suddenly and without any assignable reason, +we should earnestly warn the patient and her friends to summon the +practitioner the moment there are any symptoms of its return; for if it be +a case of placental presentation, it assuredly will return, and as +certainly much more profusely than at first. + +Where the patient has gone nearly or quite to her full time, the first +attack is much more alarming; the hæmorrhage frequently appears with a +sudden gush, and in a few minutes a serious and even dangerous quantity of +blood is lost; thus a patient whom we had seen but a few hours previously +in perfect health, was suddenly seized with profuse flooding as she was +standing at the door of her house speaking to a person, and before she +could move, a large pool of blood had formed at her feet; in another case, +the patient while standing at her tea-table was attacked in a similar +manner, and in a moment the floor was deluged with the discharge. + +Although artificial delivery by turning the child is required in every +case of central presentation of the placenta during the latter periods of +pregnancy, it is evident that this will not apply during the earlier +months, when the uterus from its size will preclude the possibility of +such an operation. Dr. Rigby has established a valuable axiom on this +point, viz. "that when the uterus is too small for the admission of the +hand, the expulsion of the placenta and foetus will happily be timely +effected by nature. It is well known that in the early months, instances +of fatal termination by floodings have been very rare, as abortion sooner +or later puts a stop to the discharge. It has been likewise before +observed, that in floodings at any period of pregnancy, women seldom die, +at least not in the first instance, unless a considerable quantity of +blood has been suddenly lost. Now, as the danger of a great and sudden +loss must obviously depend upon the size of the uterine vessels, and as +the enlargement of the vessels is in exact proportion to the increased +size of the uterus, it becomes probable that when the vessels have +acquired such a magnitude, that when detached from the placenta they would +bleed largely and suddenly, the uterus itself must have attained to such a +capacity as to admit the hand for artificial delivery." (_Op. cit._ p. 48, +6th ed.) He farther observes, "that as the most material increase of the +uterus does not take place until the end of the sixth month of pregnancy, +a hæmorrhage before that period will seldom require artificial delivery; +and after that period, should it become necessary, that it is probable the +hand may then be admitted for that purpose." (_Ibid._ p. 51.) + +In almost every case where the patient is some time short of her full +time, the os uteri will be found unyielding and but little dilated; it +will, therefore, seldom be possible, and scarcely ever proper, to +introduce the hand into the uterus under such circumstances; the os uteri +either entirely resists our efforts, or if we do overcome it, the degree +of force required to effect this has been so great, as will in all +probability have been attended with serious injury to the part itself. In +no case is it proper or safe to force delivery by artificially dilating +the os uteri, when it is contracted and unyielding (see TURNING;) but +where the placenta is presenting, it is peculiarly dangerous, for even +slight laceration of the os uteri will be followed by serious +consequences. Where the placenta is situated in the upper part of the +uterus, it is of very little consequence if the edge of the os uteri has +been torn somewhat during labour; but in the present case it is very +different; the os uteri now plays the part of the fundus, its vessels are +immensely dilated, and large ones are ruptured, which cannot be closed by +the firmest contraction of the uterus. + +"In recommending early delivery, I think it right, however, to express a +caution against the premature introduction of the hand, and the too +forcible dilatation of the os uteri before it is sufficiently relaxed by +pain or discharge; for it is undoubtedly very certain that the turning +may be performed too soon as well as too late, and that the consequences +of the one may be as destructive to the patient as the other." (Rigby, +_op. cit._ p. 37.) Cases have occurred where the os uteri has been +artificially dilated, where the child was turned and delivered with +perfect safety, and the uterus contracted into a hard ball; in fact, every +thing seemed to have passed over favourably; a continued dribbling of +blood has remained after labour, which resisted every attempt to check it; +friction upon the abdomen and other means for stopping hæmorrhage by +inducing firm contraction of the uterus were of no use, for the uterus was +already hard and well contracted; the patient has gradually become +exhausted, and at last died; on examination after death, Professor Naegelé +has invariably found the os uteri more or less torn. + +"It must be acknowledged, indeed," says Dr. Rigby, "that it may sometimes +happen that at the very first coming on of the complaint, if the discharge +be small, and more especially, if it be the patient's first child, and the +parts be close and unyielding, the admission of the hand into the vagina, +as I have directed, will be attended with the utmost difficulty, and, +perhaps, be almost impracticable: in this case let us wait (but let it be +with the patient) till the discharge increases, and has continued long +enough to relax the parts; for certainly, if the woman be able to bear +losing a little blood, which at first she may safely do, the examination +will be thereby rendered more easy, and the turning of the child, if +necessary, be more practicable and safe." (_Op. cit._ p. 36.) + +We have already shown (see TURNING, p. 236.) that there is no means of +rendering a rigid os uteri yielding and capable of admitting the hand +equal to the relaxation produced by loss of blood: wherever the powers of +the system have already suffered from the effects of hæmorrhage, we may +feel almost certain that we shall find the os uteri capable of dilating, +even if it be so little open as barely to admit the finger. Where the +patient has become faint or fallen into actual syncope, the relaxation of +the soft parts is very striking, and frequently to an extent which could +scarcely be believed by those who have not felt it; all resistance seems +to be at an end for the time, and the hand enters the flaccid passages +with scarcely a sensation of pressure from them, but rather (as has been +aptly compared, to that of some wet bladder wrapped around it.) + +"It has been advised (observes Dr. Rigby) never to introduce the hand till +nature has shown some disposition to relieve herself by the dilatation of +the os uteri to the size of a shilling, or a half-crown; and this rule is +certainly founded on a rational principle, for when it is so much dilated, +there is no doubt but the turning may be easily and safely effected; but +from some of the annexed cases it appears that a dilatation to this degree +sometimes does not take place at all; and that even when the woman is +dying from the great loss of blood, the uterus is very little open; the +reason for which, seems to be, that when the discharge has been +considerable, and more particularly when much blood has been suddenly +lost, such a faintness is brought on, that though the uterus be totally +relaxed, and might, therefore, be opened by the most gentle efforts, yet +nature is unable to make use of these efforts; and, moreover, if there be +slight pains, the adhesion of the placenta to the internal surface of the +mouth of the womb, counteracts their influence, and thereby hinders its +giving way to a power, which would otherwise, probably, very easily open +it." (_Op. cit._ p. 39.) + +_Plug._ Where, however, the case is at that doubtful period of early +pregnancy, when even under the most favourable circumstances, as +above-mentioned, the hand must experience considerable difficulty in +entering the os uteri, and yet the expulsion of the child cannot be safely +trusted to the natural powers, it becomes necessary, as in certain cases +of premature expulsion, to have recourse to such means as shall enable the +os uteri to go on dilating without the danger of farther hæmorrhage; in +other words, we must plug the vagina. "If, after the commencement of a +flooding, we favour the formation of a coagulum by means of a plug, are we +not aiding nature? It brings on labour much sooner, and the os uteri has +time to dilate without farther loss of blood." (Leroux, _Sur les Pertes de +Sang._ § 309.) By means of the plug, we enable the patient to go on with +perfect security until the pains have produced a sufficient dilatation of +the os uteri to admit the hand; after a time we may withdraw it, and if +then not satisfied with the state of the os uteri, it must be again +introduced until our object be effected. (For directions as to the use of +the plug we must refer to p. 152.) + +"This remedy should be early employed, as it will, by proper management, +save a prodigious expenditure of blood. We gain by its application +important time; time that is essential for the successful delivery of the +foetus; for, by it, the woman's strength is preserved; pain is permitted +to increase; and, eventually, though tardily, the os uteri is dilated, the +placenta and foetus thrown off, and the flooding almost immediately +controlled. The other means which we have constantly pointed out, should +also be tried: they may aid the general intentions, and render the +operation of the tampon more certain." (Dewees, _Compend. Syst. of Midw._ +§ 1142.) + +Although Dr. Rigby has given a short account of Leroux's views respecting +the use of the plug in these cases, we cannot but agree with Dr. Dewees, +in regretting that he either did not "put his plan in execution," or that +if he did, he has not given us the details of his experience upon it. From +what Dr. Gooch, however, has stated in his _Account of some of the more +important Diseases peculiar to Women_, there is every reason to suppose +that Dr. Rigby was latterly in the frequent habit of using the plug, and +that he thought highly of it. The plug is not only useful in keeping the +hæmorrhage under due control until the os uteri be sufficiently dilated, +but may occasionally prove of the greatest value in cases of extreme +exhaustion from loss of blood, where the patient is too much reduced to +undergo the act of delivery, without running the risk of dying during the +operation; the plug will enable us to wait with safety until the system +has had time to rally its powers and be recruited by the administration of +proper nourishment. "Mr. Grainger, of Birmingham, on visiting a poor woman +with placenta prævia, and apparently in a moribund condition, immediately +filled the vagina and os uteri with linen cloths, and waited two days +before he durst hazard delivery, which he accomplished with an auspicious +result." (Ingleby, _on Uterine Hæmorrhage_, p. 155.) + +_Turning._ The operation of turning the child will, in no wise, differ +from that under more ordinary circumstances, and will require to be +conducted according to the rules which we have already given. In no case +is it more important to preserve the membranes unruptured until the hand +has fairly entered the uterus than here; the hand should be carefully +insinuated between the os uteri and placenta; if possible, this should be +done at the part where the separation which has caused the flooding has +already taken place, in order to avoid all unnecessary detachment of the +placenta; the pressure of the hand prevents any great discharge of blood; +and as it gradually makes its way between the membranes and the uterus, +the arm which now occupies the vagina will effectually act as a plug. +Portal, was, probably the first who practised this mode of operation, viz. +passing his hand between the os uteri and placenta, and then between the +uterus and membranes before rupturing them: in this respect he anticipated +Peu, whose work appeared nine years after, (see TURNING, p. 234.) and +would have undoubtedly been looked upon as the originator of this +improvement in turning, had he given any reasons for this mode of +practice, or deduced any inferences from it. + +Some discrepancy of opinion has existed as to whether it is better to +perforate the placenta, or to follow the plan we have just recommended. +Dr. Rigby's authority has rather tended to confirm the former opinion, +although he afterwards modifies it so much so as to make us almost suppose +that he must have preferred the other method. He states, "that by this +means, (perforating the placenta,) not more of the placenta may be +separated than is necessary for the introduction of the hand, and, +consequently, that as little increase of bleeding as possible may be +produced by the operation; but if it be impracticable, as I have more than +once found it, and it must ever be when the middle of the placenta +presents to the hand, from the thickness of it near the funis, it must be +carefully separated from the uterus on one side, and the hand passed till +it gets to the membranes." (_Op. cit._ p. 61.) + +To Dr. Dewees are we chiefly indebted for having put the inexpediency of +perforating the placenta in the strongest possible light. "We are advised +by some," says he, "to pierce the placenta with the hand; but this should +never be done, especially as it is impossible to assign one single good +reason for the practice, and there are several very strong ones against +it. + +"1. In attempting this, much time is lost that is highly important to the +patient, as the flooding unabatingly, if not increasingly, goes on. + +"2. In this attempt we are obliged to force against the membranes, so as +to carry or urge the whole placentary mass towards the fundus of the +uterus; by which means the separation of it from the neck is increased, +and consequently, the flooding augmented. + +"3. When the hand has even penetrated the cavity of the uterus, the hole +which is made by it is no greater than itself, and consequently much too +small for the foetus to pass through without a forced enlargement, and +this must be done by the child during its passage. + +"4. As the hole made by the body of the child is not sufficiently large +for the arms and head to pass through at the same time, they will +consequently be arrested; and if force be applied to overcome this +resistance, it will almost always separate the whole of the placenta from +its connexion with the uterus. + +"5. That when this is done, it never fails to increase the discharge, +besides adding the bulk of the placenta to that of the arms and head of +the child. + +"6. When the placenta is pierced, we augment the risk of the child; for in +making the opening, we may destroy some of the large umbilical veins, and +thus permit the child to die from hæmorrhage. + +"7. By this method we increase the chance of an atony of the uterus, as +the discharge of the liquor amnii is not under due control. + +"8. That it is sometimes impossible to penetrate the placenta, especially +when its centre answers to the centre of the os uteri; in this instance +much time is lost that may be very important to the woman." (_Op. cit._ § +1153.) + +We have already stated why it is so particularly important not to use any +force in passing the hand through the os uteri: the less we separate the +placenta, the less also will be the hæmorrhage; and even this will be in +great measure controlled by the presence and pressure of the hand itself. +In no case of turning is it so important to have all the circumstances +connected with the operation as favourable as possible, for the case +itself is sufficiently dangerous without being increased by other +unfavourable causes. To hurry the delivery would be only to increase the +danger: the operation must be performed slowly and with caution: every +rule which we have given, (see TURNING,) for ensuring its safe and +successful termination, must now be adhered to with double vigilence. +"Should the woman," says Dr. Dewees, "be very much exhausted before we +commence our operations, we should use additional caution in the delivery. +It should be very slowly performed, and we should have at each step of the +progress assurances, if possible, that the uterus has not lost, or rather +that it possesses, sufficient contractility to render the completion of +the operation eventually safe, if performed with due and necessary care." +(_Op. cit._ p. 463.) + +When once the os uteri is sufficiently dilated to admit the hand, there +will not be much fear of the patient losing much blood during the turning, +for during the first part of the operation the hand and arm act both as a +compress and plug; and afterwards, when the body of the child is +advancing, this will act in a similar manner. There is little danger of +hæmorrhage coming on after the child is delivered, for the contraction of +that part of the uterus to which the placenta has been attached is much +greater in these cases than it is where the placenta is situated in the +upper parts of the uterus under ordinary circumstances. The placenta, +which is already separated to a certain extent by the introduction of the +hand, usually comes away without any trouble as soon as the child is +delivered. We once met with a case where it was firmly adherent to the os +uteri on one side, and required to be artificially removed, which was +effected without difficulty. In this instance, hæmorrhage returned after +the labour from uterine inertia, and was checked by the means already +recommended. (_Med. Gaz._ Sep. 2, 1837.) The after treatment should be +conducted upon the same principles as in other cases of hæmorrhage. + +_Partial presentation of the placenta._ Where this is the case, the danger +is rarely so alarming, nor is it always necessary to effect artificial +delivery by turning. The edge of the placenta frequently projects but a +very little over that of the os uteri, feeling, as it were, like a second +lip; at other times it covers a third or more of the opening, and is +usually attached upon the anterior portion of it. Our own observations +have rather led to the conclusion, that where the placenta is but +partially attached over the os uteri, the first attack of flooding is +rarely delayed until the full term of pregnancy, but makes its appearance +some weeks earlier. We are inclined to attribute this to the os uteri +being only in part covered with placenta; that its other portion, being +free, is more capable of dilatation from slight causes, than it would be +were the placenta centrally attached: from a similar reason we may +understand why the hæmorrhage is seldom so profuse in these cases as to be +dangerous, and why the os uteri usually dilates sufficiently soon to allow +the head to descend and be born by the natural powers. We are confirmed in +this view by what we have already quoted from Dr. Rigby respecting the os +uteri being prevented dilating by the close adhesion of the placenta--an +opinion which is, moreover, approved of by Dr. Dewees as being "both +ingenious and probable." Hence, also, we may reverse our position, and +say, that in a case of partial presentation of the placenta, we shall +seldom find the hæmorrhage very profuse, until the os uteri has attained a +considerable degree of dilatation. Besides the portion of placenta which +presents, there will be also a bag of membranes occupying the remaining +portion of the opening; we shall rarely, if ever, meet with those +difficulties connected with a contracted and unyielding state of the os +uteri, which we described in cases of central presentation; and if the +hand requires to be introduced, which is not often the case, it will +seldom experience much opposition. + +_Treatment._ In our treatment of partial presentation of the placenta, we +must be guided, in a great measure, by the strength of the pains and the +degree of dilatation which the os uteri has attained; the extent to which +it is covered by the edge of the placenta, must also be taken into +consideration. Where the pains are strong and active, the pressure of the +membranes distended by liquor amnii against the mouth of the womb will be +sufficient to check the hæmorrhage; if not, by rupturing them we shall be +enabled to let off the liquor amnii, and thus allow the head to press +directly upon the os uteri, and act in the double capacity of a plug and +compress. Where the pains are slow and inactive, the rupture of the +membranes will diminish the size of the uterus, and thus excite it to more +powerful contraction; if not, a dose of secale cornutum, repeated +according to circumstances, will be of great assistance. If the patient +has suffered a good deal by the loss of blood, a little beef-tea, in small +quantities frequently repeated, will rouse the powers; wine or a little +brandy, may also be given at intervals; but unless the prostration be very +serious, we have not found stimulants so useful as beef-tea, which is +usually, also, much more grateful. + + + + +CHAPTER XIII. + +PUERPERAL FEVERS. + + _Nature and varieties of puerperal fever.--Vitiation of the blood.-- + Different species of puerperal fever.--Puerperal peritonitis.-- + Symptoms.--Appearances after death.--Treatment.--Uterine phlebitis.-- + Symptoms.--Appearances after death.--Treatment.--Indications.--False + peritonitis.--Treatment.--Gastro-bilious puerperal fevers.-- + Symptoms.--Appearances after death.--Treatment.--Contagious, or + adynamic, puerperal fevers.--Symptoms.--Appearances after death.-- + Treatment._ + + +In enumerating the different species of Dystocia, we have mentioned a long +list of causes, by which the process of labour might be rendered one of +considerable danger either to the mother or her child; but, for the most +part, they are not of very common occurrence, those only which are of +trifling import being met with most frequently. Even under the most +dangerous forms of dystocia, as for instance, convulsions, and the +different forms of hæmorrhage, the danger, although great, is capable of +being averted, from the mother at least, in the majority of instances by +timely and skilful assistance; the means of treatment which art and +experience have supplied us with, being generally capable of affording +both certain and effective relief, if used according to the rules which we +have given when treating of these subjects; but we now come to a source of +danger which follows the most favourable as well as unfavourable +labours--which is extremely varied in its nature, fatal in its effects, +and (what renders it so peculiarly formidable) by no means uncommon in its +occurrence. + +Of all the dangers to which a lying-in woman is exposed, puerperal fever +is by far the most to be dreaded: there are few or no difficulties during +parturition which the practitioner has to contend with that can be +compared to it; there are none in which he is frequently made to feel so +helpless, and his various means of treatment so utterly inefficacious; +certain it is that puerperal fever in its worst forms has occasionally +committed such ravages among patients of this class as to rival in +destructiveness the most malignant pestilences with which the human race +has been afflicted. + +One of the greatest improvements in our knowledge of puerperal fever which +has taken place in modern times, is the having ascertained that it is not +one specific disease, but occurs under different forms, each of which is +subject to a good deal of variety, depending upon individual peculiarity, +season of the year, and numberless other circumstances. The chief error +into which authors have fallen when treating of this difficult subject, is +their having merely described the peculiar form of disease which had come +under their own notice, and to which they have exclusively awarded the +name of puerperal fever--an error in judgment which has led to still +greater errors in practice, and which has certainly tended to prevent the +subject being so clearly understood as it might have been. The mode also +in which it has been investigated by modern authors has been but of little +assistance in disclosing the true features of the disease; they have +indeed rather tended to mislead than to guide us, they have directed our +attention to certain effects of it, which they have considered to be the +disease itself, and thus rather conceal than disclose the real _natura +morbi_. + +In our printed lectures on puerperal fever we have taken a similar view. +"I am not sure if the present fashionable morbid anatomy of the day, +misnamed pathology, has assisted so much in developing the real nature of +the disease as has been supposed: it appears to me rather to have +withdrawn the attention of practitioners from a close observation of the +phenomena presented during life, to the inspection of those changes which +are to be found after death. They have rather sought to examine the +_effects_ of the disease at a time when it had attained such an extent as +to be incompatible with life, than to investigate upon correct and +physiological grounds the series of changes which were taking place during +the earlier periods." (_London Med. and Surg. Journ._ June 27, 1835.) Dr. +Alison, of Edinburgh, in his dissertation on the state of medical science +(_Cyc. Prac. Med._) has taken a similar view of this prevailing mode of +investigating the nature of disease; he considers that it is "an important +practical error to fix the attention, particularly of students of the +profession, too much on those characters of disease which are drawn from +changes of structure _already effected_, and to trust too exclusively to +these as the diagnostics of different diseases, because in many instances +these characters are not clearly perceptible until the latest and least +remediable stage of diseases--the very object of the most important +practice is to _prevent_ the occurrence of the changes on which they +depend. Accordingly, when this department of pathology is too exclusively +cultivated, the attention of students is often found to be fixed on the +lesions to be expected after death, much more than on the power and +application of remedies either to control the diseased actions, or relieve +the symptoms during life." + +"Pathological anatomy (says Dr. Stevens) is but one of the many 'points of +view in which we may consider the science of disease,' and notwithstanding +all that has been said about 'la médicine eclarireé par les ouvertures des +cadavres,' I have a firm belief that morbid anatomy has done little good, +particularly in the hands of those who do not understand its real value; +for those who are constantly mistaking the effect for the cause, or +confounding the immediate cause of death with the cause of the disease, +and forming theories on this foundation, not only deceive themselves, but +unfortunately, particularly for the inhabitants of hot climates, they have +deceived others." (_Obs. on the Healthy and Diseased Properties of the +Blood_, p. 182.) + +We have made our last quotation from one of the most valuable and original +works of the present day upon the subject of fevers, and which has tended +in great measure to unveil the mysterious nature of these diseases. Dr. +Steven's researches have been conducted in the truest spirit of +pathological inquiry, and form a striking contrast with the modern morbid +anatomy of puerperal fevers. + +We use the term _puerperal fevers_ precisely with the same meaning as Dr. +Locock has done in his valuable essay on this subject (_Library of Pract. +Med._ vol i.,) requesting our readers to bear in mind his observation, +"that they vary in their nature and treatment as much as other kinds of +fevers;" that whether occurring sporadically or in epidemics, they rarely, +appear twice alike, but vary with the season of the year and the type of +the prevailing fevers of the place; they are influenced by the rank, +habits, and constitution of the patient, as well as by the nature and +locality of her residence. + +Although we cannot quite coincide with the views of Dr. Ferguson to their +fullest extent, respecting the exclusive cause of the various forms of +puerperal fever, viz. the vitiation of the fluids, still, in great +measure, we consider them as correct, having not only taught them for many +years, but published them in our lectures on this subject in 1835. Much +praise is due to the last two mentioned authors for the able manner in +which they have handled this difficult subject, they have carefully sifted +the mass of jarring opinions, and tested them by their own great +experience; and have not only reduced the subject to a simpler form, but +have succeeded, we trust, in removing the very erroneous views of some +modern authors respecting the supposed identity of certain forms of local +inflammation with this disease. + +Having drawn our information upon puerperal fevers from the same ample +source, we willingly bear testimony to the accuracy with which they have +described the different forms; and trust that in giving a detail of our +own opinions and observations, it will be found that so far from differing +from them, we have tended to confirm, reconcile, and carry out their +views. + +_Nature and varieties of puerperal fever._ The history of puerperal fevers +at the General Lying-in Hospital, would of itself afford an excellent +monograph on this class of diseases in all their varied forms. When we +resided at the hospital in 1826, the cases were all of the inflammatory +character; they appeared to occur sporadically, among the out as well as +the in-patients; and were successfully relieved by bleeding, hot +poultices, and a mercurial purge, and occasionally leeches. During the +following years, an epidemic of a highly malignant character spread +destruction rapidly among the patients, setting at defiance the treatment +previously employed. Still more remarkable was the sudden change in the +character of the disease noticed by Dr. Locock in 1822. "In the spring of +1822, puerperal fever existed in the lying-in hospital in two very +different and well-marked forms, at an interval of about six weeks between +the last case of the first epidemic and first case of the second. The +early cases were of an active inflammatory character; the peritoneal +covering of the uterus and intestines was chiefly affected; the albuminous +and serous effusions in the fatal cases showed a sthenic state of the +system, that is, the serum was clear, the coagulable lymph firm and white; +the patients bore blood-letting, and other active treatment to a great +extent, fairly, and with much advantage; the blood drawn was strongly +cupped and highly buffed, and the fatal cases were few. Six weeks +afterwards a very different epidemic was found to exist. The same remedies +which had been so beneficial a few weeks before, were naturally at first +tried, but their bad success confirmed the sagacious remark of Gooch, that +'the effects of remedies form not only an essential but an important part +of their history.' (Gooch _on Peritoneal Fevers_, p. 35.) The fever was +attended with marked oppression and debility; the local pain was +comparatively slight; the pulse was extremely rapid from the first, with +no force, and easily compressible. In many of the cases, purulent +deposites took place in the joints and in the calves of the legs, and in +one case there was destructive inflammation of the eye." (Locock, _op. +cit._ p. 349.) + +The various forms and modifications under which puerperal fevers have +appeared at different times, have produced an equal variety of arrangement +in the classifications of authors. Thus, some who have attributed the +disease to inflammation, have merely distinguished its varieties according +to the different organs which have exhibited after death appearances of +congested or injected vessels, or have been covered and imbedded in +effusions of coagulable lymph, &c., or have had their structure more or +less broken down and disorganized. Thus, for instance, Dr. R. Lee is of +opinion, that "inflammation of the uterus and its appendages must be +considered as essentially the cause of all the destructive febrile +affections which follow parturition; and that the various forms they +assume, inflammatory, congestive, and typhoid, will in great measure be +found to depend on whether the serous, the muscular, or the venous, tissue +of the organ has become affected." (_Med. Chir. Trans._ vol. xv. part ii. +p. 405, 1829.) He accordingly arranges "the principal varieties of +inflammation of the uterus in puerperal women under the following heads, +viz. 1. Inflammation of the peritoneal covering of the uterus, and of the +peritoneal sac; 2. Inflammation of the uterine appendages, ovaria, +fallopian tubes, and broad ligaments; 3. Inflammation of the muscular and +mucous tissues of the uterus; 4. Inflammation and suppuration of the +absorbent vessels and veins of the uterine organs." (_Cyc. Pract. Med._ +art. PUERPERAL FEVER.) This arrangement is manifestly incorrect, and by +giving so partial a view of puerperal fevers, must, if adopted, +necessarily lead to serious errors in practice. "That these forms of +inflammation are the proximate cause of the various febrile affections is +most completely refuted by the detail of his own (Dr. Lee's) experience, +as relates to the varieties occurring under similar circumstances." +(Moore, _on Puerp. Fever_.) We may also add, that, according to our own +experience, and that of our colleagues at the General Lying-in Hospital, +in the worst forms of puerperal fever, the fewest traces of inflammation +have been observed; and that in the severest and most rapidly fatal cases +it has frequently happened, that not a single vestige of inflammation +could be detected. In our review of Mr. Moore's able work in the _Brit. +and For. Med. Rev._ Oct. 1836, p. 483, we have made a similar remark, and +quoted a striking passage from Dr. Stevens, when speaking of contagious +fevers, that "there is not one symptom of inflammation during the fatal +progress of the disease, nor one inflammatory spot to be seen after death, +to mark its existence, or to induce us to believe that any thing but +functional disease had existed in any of the solids; yet these are the +very cases of all others which are the most fatal." (_On the blood_, p. +179.) + +In many of the worst cases which have come under our notice, there has +neither been time nor power sufficient to produce either a symptom or a +trace of inflammation; the powers of life have from the very commencement +sunk under the deadly influence of the disease, without a single effort to +establish even a temporary reaction in the system: hence, in most +instances, we are led to the necessary conclusion, that inflammation, when +it does appear, is the result of disease, not the disease of inflammation. +"For," as Dr. Ferguson observes, "if any or more of these (phlebitis, +peritonitis, &c.) be assumed as constituting the essence of puerperal +fever, abundant examples may be found of puerperal fever, in which the +cause fixed on is absent. Thus to believers in the identity of peritonitis +and puerperal fever, we can show puerperal fever with a perfect healthy +peritoneum. To those who insist on inflammation of the uterine veins, as +constituting puerperal fever, we can show the genuine disease without +this condition." (_Essays on the most important Diseases of Women_, part +i. PUERPERAL FEVER, p. 81.) + +The _vitiation of the blood_ has long been a subject which has excited our +deepest interest, and the admirable researches of Dr. Stevens upon the +condition of this fluid under the effects of malignant fevers, have tended +to disclose the real nature of the diseases under consideration. We have +long been convinced that one of the causes of puerperal fever is the +absorption of putrid matters furnished by the coagula and discharges which +are apt to be retained in the uterus and passages after parturition,--a +view which has been adopted by Kirkland, C. White, and other older +authors. It is with sincere pleasure that we now find ourselves supported +by the able author, from whom we have just quoted, in this opinion. Dr. +Ferguson's three positions respecting "the source and nature of puerperal +fever" are highly valuable, for they have been deduced from careful +physiological experiments, and not less sound physiological reasoning; +they are as follows:-- + +1. The phenomena of puerperal fever originate in a vitiation of the +fluids. + +2. The causes which are capable of vitiating the fluids are particularly +rife after childbirth. + +3. The various forms of puerperal fever depend on this one cause, and may +readily be deduced from it. + +We do not agree with him in supposing that every form of puerperal +inflammation is produced by vitiation of the circulating fluids, because +in one species of uterine phlebitis, which occurred sporadically, and +prevailed a good deal from 1829 to 1832, it was, in our opinion, evidently +produced _directly_ by the absorption of putrid matter into the uterine +veins and lymphatics, exciting inflammation in these vessels: the same +cause, when only carried to a certain extent, produces a local +inflammation, which, when affecting the general circulation, is followed +by fever. Thus, then, we may have in the same case uterine phlebitis +followed by the typhoid malignant puerperal fever--the local and +constitutional disturbance arising from the same cause, imbibition or +absorption of putrid matter; the one being the local, the other the +general effect, but not the one resulting from the other. The doctrine of +the vitiation of the blood from its admixture with pus secreted by the +lining membrane of an inflamed vein, though very plausible, still requires +farther confirmation, for it is doubtful if the introduction of pure +healthy pus into the circulation produces any of those dangerous effects +which result from the absorption of putrid matters, whether purulent, +sanious, mucous, &c. It is the introduction into the circulation of an +animal poison generated by putrefaction, which destroys the vitality of +the blood, and renders it unfit for maintaining the vital powers. + +Few have expressed this opinion more strikingly than Dr. Kirkland, +although so long ago as 1774; and it has often created our surprise, that +amid all the numerous writings on this subject, which have excited +attention during later years, so little notice should have been taken of +his observations. We consider that Dr. Kirkland is one of the earliest +authors who has shown that puerperal fever is not the result of +inflammation, but that it may be produced by the introduction of an animal +poison into the circulation. "There are other causes beside inflammation +which bring on a puerperal fever; for it sometimes happens that coagulated +blood lodges in the uterus after delivery, and putrefying from access of +air, forms a most active poison, is in part absorbed, and brings on a +putrid fever. In this case the discharge which should immediately follow +delivery is not sufficiently large, making allowance for the difference +which happens to different women in this respect: small clots of blood +make part of the lochia, which are less in quantity than they ought to be; +but the patient has not any other sort of complaint for three or four days +till the retained blood begins to putrefy. A fever then first makes its +appearance, followed by a quick weak pulse, thirst, pain in the head, want +of sleep, sighing, load at the præcordia, restlessness, great weakness, +dejection of spirits, either wildness or despair in the countenance, and +the white of the eyes is often a little inflamed." (_A Treatise on +Childbed Fevers_, by Thos. Kirkland, M. D. p. 70.) + +The late Mr. Charles White, of Manchester, adopted a similar opinion, and +in our published lectures we have quoted largely from these two authors in +support of the opinions which we have there advanced. + +Dr. Ferguson's opinion, that the different modes in which the poison +infecting the circulation manifests itself, give rise to the different +forms of puerperal fever, is highly interesting, and deserves great +attention. He conceives that in some instances it spends its virulence +upon the peritoneum, producing the inflammatory peritoneal form of +puerperal fever. He considers that the gastro-enteric form arises "from +the action of the poison being directed to the liver, the organ through +which, as the experiments of Gaspard and Fontana, and the admission of all +physiologists show, most poisons received into the system endeavour to +escape." (_Op. cit._ p. 85.) These views have been proved by injecting +putrilage, &c., into the veins of animals, and the effects of which, both +as seen in the symptoms during life and the appearances after death, tend +strongly to confirm these opinions; still we cannot feel justified in +excluding inflammatory forms which have not been indirectly produced by +the vitiation of the circulation, but which are the more direct effects of +labour itself, or, as we have before observed, from the immediate +absorption of putrilage, &c., into the veins and lymphatics, and +production of inflammation in them. The production of inflammation in +that part of a vein or absorbent, with which putrid matter has come in +immediate contact, is an important fact, for it is by this means that +nature prevents the poison being carried into the general system, and +thus, instead of generating a malignant fever, she limits the injury to a +local inflammation, by which farther mischief is confined by the effusion +of coaguable lymph, tumefaction, and other means for rendering the vessels +impervious. In making these remarks we wish it to be distinctly +understood, that we by no means under-value the views brought forward by +Dr. Ferguson, that "the introduction of a poison into the circulation is +capable of producing local inflammation, varying according to the strength +and qualities of the agent," &c. + +The results of Professor Tiedemann's experiments, of which we have given +an abstract in the _Brit. and For. Med. Rev._ vol. i. p. 241, contain some +facts which throw much light as to the modus operandi of certain agents +when mingled with the circulation, and tend still farther to prove the +correctness of Dr. Ferguson's views. In the experiments where musk was +injected into the femoral vein of a small bitch, the effects of the poison +upon the abdominal viscera were remarkable; the veins of the abdomen were +distended with dark coloured blood, the whole intestinal canal was very +red, the mucous membrane of the stomach had a reddish tinge; that of the +whole intestinal canal was of a dark red, it was swollen, turgid, and in +the highest state of engorgement--the canal also contained a quantity of +effused dark blood in its lower part; the vessels of the liver and spleen +were gorged with dark blood. + +We are anxious to impress upon the minds of our readers the physiological +fact, that most, if not all, vegetable and animal poisons do not act +_primarily_ on the nervous system, but indirectly through the medium of +the circulation. "The physiological researches (as we have observed +elsewhere) especially during the last thirty years, both in this country +and the continent, have satisfactorily proved that most, if not all, of +the agents which exert such destructive energies on the nervous system, do +it through the medium of the circulation: this has been shown by the +experiments of Christison and Coindet, of Brodie, Emmert, Viborg, and many +others. Those of Sir B. Brodie on the action of the Woorara poison are +well known. Emmert showed this to be the case in a still more striking +manner, by amputating the leg of an animal, and leaving it connected to +the body only by means of the nerves; poisonous substances introduced into +the foot produced no effects, not even when applied to the trunk of the +nerve; and Viborg even applied one drachm of concentrated prussic acid to +the brain of a horse, which had been exposed by trepanning, without +producing any effect." (_Brit. and For. Med. Rev._ vol. i. p. 559.) + +We cannot agree with the opinion, "that the vitiated state of the blood is +the secondary and not the primary link in the chain of phenomena," and +"that the nervous system is the main instrument by which this change in +the blood takes place." (Locock, _op. cit._ p. 353.) "We believe that is +_not_ the deficiency of nervous influence which primarily tends to +deteriorate this fluid (although it may possibly react in this way +afterwards,) but the deteriorated condition of this fluid, which renders +it incapable of supplying the brain and nervous system with their due +degree of energy." (_Brit. and For. Med. Rev._ vol. ii. p. 483, 1836.) + +In considering the phenomena of fever, Dr. Stevens has well observed, that +we must not look upon them "as the result of either a nervous impression, +or local inflammation, for even in the beginning of fever its symptoms are +universal and peculiar to itself. It is not, therefore, a local affection; +and in all the idiopathic fevers, but particularly in those that are +produced by the aerial poisons, there is but one thing which is never +absent, namely, the diseased condition of the whole circulating current, +and, therefore, this alone can be fairly considered as essential to the +disease. This morbid condition of the blood is decidedly the first link in +the chain of those phenomena which constitute fever, for even before the +attack every drop of the vital currant is changed in its properties; and +wherever this deranged blood can circulate, there fever extends its +empire: for the cause which produces this disease is not confined to a +part, but acts on every fibre, and in every tissue of the living system; +it disturbs every function in the body, and deranges every faculty of the +mind. All the excretions are in a diseased state, and every one of the +secreted fluids is changed both in its quantity and quality. The blood is +the medium that conveys the poison, while the impression on the nerves is +merely the effect of the diseased condition of its natural stimulus." (_On +the Blood_, p. 273.) + +These observations just quoted, apply strictly to the causes as well as to +the phenomena of puerperal fever, more especially of the adynamic kind; +and show that, particularly in this form, we must not merely refer the +cause to the absorption of putrid matters by the uterine veins and +lymphatics, or to the commixture of the blood with pus secreted from the +coats of an inflamed vein, but to the still more pervading and truly +epidemic and contagious action of miasmata, with which the air that +surrounds the patient is charged. The lungs afford a ready and ample means +by which effluvia may be conveyed into the circulating current, and +enables us to account for the fact adduced by Dr. Stevens, that in +situations favourable to the production of fevers, the blood is frequently +found in a very unhealthy state, even before the outbreak of the disease +itself. Dr. Kirkland has nearly anticipated the discoveries of later years +upon this subject; and considering the time at which he wrote, we think +that his observations are both interesting as well as valuable. + +"Seeing then that an absorption of putrid matter will bring on a +_puerperal fever_, with common symptoms, may we not conclude that the +putrid miasms of lying-in hospitals will produce the same effect? Is it +not reasonable to suppose, that the _puerperal fever_ which has been +observed in hospitals, is owing to some cause peculiar to hospitals? +otherwise, would it not be equally frequent in other places? Dr. Pringle +informs us that the foul air occasioned by one mortified limb brought on a +malignant fever in the military hospital. Peu also seems to have proved, +that the putrid _effluvia_ exhaling from wounded men brought on a fever +which killed a great many child-bed women who lay in the same hospital; +and are not the putrid _effluvia_ arising from the lochial discharge in +lying-in hospitals capable of producing the same disease? I have sometimes +been called to women in child-bed, where the offensive _effluvia_ arising +from this kind of evacuation, pent up in a small close room, at once +evinced to what cause their fever was owing; and though I have not any +doubt, but in lying-in hospitals every attempt is made to preserve the air +pure and the patient in a state of cleanliness, yet where many women lie +in the same ward, it is perhaps impossible to obtain these advantages in +the perfection to be wished." (_Op. cit._ p. 73.) + +Van Swieten compared the state of the inner surface of the uterus with +that of a large wound,--"Something of a like nature seems to be affected +in the womb, but in a slighter manner, because the injury is here +superficial, but on a broad surface." (_Comment. on Boerhaave_, § 1329.) +He quotes also an interesting description from Moschion of the changes +which are observed in the evacuations after delivery,--"_Primo sanguis, +secundo fæculentus et paucus, ultimo purulentus_." "It hence appears," he +observes, "that that fever in lying-in women, which is called the milk +fever, does not spring solely from the milk brought into the breasts, but +also from the purifying of the womb by that gentle and superficial +suppuration. But, as even the best pus when retained too long becomes +acrid and putrefies, the same thing will hold with regard to the purulent +evacuations after delivery, if they should be kept back." "But if that +purulent matter does not come out, but being sucked back should be mixed +with the humours, it may, being brought to the viscera by a bad metastasis +of the morbid matter, give occasion to dangerous disorders." + +This comparison by Van Swieten and Dr. Kirkland, of the state of the +uterus with that of an open wound, has been recently brought into notice +by Cruveilhier, and quoted by Dr. Ferguson, in his work. "All the uterine +veins and arteries have been torn from the placenta, and they form a part +of a large wound, and are, therefore bathed in all the secretions which +necessarily take place while this wound is healing. In this respect the +uterus presents an exact analogy to the surface of an amputated stump; and +it is, therefore, not surprising, that the secondary evils of amputation +should be so similar to those of the puerperal state." (_Op. cit._ p. 75.) +Professor Schönlein also considers that the contagion of puerperal fever +has the greatest similarity with hospital gangrene. + +The causes of puerperal disease which have been enumerated by Cruveilhier, +apply almost solely to those inflammatory affections of the puerperal +state which do not depend upon a vitiated state of the circulation, but +"are derived from the changes induced by parturition, and are dependent +on, + +"1. The organic changes induced by pregnancy. + +"2. Those induced by the act of labour. + +"3. Those consecutive of labour. + +"1. Pregnancy:--the hyperthrophy of the uterus; the enlargement of the +ligamenta lata; the traction on the peritoneum of the neighbouring organs; +the extraordinary development of the arteries, veins, and lymphatics. + +"2. Changes induced by labour:--bruising of all the soft parts--they +appear raw. + +"3. Changes after labour:--the woman presents the faithful picture of one +who has undergone a serious surgical operation. The internal surface of +the womb may be compared to a vast solution of continuity; the whole of +the mucous membrane has been altered by the inflammation, of which it has +been the seat; the gaping veins are like the open mouthed vessels of an +amputated limb. + +"Except just at the inner surface of the cervix uteri, there is no mucous +membrane at all; but the muscular tissue of the uterus is every where +exposed. This, therefore, like the stump, is to be covered by a new +membrane. + +"This process of reparation is accompanied by a traumatic fever, called +milk fever. Like the fever from wounds, it has its period of incubation, +varying in various individuals: it lasts about twenty-four hours, and +vanishes on the third day. + +"As in amputation, a false membrane covers the stump, and precedes +cicatrisation, so the inner surface of the womb is first covered with a +false membrane before it is cicatrised. If there be no lochial discharge, +there is union by the first intention, as in the stump where there is no +discharge: this is the rarest of all cases. + +"Ordinarily, this false membrane is thrown off with a purulent discharge, +which is the lochia. At first it is sanious, _i. e._ mixed with blood, and +fetid; then less fetid and more purulent; then thin and serous. The +quality and quantity of the discharge are, as in amputations, an index of +the state of the wound." (_Cruveilhier_, quoted by Dr. Ferguson, p. 76.) + +The comparison between the inner surface of the uterus shortly after +parturition and that of a stump, does not hold good in every respect: in +the one, the open mouths of the vessels are pretty firmly compressed by +the contracted state of the surrounding uterine tissue, whereas, in the +other they are uncontracted beyond the mere effects of the traumatic +inflammation upon their cut extremities, and they are surrounded by the +flaccid surface of divided muscles: still, however, it is quite sufficient +to show, that the inner surface of the uterus must be for some days bathed +in mucous, sanious, and purulent fluids, highly prone to decomposition; +and that, in this state, absorption is peculiarly liable to take place. + +The vehement exertions of the uterus and abdominal muscles during labour, +and the violent pressure to which the abdominal circulation has been +subjected at this time, are sources of inflammation, which, although not +noticed by Cruveilhier, are frequently met with quite independent of +puerperal fever, although, from what we have already stated, it will be +evident that the disposition to absorption and consequent vitiation of the +blood will be still farther increased by the excited state of the +circulation. + +Where blood has been vitiated by the action of aerial poisons, or +introduction of putrid matter into its current, changes are quickly +produced in its condition, which not only unfit it for the varied +functions which it has to perform, especially in maintaining the activity +of the brain and nervous system, but which may be perceived, as already +shown, before the disease itself appears. It is dark, and of an unhealthy +tinge. In severer forms of typhus, "when first drawn, it has a peculiar +smell, and coagulates _almost invariably_ without any crust. There are +black spots on the surface of the crassamentum; the coagulum is so soft +that it can easily be separated with the fingers, and during its +formation, a large quantity of the black colouring matter falls to the +bottom of the cup. When the serum separates, it has generally a _yellow_, +and in some cases even a _deep orange_ colour." (Stevens, _op. cit._ p. +219.) + +Dr. Tweedie has observed similar conditions of blood in the common typhus +of the metropolis, and remarks, "that in this class of fevers, the +crassamentum of the blood, instead of forming a firm coagulum, is loose, +small in proportion to the quantity of serum, and so soft that it breaks +readily on attempting to raise it, resembling in consistence half-boiled +currant jelly, and that in some instances, when abstracted late in the +disease, it is scarcely coagulated at all." (Tweedie, _Clin. Illust. of +Fever_, quoted by Dr. Stephens.) + +This accords closely with the appearances of blood drawn from patients +under puerperal fever, especially of the adynamic form. The blood is of a +dark muddy colour, in some cases resembling even thin treacle in +consistence: in this state the coagulation is very imperfect, so that +after a time it merely forms a homogeneous semi-gelatinous mass, with +little or no separation of serum from the crassamentum. After death the +blood is found perfectly fluid, readily infiltrating and staining the +coats of the vessels which contain it, and resembling thin watery claret, +both in colour and consistence. In the other forms, which are of a more +inflammatory character, it is highly buffed and cupped; the crassamentum +is small, the albuminous layer upon it is of a muddy yellow colour; and +the serum, which is frequently large in proportion, is of a similar +colour, or even of a slight bilious tinge; in some, there has been +occasionally observed a white cloudy appearance, as if from the admixture +of milk. + +The mortality of puerperal fevers depends in great measure upon the form +they assume; and, as we have already stated, this will vary in great +measure according to the period of the year, the nature of the season, and +the type of the prevailing epidemic fevers in the neighbourhood, whether +they assume the character of synochus, or low malignant typhus. It varies +a good deal according to the class of patients attacked, being more +frequently of the inflammatory character among the middling and higher +classes, whereas, among the lower orders, who are exposed to the +depressing effects of cold, damp, and ill-ventilated dwellings, of +insufficient clothing and food, of an atmosphere poisoned with the noxious +effluvia arising from a dirty and thickly inhabited suburb, and habitual +intemperance, it generally assumes the adynamic or contagious form. This +is the reason that puerperal fever is not only seen less frequently among +the middling and upper ranks, but even when it does appear, from being +usually of the inflammatory form, it is more tractable. It is in lying-in +hospitals, where it appears in all its terrors, and occasionally assumes +such a degree of malignity as almost to equal the plague or yellow fever, +in the frightful rapidity of its course, and in the almost certain +fatality of its termination. Few have witnessed it in a more destructive +form than the late Dr. W. Hunter at the British Lying-in Hospital. He +observes in his lectures that he had seen a great many cases of it in the +hospital, "and particularly in one year, when it was so remarkably +prevalent there. It was so bad, that not only every gentleman belonging to +the hospital, but all our friends in town, had a consultation to think +whether we should shut up the house. _In two months thirty-two patients +had the fever, and only one of them recovered._" (_MS. Lectures._) + +Although puerperal fever has never yet attained the frightful degree of +mortality at the General Lying-in Hospital, nevertheless, it has appeared +repeatedly with such malignity, as to commit fearful ravages among the +patients. In these epidemics, the first few cases are generally +comparatively mild, being of the peritonitic or gastro-bilious form +(_Douglas_:) but as it advances, the malignant adynamic form, which is so +destructive, prevails. In some epidemics, as is seen in common fevers, +after a short time the disease has become more tractable, it has assumed a +milder character, and ultimately has again disappeared. This corresponds +with the admirable remarks of Dr. Gooch, to whose graphic pen we are +indebted for much valuable information on the subject of puerperal fevers. +"Another remarkable circumstance about this disease is, that, when it is +most prevalent, it is most dangerous. Each case is more difficult of cure +than when it occurs seldomer. The practitioner finds, that, although the +group of symptoms resembles what he was formerly accustomed to, he has now +to deal with a disease far more obstinate and destructive, and his usual +remedies are not so successful as formerly; he loses case after case in +spite of his best efforts. When it has been thus raging for a considerable +time, it at length subsides; the case becomes less frequent and less +severe; the practitioner finds his treatment becoming more successful, +partly because experience has taught him to detect it earlier, and to +treat it better, but probably also because the disease has itself become +milder." (Gooch _on Peritoneal Fevers_, p. 3.) + +The table of the cases at the General Lying-in Hospital and their +mortality, which Dr. Ferguson has calculated during the twelve years, from +March 1827, to April 1838, is highly important, and points out the period +of the year in which puerperal fever, prevails most, and the contrary. The +last two and the first seven months of the year are those in which the +greatest mortality occurred; whereas, in the month of July, during this +whole period, not a single patient died; in August only one; in September +two; and again, none in October, although several were attacked. +"Puerperal fever was _epidemic_ in the years 1828, 1829, 1835, 1836. 1838; +in the other years it was only sporadic. The greatest mortality was in the +years 1835 and 1838, in the last of which 20 in 26 died. The malady +commenced in January, in which month Dr. Rigby saved only 1 out of 9. The +hospital was closed for a month, and opened again in March, when he +succeeded in rescuing only 2 in 8. Thinking that another mode of treatment +might be more successful, I determined to bleed largely, and to salivate. +This plan was fairly tried under the constant attendance of Dr. Cape, and +with my supervision, but 3 only in 9 lived. Seeing that no treatment was +of avail, the hospital was closed from May till November." (Ferguson, _op. +cit._ p. 277.) + +_Different species of puerperal fever._ Having premised these general +observations on puerperal fevers, we now proceed to consider them +separately, according to the various forms which they exhibit; and in +doing so, shall adopt the arrangement of the subject made by Dr. Douglas, +viz. under the three heads of inflammatory gastro-bilious, and the +contagious or adynamic form. It is not only one of the earliest, but in +our opinion, one of the most correct; nor do the arrangements adopted by +Drs. Locock and Ferguson differ essentially from it. We hope by this means +to combine the advantages which each affords, while we hold ourselves free +to differ or coincide with either, as our opinions lead us, trusting that +we shall thus be able to render this complex and difficult subject more +complete. + +Under the inflammatory form we shall not only consider the acute +peritonitis, so ably described by Dr. Locock, which is chiefly produced by +the effects of labour, to which we have already alluded in the quotation +from Cruveilhier, but also that form which, according to Dr. Ferguson, +arises from vitiation of the blood, by the introduction of putrid matter +into the circulation; a form which has not only a great disposition to +assume a typhoid character, but also to become epidemic. Under this head +we must also bring the uterine inflammation and phlebitis, which we have +described, as resulting from a direct action of putrid matters contained +in the uterus, a form which is very liable to pass into uterine, and +afterwards general peritonitis; lastly, there remains that species of +nervous abdominable pain, which has received the name of false +peritonitis. + + +_Puerperal Peritonitis._ + +_Symptoms._ The acute peritonitis, which has been produced by the effects +of labour, generally makes its appearance at an early period after. The +labour has probably been either tedious or severe, the efforts of the +uterus and abdominal muscles have been violent, especially during the last +stage; and from the moment of the child's birth, the patient has +complained of considerable soreness over the lower part of the abdomen, +amounting to much pain and tenderness when touched. At first she is +tolerably easy, so long as she lies still, and keeps the abdominal muscles +in complete repose; but, by degrees, fits of pain come on, they become +more frequent, and the intervals between them shorter and shorter, until +the pain is constant; she now complains of much tension and fulness of the +abdomen; the tenderness is greatly increased, both in severity and extent, +and is often attended with the painful sense of twisting about the +umbilicus, which is observed in ordinary forms of peritonitis. The pain +and tension are now so severe that she is constrained to lie wholly upon +her back, with the knees drawn up, in order to relax the abdominal +muscles, and thus, if possible, alleviate her sufferings. The abdomen +itself is evidently fuller to the feel, and is beginning to be tympanitic; +the breathing is quick and anxious; the tongue has a thin coating of white +fur, which is browner and thicker at the back; the pulse is quick and +hard, sometimes small and wiry, occasionally full and strong; the lochia +and milk have either never appeared, or only in small quantities, to be +quickly suppressed again. As the tympanitis increases, the breathing +becomes more anxious and painful; for every effort of the diaphragm in +inspiration is followed by severe pain, from the movement which it +produces in the abdominal contents. After awhile, the flatulent distention +of the intestines, particularly of the stomach, renders the diaphragm +irritable, and provokes hiccough, which is excessively painful from the +involuntary jerk which it gives to the abdomen; or, what is still worse, +retching and efforts to vomit frequently come on, which greatly aggravate +her sufferings. She now lies upon her back, perfectly helpless and +immoveable, for the slightest attempt to touch her is insupportable; even +the jar of a person walking heavily across the room excites pain. The +abdomen is now even larger than it was before labour, her anxiety and +restlessness increase, and she rapidly becomes exhausted from suffering +and want of sleep. The face becomes sallow, the features fallen, the +tongue dry and brown, and sordes collect upon the teeth; she falls into an +uneasy slumber, during which, the eyelids remain partly open, or she +mutters incoherently with low delirium. The abdomen is less painful, but +not diminished in size; the pulse is small, hurried, and feeble; subsultus +tendinum and picking of the bed-clothes follow, with all the other +symptoms of approaching dissolution. + +Where the attack has risen from the introduction of putrid matter into the +circulating current, it usually appears somewhat later, seldom before the +third day after labour: it is almost invariably preceded by a severe +rigour, followed by intense headach, and darting pain about the lower part +of the abdomen, which gradually becomes constant. There is a nearer +approach to the adynamic form, or rather, it is frequently attended, or at +least followed, by this disease; hence the inflammatory stage is shorter, +the pulse is even more rapid, and loses its strength sooner than in the +other form; the milk and lochia have usually not only been established, +but continue, we think, longer afterwards than in the other case; the pain +is perhaps less in many instances, but in other respects, the first part +of the attack does not differ essentially from the form above described; +but as the disease advances, it gradually assumes the adynamic form; the +inflammatory symptoms of the early part of the attack are merged in the +general collapse which now exists, the same cause which had produced the +peritoneal inflammation now acting on the whole system. + +Peritonitis occurring by itself, is, as Dr. Ferguson observes, of +comparatively rare occurrence in puerperal women, the condition of the +system during childbed, disposing it quickly to assume more or less of the +adynamic character. + +_Appearances after death._ On examining cases of fatal puerperal +peritonitis, we shall find marks of inflammation, or its consequences, +over a large extent of the peritoneum; large portions of it are highly +congested, and more or less thickened; considerable effusions of serum or +sero-purulent fluid, mixed with flakes of coagulable lymph, into the +abdominal cavity: the omentum adhering to the intestines, and also the +intestines to each other, by means of coagulable lymph, in which they are +occasionally completely imbedded; the broad ligaments and ovaries are +frequently much inflamed, covered with lymph, and the latter more or less +softened; the Fallopian tubes engorged and adhering to the neighbouring +parts; the uterus is covered at its fundus with a coating of coagulable +lymph, as if it had been smeared with a quantity of dirty white paint, and +this extends more or less in patches over the various reflexions of the +peritoneum, in the upper parts of the abdominal cavity. + +_Treatment._ We may take it as a rule, that the earlier we see the patient +in the disease, the less active will be the treatment required. At first, +when the pain has not yet assumed its full intensity, and only occurs in +paroxysms, when little or no traces of abdominal tension and fulness are +to be perceived from incipient tympanitis, we may frequently succeed in +cutting short the disease by a full dose of calomel and James's powder, +with some morphia or Dover's powder, to allay irritation and assist in +producing a general determination to the skin; this must be followed by +some castor oil, and if the pain is no longer constant, with the addition +of a few drops of Liquor Opii Sedativus. Where the pain has already become +severe, a draught of sulphate and carbonate of magnesia in peppermint +water, with a little antimonial wine and henbane, will be preferable. We +have long since been convinced, that common black draught, or any form of +purge which acts violently or gripes, is objectionable, having frequently +seen a return of pain brought on by its action. A hot poultice of +linseed-meal, large enough to cover the whole abdomen, and as hot as the +patient can bear it, must be applied; this, if made properly, will prove a +great relief, for it not only allays the pain, but quickly acts as a +powerful diaphoretic: there is a little art in making this, and unless it +be done properly, it is apt to produce much discomfort, and do more harm +than good. The water should be poured boiling hot on the linseed-meal, and +the mixture well beaten with a large spoon, until it forms a nearly +gelatinous mass; it should then be spread upon a large piece of linen, so +as to be between a quarter and half an inch in thickness; there is now +only one layer of cloth between the poultice and the patient's abdomen, +and it can be applied or removed with perfect facility: without these +precautions it is apt to form a pudding-like mass, which greatly annoys +the patient from its weight, and from being applied directly to the +abdomen, smears about, and is not easily changed. A poultice made in the +manner now described, will keep hot for three hours at least, and is by +far the most effective form of fomentation which can be employed. Common +fomentations of sponges, or flannels wrung out of hot water, are by no +means desirable, as from the constant exposure, which is required for +their frequent repetition, the patient has little benefit from the +temporary heat, and is very liable to catch cold. + +If the symptoms do not yield to this treatment, but assume a more +formidable aspect, or if the attack has not commenced in this gradual +manner, but has come on much more suddenly and with greater violence, +recourse must be had immediately to the lancet. Leeches are seldom proper +as a substitute for bleeding, although they frequently prove of great +value afterwards. A certain effect is required to be produced upon the +general circulation, before leeches are capable of affording even a +temporary relief; and so far from economizing the patient's powers by +using leeches instead of the lancet, we shall find that in order to +overcome the inflammation by this means, the patient will require to lose +a far greater quantity of blood than if it had been suddenly removed from +the circulation by bleeding. Upon the same principle, therefore, we must +take care, that the blood shall be drawn _pleno rivo_ from an ample +orifice: we thus spare the patient an unnecessary loss of power, for the +required effect upon the circulation is produced in a much shorter time +and with less expenditure of blood, than if the blood had been slowly +dribbled from a small opening. + +"In the treatment of acute inflammation in the vital organs, the customary +practice is to consider local bleeding as a milder means of effecting the +same object as general bleeding, and to postpone it till the stage for the +latter is over. To me it appears that they are calculated to effect two +different objects, both of which are necessary at the beginning of the +treatment; the one to reduce the violence of the general circulation, the +other to empty the distended capillaries of the part. As long as the pulse +is quick, full, and hard, it is in vain to take blood from the affected +part; if we could completely empty its gorged capillary vessels, they +would be instantly gorged again, whilst the heart and large arteries are +injecting them with so much violence. On the other hand, after having +reduced the force of the general circulation, the capillary vessels of the +part often remain preternaturally injected: this, I conclude, from the +fact that the patient is often not relieved till local blood-letting has +been used, and then is relieved immediately. Hence, as soon as the patient +has recovered from the faintness occasioned by bleeding from the arm, +leeches ought to be applied without delay." (Gooch, _on Peritoneal +Fevers_, p. 47.) + +It is impossible to fix what quantity of blood is to be drawn; nor is it +easy, either from the patient's appearance or the feel of her pulse, to +foretell how much she will require to lose: a certain effect is to be +produced on the circulation in order to bring it under such control as +will moderate the state of inflammation. No two patients are alike in this +respect; and it frequently happens, that where, from external appearances, +we might have expected to find most strength, faintness is quickly +produced, and _vice versâ_: on the whole, we think that where the patient +has a small, quick, and oppressed pulse, we may expect she will require to +lose a large quantity of blood, for in these cases the pulse rises in +volume and strength as the bleeding proceeds; hence, as before observed, +we must "carry the bleeding to its proper limits, which is the approach +to, or actual state of, syncope." So far from removing the pillows, and +letting her lie with the head low, so as to recover from her faintness as +quickly as possible, it will be much better to support her in a sitting +posture, and thus prolong the state of faintness for some while; the +dilated vessels have now time to contract, the heart returns to a more +moderate and healthy action, the effects of the bleeding are much more +permanent, and the chances of its repetition being required considerably +diminished. From this state of relaxation and temporary collapse being +prolonged, we find that the secretion of the skin, and particularly the +intestinal canal, are more easily re-established, the operation of a +purgative being now much quicker and more effective. + +As soon after the bleeding as possible, a smart dose of calomel and +James's powder, followed by an active saline laxative, must be given; and +the combination of sulphate and carbonate of magnesia with antimonial wine +and Tinct. Hyosc. already recommended, is preferred by us: it is better +given in divided doses, as then the effects of the antimonial is +prolonged. The action of the bowels may also be assisted by a domestic +enema: and if there are no signs of action in the bowels after two hours, +the purgative should be repeated. The results of the leeches, fomentation, +and purging, will guide us as to the necessity of repeating the bleeding. +Dr. Gooch's truly practical remarks on these points are well worthy of +attention:--"I waited till the purgatives had operated fully, that I might +know what impression the combined operation of general and local +blood-letting had produced on the disease, before deliberating on the +employment of a second blood-letting. The common effect, of these remedies +was this, as long as the faintness lasted in the slightest degree, the +pulse remained soft and often slower, and the pain was much less, or +ceased altogether; but an hour or two after the bleeding, when the +circulation had recovered, the pain returned more or less, and the pulse +regained much of its hardness or incompressibility. This state continued +till the leeches had bled freely, and the purgatives had acted repeatedly +and copiously." (_Op. cit._ p. 48.) + +If, however, the pain has experienced but little abatement, or has +returned as severely as before; if the pulse has quickly reassumed its +former condition; if the action of the purgatives has not taken place, or +has been at most unsatisfactory, even with a repetition of the saline, we +are justified in having recourse to a second bleeding; the faintness this +time will probably be more complete; the effect upon the disease more +decided; and, in all probability, it will be quickly followed by free +evacuations from the bowels, which produce great relief. In some cases the +bleeding requires to be repeated again and again before the disease can be +subdued: this, however, usually arises not so much from the obstinacy of +the attack, as from the first bleedings not having been performed in an +effective manner. "The pulse," says Dr. Locock, "is the best guide, for +the pain after the first full relief from the bleeding is often of a mixed +character, partly inflammatory, partly nervous, to be detected only by +watching closely the other symptoms. The tenderness is a less certain +guide, for few will bear pressure for a considerable time after the +inflammatory symptoms have been entirely relieved. Many patients also from +fear shrink from the pressure of the hand, although by drawing off the +attention, it will be found that they bear firm and steady pressure very +well." (_Op. cit._ p. 355.) + +Throughout the whole process of treatment, the linseed-meal poultices must +be continued, and, if not made too heavy, can be borne when there is a +considerable degree of abdominal tenderness. + +In all cases where the disease has not been completely checked in the very +outset, but has shown a disposition to return, the treatment +above-mentioned should now be followed by a mild mercurial course. The +effects of mercury in allaying inflammation at a certain stage, which does +not appear to be fully under the control of mere antiphlogistic remedies, +have been amply proved by British practitioners: this applies particularly +to inflammation of serous membranes: mercury not only tends to prevent the +effusions of serum and coagulable lymph, but, where they have taken place, +it is of great value in promoting their absorption. We agree with Dr. +Locock, that calomel is by far the best form in which it can be used, +where we wish to obtain its specific effects. The Hydrargyrum cum Cretâ, +which we have occasionally found useful in the gastro-bilious or enteric +form to restore a depraved state of intestinal secretions, has failed us +in the other forms where we wished to produce salivation. The purgative +dose of calomel, which we have advised to be given after the bleeding, +ought not to be less than six to eight grains; but now, as the dose is to +be repeated every two or three hours, a smaller quantity will be +sufficient: in order to save time we usually begin with five grains of +calomel, and an equal quantity of Dover's powder, and repeat this in an +hour's time, after which, we proceed with doses of two or three grains +every second or third hour according to circumstances. The sooner the +system can be brought under the influence of mercury the better, the pulse +becomes softer and less frequent, the pain and tension of the abdomen +diminish, the tongue becomes moist and natural at the edges, and general +improvement follows. Throughout the whole attack the vagina should be +occasionally washed out with warm water, more especially if we have reason +to suspect that the disease has arisen from the imbibition or absorption +of putrid matter. The smell of the patient will frequently guide us in +this respect, and point out the condition of the passages and their +contents; even if there be no putrid matter lodging there, the application +of warm water will always act as a comfortable fomentation to the patient, +and assists not a little in favouring a return of the lochia. + +If the pain and swelling of the abdomen still continue, and the case is +evidently becoming more unfavourable, we have occasionally sprinkled the +abdomen with spirit of wine or oil of turpentine, and then covered it with +a fresh poultice: this has acted as a powerful rubefacient, and has in +some cases relieved the patient at a very advanced stage. We have also +tried blistering the abdomen, and dressing the vesicated surface with +strong mercurial ointment, as recommended by Dr. Locock; but we have not +met with the success which he mentions, probably from the disease having +already assumed the malignant characters of the adynamic form, and, in +some instances, because the patient could not endure the intense smarting +which it produced. We have occasionally covered the abdomen with +camphorated mercurial ointment without previous blistering, and with good +effect. The internal use of turpentine, circular friction upon the +abdomen, and enemata of Mist. Assafoetidæ, &c., which we have sometimes +found useful in removing the tympanites of the adynamic puerperal fever, +and which does not depend on an acute form of inflammation, are scarcely +applicable in the present case. + +When the powers are beginning to fail, as a last hope we must have +recourse to stimulants combined with nourishment: the Mist. Spiritus Vini +Gallici of the last London pharmacopoeia,--anglice, "egg and brandy,"--has +for many years been used at the Lying-in Hospital to support the system at +this last stage, and sometimes even under the most unfavourable +circumstances with marked success; powerful doses of ammonia will be +required at frequent intervals, and an occasional opiate, to procure the +still farther refreshment of sleep. Even where the face is assuming a +Hippocratic appearance, the pulse so feeble and rapid as scarcely to be +counted, where the abdomen is immensely distended, with cessation of pain +and cold clammy state of the skin, we ought not to despair; no case, +however bad, is entirely hopeless; and although the majority of such cases +perish in spite of the greatest care and activity, still we are justified +in persevering till the last, knowing from experience that we every now +and then succeed even at this late hour in rescuing our patient.[145] + + +_Uterine Phlebitis._ + +In describing the other species of inflammatory puerperal affection, which +we have designated by the title of uterine inflammation or phlebitis, and +which we conceive arises in most instances, from the presence and +absorption of putrid matter in the uterus, we shall merely confine our +description to the early part of the disease, because, as it invariably +terminates in peritotinis if not stopped at an early period, it will be +unnecessary to go over this part of our subject again. + +_Symptoms._ This affection generally makes its appearance on the second, +third, or fourth day after labour, and varies considerably in its mode of +attack. In some cases it will be observed to come on suddenly, with +scarcely any premonitory symptoms. The patient is suddenly seized with +severe griping pain in the lower part of her abdomen, generally extending +more or less to one side, and usually preceded by a smart shivering fit, +which is followed by intense headach. On examining the abdomen, the uterus +is hard, larger than natural, and excessively painful to the touch; the +pulse quick and usually small; the tongue covered with a thin white fur, +becoming brown and thicker towards the back part; the countenance anxious. +With all this, the abdomen is neither hard nor painful upon moderate +pressure; not even over the uterus itself do we produce pain, until we +begin to press so hard, that the organ becomes plainly distinguishable to +the hand through the soft integuments. The lochia has either not appeared +at all, or has been suddenly suppressed; and in all probability, the +secretion of milk has followed a similar course. + +Or the disease may commence in a much more gradual manner. The after-pains +are observed to increase in severity and duration, producing a +considerable degree of pain over the whole abdomen, but especially the +uterus, which, during the paroxysms, is harder than in the intervals. The +pains are increased by the slightest pressure, if _suddenly_ applied; but, +if gradually increased, the patient will bear a considerable degree of +pressure, not only without complaining, but will even remark that the pain +is, as it were, benumbed by it; if the hand be now suddenly removed, very +severe suffering is produced. The pains become more and more constant, +until they assume the uniform character of inflammation of the uterus, as +already described, when the disease makes its attack suddenly. If the +disease be not checked in its progress, the pain becomes more intense, +and gradually extends over the whole surface of the peritoneum; the +abdomen swells from tympanitis, and is followed by the other symptoms of +acute peritonitis already described. The latter stages of the attack are +almost invariably mingled with symptoms of the malignant form of puerperal +fever,--a circumstance which, when we consider the probable source of the +disease is not to be wondered at. Indeed, we may say, that by the time the +peritonitis is fairly established, the introduction of putrid virus into +the circulation has been of sufficient duration and extent to render the +production of adynamic symptoms almost unavoidable. + +_Appearances after death._ Examination after death shows that the uterus +and its appendages have been the chief seat of the inflammation, its whole +peritoneal surface thickly covered with exudations of coagulable lymph; +the broad ligaments vascular; the Fallopian tubes livid, swollen, and +softened; the ovaries greatly altered in appearance and structure, being +generally more or less swollen and much softened,--at times the natural +tissue of the gland completely broken down into a pulpy semi-purulent +mass, at others the external surface only has been red or gorged with +dark-coloured vessels; the whole uterine appendages thickly imbedded in +cogulable lymph. The uterus is large and soft, deposites of pus have been +found beneath its peritoneal covering, or in the proper muscular tissue of +the organ; and in many cases, on cutting into its substance, pus has +appeared in numerous little points, oozing from the veins or absorbents +which have been divided. In those veins which are large enough to be +traced by dissection, their coats have been found vascular, thickened, and +in many places lined with lymph, so that the vessel has become completely +impervious: in others, they have been filled for a space with pus, and +their canal then obliterated, either by swelling, effusion of lymph, or by +plugs of fibrine from coagulated blood. These changes in ordinary cases do +not extend beyond the substance of the uterus; but where the disease has +been of some duration, as well as severity, they become much more +extensive, affecting the neighbouring veins to some distance. +"Inflammation," says Dr. R. Lee, who has examined this subject with great +care, "having once begun, it is liable, as I have before stated, to spread +continuously to the veins of the whole uterine system, to those of the +ovaria, of the Fallopian tubes, and broad ligaments. The vena cava itself +does not always escape, the inflammation spreading to it from the iliac, +or from the spermatic veins." (_Researches on the Pathology and Treatment +of some of the more important Diseases of Women_, p. 54.) + +The surrounding structures are generally implicated in the inflammation; +the muscular tissue of the uterus becomes soft and of a dark red, or even +dirty black colour, and, as before stated, the peritoneum which covers the +organ is particularly affected. The appearances after death in this +species of puerperal fever are those most commonly observed, for puerperal +peritonitis is rarely met with in its uncomplicated form, being usually +more or less mixed up with it; on the other hand, the majority of cases +which belong to the adynamic form of puerperal fever (except the most +malignant) are generally preceded to a certain extent and attended by this +disease. + +_Treatment._ In the early stage of the disease, before inflammation +(especially peritonitis) has been established, we do not consider that the +lancet is required, merely because there is pain with a quick pulse. The +uterus may be hard, swollen, and painful, and yet there is not actual +inflammation present: we will not deny that inflammation will quickly +follow, if nothing be done to remove this state of uterine irritation. The +pulse is quick, but seldom hard; and even if it be at all sharp, it +produces but little resistance to the pressure of the finger. In these +cases we may bleed, but we seldom reduce the quickness of the pulse, +although it sinks still farther in point of strength. There is seldom much +buffy coat upon the blood when drawn at this stage; and if the pain be +relieved for a short time, it returns again as soon as the system has +recovered from the immediate effects of the syncope. We do not see that +striking relief follows a copious venesection in cases of this sort, which +is remarkable in inflammation of the abdominal viscera under other +circumstances; and we are more than ever convinced, not only from the fact +just mentioned, and from the results of our own experience, but from the +unfavourable results of the practice in which bleeding has been uniformly +and largely employed, that it is _not_ a remedy which is _always_ to be +premised before the employment of other treatment, as in cases of simple +inflammation of the viscera or serous membranes. The only circumstances we +apprehend, under which venesection ought to be employed in this affection +are, where the pain is constant, without intermission, and where, besides +its rapidity, the pulse betrays a degree of wiry resistance to the finger, +which can never be mistaken. In this case the blood drawn will show all +the usual marks of inflammation, and the relief procured will be +proportionally great. On the other hand, where the pain, although severe, +is not constant, but the patient experiences every now and then a slight +abatement in its severity, or a short intermission altogether; where the +pulse, although rapid, is soft, and resists the finger but feebly, we +shall seldom produce any permanent relief by bleeding; the pulse becomes +weaker, but its rapidity, so far from being diminished, is rather +increased. The pain may be relieved for a short time, but it almost always +returns as severely as before the venesection. + +Under these circumstances, the pure antiphlogistic treatment seems to have +little or no control, either in removing the pain, or diminishing the +pulse, or in preventing the disease from running into that state of +tympanitic peritonitis, which is so fatal in its effects; and we are not +only losing time by employing an inefficacious mode of treatment, but are +exhausting the powers of the system, already more or less depressed. +"Large hæmorrhages," as Dr. Ferguson correctly observes, "favour +absorption," (_op. cit._ p. 108;) and it would seem that by thus reducing +the powers of the system, we diminish its capability of ridding itself by +the natural outlets of the virus which has been carried into the +circulation; nor do we see how this is to be assisted by bleeding. If a +state of actual hæmorrhage has been induced, bleeding, of course, must be +used with the greatest promptness; but in employing this remedy in the +above-mentioned form of puerperal fever, although we relieve the +inflammation for a time, the cause is not removed. It still continues to +act, and the symptoms return under much more formidable circumstances, +from the increased debility of the system confining our means of treatment +within still narrower limits. + +According, therefore, to the views which we have taken of this form of +puerperal fever, the indications for treating it will be the following: +_first_, to subdue any inflammatory symptoms, if they be present; but it +must be remembered, that we have no positive proof of the existence of +inflammation, merely from the presence of pain and a rapid pulse, although +these two symptoms denote a state of irritation, advancing with rapid +strides into actual inflammation. The character of each must be carefully +ascertained before we are justified in deciding upon the necessity of +bleeding. As this operation is generally performed in the erect posture, +to favour a state of syncope, we are following a _second_ indication at +the same moment, and perhaps one of the most important, viz. placing the +patient in such a posture as will promote the escape of any coagula and +discharges which may have been stagnating in the uterus or vagina. To +effect this still more completely, a stream of warm water should be thrown +up briskly into the uterus, to dislodge any offensive irritating matter +which may have collected: the relief thus produced is sometimes quite +extraordinary, the pain abates, the uterus becomes less hard, the pulse +more natural, and the patient expresses herself greatly relieved. The rule +which we have made in our treatment of natural labour, viz. that if +possible, the patient should sit up to take her food, and suckle her +child, and especially that she should always kneel to pass water, should +never be neglected, for in many of these cases it will be found that the +patient has not stirred from the horizontal posture, and that the attack +had evidently followed the accumulation of stagnant lochia, &c., which +from the warmth of the adjacent parts, and free contact with the external +air, has rapidly become offensive; and, moreover, from her position, has +been prevented from being discharged. To ensure that the uterus has +expelled any coagula which may have lodged in it, is a powerful argument +in favour of applying the child to the breast as soon as possible after +labour; this refers particularly to those long slender coagula, which were +first noticed in the uterine veins by Dr. Burton, in 1751, as one of the +chief causes of after-pains; for by thus inducing firm uterine +contraction, the greater part of these will be generally expelled, and +access of air to the venous orifices prevented. "These coagula may be +distinctly perceived for several weeks after delivery, and both in their +form and colour they differ from those produced by inflammation." (R. Lee, +_op. cit._ p. 53.) + +Our _third_ indication is to increase the action of all the excretory +functions, and thus, as far as possible, remove the virus, which may have +already entered the system. There is no remedy with which we are +acquainted that has such a power of producing a general erethism +throughout the whole excretory system, as calomel in large doses. The +secretions of the liver, the mucous membrane of the intestinal canal, of +the skin, and kidneys, are all very remarkably increased by the action of +a large dose of this medicine, and we cannot help attributing the return +of healthy lochia, which so frequently follows such a dose of colomel, to +a similar action on the vessels of the uterus and vagina. No effort of +nature can be so well directed for the removal of any noxious principle +from the circulating fluids as a general increased action of the excretory +system, and we have seldom or never seen calomel act with such success in +this form of puerperal fever, except where it had been given in a +sufficient dose to produce this effect. Salivation is by no means a +necessary object, nor have we seen it produced even by a scruple dose of +calomel. It is, however, seldom necessary to exceed ten grains at a time, +although this may occasionally be required to be repeated. It should +always be combined with some medicine which will assist its diaphoretic +action. For this purpose, in cases where the pain is constant, without any +remission, showing that a state of inflammation has been already induced, +it will be advisable to combine it with a little of James's or antimonial +powder. Where, on the other hand, the patient experiences evident +abatement or even remissions of pain, ten grains of calomel with an equal +quantity of Dover's powder, made up into pills, will be preferable; the +opium acts by relieving the pain, and contributing to induce a copious +perspiration. To assist this, and also to relieve pain still more, a hot +linseed-meal poultice, as above described, will be of great service; and +in a few hours (or the next morning, if the calomel has been given over +night,) a saline of sulphate and carbonate of magnesia should be given. +The vagina should be well syringed with warm water, and repeated from time +to time as occasion requires; in like manner, the poultice must be +continued until the pain has entirely ceased. + +The general result of this treatment is, that in twelve or eighteen hours +the uterus loses its tenderness and hardness, the pulse becomes fuller +and softer, the tongue cleaner and more moist, the kidneys and bowels have +acted copiously, and the lochia and milk have returned. + + +_False Peritonitis._ + +Under this title, which we believe first originated at the General +Lying-in Hospital, and which has been adopted by Dr. Locock in his article +upon the subject, we propose to describe that peculiar species of +abdominable pain, which Dr. Ferguson has called the _transient_ form of +peritonitis. Strictly speaking, neither of these terms are exactly +appropriate, for the disease appears to depend upon a state of high +nervous irritability, perfectly independent of inflammation, or any other +affection of the peritoneum; still, however, as it has been most +frequently known and described under the former of these appellations, we +shall also continue to use it, merely warning our reader, that the +appellation of false peritonitis is more conventional than correct. +Properly speaking, it should be called _nervous abdominal pain_; for we +have reason to think that its real seat is in the muscular coat of the +intestines, and in the abdominal muscles themselves, much more than in any +portion of the peritoneum. + +The disease chiefly attacks women of a delicate frame, and irritable habit +of body, with small features, fair complexion, and of a nervous hysterical +disposition, whose powers have but ill sustained them through the +processes of pregnancy and parturition, and are now beginning to fail +under that of lactation. Her mind is anxious and depressed, the sleep is +restless, the circulation irritable and feeble; she is pale, forebodes all +sorts of evils, and is unusually sensitive; complains inordinately of her +sufferings in trying to suckle the child, and of the severity of her +after-pains; not unfrequently she has severe headach, of that species +which affects the top of the head, and which is generally considered to +arise from a state of debility and anæmia. In many cases the pain has +evidently been produced by the action of a griping purge. The pain is of +the most intense character; indeed, in many cases, it is evidently too +severe for the ordinary suffering from abdominal inflammation. So +irritable are the abdominal muscles, that the slightest motion, even that +of respiration, will throw them into cramp-like contractions to the great +agony of the patient. The breathing is short and timid, like that of a +person under a severe attack of pleurodyne: the slightest touch of the +hand, or of a single finger, produces intolerable suffering, not so much +from the pain which its pressure produces, but from the sudden and +involuntary contraction to which the irritable muscles are thus excited. +The quickened breathing, from a dread of the abdomen being touched, is +frequently sufficient to bring on a paroxysm. If by soothing words and +promises of cautious proceeding we induce her to let us apply our hand +upon the abdomen so gently that it does not even rest with its weight upon +it, we shall find that we may now gradually increase the pressure, until +by degrees it becomes considerable, not only without her feeling any +increase of pain, but with complete relief--the pressure of the hand +appearing as it were, to benumb the pain. If we withdraw the hand in the +same gradual manner, no pain will be produced; but if we remove it +suddenly, a spasm of the muscles, with intense pain, is instantly excited. + +The pulse is in an equally irritable state; after a few beats it rises in +rapidity as soon as the patient's mind is directed to it; in others it is +permanently quick. The tongue is sometimes slightly covered with a thin +fur; in others it is pale and flabby; and in others disposed to be glazed, +red, and dry. + +The disease rarely exists long uncomplicated with any other form of +puerperal affection, but soon passes either into acute peritonitis, or +into the typhoid state of the malignant form, the latter transition being +almost certain, if the practitioner has considered it as an inflammatory +affection, and treated it antiphlogistically. + +It is to the late Dr. Gooch that we are indebted for having first called +the attention of the profession to this disease, and pointed out its true +characters by the nature of the remedies which proved successful in +relieving it. "The effects of remedies on a disease, if accurately +observed, form the most important part of its history; they are like +chemical tests, frequently detecting important differences in objects +which were previously exactly similar. How many diseases are there in +which the symptoms are inadequate guides?" "The local pains and +constitutional disturbance which occur in feeble and bloodless persons, +and which are aggravated by bleeding and other evacuants, strikingly +resemble the local pains and constitutional disturbance which occur in +vigorous and plethoric persons, and which the lancet and other evacuants +relieve and ultimately cure; yet how many years is it before the young +practitioner learns that there are cases apparently so similar, yet really +so different, and how to distinguish them; and how many practitioners are +there who never learn it at all? Symptoms and dissections can never do +more than suggest probabilities about the nature of the disease, and the +effects of a remedy on it. A trial of the remedies themselves is the only +conclusive proof." (_Op. cit._ p. 37.) + +In those cases which proved fatal, the post mortem appearances only tended +to confirm the nature of the disease. So far from marks of inflammation +being found, there was not a single trace to be discovered; in fact, an +entirely opposite condition existed; the peritoneum and viscera were pale +and bloodless. + +_Treatment._ It is of the highest importance to distinguish these +affections from a state of inflammation; the treatment of the one will be +precisely the reverse of the other. The lancet is as little indicated in +this case, as it is in puerperal convulsions from anæmia, and the effects +produced will be scarcely less mischievous. The fatal cases which Dr. +Gooch has recorded, show that it was not the disease so much as the +treatment which destroyed the patients, and prove, as we have already +stated, that the presence of pain and a quick pulse do not surely indicate +a state of inflammation, without being confirmed by the general symptoms +of the patient's condition. "These cases taught me a new view of the +subject: they taught me that a lying-in woman might have permanent pain +and tenderness of the abdomen, with a rapid pulse, independent of acute +inflammation of the peritoneum or any other part; that these symptoms may +depend on a state which blood-letting does not relieve, and which, if this +remedy is carried as far as it requires to be carried in peritonitis, may +terminate fatally; and that the most effectual remedies are opiates and +fomentations. Most of the patients who were the subjects of these attacks, +were women, who, in their ordinary health, were delicate and sensitive; +the attack sometimes seems to originate in violent after-pains, gradually +passing into permanent pain and tenderness, resembling inflammation, or in +the painful operation of an active purgative; but it could sometimes be +traced to no satisfactory cause--the patient had had a common labour, and +had experienced no unusual cause of debility or irritation. The pulse in +all these cases, although quick, was soft and feeble: this, together with +the previous constitution of the patient, were my chief guides. When I +could trace it to any irritating cause, such as a griping purge, and when +blood had been already drawn without relief, and without being buffed, I +saw my way still clearer. When I doubted, I applied leeches to the +abdomen." (_Op. cit._ p. 72.) + +In ordinary cases a dose of Liquor Opii Sedativus, or of Dover's powder, +repeated according to circumstances, will be sufficient to stop the +attack, taking care to clear the bowels of any irritating matter with +castor oil in some aromatic water, guarded by a few drops of Battley's +solution. In many of these cases, where the circulation is below the +natural standard in point of power, and the disease is more or less +complicated with hysteria, the opiates should be combined with a gentle +stimulant, of which camphor is by far the best. Five grains of powdered +camphor with half a grain of hydrochlorate of morphia and a sufficient +quantity of extract of henbane, to form two pills, may be repeated at +intervals, whenever the pain shows a disposition to return, and +constipation prevented by castor oil and Liq. Opii Sedativus as +before-mentioned, or a gentle draught of sulphate of potass, rhubarb, and +manna. In most cases, when the stomach and bowels are in a proper +condition, mild tonics will prove useful, as equal parts of extract of +gentian, henbane, with or without a grain or two of quinine or sulphate of +iron, at night; and, if necessary, the infusion of some vegetable tonic +during the day. The diet should be simple but nutritious, and a certain +quantity of malt liquor or wine allowed daily, if the condition of the +patient permit it. In some instances the low diet which is usually deemed +requisite for the first few days after labour, has appeared to have been +the cause of this highly irritable condition, especially in those who have +habitually accustomed themselves to pamper the appetite, and to use +fermented or spirituous liquors in excess: with spirit drinkers, the loss +of their daily stimulus is almost sure to be followed by a low, feeble, +irritable state of the system, much gastric and nervous derangement, and +the paroxysms of pain just described. It is astonishing how quickly every +symptom subsides, and the system returns to a natural condition, by the +daily allowance of a small quantity of their favourite beverage. + + +_Gastro-bilious Puerperal Fever._ + +This is the gastro-enteric species of Dr. Ferguson, and corresponds with +the "puerperal intestinal irritation" described by Dr. Locock. In its +simple uncomplicated form, this disease cannot be considered as a +dangerous affection; it occasionally passes into inflammation, but more +frequently it assumes after awhile the typhoid or malignant form, +especially where its true characters have not been recognised, and the +powers of the system have become much exhausted by its severity and long +continuance. + +Like the false peritonitis it is frequently met with in cases where, from +unwholesome or intemperate living, the digestive organs are greatly +deranged, or where the bowels have been much neglected for some weeks +before labour. We cannot help thinking that the view which Dr. Ferguson +has taken of its cause, viz., a vitiated state of the fluids, as with the +case of puerperal peritonitis, is far too exclusive, inasmuch as it is +evidently produced in many instances by the direct irritation of matters +which are contained in the intestinal canal: in others, we fully agree +with him, that it is produced indirectly by the introduction of an animal +poison into the circulation, which spends its virulence upon the stomach, +liver, or intestines, or which, in other words, nature endeavours to +remove from the system by these outlets. In the early stage of uterine +irritation, or of phlebitis, from the absorption of putrid fluids, we have +shown that the cause at first, in most instances, acts directly, and not +through the medium of the circulation, otherwise the symptoms would not be +so instantly checked by washing out the uterus with warm water, and thus +removing the source of mischief; so in the gastro-bilious or enteric +form, the symptoms _at first_ are produced in most, if not all cases, by +the direct irritation of the unhealthy intestinal contents, upon the +removal of which they at once disappear; although at the same time, if the +source of irritation be not removed, we have no doubt but absorption will +take place sooner or later and vitiate the circulation. Thus, Dr. Kirkland +considers that retained fæces during a lying-in are capable of bringing on +symptoms which "may, properly enough, be called puerperal fever" (_op. +cit._ p. 87;) and Dr. John Clarke, in enumerating the different causes +entertained by "writers of good reputation," mentions, where fæces are +detained in the intestines, "the thin putrid parts of which are supposed +to be taken up into the blood." (_Practical Essay on the Management of +Pregnancy and Labour_, by J. Clarke, M. D., 1806, p. 53.) + +There is, however, no reason to confine the source of the putrilage, which +infests the circulating current, in cases of gastro-bilious or intestinal +irritation, to unhealthy fæcal matter in the intestines; for in the +experiment made by Professor Tiedemann, to which we have already alluded, +viz. of injecting musk into the femoral vein of an animal, the poison +seemed to concentrate itself upon the mucous membrane of the intestinal +canal; and from the diarrhoea which had commenced shortly before death, it +is probable, if the dose had been smaller, that nature would have +succeeded in ridding the system of it by this means; we may, therefore, +conclude, in most of the cases of this affection, which are not the result +of direct enteric irritation, but an effort of nature to purify the +circulation by expelling the morbid matter, with which it had been +vitiated, through the medium of the mucous membrane of the bowels, that +the uterus had been the source of its origin, introduction, or absorption, +into the system. + +_Symptoms._ This form of puerperal fever seldom commences so soon after +labour as any of the other species, and frequently the symptoms are so +trifling, at first, as scarcely to excite attention. There is an +indistinct uneasiness about the abdomen; the tongue is never quite +natural, being either slightly furred with a few prominent papillæ, or +pale and flabby; the appetite is irregular, or fails considerably; the +patient complains of weariness and lassitude; there is, perhaps, slight +headach across the eyes and forehead; the face has a sallow tinge, and if +her complexion be dark, there is a leaden-coloured ring beneath her eyes; +the sleep is unrefreshing; the spirits are unequal and anxious; she is +chilly at times, and at others, has considerable flushings of heat, with +increase of headach. The abdomen becomes full and doughy to the feel; it +is somewhat tender to the touch, but not distinctly so, as in peritonitis; +the motions are dark, sparing, and excessively offensive; sometimes hard +and scybalous; but more usually they assume the character of an irritable +diarrhoea, with much acrid slimy mucus, the evacuation of which, is +attended with much flatus, and for a time produces great relief, +although, at the moment of passing, it is frequently attended with a good +deal of forcing. The abdomen becomes more tender, with severe griping +flatulent pains at intervals; the diarrhoea assumes somewhat of the +characters of dysentery; the pulse becomes quick and irritable; the tongue +red and glossy at the tip and edges, with a patch of thin white fur in the +middle, or with a red centre between two parallel streaks of creamy +fur--the back part yellow, verging into brown; the breath is of a faint +disagreeable odour; the attacks of fever, from time to time, are more +distinct; and frequently, during the sweating stage, the skin throws out a +strong peculiar odour, which taints the air of the whole room. In some +cases there is frequent vomiting, either of watery fluid mixed with ropy +mucus, or of a greenish colour; the result probably of subacute +inflammation of the stomach. As the irritation of the intestinal canal +increases, she becomes more exhausted, and rapidly emaciates. The tongue +now becomes preternaturally red, its surface glossy smooth, the centre is +parched and brown, and sometimes traversed with fissures; the fever +assumes a low typhoid character, with delirium at night, and gradual +sinking. The appearance of the evacuations varies considerably; at times +they appear to consist of minute membranous shreds, floating in dark brown +water; in others, they are clay-coloured, slimy, adhesive, excessively +offensive, and even pungent; whereas, in others, they seem to consist +chiefly of dark unhealthy bile, mixed with water and mucus. + +This form of disease is frequently met with in patients who have been +weakened by hæmorrhage, and necessarily tends to aggravate the state of +anæmia which is present. She has the intense pain at the summit of the +head, which characterizes this condition; she gets but little sleep, and +that is disturbed by restless and uneasy dreams; she lies with the eyelids +half closed, and the occasional twitchings of the muscles betray the +irritable condition of the system; exhaustion quickly supervenes, and is +usually attended either with low delirium, or the anæmic form of puerperal +mania. + +_Appearances after death._ If the dysenteric affection has been very +severe, we shall probably find softened or even ulcerated spots in the +mucous membrane of the large intestine; but in other cases, there have +been no lesions of the kind; the intestines have been found a good deal +distended with gas, but pale and bloodless. Where the disease has passed +into the typhoid species, other appearances belonging to this form will be +observed: coagulable lymph will probably be effused, and those changes in +the structure of the uterus, which we shall mention when we come to the +consideration of this species. + +_Treatment._ The treatment will, in great measure, depend upon whether the +disease is the result of irritation from loaded bowels, scybalous and +unhealthy contents, &c., or from that engorgement of the circulation +belonging to the chylopoietic viscera, with more or less fever, which +indicates the efforts nature is making to rid the circulation, by this +outlet, of any morbid principle with which it may have been infected. + +In the first case it is simple enough, and, in most instances, the disease +is prevented, or, at any rate, checked in its very outset, by the dose of +castor oil which is customarily given on the second or third day after +labour. If the pulse be quick, the headach severe, with much fulness and +uneasiness of the abdomen, and more especially if the bowels have been +constipated, or in an unhealthy state before labour, five grains of +calomel and carbonate of soda, made up into two pills, with extract of +henbane, and followed in a few hours by a dose of castor oil, guarded with +some Liquor Opii Sedativus, as before recommended, will be required. We +combine a little soda with the calomel, to prevent it griping and acting +violently, which it is liable to do where there is much acidity of +stomach, from its being converted into the bichloride. We also think that +there will be less chance of vomiting, when the calomel is combined with +the soda, than with an antimonial, as recommended by Dr. Locock; a common +domestic enema of gruel and salt will assist the purgative, and bring away +much unhealthy fæculent matter. The medicines will generally require to be +repeated in twenty-four hours, to insure the removal of the irritating +cause from the bowels; the abdomen becomes softer and more free from +uneasiness; the pulse rises in strength and fulness, but diminishes in +rapidity, and the patient experiences general relief in her symptoms. She +may now take an ammoniated saline, with tincture of hop or henbane during +the day; five grains of Hydrarg. cum Cretâ with carbonate of soda and +henbane at night, instead of the calomel, and a draught of rhubarb and +magnesia with some aromatic confection the next morning, or of rhubarb and +manna with sulphate of potash, rendered warm by a little spirit of nutmeg. + +If diarrhoea has come on spontaneously at an early period, the true nature +of the case is more liable to be mistaken; still, however, the evidences +of gastric and enteric irritation are quite sufficient to guide the +cautious and observant practitioner. The calomel here is not so desirable +as where there is constipation; eight or ten grains of Hydrarg. c. Cretâ +will produce less irritation, and act as effectually: it will require to +be followed by the same treatment as above-mentioned, and to be repeated +according to circumstances. + +The diet should be chiefly farinaceous with milk; rice-milk, when the +bowels have been sufficiently cleared, is generally very useful; it is +slightly constipating, and soothes the irritable mucous membrane with its +bland consistence. Milk and soda-water, as mentioned by Dr. Locock, or +with lime-water, is very beneficial, especially where the tongue is +disposed to remain red, with a smooth glossy surface; as convalescence +proceeds, a tea-spoonful of the concentrated essence or decoction of +sarsaparilla may be added with advantage. + +This form of puerperal affection is never epidemic; it is mere intestinal +irritation after labour from scybalous and other unhealthy contents; but +this is not the case with the "gastro-enteric form," described by Dr. +Ferguson; in the former, the febrile excitement of the circulation is but +trifling, and frequently can scarcely be said to exist; whereas, in the +latter, the disease rarely appears sporadically, but in conjunction with +numerous cases of the same character, or of the malignant adynamic form; +it is also, invariably accompanied with much febrile disturbance, and +usually of a low form, unless complicated with abdominal inflammation at +an early period. + +"This form of puerperal fever," as Dr. Ferguson observes, "assumes the +general characters of a mild typhus, accompanied with intestinal +irritation." (_Op. cit._ p. 22.) The object of our treatment here is very +different to that of the other form just mentioned; it is to unload the +gorged circulation of the stomach, liver, and bowels, of the noxious and +excrementitious matters which nature has brought to these emunctories, in +order that they may be discharged from the system. It is in these cases +where, although little or no food has been taken for some time, and +without any evidences of fæcal accumulation, we find the exhibition of +certain purgatives, especially calomel, to be followed by such copious +fæculent evacuations, which we have every reason to believe have been +secreted by the liver and bowels under the action of this powerful remedy. +The treatment recommended by Dr. Ferguson, is so in accordance with our +own views, and so concisely expressed, that we may be allowed to quote it. + +"The following," says he, "I have found the most suitable treatment. Get +rid of all local inflammations as soon as possible by leeching or by +moderate depletion, so as to reduce the malady into simple fever with +gastro-enteric irritation. When the skin is early dusky, and there is +nausea or vomiting, begin with an emetic. If there be no nausea nor +vomiting, but intestinal flux, with a red tongue smeared with suburra, a +large dose of calomel, from ten to fifteen grains should be given. Small +doses create purging, pain, and irritation, while the full dose produces +one to six large pultaceous stools, after which the tongue is cleaned, +rendered less red and more moist, and the pulse usually falls. These +stools, when examined, appear to contain the fæcal matter suspended in +large quantities of mucus and greenish bile, as if the turgid capillaries +of the irritated intestinal canal and liver had been freed from their +load. In some instances, a repetition only of the same dose is required to +efface the main features of the malady, and to leave nothing but debility +to support. In others, after a short respite, diarrhoea re-commences, and +soon is apt to become colliquative." (_Op. cit._ p. 158, 159.) + +We have already shown the effects which calomel possesses in large doses +of rousing the different excretory organs into full action, and thus +assisting to secrete or separate from the circulation any offending +principle which may have been carried into it. We are also convinced that +where calomel has been promptly given in this manner, the chances of the +disease being prolonged or terminating in the adynamic form are +considerably diminished. Dr. Hamilton, in speaking of the advantages +derived from the use of purgative medicines in typhus fever states, "I am +now thoroughly persuaded, that the full and regular evacuation of the +bowels relieves the oppression of the stomach, cleans the loaded and +parched tongue, and mitigates thirst, restlessness, and heat of surface; +and that thus the later and more formidable impression on the nervous +system is prevented, recovery more certainly and speedily promoted, and +the danger of relapsing into the fever much diminished." (_Observations on +the Utility and Administration of Purgative Medicines in several +Diseases_, by James Hamilton, M. D. p. 35.) + +As the gastro-enteric form of puerperal fever which we have just +described, is frequently observed in epidemics of the adynamic form, +particularly at their commencement and going off, and frequently +complicated with it, we would rather consider those local inflammations +and deposites of puriform fluid in the muscles, joints, &c., which are +occasionally seen after severe cases, to the disease being complicated +with, or assuming the nature of, the malignant form. + +If the symptoms have not yielded to the treatment which we have +recommended, the alvine discharge becomes excessively unwholesome and +fetid, the skin exhales a strong and unpleasant odour, the strength fails, +the tongue is either dry and brown, or smooth and red like raw meat, the +fever sometimes assumes the remittent character as described many years +ago by Dr. Butter, of Derby; in others, the febrile symptoms subside, +leaving the case one of chronic or subacute inflammation of the lining +membrane of the bowels, with occasional attacks of irritative fever +arising from it. In these cases mercurials, except in mild and guarded +doses, appear to aggravate the irritation of the mucous membrane, and +increase the disposition of it to ulcerate: five grains of Hydrarg. cum +Cretâ and Dover's powder may be given once, or at the utmost, twice, in +the twenty-four hours; half a drachm of carbonate of ammonia neutralized +by lemon juice, and rendered alkalescent by a little Spirit. Ammon. Arom., +may be given in some aromatic water every three or four hours; injections +of starch into the rectum with a few drops of Battley are also useful. In +some cases, where there was continued flatulence, a small quantity of +turpentine in some castor oil has had an excellent effect. Others, where +every means had seemed to fail, have yielded under the use of copavia. Dr. +Locock has found advantage from the occasional use of very small doses +(eight to ten grains) of epsom salts with a few drops of laudanum in some +aromatic water. The after treatment, as also, the rules for diet, are the +same as in the other form. + + +_The Contagious, or Adynamic, Puerperal Fever._ + +Although we have classed under the head of "puerperal fevers" a variety of +affections connected with, and arising more or less from, the same cause +with the dreadful malady which we are now about to describe, and although +every form and modification of them is liable to assume its characters, +still we must confess that the term _puerperal fever_ belongs _par +excellence_ to this form, the adynamic, malignant, and, as we have upon a +former occasion called it, the genuine puerperal fever. + +It is in this form of disease that the vitiated state of the blood is +shown with most distinctness, not only from the condition of the blood +both during life, and after death, but also from the close connexion which +exists between it and the plague, African typhus or yellow fever, and the +other malignant fevers, both of the temperate as well as the tropical +climates. + +The interesting and daring researches of M. Bulard upon the pathology of +the plague, tend to throw great light upon the nature of this formidable +disease, and to confirm the views which we have long entertained of this +and other diseases of the same class, that the essence of the disease +consists in the vitiated condition of the blood. + +_Symptoms._ The onset of this disease is almost invariably accompanied +with a smart rigour, followed by intense headach, and rapid but generally +powerless pulse. It seldom begins before the third day, although in some +cases it seems to have commenced from the time of her delivery; whereas, +in others the patient has gone on to recover favourably until the tenth or +even the fourteenth day before being seized, and had already felt +sufficiently well to leave her bed and sit up. The powers of the system +seem prostrated at once; the shrunken features and dusky hue of the skin, +the leaden colour of the lids, and circumscribed crimson or almost purple +patches upon the cheeks, the short imperfect breathing and occasional deep +sighing to relieve it, indicate but too surely the nature of the disease, +and its depressing effects upon the whole system. + +"The sensorium," says Dr. Douglas in describing this form, "is seldom in +any degree disturbed, whereas, in the others, it is so frequently, and +even sometimes it is excited to high delirium. The pulse here is usually +from the moment of the attack, soft, weak, and yielding, and in quickness +often exceeds 150; whereas, in the first species it is full, bounding, and +often incompressible; and in the second, small, hard, and contracted, and +in both, moderately quick. The eye, instead of being suffused with a +reddish or yellow tint, as in the others, is here generally pellucid with +a dilated pupil. The countenance, instead of being flushed, as in the +others, is here pale and shrunk with an indescribable expression of +anxiety; an expression altogether so peculiar, that the disease could on +many occasions be pronounced or inferred from the countenance alone. The +surface of the body instead of being, as in others, dry and of pyrexial +high heat, is here usually soft and clammy, and the heat not above the +natural temperature; and not only is the skin cool with clammy exudation, +but the muscles to the impression of the finger feel soft and flaccid, as +if deprived of their vis vitæ by the influence of contagion. Indeed, there +is such prostration of muscular strength and depression of vital principle +from the very outset of the attack, that I must suppose the contagion to +act through the medium of the nervous system in a manner analogous to that +of the contagion of plague." (_Report on Puerperal Fever._ _Dub. Hosp. +Rep._ vol. iii.) + +Where the powers of the system are not annihilated from the commencement +of the attack by the depressing effects of the poison with which the +circulation is impregnated, an effort at reaction is frequently made, and +for some hours afterwards the surface of the body is hot and dry; but +sooner or later, as the stage of collapse comes on, it then assumes the +same cold death-like feel, as in the worst cases of malignant cholera. The +character of the attack will be in great measure modified by the intensity +of the poison, and the extent with which the circulation has been infected +by it. The same effort to produce such a state of reaction as will raise +the temperature of the skin, will probably assist nature in throwing it +off under the form of peritonitic or gastro-enteric species of puerperal +fever already described; whereas, where the circulation has been +thoroughly impregnated with it in its concentrated form, the vital powers +succomb at once, and a state of collapse exists from the very commencement +of the disease. The course which the symptoms follow and the duration of +the disease, will, therefore, depend not only on the severity of the +attack, but also on the power of the particular constitution to resist the +deadly effects of the morbid principle upon which the disease depends. +When broken down by previous disease, intemperance, poverty, and +depressing passions of the mind, the vital powers can make no stand +against the powerful enemy by which they are attacked; "the blood is so +much vitiated, even early in the disease, that it loses the power of +stimulating the heart so as to keep up its healthy action; and, perhaps, +also the vascular organs are early affected by the action of the poison, +and lose the power of either feeling the stimulus, or reacting with force +on the impression, which is communicated to their internal surface by the +vitiated blood. In such cases, in place of increased excitement, there is +frequently a want of action in the whole system." (Stevens, _op. cit._ p. +188.) The patient sinks without pain or complaint, beyond that of +debility, but in such cases with a rapidity which would almost claim for +the disease the name of "plague." The tongue becomes dry, red, and brown +at the back part, the pulse weaker and more rapid, the debility and +exhaustion more overpowering; still, even in this state, her mind usually +remains clear, unconscious of the fate which awaits her, and occasionally +even cheerful: a peculiar sickly odour exhales from the skin, and in many +cases so distinctly, as to warn us the moment we enter the room of the +patient's condition. The dusky ashen hue of the skin becomes darker, the +fingers are shrivelled, and the nails dark, or of a livid black as in +cholera; diarrhoea frequently attends, the fæces are unhealthy, and of the +same peculiar odour just noticed; during the first stage the lochia are +generally present, although of an unhealthy character; the milk also +continues in the milder cases, but as the stage of collapse approaches +they both disappear, and the breasts become quite flaccid. In some cases +there is vomiting from an early period, with more or less tympanitic +distention; but these symptoms rather depend upon the disease being +complicated with one of the other modifications. Livid purpurous blotches +sometimes appear upon the legs, &c. and in some epidemics it is +accompanied with dark or livid eruptions. The surface has now the cold wet +feel in its greatest degree, and in some cases even the tongue feels cold +to the finger; a drowsy state of insensibility generally follows and +continues until death. + +The symptoms here enumerated present the characteristics of fever under +its different degrees of intensity. The peritonitic and gastro-enteric +forms may be compared with the ordinary fevers of temperate climates, and +which are attended with more or less inflammation of some organ. The +malignant adynamic form corresponds closely with the malignant typhus of +this, and the pestilential fevers of warm countries, more especially the +plague and the African typhus or yellow fever. In all of these diseases, +the vitiated state of the blood appears to be the essential condition of +their existence, quite independent of any inflammatory action; in fact, in +this form, so rapid and overpowering are the effects of the poison which +pervades the circulation, and so completely does it paralyze the whole +system, that there is neither time nor sufficient vis vitæ to make any +effort at reaction. Hence, as Mr. Moore has correctly observed, "when the +patient is rapidly destroyed by the violence of the disease, the morbid +changes bear no proportion to the severity of the previous symptoms; a +dubious trace of inflammation, a little serum, or a few feeble adhesions, +are all that dissection under such circumstances displays." (_Inquiry into +the Pathology, Causes, and Treatment, of Puerperal Fever_, p. 63.) In many +of the most rapidly fatal cases which we have witnessed, there have not +been even these questionable evidences of inflammation. The tissues have +been pale and bloodless, the uterus softened, its internal surface ragged, +and with a dark gangrenous appearance, extending to the os uteri, and dark +thin claret-like blood in all the larger vessels. The heart is flabby, +soft, and filled with dark blood; the lungs, liver, spleen, and kidneys +much softened; the spleen dark, sometimes enlarged and almost pulpy. If we +compare these appearances with those observed by M. Bulard in cases of +plague, we shall find a striking coincidence between the two diseases. +This intrepid pathologist remarks, that "the state of general turgescence +and dilatation of the venous system; the presence of inflammable gas in +eight cases in the cellular tissue, in the veins of the head, feet, and +abdomen; the presence of petechiæ, both internally and externally; the +general softening of the tissues; the enlargement, softening, and breaking +down of the spleen; the petechial state of the mucous membrane of the +stomach; the effusions of blood on the inner surface of that organ; the +passive hæmorrhages and boils, are symptoms which result from a change in +the condition of the blood. The symptoms connected with the state of the +nervous system, viz. the rigours, headach, and confusion of mind, the +quick and small pulse, the hurried respiration and vomiting, and also the +petechiæ, carbuncles, and buboes, are neither those of vascular nor +nervous inflammation. The blood has never shown the buffy coat; it was +found just as black in the arteries as in the veins, but in the former, in +much smaller quantity; it always had the appearance of being dissolved." +M. Bulard observes, that the decomposition of the blood is quite +independent of putrefaction being present before death takes place; and he +feels convinced that it is not only the sole cause of death, but must also +be looked upon as the origin of the various morbid phenomena during the +course of the disease. He considers "these phenomena to result from an +actual poisoning of the blood, similar appearances being observed in all +cases where putrid matter and morbid secretions have been introduced into +the system." With regard to the supposed inflammatory nature of the +plague, M. Bulard states, that in many cases not the slightest trace of +inflammation could be found. The changes in the spleen are of by far the +most invariable occurrence. In one hundred autopsies, this organ was found +only five times in a healthy state. + +Where, on the other hand, the powers of the constitution, or the +diminished virulence of the disease, have enabled the system to withstand +the depressing action of its immediate effects, we find it considerably +modified, both in the symptoms which it presents during life, and the +appearances after death. Instead of being little else than a state of +collapse from the very outset of the disease, under which, not a single +attempt is made by the powers of the system to set up even the most feeble +effort of reaction, a variety of symptoms attend its commencement and +progress, indicating that the vis vitæ has not altogether succumbed +beneath the deadly effects of the malady. The very rigour itself, when +violent, the headach and flushing of the face, if severe, are rather +favourable than otherwise, and show that the system still possesses some +power of reaction. It is usually observed, that where the attack commences +with these precursory symptoms well marked, it is generally accompanied +with peritoneal pain, tympanitis, and other symptoms of inflammatory +action; whereas, in the worst cases, we have already stated, that from the +very commencement of the disease there is neither a symptom of +inflammation during life, nor a trace of it to be found afterwards. Dr. +Armstrong rightly observed, that inflammation is not an essential +constituent of typhus; and the same holds good in the strictest sense of +the word, with the typhoid or adynamic puerperal fever. + +"Whatever the remote cause of fever may be, it is very evident that this +cause must invariably exist, not only at the moment of attack, but even +previous to that period. Now in the fevers from poison, the blood is +invariably diseased previous to the commencement of the cold stage. During +this period there are premonitory symptoms; but these are evidently the +effect of the diseased state of the vital fluid: and that these precursors +of fever are not the effect of any local inflammatory disease, is evident +from the fact, that frequently during this period there is no pain in any +of the organs, but a want of action, particularly in the extreme vessels, +and consequently a decrease of heat in the whole system. + +"If inflammation in any of the organs were, in reality, the cause of +fever, then the disease ought to be fatal, exactly in proportion to the +violence of the local affection; but the very reverse of this is the +truth. Mere excitement can easily be reduced, and the inflammatory form of +fever is decidedly the most easily cured, though in it the excitement is +often so great that the organs are very liable to be injured; while the +malignant form of fever is by far the most fatal, though in this the +excitement is less, and the organs are seldom affected. This is +particularly the case in the worst form of the African typhus, and +probably other varieties of malignant fever, where the blood is under the +influence of an active poison, and where its vitality is diminished, and +its structure is injured even before the attack. + +"Those who have seen most of the malignant diseases know well that +excitement in fever is invariably a good symptom; for this is a sure sign +that the blood has not yet undergone any fatal change, and independent of +this, mere increase of action is always at the mercy of the lancet. But +neither the lancet nor leeches, gum water, vitriolic emetics, calomel, +antimony, brandy, opium, or acids, can redden the colour of the black +blood, which we invariably meet with in pestilential diseases, or remedy +the diseased state of the vital current, so as to cure that fatal form of +fever where the malignant symptoms are produced, not by excitement, but by +the vitiated state of that mysterious fluid, which in health gives life +and nourishment to every solid of the system, and which, when diseased to +a certain extent, is by far the most frequent cause of death in all those +fevers that are produced by some deleterious poison acting, in the first +place, on the vital current, and then on the brain and the whole system +through the medium of the blood." (Stevens, _on the Blood_, p. 186.) + +We have quoted thus largely from the observations of Dr. Stevens and M. +Bulard, to whose admirable researches we are so greatly indebted for our +present knowledge, respecting the nature of pestilential diseases both of +the East and West, for they tend not only to show the true pathology of +malignant puerperal fever, but also the class of diseases to which it +belongs. + +_Appearances after death._ Where more or less inflammatory action has +accompanied the first part of the disease, the lesions observed after +death differ considerably from those of acute peritonitis: the effusions +of cogulable lymph, of serum, and sero-purulent fluid, are seldom met with +to such an extent where the case has been one of inflammation +uncomplicated with the adynamic form of puerperal fever, even although it +may have been exceedingly violent; whereas, in the present case, although +there has been scarcely sufficient power in the system to set up even a +moderate degree of inflammatory action, the intestines and uterine +appendages are found glued together, and thickly imbedded in immense +effusions of lymph. The ovaries, Fallopian tubes, and broad ligaments are +engorged with purple vascularity, softened, and, especially the ovaries, +quite disorganized, with numerous effusions of sero-purulent matter +beneath their peritoneal coverings, or into their parenchymatous tissue. +In others, their whole substance has been softened and pulpy, with little +cyst-like cavities filled with blood or pus, the remains of the Graafian +capsules. During the fatal epidemic which prevailed at the General +Lying-in Hospital, in the early part of 1838, we met with several cases +where the ovaries had entirely disappeared, their site being only +discoverable by an oval thickening of the broad ligament, something like +an empty cyst of peritoneum; this contained a small quantity of livid +pulpy débris of the ovary, and (on that side where conception had taken +place) a remarkably well marked or rather exaggerated corpus luteum. The +uterus is larger and its tissue much softer than under ordinary +peritonitis, so that, in many instances, the finger can be easily pushed +through its whole substance. + +Where the constitution has borne the brunt of the attack without immediate +collapse, and the local mischief been controlled by appropriate means, we +find that fresh efforts are made to rid the circulation of the morbid +matter with which it is infected. The patient is suddenly seized with +severe pain, with heat, redness, and swelling of one of the large joints, +presenting all the appearances of arthritic or rheumatic inflammation, and +also of certain muscles, especially the supinators of the arm, the glutæi, +and gastrocnemii. The painful spot soon becomes hard, it is intensely +tender, and in two or three days the feeling of fluctuation indicates the +formation of an abscess, from which a large quantity of greenish coloured +pus mixed with blood and serum is discharged. The cellular tissue beneath +the skin and between the muscles is equally affected, and if examined when +the abscess is just beginning to form, will be found of a dirty brown +colour, softened, infiltrated, and here and there condensed with lymph or +pus, precisely as in cases of gangrenous erysipelas: the muscular tissue +has entirely lost its red colour, and closely resembles the appearance of +boiled meat, its structure so softened as to tear easily under the +fingers, and interspersed with deposites of immature lymph and purulent +fluid, the commencement of what would have been an abscess. Like +gangrenous erysipelas the extent of the abscess does not seem to be +limited by a surrounding wall of healthy lymph, as seen in a common +phlegmon, but if deep beneath the surface it continues to spread in all +directions until nearly the whole limb appears to be implicated in one +immense abscess: hence, in those patients who have recovered under these +attacks, the limb has frequently been rendered useless, the muscles being +atrophied and coherent. + +Inflammation of a similarly arthritic or rheumatic nature occasionally +also attacks the eye, and presents all the usual characters of arthritic +iritis under ordinary circumstances: there is the same intolerance of +light, pain of the eye, dimness of vision, contracted pupil, and peculiar +white ring round the edge of the cornea, which distinguishes this +affection; but in the present case, the disease runs a far more rapid +course, and defies the remedies which in common cases would be sufficient +to check it; the inflammation soon extends to the deeper seated structures +of the eye, the pain is excrutiating, and, in two or three days, +disorganization takes place, followed by suppuration, staphyloma, and +bursting of the cornea. So rapid and destructive is its course, that, +although five or six cases have come under our notice, in only one +instance, with the greatest difficulty, was the eye saved, and, even then, +not before it had been considerably injured. + +These attacks are attended by severe pains of a similar nature in +different parts of the body, more especially the joints and limbs; and, +from the arthritic character which they assume, tend, in our opinion, +still farther to elucidate the real condition of the system. The analogy +between gout or rheumatism, and those diseases which arise from a vitiated +state of the blood, is exceedingly close, nay, even identical, for in +both, a principal pervades the circulating fluids which requires to be +removed; and if this be not effected by any of the excretory organs, +nature endeavours to throw it off by some process of local inflammation. +The connexion between puerperal fever and typhus is very close, for it not +only assumes the characters of the typhus epidemics which may chance to be +prevailing at the time, but we have distinct evidence that the contagion +of typhus will, in a puerperal woman, manifest itself under the form of +puerperal fever. Dr. Collins has recorded a very interesting case of this +sort:--"A patient was admitted at a late hour at night into one of the +wards, labouring under a bad form of typhus fever, with petechial spots +over her body; when observed next morning, she was removed into a separate +apartment, where she died shortly after. The two females who occupied the +beds adjoining hers, while she remained in the large ward, were attacked +with puerperal fever, and died." (Collins, _op. cit._ p. 381.) During a +typhus epidemic which prevailed a few years ago in the poor districts of +the metropolis, a prominent feature of which were petechiæ and a livid +rubeoloid eruption, precisely the same appearances were observed among the +cases of adynamic puerperal fever at the General Lying-in Hospital. + +The same has been observed with erysipelas; and, in one short but severe +epidemic, the child of every woman who had died of the disease perished +also from erysipelas, so severe that it ran its course in a few hours. Dr. +Gordon, of Aberdeen, remarks, that "with it and, at the same time, +epidemic erysipelas began, progressed with equal pace, arrived at its +acmé, and terminated together." He also says, that a very frequent crisis +of the disease was an external erysipelas. Mr. Hey remarks, that +infectious fevers were common at the time; and he does not recollect ever +having seen such malignant cases of erysipelas as then. Dr. Clark also +observes, that those inflammatory diseases which occurred were principally +erysipelatous. Dr. Armstrong states, "that in 1813 (the year of its +greatest prevalence throughout England) low fever, typhus, and acute +rheumatism also prevailed to an uncommon degree." (Moore, _on Puerp. +Fever_, p. 164.) + +During the same epidemic, to which we just now alluded, the housemaid of +the hospital, a healthy young woman, was suddenly seized with sore-throat +and violent erysipelas of the head and face, from which she was saved with +great difficulty; her sister came and attended her, as the nurses were too +much occupied by the number of patients who were ill; just at the time +that she was pronounced out of danger, her sister, not feeling well, went +home, sickened, and died, in less than three days, of typhus fever. + +The contagious nature of puerperal fever has long since ceased to be a +matter of doubt, and instances have repeatedly occurred of practitioners +and nurses communicating the disease to several patients in succession. +Dr. Gooch has recorded some striking instances of the kind, and we could +enumerate many others if necessary. Where a practitioner has been engaged +in the post mortem examination of a case of puerperal fever, we do not +hesitate to declare it highly unsafe for him to attend a case of labour +for some days afterwards. The peculiar smelling effluvia which arises from +the body of a patient during life is quite, in our opinion, sufficient to +infect the clothes; and every one who has made a minute dissection of the +abdominal viscera, especially in fatal cases of puerperal fever, knows +full well that it is almost impossible to remove the smell from the hands +for many hours, even with the aid of repeated washing; it must be, +therefore, self-evident, that, under such circumstances, it would be +almost criminal to expose a lying-in patient to such a risk. + +That the discharges from a patient under puerperal fever are in the +highest degree contagious, we have abundant evidence in the history of +lying-in hospitals. The puerperal abscesses are also contagious, and may +be communicated to healthy lying-in women by washing with the same sponge: +this fact has been repeatedly proved at the Vienna hospital; but they are +equally communicable to women not pregnant; on more than one occasion the +women engaged in washing the soiled bed linen of the General Lying-in +Hospital have been attacked with abscesses in the fingers or hands, +attended with rapidly spreading inflammation of the cellular tissue. + +We have stated that puerperal fever may arise from the effluvia which +exhales from the body of the patient, and from the various discharges; it +may also be produced by noxious exhalation from sewers, ditches, and other +sources of miasmata, the effects of which in producing typhus have been +long ascertained. "With regard to the General Lying-in Hospital, its +locality rather below the level of the river, and surrounded by a +mesh-work of open sewers fifteen hundred feet in extent, receiving the +filth of Lambeth, and some not thirty feet from the wards of the +institution, may account for its unhealthiness. It is only after repeated +remonstrances, that these sources of pollution have in part now begun to +be obliterated." (Dr. Ferguson, _op. cit._ p. 104.) The commissioners of +sewers refused the application of the hospital, to have the nearest of +these nuisances properly bricked over, and assigned this remarkable reason +for so doing, viz. that the hospital had come to them, not they to the +hospital. Consent was ultimately only obtained by the agreement, that a +large portion of the expense should be borne by the institution. On +completing the work they afforded us a striking instance of the effects of +effluvia on lying-in women; a large quantity of black pestilential mud had +been thrown out in making the necessary excavations, this they refused to +remove, and actually spread it upon the ground to a considerable extent; +the consequence was, that the first two cases of puerperal fever after the +re-opening of the hospital occurred within twenty-four hours of this +unjustifiable act. + +_Treatment._ The fatal character of this disease and the varied form of +its epidemics will in part explain why so much discrepancy of opinion +should have existed among authors and practitioners respecting its +treatment. Where its remote cause has been but imperfectly known, it is +not to be wondered that practitioners, finding their efforts unsuccessful, +should lose their confidence in any one set of remedies or mode of +treatment, and try a variety, in the vain hope of hitting upon the right +one. But in a great measure this is to be attributed to the difference of +the affections which have been described by various authors under the same +head; each has described it as it occurred to himself; and in many +instances it has been only the description of a single epidemic, and, +therefore, has given to the world the treatment which his experience in +that particular form has proved successful. Thus, the lancet has been +looked upon as the only means of saving the patient by those who have +witnessed the inflammatory modification of the disease; whereas, in the +hands of those who had to treat it in its adynamic malignant form, +bleeding (as but too frequently every thing else) proved utterly +inefficacious. + +A variety of plans have been tried in this last species, and their success +described by Dr. W. Hunter in his lectures, gives a fearful view of the +nature of the disease we have now to deal with. We continue the quotation +which we have already made from him. "In two months thirty-two patients +had the fever, and only one of them recovered. We tried various methods. +One woman we took from the beginning and bled her, and she died; to +another we gave cooling medicines, and she died: to a third we gave warm +medicines, such as Confect. Cardiac., cordial julep, Mithridate, &c., and +she died. In private practice it was the same, and at least three out of +four would die." (_MS. Lectures._) + +There is no doubt that, wherever the state of the patient will permit it, +the lancet should be tried. Where the pulse is quick and small, with +little power, it is scarcely more than an experiment to ascertain how the +system will bear the bleeding: in the worst cases of the adynamic form, +uncomplicated by the slightest effort at reaction, the state of collapse +at once forbids such an attempt: but in many instances the circulation is +merely oppressed, the pulse rises in volume as the depletion proceeds; and +where from its feel before the operation we had little hopes of taking +away more than five or six ounces, we are often enabled to continue it +until a considerable quantity is lost. In other cases frightful exhaustion +is the immediate effect, and warn us instantly to discontinue it. The +capability of bearing bleeding may be always looked upon as a favourable +prognostic, not only because the patient's strength is better than we had +perhaps expected, and also because these are precisely the cases where +mercury can be used with decided benefit. Whether it be the bleeding, +which, in all probability, renders the system more easily brought under +the influence of this medicine, we will not stop to consider; at any rate, +its effects are not only more easily obtained, but they exert a more +decided control over the progress of the disease, the pain abates, the +tympanitic abdomen becomes less tense, the pulse slower, fuller, and +softer, the tongue moister, and there is a sense of general improvement in +the patient's feelings. But in the adynamic form, when present in its +greatest intensity, either there is not sufficient time to impregnate the +system, or it is less sensible to its effects; at any rate, even if we +succeed in producing salivation, little or no improvement follows. + +In those cases where the inflammatory symptoms assume a metastatic +character, we must act according to the organ implicated. The attacks are +frequently of a very sudden nature, the patient being seized, without the +slightest warning, with severe pain and heat of head, throbbing of the +temples, intolerance of light and sound, and occasionally violent +delirium; the face is flushed, the carotids are seen strongly pulsating. +These signs denote a dangerous attack of cerebral congestion, which +requires the most prompt and active measures for its suppression. In these +cases the aberration of mind frequently continues for some time, even +after the symptoms of active inflammation have subsided, and form a +species of puerperal mania of a very dangerous character, which we shall +describe under its proper head. In other cases, effusion rapidly comes on, +followed by fatal coma or convulsions. + +In some instances, the inflammatory action seems to fix itself upon the +chest: the patient is suddenly seized with great dyspnoea, oppression, and +pain, which latter is much increased by every effort at respiration, and +sometimes is so violent as to threaten suffocation, unless promptly +relieved by the lancet. These attacks sometimes return two or three times, +with the same degree of sudden violence, or change with equal rapidity +from one part to another. + +So long as there are symptoms of local inflammation present, leeches and +hot poultices, &c., must be applied, as already mentioned; but it must +ever be borne in mind, that the local affection is _not_ the disease, but +one of its effects. We must, therefore, direct our energies to ridding the +system of the cause upon which it depends. In all cases we think it +desirable to begin the calomel in doses of five grains, at intervals of +two hours; and if properly guarded with Dover's powder, no disposition to +purging will be produced: by this means we not only gain time, but, which +is also of great importance, we premise a general increase of the +excretions, which tends not a little to relieve the system. After two such +doses, the calomel may be given at the ordinary rate of two grains every +two hours, with half a grain of opium, or, what is still better, a little +Dover's powder, until slight marks of salivation begin to appear. The +action should now be kept up by an occasional dose, but never allowed to +become at all severe, as considerable exhaustion may be the result. The +dark and offensive lochia should be constantly removed by the most +scrupulous attention to cleanliness, and by frequently washing out the +vagina and uterus with warm water. + +If diarrhoea has set in to an exhausting degree, the opiates must be +increased, and the Hydrarg. cum Cretâ substituted for the calomel. Saline +draughts of citrate or acetate of ammonia, rendered alkaline in excess by +Sp. Ammon. Arom. may be given from time to time; they appear not only to +refresh the patient, but also to allay flatulence and vomiting, if +present. For her common drink we recommend a solution of carbonate of soda +in water, in the proportion of two drachms to a pint, slightly flavoured +with orange peel; and whenever she has taken this freely, we have observed +a considerable amelioration in her symptoms. + +Although strongly inclined to advocate Dr. Stevens's views respecting the +action of salines in diseases of this character, we must confess that we +have been in great measure deterred from carrying them out to the full +extent that we could have wished, by the repugnance of the patient to +taking a draught so intensely salt as his celebrated mixture. On several +occasions we have seen the most beneficial effects from the use of +salines; and in two cases, during one of the most malignant epidemics, +where every thing seemed to be equally fruitless in arresting the progress +of the disease, the exhibition of repeated doses of soda, and encouraging +the patient to drink largely of the above-mentioned solution, was followed +by the happiest effects. We have again recently tried the common salt, +disguised as far as possible in the form of an effervescing draught, and +in two cases with very decided results. + +The acid state of the mouth is a very constant symptom in this disease, +and the contents of the stomach after vomiting are frequently intensely +sour, so that in most instances the soda drink has been greedily longed +for, and by some patients even called lemonade. We have also tried still +more recently warm injections into the vagina, of a weak solution of salt +and water, but at present, can give no opinion from merely a case or two. + +Ice has been lately recommended by Professor Michaelis, of Kiel, not only +internally but externally, by means of a large bladder. According to his +observations it diminished the pain and tympanitis, reduced the quickness +of the pulse, and relieved the patient considerably; this was followed by +a profuse diarrhoea of light coloured and offensive evacuations, under +which the pulse rose in power, followed by general improvement. We tried +it on one occasion; it was swallowed with avidity like barley-sugar; it +relieved the sense of inward heat and thirst, stopped the hiccough and +vomiting which had become very troublesome, and seemed to diminish the +tympanitis, but collapse followed as rapidly as in other cases; nor have +our subsequent observations been more favourable. It may be given with +advantage with other medicines to relieve several distressing symptoms, +but does not appear to us to exert any power in arresting the progress of +the disease. + +The patient's diet should be mild but nutritious, much more so than in the +other forms of puerperal fever; and if there be symptoms of sinking, wine +and ammonia, &c., must be given with a liberal hand. + +In reviewing what we have said upon the treatment of adynamic puerperal +fever, we repeat our conviction, that where the state of collapse has +precluded all antiphlogistic measures, and given us but little cause to +expect much relief from mercury, we know of no treatment which holds out +such rational hopes of success as the saline, based as it is upon the same +principles on which it has been employed by Dr. Stevens, in the malignant +fevers of warm climates, and by British physicians in the epidemic typhus +of this country. + + + + +CHAPTER XIV. + +PHLEGMATIA DOLENS. + + _Nature of the disease.--Definition of phlegmatia dolens.--Symptoms.-- + Duration of the disease.--Connexion with crural phlebitis.--Causes.-- + Connexion between the phlegmatia dolens of lying-in women and + puerperal fever.--Anatomical characters.--Treatment.--Phlegmatia + dolens in the unimpregnated state._ + + +_Nature of the disease._ Although we shall not be justified in stating +that the disease is one of the sequelæ of puerperal fever, inasmuch, as it +is occasionally met with, entirely independent of labour and the puerperal +state, still we must recognise a very close relation between these two +diseases, especially between it and the uterine phlebitis, since, in a +majority of instances, they both arise from the same cause, viz. +absorption or imbibition of a morbid poison. At the same time, we can by +no means agree with Dr. R. Lee, that "the swelling of the affected limbs +in phlegmatia dolens, and all the other local and constitutional symptoms +of this affection, invariably depend on inflammation of the iliac and +femoral veins;" and, therefore, do not consider his proposition +justifiable, "to substitute the term crural phlebitis in place of +phlegmatia dolens" (_Researches on the Pathology and Treatment of some of +the more important Diseases of Women_, p. 116,) for cases occur where the +disease has manifested itself to a very considerable extent without any +inflammation of the veins whatever. On the other hand, we willingly allow +that in many others it has been preceded by crural phlebitis, although we +most distinctly deny that it is ever identical with that disease. + +_Definition of phlegmatia dolens._ We may define phlegmatia dolens to be +tumefaction of a limb from inflammation and obstruction of the main +lymphatic trunks leading from it. It is most frequently seen in the +puerperal state, attacking one or both extremities, and is then almost +always a concomitant or a consequence of puerperal fever. In the +unimpregnated state it is usually the result of some organic malignant +disease. "Women of all descriptions are liable to be attacked by it during +or soon after childbed; but those whose limbs have been pained and +anasarcous during pregnancy, and who do not suckle their offspring, are +more especially subject to it. It has rarely occurred oftener than once to +the same female. It supervenes on easy and natural as well as on +difficult and preternatural births. It sometimes makes its appearance in +twenty-four or forty-eight hours after delivery, and at other times not +till a month or six weeks after; but in general the attack takes place +from the tenth to the sixteenth day of the lying-in." (_An Essay on +Phlegmatia Dolens_, by John Hull, M. D. p. 132.) + +_Symptoms._ As the phlegmatia dolens of lying-in women is almost +invariably preceded by symptoms of puerperal fever, many of its early +symptoms will differ but little from that disease. The patient is usually +attacked with rigours, followed by flushing, headach, and generally more +or less abdominal pain, with a quick pulse, or the disease has come on +when recovering from a severe attack of puerperal fever. + +"The complaint generally takes place on one side at first, and the part +where it commences is various: but it most commonly begins in the lumbar +hypogastric or inguinal region on one side, or in the hip, or top of the +thigh, or corresponding labium pudendi. In this case the patient first +perceives a sense of pain, weight, and stiffness, in some of the +above-mentioned parts, which are increased, by every attempt to move the +pelvis or lower limb. If the part be carefully examined, it generally is +found rather fuller or hotter than natural, and tender to the touch, but +not discoloured. The pain increases, always becomes very severe, and in +some cases is of the most excruciating kind. It extends along the thigh, +and when it has subsisted for some time, longer or shorter in different +patients, the top of the thigh and labium pudendi become greatly swelled, +and the pain is then sometimes alleviated, but accompanied with a greater +sense of distention," (Hull, _op. cit._ p. 184.) The pain next extends +down to the knee, and if depending on a state of phlebitis is most severe +in the course of the femoral vein, which is felt hard and swollen, and +rolling distinctly under the finger when pressed upon: it is precisely in +the direction of this vessel that the greatest pain is felt on pressing +with the hand: if phlebitis be not present, the pain is diffused more +equally over the limb, and is more connected with the state of tension, or +otherwise, is confined chiefly to the groin or upper part of the thigh. +"When it has continued for some time, the whole of the thigh becomes +swelled, and the pain is somewhat relieved;" "the pain then extends down +the leg to the foot; after some time the parts last attacked begin to +swell, and the pain abates in violence, but is still very considerable, +especially on any attempt to move the limb. The extremity being now +swelled throughout its whole extent, appears perfectly or nearly uniform, +and it is not perceptibly lessened by a horizontal position, as an +oedematous limb. It is of the natural colour or even whiter, is hotter +than natural, excessively tense, and exquisitely tender when touched; when +pressed by the finger in different parts, it is found to be elastic, +little if any impression remaining, and that only for a very short time. +If a puncture or incision be made into the limb, in some instances no +fluid is discharged, in others a small quantity only issues out which +coagulates soon after, and in others a larger quantity of fluid escapes +which does not coagulate; but the whole of the effused matter cannot be +drawn off in this way. The swelling of the limb varies both in degree and +in the space of time requisite for its full formation. In most instances, +it arrives at double the natural size, and in some cases at a much +greater. In lax habits, and in patients whose legs have been very much +affected with anasarca during pregnancy, the swelling takes place more +rapidly than in those who are differently circumstanced; it sometimes +arrives in the former class of patients at its greatest extent in +twenty-four hours or less, from the first attack." (Hull, _op. cit._) + +Phlegmatia dolens rarely or never proves fatal of itself; the patient +either dies in consequence of the puerperal fever which has preceded or +attended the affection, or from the system gradually sinking under the +injury which it has sustained. In those cases where the patient has +struggled through, the limb remains for a long time afterwards swollen, +stiff, and incapable of motion, from which it slowly and not always very +perfectly recovers. + +_Duration of the disease._ "The duration of the acute local symptoms has +been very various in different cases. In the greater number, they have +subsided in two or three weeks, and sometimes earlier, and the limb has +then been left in a powerless and oedematous state. The swelling of the +thigh has first disappeared, and the leg and foot have more slowly resumed +their natural form. In one case, after the swelling had subsided several +months, large clusters of dilated superficial veins were seen proceeding +from the foot along the leg and thigh to the trunk, and numerous veins as +large as a finger were observed over the lower part of the abdominal +parietes. In some women, the extremity does not return to its natural +state for many months, or years, or even during life." (Lee, _op. cit._ p. +119.) + +_Connexion with crural phlebitis._ We have already stated, that in +phlegmatia dolens the lymphatic circulation of the swollen limb has been +obstructed by inflammation and obliteration of the main lymphatic trunks +leading from it. To call this disease "crural phlebitis," because in a +case where the crural vein has been inflamed, the inflammation has spread +to the surrounding fascia, or cellular tissue, through which the larger +lymphatics of the thigh pass in their way to the abdominal cavity, is +manifestly incorrect, and tends to confound two diseases together, which +are of a very different character. From the situation of the crural vein +as it emerges upon the anterior and upper part of the thigh, and the +cribriform appearance of the inner side of the femoral sheath, and of the +cellular tissue which fills up the opening in the fascia lata at this +part, owing to the numerous lymphatic trunks by which it is perforated, +it would be nearly impossible that these structures should escape being +inflamed wherever the attack of crural phlebitis is at all severe; and +shows that although, as we have stated, phlegmatia dolens may occur +without crural phlebitis, it is very questionable if crural phlebitis can +exist to any extent without phlegmatia dolens. + +To MM. Bouillaud and Velpeau, and also to Dr. Davis, are we chiefly +indebted for having first pointed out the fact, that the large venous +trunks of the thigh and leg are frequently found inflamed in this disease. +Great credit is also due to Dr. R. Lee for his indefatigable researches +into the history and anatomy of crural phlebitis, for they have taught +practitioners to be on the watch for the existence of the one disease +whenever the presence of the other has been determined. + +"The sense of pain, at first experienced in the uterine region, has +afterwards been chiefly felt along the brim of the pelvis, in the +direction of the iliac veins, and has been succeeded by tension and +swelling of the part. After an interval of one or more days, the painful +tumefaction of the iliac and inguinal regions has extended along the +course of the crural vessels, under Poupart's ligament, to the upper part +of the thigh, and has descended from thence in the direction of the great +blood-vessels to the ham. Pressure along the course of the iliac and +femoral vessels has never failed to aggravate the pain, and in no other +part of the limb has pressure produced much uneasiness. There has +generally been a sensible fulness perceptible above Poupart's ligament, +before any tenderness has been experienced along the course of the femoral +vessels; and in every case at the commencement of the attack, I have been +able to trace the femoral vein proceeding down the thigh like a hard cord, +which rolled under the fingers." (R. Lee, _op. cit._ p. 117.) + +_Causes._ We consider that the causes of crural phlebitis in the puerperal +state are of precisely the same nature as those of uterine phlebitis, +already mentioned, viz., the absorption or imbibition of putrid matter +contained in the uterus; and from reasons which are self-evident, it will +be easily understood why the former affection is so frequently preceded by +the latter, or at any rate, by some modification of puerperal fever. Mr. +Tyre, of Glouscester, in an essay published 1792, and quoted by Dr. Hull, +has taken a somewhat similar view of the subject, although he does not +appear to have confirmed it by actual observation. He conceived that "the +obstruction to the return of the lymph may commence in the primary +inflammation of a trunk or trunks; and, probably, this may be the case +more frequently than I have hitherto discovered, or suspected it to be." +He considered also that "the remote cause may still be sought for in +pressure, in the presence of absorbed acrimonious matter, or in +inflammation continued from some absorbent to the trunk or trunks," (_An +Essay on the Swelling of the Lower Extremities incident to Lying-in +Women_;) but he overlooked the fact, that this inflammation of the +lymphatic trunks, when passing through the cribriform portion of the +fascia lata, was a result of its having either extended from the inflamed +crural vein, or from inflammation of the peritoneum in the pelvis, and of +the subperitoneal tissues. + +_The connexion between the phlegmatia dolens of lying-in women and +puerperal fever_ has been demonstrated even still more closely by Dr. +Hull, a fact which later experience, and a more intimate knowledge of +these two diseases has tended to confirm. "It is, perhaps, in every +instance, accompanied by considerable marks of pyrexia, and is very +frequently preceded by coldness and rigours, which are succeeded by a hot +stage, and during this, the pain, stiffness, heat and other inflammatory +symptoms invade the loins, hypogastrium, inguen, or some part of the lower +extremity, just as they attack the peritoneum in puerperal fever." We may +safely assert, that, whenever this disease attacks a lying-in woman, it is +invariably preceded by some form of inflammatory puerperal fever, the +inflammation having either been transmitted along the vein, or along the +subperitoneal tissues, until it reached the above-mentioned cribriform +portion of the fascia lata, so that every lymphatic trunk which passed +through it would necessarily be implicated in the inflammatory process, +and thus rendered impervious. The opinion, therefore, of the inflammation +passing along an absorbent until it reaches the main trunks of the +lymphatics, appears to be objectionable, as we find it to have been rather +transmitted by communication of adjacent parts, although occasionally it +attacks the neighbouring glands, producing enlargement and suppuration of +them. + +_Anatomical characters._ The details of a dissection which Dr. Lee has +reported with great minuteness, show marks of severe inflammation to such +an extent around the crural vein, that it is evident the greater part, if +not all, of the large lymphatic trunks in that neighbourhood had been +rendered impervious by it. "The common iliac, with its subdivisions and +the upper part of the femoral veins so resembled a ligamentous cord, that +on opening the sheath the vessel was not, until dissected out, +distinguishable from the cellular substance surrounding it. On laying open +the middle portion of the vein, a firm thin layer of ash-coloured lymph +was found in some places adhering close to, and uniting its sides, and in +others, clogging it up, but not distending it. On tracing upwards the +obliterated vein, that portion which lies above Poupart's ligament, was +observed to become gradually smaller, so that in the situation of the +common iliac, it was lost in the surrounding cellular membrane, and no +traces of its entrance into the vena cava were discernible. The vena cava +itself was in its natural state. The entrance of the internal iliac was +completely closed, and in the small portion of it, which I had an +opportunity of examining, the inner surface was coated with an +adventitious membrane. The lower end of the removed vein was permeable, +but its coats were much more dense than natural, and the inner surface was +lined with a strong membrane, which diminished considerably its caliber, +and here and there fine bands of the same substance ran from one side of +the vessel to the other. The outer coat had formed strong adhesions with +the artery and the common sheath: the inguinal glands adhered firmly to +the veins, but were otherwise in a healthy condition." (_Op. cit._ p. +123.) + +In the other case there is also inflammation of the cellular tissue which +fills up the femoral ring, but instead of having been a consequence of +crural phlebitis, it has extended to this part from puerperal inflammation +of the peritoneum and cellular tissue beneath. + +In our midwifery hospital reports (_Med. Gaz._ Oct. 24. 1835,) we have +given the details of an interesting case of this sort which came under our +notice during the former year, and which are rendered peculiarly valuable +by a most elaborate dissection of the parts after death, by Mr. Nordbald, +who was house-surgeon at the time. The patient was single, excessively +deformed in her back, and with the peculiarly unhealthy appearance of +persons thus afflicted; her labour had been perfectly natural, but on the +following day she was seized with rigours, followed by flushings, a quick +pulse, and abdominal pain: these symptoms were in great measure relieved, +and she appeared to be slowly improving. On the ninth day after labour, +she first complained of pain at the outside of the left thigh, extending +from the ilium to the knee, very exactly in the course of the +inguino-cutaneous nerve: it was tender to the touch, but there was no pain +on pressing the femoral vein at the groin. On the following day, the pain +and swelling of the thigh had increased, but still no pain was to be +detected on pressing the femoral vessels: leeches were ordered, but she +sunk immediately after their application, and died early the next morning. +Upon examination after death, the body was found "much attenuated; the +left thigh one third greater in circumference than the right; abdomen +tympanitic, not tense; parietes very thin; the lower part of the ileum, +caput coli, and arch of the colon contain air; a streak of inflammation is +delineated along the anterior surface of the colon from the centre of the +arch, throughout the descending portion of this intestine, to the left +iliac region; it is marked by a transverse band of capillary vessels, +minutely injected in the thickened peritoneum, along the whole of this +course. A few convulsions of the small intestines were smeared with recent +lymph, and one fold was found to adhere closely to the left side of the +pelvic peritoneum at the point of reflexion of the ligamentum latum uteri. +A few small portions of coagulable lymph were also found loose amongst the +intestines. At the posterior surface, and left side of the body of the +uterus, soft lymph and pus were effused for the space of an inch beneath +the peritoneal covering of this viscus, the membrane itself being highly +vascular from inflammation, but still showing the effusion through its +texture; the fundus of the uterus, where it has the Fallopian tube and +round ligament attached, was similarly affected, though in a slighter +degree; lymph and pus were effused here also. From these two points, the +inflammation appears to have spread to the rest of the serous membrane: +from the first indicated point it has progressed along the posterior fold +of the broad ligament to the surface of the rectum and colon; from the +second situation the round ligament and Fallopian tube have formed the +continuous line of its progress. On raising the peritoneum from the iliac +fossa, the cellular membrane which envelopes the round ligament, where +this cord is about to pass under the epigastric vessels, after quitting +the peritoneal cavity, was found infiltrated and condensed with lymph and +pus. The whole of the cellular membrane (which it will be borne in mind is +the fascia propria of Sir Astley Cooper, and which fills the _femoral_ +ring, and moreover forms the medium of transmission for the lymphatics of +the thigh) was in the same condition, densely matted by lymph, and +containing pus in the interstices.[146] The lymphatic glands in the groin +were slightly enlarged, and some serous fluid was effused into the +surrounding tissue; the femoral vein and artery were free from disease; +the inner coat of the former vessels, as well as the internal and external +iliac veins and vena cava, had not the slightest trace of increased +vascularity or thickening. The chain of glands from the femoral ring along +the course of the iliac vessels and aorta _on the left side_, were +enlarged, soft, and vascular; several of these lymphatic bodies contained +between the layers of the meso-colon were found enlarged, and to contain +soft lymph. The uterus was of the size usually found at this period; its +tissue dense; the section shows the sinuses still large; the openings on +the internal surface plainly indicated by adherent coagula." + +We had been led at that time to suppose that phlegmatia dolens and crural +phlebitis were identical, and that, therefore, this was not a veritable +case of the disease, because no traces of inflammation of the veins were +to be found. The history of the disease; its connexion with the puerperal +fever which had preceded it, the examination after death, and the inflamed +state of the cellular tissue which was perforated by lymphatic trunks on +their way from the thigh to the abdominal cavity, plainly show that it +was not only a case of phlegmatia dolens, but that the proximate cause of +this affection is obliteration of the lymphatics, whether from +inflammation of the adjoining vein, or of the layer of cellular tissue +through which they pass. + +_Treatment._ As the earlier part of the disease, when occurring in +lying-in women, is invariably accompanied with some form of puerperal +fever, the treatment of this stage will be according to the rules we have +already laid down in the preceding chapter. It is especially towards the +wane of the attack, that any sensation of pain, or even tension about the +hip or groin should be regarded with suspicion, and a careful examination +of the part immediately instituted. The painful spot should be immediately +covered with leeches, and if any pain or swelling be perceptible in the +course of the femoral vein, this must be similarly treated in order to +allay the inflammation; after this, cold evaporating lotions must be +applied; and although we have not yet given it a trial, we would recommend +the application of ice over the femoral ring. If she has not taken calomel +to such an extent as to affect the system, it may now be given for that +purpose; and when the pain has ceased, the part may be covered with a +plaster of camphorated mercurial ointment. As the disease, in most +instances, is a local affection consequent upon a general one, which has +been more or less subdued, by the time that this has appeared, it will +frequently be necessary to combine the local depletion and exhibition of +mercurials with mild tonics, in order to sustain the powers of the system +already somewhat exhausted by the debilitating effects of the puerperal +fever. The diet should if possible be nourishing, and we shall frequently +find that the general symptoms improve under the use of beef-tea, meat, +jellies, &c. + +When the acute stage of the disease is past, more powerful tonics, as +quinine, will be required; and now we may direct our attention to reduce +the swelling of the limb; it may be gently rubbed with the compound +camphor liniment for the purpose of stimulating the absorbents. Dr. Hull +has given a useful formula for the same object:--"[Symbol: Recipe]. Ung. +Adipis Suillæ, [Symbol: ounce]jss; Camphoræ, [Symbol: dram]iij; quibus +liquefactis admisceantur Ol. Essent. Lavend. gtt xij; Tinct. Opii, +[Symbol: dram]ij. Fiat Linimentum, quotide ter quaterve utendum." (_Op. +cit._ p. 161.) + +Phlegmatia dolens occurring in the unimpregnated state, is generally in +connexion with some malignant disease of the uterus: it has been chiefly +observed in cases of carcinoma uteri, and has evidently been produced by +the absorption of the fetid discharges which attend this loathsome +disease. In all the instances which have come under our knowledge, the +swelling of the leg has been preceded by crural phlebitis; the veins have +been felt through the emaciated integuments like a hard cord running along +the inside of the leg, acutely painful to the touch. A fact connected +with these cases, and for which we are indebted to our late friend and +colleague Dr. H. Ley, tends greatly to prove the manner in which the +disease is produced. The symptoms of it have never been observed so long +as the patient was able to keep up, for by this means a free escape was +allowed to the acrid discharges, which are so profuse in the last stages +of cancer: but when her strength has been so broken down by loss and +suffering that she was obliged to keep her bed, the horizontal position of +her body no longer allowed the vagina to drain itself of the fetid +secretions with which it was filled, and absorption and venous +inflammation have been the result. + +In our published lectures, we have mentioned two cases of phlegmatia +dolens, which had been under our care at St. Thomas's Hospital, and where, +in both, the disease had been thus produced during the ulcerative stage of +cancer uteri: the interest of them was somewhat increased by their having +been admitted at the same time, and by their happening to lie next to each +other in the same ward: in one, the attack of crural phlebitis was severe, +and the swelling of the limb very considerable; in the other, the +affection was less severe: we did not take any notes of the cases, and +must, therefore, refer to a similar one which has been recorded by Mr. +Lawrence, and in which, the appearances after death were accurately +detailed. The patient came under his care, on account of shooting pains in +the loins and hypogastric region, which was tender upon pressure; she had +incontinence of urine, and a sanious discharge from the vagina. + +On examination, instead of the os tincæ and cervix uteri, a large +irregular ulcerated excavation was found at the posterior end of the +vagina. Shortly afterwards, increased uneasiness was experienced in the +lower part of the abdomen, the right lower extremity swelled in its whole +extent, with pain in the course of the femoral and iliac vessels, and all +the other symptoms of phlegmatia dolens. The disease was treated by +leeches and other antiphlogistic means, and the pain abated considerably; +it, however, returned, and in about three weeks after, she died from a +violent attack of uterine hæmorrhage. On dissection, the fundus uteri was +found somewhat enlarged and firm, the cervix had been destroyed by that +kind of phagedenic ulceration, which is commonly called cancer of the +uterus. The hypogastric vein was closed in consequence of previous +inflammation of its coats, and the same change had taken place in the +internal iliac, the common iliac, the external iliac, the femoral and +profunda veins, as well as in the internal saphena, all of which were +completely impervious. The affection terminated above at the junction of +the common iliac with that of the opposite side, the latter vessel being +quite natural. The saphena vein was closed for a length of about four or +five inches, beyond which it was natural. The right spermatic vein was +closed in its lower half. The coats of the affected vessels, and the +surrounding cellular substance were a little thickened, and their cavities +were plugged by a closely adherent and tolerably firm substance of a light +brown colour; at some parts, the vessels and their contents were of a dark +livid hue. (_Med. Chir. Trans._)[147] + + + + +CHAPTER XV. + +PUERPERAL MANIA. + + _Inflammatory or phrenitic form.--Treatment.--Gastro-enteric + form.--Treatment.--Adynamic form.--Causes and symptoms.--Treatment._ + + +There are many points of similarity between puerperal convulsions, and the +disease which we are now about to consider, so that an acquaintance with +the nature of the one, will greatly assist the reader in his study of the +other: the same causes which induce the one, will, with trifling +modification, induce the other; the different species of puerperal mania, +will, therefore, resemble more or less those of puerperal convulsions. + +Disorder of the mind, which comes under the head of puerperal mania, is +rarely met with before labour; for when it occurs during pregnancy it is +usually referrible to causes unconnected with that state, as to hysteria; +or is, a form of ordinary mania arising from hereditary predisposition, +cerebral diseases, &c. It is true these are conditions which will render +the patient exceedingly liable to an attack of derangement during labour, +and especially during the puerperal state; but the identity of the +affections cannot well be carried farther. + +According to our own experience puerperal mania may occur under one of the +three following conditions, viz.-- + +1. Where it is attended with, and probably depends upon, cerebral +congestion or inflammation. + +2. Where it arises from gastro-enteric irritation. + +3. Where it is the result of general debility and anæmia. + +The last two rather deserve the title of melancholia. + +_Inflammatory or phrenitic form._ We shall divide the inflammatory form +into two species: first, where it is wild and furious delirium with +phrenitis; secondly, where it is connected with, and is the result of, +puerperal fever. The first, usually comes on during labour: the patient is +attacked with violent pain, heat, and throbbing of the head, which are +greatly increased by her efforts during the throes; the pulse becomes +quick and hard; the face flushed and crimson; the eyes wild, and the +manner more and more unnatural: if this state be not promptly checked, +the cerebral excitement becomes more intense, furious delirium follows, +which in its turn is succeeded by coma, effusion and paralysis. + +On examination after death the ordinary appearances of fatal phrenitis +manifest themselves, viz. preternatural fulness of the cerebral vessels, +thickening and opacity of the different membranes, softening or even +suppuration of the substance of the brain, extravasation of blood, or +effusion of serum into the cavities or substance of the brain, or between +its membranes. + +The other form of inflammatory puerperal mania, is only seen _after_ +labour, and is invariably connected with, and preceded by, symptoms of +puerperal fever. These are the cases of puerperal mania, where the disease +comes on with a rigour, a quick pulse, violent headach, and abdominal +pain. In some, the attack has appeared from the very commencement to +concentrate itself upon the brain; but in others, it more frequently +appears in a day or two afterwards, when, from the subsidence of the +abdominal pain, we are beginning to hope that the disease has been more or +less controlled. The patient is suddenly seized with intense headach, and +other symptoms of cerebral congestion, accompanied by disordered mind; but +there is not that degree of furious delirium which is seen in the acute +phrenitis; there is less excitement, but there is also, less strength; the +powers of the system are rapidly giving away, not so much under the +effects of the local disease, as under those of the general affection by +which the local disease has been produced. The patient is frequently both +violent and obstreperous; but we seldom see that state of wild and furious +raving which is observed in acute phrenitis. The former of these two +species is of very rare occurrence, but from not being complicated with +puerperal fever, it is perhaps not so dangerous, if promptly treated, as +the other. Dr. Ferguson, has correctly observed, in puerperal fever, that +"any cerebral disturbance diminishes the chances of recovery," and that +"the presence of delirium in any case is almost always followed by a fatal +result." (_Op. cit._ p. 49, 50.) + +The patient in whom we have chiefly observed phrenitic symptoms during +labour were stout, robust, short-necked women, with black oily hair, and a +swarthy complexion: from an early stage they had exerted themselves during +the pain in a most violent and unnecessary degree, and had gradually +worked themselves into that state of excitement, which was followed by the +symptoms above-mentioned: in two instances, it was ascertained that the +patient had received a violent blow on the head, either during pregnancy, +or on some previous occasion. In similar habits the same symptoms have +been observed occasionally to accompany the first appearance of the milk, +or to follow its sudden suppression when established, or a similar state +of the lochia. + +_Treatment._ The treatment differs but little from that of the congestive +epileptic convulsions, already described: she must be bled to fainting, +leeches must be applied to the temples, the head shaved and cold applied +to it, the feet should be put into hot water, and the bowels opened by an +active purge of calomel. If the child be not delivered, and the passages +are sufficiently dilated, the forceps should be applied to shorten the +labour. + +In the other case, which is accompanied with puerperal fever, the +propriety of bleeding to any considerable extent will be more +questionable; it has probably been already employed in the early part of +the original disease, and her powers more or less reduced by it: we must +here rather trust to leeches and cold to the head, and bringing the system +as soon as possible under the influence of calomel and opium. Whether or +not the improvement which follows in some cases of puerperal fever has +resulted from the use of saline medicines, we will not pretend to +determine; but as, on more than one occasion, we have seen calm and +refreshing sleep succeed their exhibition, it is not improbable that they +might prove useful in this form of the disease. + +We presume that these are the cases to which Dr. Gooch has referred, when +he described them as being "attended by fever, or at least, the most +important part of it--a rapid pulse;" and that the majority of them prove +fatal: their unfavourable result, however, is not so much from the local +affection, as from the puerperal fever under which the patient sinks. + +Pure phrenitis, which is a rare disease during labour or the puerperal +state, is by no means difficult to control by active antiphlogistic +treatment, if taken in sufficient time, before the brain has suffered any +serious injury; nor is there much danger of her continuing deranged even +after the inflammatory symptoms have been reduced. This appears to be also +the case in that form which attends puerperal fever; but here the danger +to life is so much greater, that we rarely have an opportunity of +ascertaining the duration of the mental disorder after the symptoms of +cerebral inflammation have been subdued, since most of these cases +terminate fatally. + +_Gastro-enteric form._ In the gastro-enteric form, the cerebral symptoms +are of a much milder character: the head is perhaps warmer than natural, +and it aches a good deal across the forehead and eyes; the face is seldom +flushed, but it is sallow, the eye is yellow, the tongue is foul, the +breath offensive, and if any evacuations have been passed, they are +excessively unhealthy; the abdomen feels full and loaded, the pulse is +irritable, but devoid of strength; the patient is seldom violent, and if +so, can usually be restrained by the mildest measures. Her previous +history will also assist us in our diagnosis; we shall, probably, find +that she has for some time suffered from constipation and deranged bowels, +or is known to have greatly neglected them before her confinement. + +Puerperal mania from this cause is a result of cerebral irritation, not +inflammation, and is a state which will generally cease the moment the +cause is removed. As is the case with puerperal convulsions from +gastro-enteric irritation, so here the moment we break the chain of morbid +sympathies, upon which the disease depends, the symptoms disappear, and +are instantly followed by a clearing up of the mental disorder. It usually +comes on during the first few days after labour, before the patient has +taken the laxative medicine which is customary at this time, and seems to +be excited to an outbreak by any little source of mental annoyance or +irritation. At first, it appears to be little else than giving way to +caprice and temper, but by degrees her manner becomes more changed; and +ultimately she grows violent and unmanageable. The state of mind, however, +is very different to that of the inflammatory form of puerperal mania; +there is no raving delirium, and but a slight degree of incoherence; she +understands what is said to her, but reasons erroneously under the +influence of a false impression. This state rarely proves dangerous either +to her life or her reason, if the proper treatment has been promptly had +recourse to; but where it has been allowed to run on for some time, or she +has been reduced by antiphlogistic treatment under an erroneous fear of +cerebral congestion or inflammation, there may be reason to fear that she +will ultimately sink, or at any rate, that the derangement will become +permanent. + +_Treatment._ As the pulse scarcely ever betrays a febrile or inflammatory +condition of the system, for although quick, it is seldom observed to be +full and hard, bleeding is rarely required in this form of puerperal +mania, leeches and cold applications being almost sufficient to control +any symptoms of determination to the head which may be present: it is upon +purgatives that we must place our chief hope in this disease, for until +the bowels have been thoroughly and effectively cleared, there will be +little chance of the symptoms being alleviated. In some cases it is +scarcely credible to what an extent this may be carried; day after day +sees the patient relieved of copious, dark, and offensive evacuations, +which are evidently not merely the result of enormous accumulations in the +bowels, but of excrementitious matters, which are thrown off by the +secreting vessels of the liver and alimentary canal. So far from producing +debility, the pulse rises with each relief and becomes fuller and slower, +the face resumes a healthier aspect, the tongue becomes cleaner, the +headach subsides, reason regains its ascendancy, and this favourable +change is followed by calm and refreshing sleep. We could quote several +cases of our own, in illustration of this form of puerperal mania and its +treatment, where the symptoms have quickly yielded, as soon as the source +of irritation had been removed from the system; the patient has recovered +favourably, although in most instances she has retained a sufficient +recollection of what had passed to feel much vexed and even shocked at, +what she was aware had been, very strange and unruly conduct; but we +prefer selecting Dr. Gooch's thirteenth case, of which the details are +given so graphically, as not a little to enhance the value of it. + +"A lady, twenty-two years of age, clever, susceptible, and given to books, +was confined with her first child at ----, -- miles from town: she was +anxious to nurse it; but several days passing with little appearance of +milk, doubts began to be entertained whether she would be able: _she_ +thought she would, her nurse and surgeon thought she would not: this led +to irritating discussions; her manner became sharp, quick, and unnatural; +and at the end of a few days she was decidedly maniacal. I and another +physician were now sent for; we found her in a straight waistcoat, +incessantly talking and reciting poetry; her skin was hot, her pulse full, +and much above 100; her tongue covered with a dark thick fur; her bowels +were confined, and her stools excessively dark and offensive; she took a +dose of calomel and jalap, followed by small doses of sulphate of +magnesia; these produced a few evacuations, but they were followed by no +relief; she talked almost incessantly, scarcely ever slept, and was so +violent that it was impossible to keep her in bed without the straight +waistcoat. Thus three days passed from our first consultation. The +physician who attended with me, thinking the case would be protracted, +withdrew, and I was directed to take Dr. Sutherland down with me. As the +purgative had operated very moderately, and the tongue and stools were as +unnatural as at first, he proposed a more active purge. The next morning, +therefore, she took a strong dose of senna and salts, made still more +active by the addition of tincture of jalap; after this had been taken +about three hours, it procured a very large evacuation, nearly black, and +horribly offensive; this was as usual discharged into the bed without any +notice on the part of the patient; it acted again an hour or two +afterwards; but now the nurse, who was sitting by her bed-side, was +surprised to see her turn round, and in a calm and natural manner request +to be taken up, as her medicine was going to operate; her waistcoat was +immediately loosened, and she was taken out of bed, when she voided a +stool of prodigous size, as dark and offensive as the first, and then +walked back to her bed calm and collected. We saw her not many hours +afterwards; her waistcoat was off, she was lying on her sofa perfectly +tranquil, answered questions correctly, manifested no vestige of her +complaint, excepting some strangeness in the expression of her +countenance, and a timidity and abstinence from conversation which was not +natural to her: she recovered rapidly and uninterruptedly." (_Account of +some of the most important Diseases peculiar to Women_, by Robert Gooch, +M. D. p. 156.) + +The chances of recovery in puerperal mania, from, gastro-enteric +irritation are as great as they are small in the inflammatory form +connected with puerperal fever: the danger is more from erroneous practice +on the part of the medical attendant, who either prostrates the powers of +life by active depletion, under the supposition that he is treating a case +of cerebral congestion, or aggravates the disorder of the mind into wild +delirium, by the exhibition of opium, to procure sleep. It is in these +cases that we occasionally see so much relief procured by the action of +emetics, as at one time to have been considered nearly specific in this +disease, by some of the French practitioners. If the powers be good, we +cannot agree with Dr. Gooch, in objecting to the use of antimony; when in +a sufficient dose, and combined with ipecacuanha, it is too speedy in its +operation to depress the patient much by nausea, and has the additional +advantage of acting as a rapid and effectual purge: when its action is +over, she usually falls into a sound sleep, perspires freely, and wakes +greatly refreshed. + +The indiscriminate use of emetics in puerperal mania, is not less +mischievous than that of bleeding; they are chiefly indicated in those +cases, where, in addition to the symptoms above-mentioned, there are signs +of a foul and oppressed stomach, and where the patient either complains of +nausea, or has already made several attempts to vomit. As soon as the +offending cause is removed, the bowels should be kept open by mild +alterative and laxative medicine, as equal parts of blue pill, compound +extract of colocynth, and extract of henbane, in two pills at night, and a +mineral acid in some bitter infusion during the day. The food should be +bland but nutritious, the mind quietly but agreeably occupied, and all +excitement carefully avoided. In this form of puerperal mania, it is not +only a rare occurrence to find that the disordered state of the mind +continues, when the cause which had produced it no longer exists, but it +is scarcely ever known to return in the patient's subsequent confinements. +In the case which has been so ably recorded by Dr. Gooch, the patient has +since had a very large family, her labours have all been perfectly +favourable, and without the slightest symptom of her former disease. + +The _adynamic form of puerperal mania_ is by far the most common species +of the disease, and like the adynamic puerperal convulsions, arises from +causes which produce exhaustion and collapse in the general powers of the +system. It is to Dr. Gooch that we are indebted for a masterly exposition +of this disease, and for having been one of the first to point out its +real character. + +_Causes and symptoms._ This form of disordered mind is a disease of true +debility, and is closely allied to delirium tremens, and convulsions +produced by anæmia. It can scarcely be said to deserve either the terms +"puerperal," or "mania," for we frequently see a very near approach to it +in females who are much weakened by hæmorrhage, either from menorrhagia, +malignant disease of the uterus, or abortion; and from being a disease +which arises from great exhaustion, it rather deserves the name of +melancholia, than of mania. In lying-in women, "there are two periods at +which this is chiefly liable to occur; the one soon after delivery, when +the body is sustaining the effects of labour, the other several months +afterwards, when the body is sustaining the effects of nursing." (Gooch, +_op. cit._ p. 109.) In the one case, it is usually the result of profuse +hæmorrhage, in the other, it is produced by suckling her child when she is +not strong enough for this purpose. "I have repeatedly seen the +commencement of mental derangement in women who had recovered from their +confinement and had been suckling several months. Nearly all these cases +were instances, not of mania but of melancholia. They occurred in women +who had been debilitated by nursing. The disease at this period has been +attributed to weaning; but, in all cases, I have seen, the disease has +begun before the weaning, and this measure has been resorted to, because +the patient had neither milk nor strength to fit her for a nurse. There +was a peculiarity about the commencement of the disease which I have +seldom or never noticed at the commencement of mania; there was an +incipient stage in which the mind was wrong, yet right enough to recognise +that it was wrong." (Gooch, _op. cit._ p. 114.) + +This half-way state of mind between reason and derangement is frequently +seen in women who have been exhausted by menorrhagia, leucorrhoea, &c., or +who have been drained by nursing. We confess that we can see but little +difference in the effects of anæmia upon the brain and nervous system, +whether it be in the unimpregnated or puerperal state, beyond that, on +account of the great changes which have taken place in the system by the +process of labour, by the secretion of milk, &c., the system is probably +more irritable, and susceptible than it would otherwise be. Nothing is +more common than to see, in cases of menorrhagia, the mind becoming +enfeebled, the memory impaired; the patient begins to find that she can no +longer control her thoughts in the ordinary manner, but that strange +trains of ideas will pass through her mind, the source of which she cannot +explain, and frequently so unaccountably, as to cause her serious +uneasiness: "If this goes on so, I shall lose my senses," is almost a +never failing observation; and the dread that this will be the case, tends +to depress the system still more. The sleep is disturbed by frightful +dreams, or she passes night after night in wakeful restlessness; she +worries herself about trifles, her manner changes, and the mind at length +is quite disordered. The same train of symptoms is a frequent result of +over-suckling, and as Dr. Gooch has justly observed, is not the result of +weaning. "In all the cases which I have seen, months after delivery, the +weaning has been the consequence of the disease, not the disease the +consequence of the weaning. The patients had been reduced in health by +nursing, their memories had become enfeebled, their spirits depressed, and +their minds ultimately disordered; they were directed to wean their +children, because they had neither milk nor strength to enable them to +nurse." (_Op. cit._ p. 130.) + +A similar state of mind may be induced at an earlier period and more +suddenly, by the effects of a profuse hæmorrhage, by serious discharges, +which occasionally take place shortly after labour, or even by mental +depression; in fact, by whatever lowers the vital powers to a considerable +extent. In these cases, the very history and appearance of the patient are +sufficient to explain the nature of the disease: her hollow eyes, pale +face, and blanched lip, show distinctly how her strength has been reduced. +The source and extent of her debilitated state will in great measure +determine the degree of danger, and the chances of her recovery. In +ordinary cases of this form there is not much to fear, as far as the life +of the patient is concerned; and the cases which have come under our own +notice confirm the excellent remark of Dr. Gooch, "that mania is a less +durable disease than melancholia; it is more dangerous to life, but less +dangerous to reason." But if the disordered mind has come on shortly after +labour, in consequence of profuse flooding; if the powers of the system +have rallied but imperfectly, and from the tinnitus aurium, strabismus, +half vision, &c., it is evident that the cerebral functions are greatly +impaired; if the nights are passed without sleep, and the days in +continued and exhausting excitement; if the pulse be feeble and rapid, the +skin cold and clammy, the face covered with perspiration, and there is a +disposition to colliquative diarrhoea, we shall have but too much reason +to fear an unfavourable issue; every symptom denotes that the powers of +the system have received a fatal blow, and she either sinks exhausted, or +dies in a state of coma, probably from serous effusion upon the brain. On +the contrary, if in addition to a general improvement, she has enjoyed +some hours of refreshing sleep, there is every prospect, not only of +returning health, but also of reason. A mere gleam of returning reason +without a corresponding improvement of health, will afford but little +satisfaction to the mind of a discerning practitioner, for it gives no +assurance that the danger of fatal sinking is at all diminished. + +Disordered mind coming on some weeks after delivery from the effects of +over-nursing, when the patient has been unable to afford the necessary +supply to her child, is seldom attended with so much danger to life, as +where suddenly induced immediately after labour by hæmorrhage: the +intermediate stage between reason and derangement is more distinctly +marked, and is of considerable duration; and the gradually increasing +affection of the mind frequently warns even the patient herself to seek +medical advice before the symptoms become more serious. + +We believe that the proportion of patients in whom the mind continues +deranged after their health has been restored, is very small, and feel +convinced that the results afforded by the practice of lunatic hospitals +are far from giving a correct estimate. A large majority of the cases of +derangement in lying-in women are of such short duration that they never +come even under the notice of those members of the profession whose +attention is particularly devoted to this branch of medical practice, +still less do they require to be removed into asylums for lunatics. "The +records of hospitals contain an account of cases which have been admitted +only because they were unusually permanent; they are the picked obstinate +cases, and can afford no notion of the average duration of all kinds; the +cases of short duration, which last only a few days or a few weeks, which +form a large proportion, are totally lost in the estimate of a lunatic +hospital." (Gooch, _op. cit._ p. 125.) The results of Dr. Gooch's +practice, which is known to have been very extensive, and especially in +consultation, shows that out of a considerable number of cases only two of +his patients remained disordered in mind, "and of these, one had already +been so before her marriage." There are two classes of patients in whom +disordered mind is not only much to be apprehended during their lying-in, +but in whom there will be some reason to fear that it may become +permanent; first, in those who have already been deranged, independent of +the puerperal state, or who inherit a strong predisposition to mental +disease; and secondly, in those where hysteria has existed in an unusual +degree during the latter part of pregnancy. These circumstances justify us +in using every precaution in their lying-in to avoid any thing which may +excite the disease; but, as already stated, not only is the disorder of +the mind rarely of any duration, but it is seldom known to recur on any +subsequent occasion. + +_Treatment._ Our indications of treatment are two-fold, viz., to rouse and +support the powers of the patient, and to allay as far as possible the +irritability of the brain and nervous system. + +If the patient has been prostrated by hæmorrhage, not only a nutritious, +but even a cordial and stimulant diet will be necessary: the emulsion of +egg and brandy, which we have before recommended in anæmic puerperal +convulsions, will here prove very useful; and it must be given in small +but frequently repeated doses, until an improvement is observed in the +pulse and in her general appearance. Under all circumstances, it will +scarcely ever be proper or even safe to confine her to low diet: beaf-tea, +veal-broth, &c. should be given in considerable quantities during the +twenty-four hours; and it is surprising what improvement will even take +place merely from the administration of this bland nutriment. If the face +be pale and the pulse low, wine may be given according to the +circumstances of the case. + +To calm the cerebral excitement and procure sleep, sedatives will prove of +the greatest value, and require to be repeated until the nervous system is +fairly under their influence. The intense pain at the vertex, which of +itself is sometimes quite sufficient to produce delirium, the tinnitus +aurium, &c., all cease; the pulse becomes softer, fuller, and slower; and, +even if sleep be not immediately induced, a state of calm tranquillity +follows, in which the mind becomes more composed. The Liquor Opii +Sedativus may be given in a dose of twenty-five minims, and repeated in an +hour or so according to circumstances. The combination of camphor with +morphia, or extract of henbane, is an excellent form, and may be given +with perfect safety to a considerable extent. + +The bowels should be opened by the mildest laxatives, such as castor oil, +rhubarb and manna, &c., medicines which will neither act violently, nor +weaken by producing watery evacuations; and, once in every few days, it +will be desirable to rouse the action of the liver by Hydrarg. c. Cretâ, +with extract of hop or gentian. To assist still farther in restoring her +health and strength, she should take an infusion of a vegetable bitter +with a mineral acid. As soon as her strength will permit, a change of +residence may be recommended, and she should remove to some quiet +watering-place, where invigorating air and agreeable scenery and +occupations will assist in completing her recovery. + +"The constant attendants on the patient ought to be those who will control +her effectually but mildly, who will not irritate her, and will protect +her from self-injury. These tasks are seldom well performed by her own +servants and relatives. + +"If the disease lasts more than a few days, and threatens to be of +considerable duration, her monthly nurse and own servants ought to be +removed, and a nurse accustomed to the care of deranged persons placed in +their stead. Such an attendant will have more control over the patient, +and be more likely to protect her from self-injury." "With regard to the +removal of her husband and relations, this also will be a question; if the +disease threatens to be lasting, it is generally right. Interviews with +relations and friends are commonly passed in increased emotion, +remonstrance, altercation, and obviously do harm: large experience also is +decidedly favourable to separation as a general rule; yet there may be +exceptions, which the intelligent practitioner will detect by observing +the effect of intercourse." (Gooch, _op. cit._ p. 158.) + + + + +INDEX. + + + _Abdomen_ of the foetus, labour obstructed by depositions in the, 284. + Pendulous, 308. + Management of the, 309. + + _Abdominal_ muscles, faulty action of the, obstructing labour, 336. + + _Abnormal_ Parturition, divisions and species of, 263. See _Dystocia_. + + _Abortion_, 141. + Explanation of the term, 141. + Period at which it is most common, 142. + Causes of, 142. + Death of the embryo, 142. + External violence, 143. + Mental emotions, 143. + Irritable uterus, 144. + Symptoms of, 144. + Treatment of, 146. + Prophylactic, 146. + In the attack, 149. + After expulsion, 155. + + _Abscess_, mammary, 191. + Treatment of, 192. + + _Absorption_ of retained placenta, 358. + + _Adynamic_ puerperal fever, 450. See _Puerperal Fever_. + Mania, 473. See _Puerperal Mania_. + + _After-pains_, 197. + Causes of, 197. + Utility of, 198. + + _Age_, rigidity of the passages from, obstructing labour, 314. + Influence of, on the contractile power of the uterus, 327. + + _Allantoidis_ Liquor, situation of the, 54. + + _Allantois_, mode of its formation, 70. + Its existence in the human embryo, 70. + Functions of the, 70. + + _Amnii_ Liquor spurius, situation of the, 54. + Characters of the, 55. + Source of the, 55. + Use of the, 55. + Formation of the bag of the, 162. + Excessive quantity of, 287. + + _Amnion_, description of the, 54. + Formation of the, 69. + Dropsy of the, 287. + + _Anatomy_ of utero-gestation, 15. + Of the pelvis, 15. + Of the sacrum, 16. + Of the coccyx, 17. + Of the ovaria, 22. + Of the Fallopian tubes, 28. + Of the uterus, 30. + Comparative, of the, 34. + Of the external organs of generation in the female, 45. + + _Anæmic_ puerperal convulsions, 387. + + _Anchylosis_ of the foetal joints, obstructing labour, 284. + + _Anteversion_ of the uterus, 309. + + _Apoplectic_ puerperal convulsions, 387. + + _Areola_ of the breasts, 86. + + _Arm_, presentation of the, 272. See _Labour_. + With the head, 273. See _Presentation_. + + _Arthritic_ inflammation supervening upon puerperal fever, 456. + + _Artificial_ premature labour, 250. + + _Atony_ of the uterus, 324. + Causes of, 325. + Debility, 325. + Derangement of the digestive organs, 326. + Mental affections, 326. + Age and temperament, 327. + Plethora, 327. + Rheumatism of the gravid uterus, 328. + Inflammation of the uterus, 329. + Treatment of, 339. + + _Auscultation_ in the diagnosis of pregnancy, 89. + Uterine souffle, 90. + Funic souffle, 93. + Mode of ascertaining twin pregnancy by means of, 100. + During the pains, 159. + + _Axes_ of the pelvis, 21. + + + _Ballottement_, method of performing, 94. + + _Bladder_, distended or prolapsed, obstructing labour, 322. + Stone in the, 323. + + _Blastodermic_ Membrane, 65. See _Egg_. + + _Blood-vessels_, uterine, enlargement of, during pregnancy, 38. + Their connexion with the placenta, 57, 58. + + _Breasts_, changes which they undergo during pregnancy, 86. + Abscess of the, 191. + + _Breech_, presentation of the, 210. See _Nates_. + + _Brim_ of the pelvis, situation of the, 17. + + _Bronchial_ Processes, description of the, 71. + + + _Cæsarean_ Operation, 243-278. + Indications for its performance, 243. + Different modes of performing it, 246. + History of the, 248. + + _Canalis_ venosus, situation of the, 78. + + _Caput_ succedaneum, in what it consists, 165. + + _Carunculæ_ myrtiformes, how produced, 46. + + _Cerebral_ tumours in the foetus, obstructing labour, 283. + + _Chest_, morbid depositions in the foetal, obstructing labour, 284. + + _Child_, size of, at birth, 281. + Its influence on the duration of labour, 282. + Unnatural form of the, 282. See _Foetus_. + + _Chorion_, description of the, 52. + Changes which it undergoes during pregnancy, 53. + + _Cicatrices_ in the vagina obstructing labour, 315. + Treatment of, 316. + Of the os uteri, 311. + + _Circulation_, foetal, 77. See _Foetus_. + + _Clitoris_, anatomical description of the, 46. + + _Coccyx_, anatomical description of the, 17. + + _Colic_, occurring during pregnancy, 104. + Treatment of, 104. + + _Colostrum_, nature and use of the, 190. + + _Conception_, false, 112. See _Mole_. + + _Constipation_ during pregnancy, 104. + Treatment of, 104. + + _Contagious_ nature of adynamic puerperal fever, 458. + + _Contracted_ vagina, obstructing labour, 315. + + _Contractile_ power of the uterus, derangement of the, 324. + Causes of, 325. + Treatment of, 329. + + _Contraction_, hour-glass, of the uterus, 354. See _Placenta, encysted_. + + _Convulsions_, puerperal, 376. + Epileptic, 377. + Causes of, 377. + Symptoms of, 377. + Tetanic, 381. + Diagnosis of labour during, 382. + Prophylactic treatment of, 383. + Treatment during the attack of, 383. + Apopletic, 387. + Anæmic, 387. + Symptoms of, 388. + Treatment of, 388. + Hysterical, 390. + Symptoms of, 390. + + _Copulative_ Organs, 22. + + _Cord_, umbilical description of the, 63. + Vessels of the, 63. + Length of the, 63. + Round the neck of the child, 183. + Ligature of the, 184. + Rupture of the, 364. + Prolapsus of the, 368. + Diagnosis of, 368. + Causes of, 368. + Treatment of, 372. + Reposition of the, 373. + Unusual shortness of the, 288. + Knots upon the, 290. + + _Corpus_ Luteum, nature of the, 25. + Appearance of, at different periods after conception, 25. + + _Cotyledons_ of the placenta, situation of the, 56. + + _Cough_, spasmodic, occuring during pregnancy, 104. + Treatment of, 104. + + _Cranium_, presentation of the, 200. See _Presentation_. + + _Crotchet_, mode of its application, 260. + + + _Death_ of the foetus, signs of the, 107. See _Foetus_. + + _Debility_, insufficient uterine action from, 325. + + _Decidua_ membrana, description of the, 48. + Its connexion with the uterus, 49. + With the ovum, 50. + With the placenta, 51-55. + With the Fallopian tubes, 51. + Vera, 51. + Reflexa, 51. + + _De Graaf_, vesicles of, 24. + + _Delirium_ occurring during labour, 167. + + _Depositions_, morbid, in the foetal cavities, obstructing labour, 284. + + _Development_ of the ovum. See _Ovum_. + + _Diagnosis_ of pregnancy, 80. See _Pregnancy, signs of_. + Of twin Pregnancy, 100. + + _Diameters_ of the pelvis, 19. + + _Diarrhoea_ during pregnancy, 105. + Treatment of, 105. + + _Diet_ during labour, 179. + Lactation, 195. + + _Dilatation_ of the perineum during labour, 166. + + _Distended_ bladder, obstructing labour, 322. + + _Dropsy_ of the amnion, 287. + + _Ductus_ arteriosus, situation of the, 78. + + _Duration_ of pregnancy, 136. + Causes which determine the, 139. + Of labour, prognosis as to, 178. + Wigand's views, 178. + + _Dystocia_, 263. + Divisions and species of, 263. + Malposition, 264. + Faulty form and size of the child, 281. + Faulty condition of the parts which belong to the child, 282. + Abnormal state of the pelvis, 292. + Faulty condition of the soft passages, 308. + Faulty condition of the expelling powers, 324. + Inversion of the uterus, 345. + Encysted placenta, 354. + Precipitate labour, 361. + Prolapsus of the umbilical cord, 368. + Puerperal convulsions, 376. + Placenta prævia, 393. + Puerperal fevers, 415. + Phlegmatia dolens, 463. + Puerperal mania, 473. + + _Dystocia_ epileptica, 381. See _Convulsions, puerperal_. + + + _Eclampsia_ parturientia, 376. See _Convulsions, puerperal_. + + _Egg_, bird's, its analogy with the human ovum, 64. + Blastodermic membrane, 65. + Vitelline membrane, 65. + Yelk bag, 65. + Germinal vesicle, 65. + + _Embryo_, development of the, 64. + + _Embryulcia_, 261. See _Perforation_. + + _Encysted_ Placenta, 354. See _Placenta_. + + _Epileptic_ Convulsions, puerperal, 376. See _Puerperal Convulsions_. + + _Eutocia_, 156. See _Labour, natural_. + + _Evolution_, spontaneous, of the foetus, 270. + + _Examination_ during labour, mode of its performance, 174. + + _Exostosis_ of the pelvis, 300. + Prognosis in, 305. + + _Expelling_ powers, faulty state of the, after the birth of the child, + 337. + + _Expulsion_, spontaneous, 270. + Of the child, 166. + Delirium accompanying the, 167. + Of the placenta, 167. + + _External_ organs of generation in the female described, 45. + + _Extirpation_ of the uterus, 332. See _Inversion_. + + _Extraction_, method of performing, after turning the child, 239. + After perforation, 259. + + _Extra-uterine_ pregnancy, 117. + Varieties of, 117. + Tubarian, 118. + Ovarian, 118. + Ventral, 119. + In the substance of the uterus, 117. + Symptoms of, 118. + Causes of, 119. + Treatment of, 120. + Case of, 120. + + _Eye_, rheumatic inflammation of the, after puerperal fever, 456. + + + _Face_ Presentation, 206. See _Presentation_. + + _Fallopian_ Tubes, description of the, 28. + Their agency in impregnation, 29. + Changes which they undergo during pregnancy, 29. + Pregnancy of the, 117. + + _Febris_ lactea, 191. See _Milk Fever_. + + _Feet_, rules for finding the, in the operation of turning, 237. + Presentation of the, 273. See _Presentation_. + + _Female_ Pelvis, distinction between it and the male, 17. + Organs of generation described, 22. + + _Fever_, milk, 192. See _Milk Fever_. + Puerperal, 415. See _Puerperal Fever_. + + _Fibrous_ structure of the uterus described, 32. + + _Flatulence_ during pregnancy, 104. + Treatment of, 104. + + _Flooding_, 338. See _Hæmorrhage_. + + _Foetus_, characters of a full-grown, 75. + Nutrition of the, 75. + Circulation in the, 77. + Changes which it undergoes at the moment of birth, 78. + Signs of the death of the, 107. + Premature expulsion of the, 141. See _Abortion_. + Size and form of the, at birth, 281. + Morbid depositions in the cavities of the, 284. + Anchylosis of the joints of the, 284. + Spontaneous evolution of the, 270. + + _Foramen_ ovale, situation of the, 77. + + _Forceps_, description of the, 216. + Varieties of the, 217. + General indications for their use, 221. + Mode of applying the, 222. + History of the, 227. + + _Formative_ Organs, 22. + + _Fracture_ of the parietal bone of the foetus from pelvic deformity, 302. + + _Funic_ Souffle, 93. See _Auscultation_. + + _Funis_, 63. See _Cord, umbilical_. + + _Funnel-shaped_ Pelvis, 298. + + + _Gastro-bilious_ puerperal fever, 444. See _Puerperal Fever_. + + _Gastrotomy_, 243. See _Cæsarian Operation_. + + _Generation_, internal organs of, described, 22. + External organs of, 45. + + _Germinal_ Vesicle, 65. See _Egg_. + + _Graafian_ Vesicles, description of the, 25. + + + _Hæmorrhage_, uterine, after the birth of the child, 338. + Treatment of, 339. + In placental presentation, 399. + Treatment of, 406. + + _Hand_ and feet, presentation of the, 274. See _Presentation_. + + _Headach_ during pregnancy, treatment of, 104. + + _Heartburn_ during pregnancy, 103. + Treatment of, 103. + + _Hour-glass_ Contraction, 354. See _Placenta, encysted_. + + _Hydrocephalus_, obstructing labour, 282. + + _Hymen_, description of the, 45. + Unruptured, impeding labour, 316. + + _Hysterical_ puerperal convulsions, 390. See _Convulsions_. + + _Hysterotomy_, 243. See _Cæsarian Operation_. + + + _Inclination_ of the pelvis, 21. + + _Indusium_, 23. See _Ovaria_. + + _Inflammation_ of the uterus, affecting its contraction, 329. + + _Inversion_ of the uterus, 345. + Causes of, 345. + Diagnosis of, 346. + Symptoms of, 346. + Treatment of, 347. + Chronic, 351. + + + _Joints_, anchylosis of the foetal, obstructing labour, 284. + + + _Kiesteine_, 96. + + + _Labia_, anatomical description of the, 47. + Varicose and oedematous swellings of the, 317. + + _Labour_, premature. See _Premature Expulsion of the Foetus_. + Natural, 156. + Preparatory stage of, 157. + First contractions, 157. + Action of the pains, 158. + Auscultation during the pains, 159. + Effects of the pains on the pulse, 160. + Symptoms during and between the pains, 160. + Characters of a true pain, 161. + Formation of the bag of liquor amnii, 162. + Rigour at the end of the first stage, 162. + Show, 163. + Duration of the first stage, 163. + Second stage of, 164. + Straining pains, 165. + Dilatation of the perineum, 166. + Expulsion of the child, 166. + Third stage of, 167. + Expulsion of the placenta, 167. + Twins, 168. + Treatment of, 169. + State of the bowels, 170. + Management of the first stage, 174. + Examination of the patient, 174. + Position of the patient, 176. + Diet during labour, 179. + Supporting the perineum, 179. + Perineal laceration, 181, 182. + Cord round the child's neck, 183. + Ligature of the cord, 184. + Passage of the shoulders, 184. + Management of the placenta, 186. + After treatment, 188. + Lactation, 189. + Milk fever and abscess, 191. + Excoriated nipples, 193. + Diet during lactation, 195. + Management of the lochia, 196. + After-pains, 197. + Mechanism of, 199. See _Parturition_. + Abnormal, 263. + Precipitate, 361. See _Precipitate Labour_. + + _Laceration_ of the perineum, 181, 182. + Of the uterus, 274. See _Rupture_. + + _Lactation_, management of, 189. + Diet during, 195. + + _Ligaments_ of the uterus, 31. + + _Ligature_ of the funis, 184. + + _Liquor Amnii._ See _Amnii Liquor_. + + _Lochia_, management of the, 196. + + + _Malacosteon._ See _Mollities Ossium_. + + _Male_ and female pelves, distinction between the, 17. + + _Malposition_ of the child in utero, 264. + Rareness of its occurrence, 265. + Causes of the, 266. + Symptoms of, 268. + With deformed pelvis, 272. + With rigidity of the uterus, 272. See _Presentation_. + + _Mamma._ See _Breasts_. + + _Mammary_ Abscess, 191. + + _Mania_ connected with precipitate labour, 366. + Puerperal. See _Puerperal Mania_. + + _Mechanism_ of parturition, 199. See _Parturition_. + + _Membrana_ decidua, 48. See _Decidua Membrana_. + + _Membrane_, blastodermic, 65. + Vitelline. See _Egg_. + + _Membranes_, formation of the, 48. + Premature rupture of the, 287. + + _Menses_, cessation of the, in pregnancy, 83. + + _Mental_ affections, impairing uterine contraction, 326. + + _Midwifery_, explanation of the term, 13. + Operations of, 216. + Forceps, 216. + Turning, 230. + Cæsarian operation, 243. + Artificial premature labour, 250. + Perforation, 161. + + _Milk_ Fever, 191. + Treatment of, 192. + + _Miscarriage_, 141. See _Abortion_. + + _Mole_ pregnancy, 112. + Nature and origin of, 112. + Diagnostic symptoms of, 114. + Treatment of, 116. + + _Mollities_ Ossium, 295. + Causes of, 296. + Pelvic deformity from, 296. + Varieties of pelvic deformity from, 296. + + _Monsters_, difficult labour in cases of, 284. + + _Movements_ of the foetus, value of, as a sign of pregnancy, 88-94. + + + _Nates_, presentation of the, 210. + Modifications of, 210. + Varieties of, 210. + Mechanism of labour in, 211. + Diagnosis of, 213. + Management of, 213. + Comparative frequency of, 215. + + _Navel-string._ See _Cord, umbilical_. + + _Nutrition_ of the foetus, 75. See _Foetus_. + + _Nymphæ_, anatomical description of the, 47. + Varicose and oedematous swellings of the, 317. + + _Nipples_, excoriated, 193. + Treatment of, 194. + + + _Oedematous_ swellings of the labia and nymphæ, 317. + + _Operations_ in midwifery. See _Midwifery_. + + _Operation_, Cæsarian. See _Cæsarian Operation_. + For Inducing premature labour, 253. + + _Organs_ of generation, internal, in the female, 22. + External, 45. + + _Ossa_ innominata, description of the, 15. + + _Ossium_, Mollities, 295. See _Mollities_. + + _Os Uteri_, rigidity of the, 310. + Adhesion of the edges of the, 311. + Cicatrices of the, 311. + Agglutination of the, 312. + + _Ovaria_, description of the, 22. + Situation of the, 22. + Arteries of the, 23. + Tunica albuginea of the, 23. + Graafian vesicle, 24. + Appearance of the, during childhood, 28. + Diseases to which they are liable, 28. + + _Ovarian_ Pregnancy, 118. See _Extra-uterine Pregnancy_. + + _Ovaries._ See _Ovaria_. + + _Ovum_, development of the, 48. + Membrana decidua, 48. + Chorion, 52. + Amnion, 54. + Liquor Amnii, 55. + Placenta, 55. + Umbilical cord, 63. + Analogy between the human, and the bird's egg, 64. + Order of development, 66. + + + _Pains_, labour, action of, 158. + Auscultation during, 159. + Effects of, on the pulse, 160. + Symptoms to be observed during and between, 160. + Characters of true, 161. + Straining, 165. + Spurious, 172. + Causes of, 172. + Diagnosis of, 172. + Treatment of, 173. + + _Palpitation_ during pregnancy, 104. + Treatment of, 104. + + _Parietal_ Bone, fracture of the foetal, from pelvic deformity, 302. + + _Parturition_, mechanism of, 199. + Cranial presentations, 200. + Face, 206. + Nates, 210. See _Presentation_; _Labour_. + + _Pelvis_, anatomy of the, 15. + Brim of the, 17. + Distinction between the male and female, 17. + Diameters of the, 19. + Before puberty, 20. + Axes of the, 21. + Inclination of the, 21. + Malposition of the child with deformed, 272. + Abnormal state of the, 292. + Equally contracted, 292. + Unequally contracted, 293. + Causes of, 293. + Symptoms of, 298. + Funnel shaped, 298. + Obliquely distorted, 299. + Exostosis of the, 300. + Diagnosis of contracted, 300. + Treatment of, 303. + Prognosis of, 304. + + _Pendulous_ Abdomen, obstructing labour, 308. + Management of, 308. + + _Perforation_, 256. + History of, 256. + Instruments employed in the operation of, 256. + Indications for its performance, 257. + Extraction after, 259. + Embryulcia, 261. + + _Perforators_, different kinds of, 250. + + _Perineum_, obstructing labour, 317. + Dilatation of the, 166. + Mode of supporting the, in labour, 179. + Laceration of the, treatment of, 181. + + _Peritonitis_, puerperal, 420. + Symptoms of, 420. + Anatomical characters of, 430. + Treatment of, 431. + False, 441. + Symptoms of, 441. + Treatment of, 443. + + _Phlebitis_, uterine, 436. + Symptoms of, 436. + Anatomical characters of, 437. + Treatment of, 438. + Crural, connexion of, with phlegmasia dolens, 465. + + _Phlegmasia_ dolens, 463. + Nature of, 463. + Definition of, 463. + Symptoms of, 464. + Duration of, 465. + Connexion of, with crural phlebitis, 465. + With puerperal fever, 467. + Causes of, 466. + Anatomical characters, 467. + Treatment of, 469. + + _Physiology_ of utero-gestation, 15. + + _Placenta_, description of the, 55. + Cotyledons of the, 56. + + _Placenta_, decidua of the, 51-56. + Circulation of the uterine blood through the, 57-61. + Sulci of the, 57. + Foetal surface of the, 60. + Expulsion of the, 167. See _Labour_. + Management of the, 186. + In twin cases, 187. + Prævia, 393. + History of, 393. + Symptoms of, 402. + Comparative frequency of, in different years, 405. + Treatment, 406. + Partial presentation of the, 413. + Treatment of, 414. + Retention of the, 337. + Encysted, 354. + Situation of, 354. + History of, 354. + Adherent, 356. + Treatment of, 356. + Left in the uterus, 357. + Absorption of retained, 358. + + _Plethora_, effects of, on uterine contraction, 327. + + _Plug_, utility of the, in restraining hæmorrhage, 410. + Best means of applying, 152. + + _Position_ of the patient during labour, 176. + + _Precipitate_ labour, 361. + From violent uterine action, 361. + From deficient resistance, 363. + Effects of, 363. + Treatment of, 365. + Connexion of, with mania, 366. + + _Pregnancy_, changes induced in the uterus by, 36. + Seat and appearance of the uterus in the different stages of, 39. + Signs of, 80. + General, 81. + Cessation of the menses, 83. + Areola, 86. + Movements of the foetus, 88-94. + Auscultatory signs, 89. + Ballottement, 94. + Urinary deposites, 96. + Purple hue of the vaginal entrance, 97. + Diagnosis of twin, 100. + Treatment of, 101. + Morning sickness, 101. + Heartburn, 103. + Constipation, 104. + Flatulence, 104. + Colicky pains, 104. + Headach, 104. + Spasmodic cough, 104. + Palpitation, 104. + Toothach, 104. + Diarrhoea, 105. + Pruritis pudendi, 105. + Salivation, 106. + Mole, 112. See _Mole Pregnancy_. + Extra-uterine, 117. See _Extra-uterine Pregnancy_. + Duration of, 136. + + _Premature_ expulsion of the foetus, 141. See _Abortion_. + + _Premature_ Labour, 141. + Artificial, 250. + History of, 250. + Period for inducing, 253. + Mode of operating, 253. + Rupture of the membranes in, 287. + + _Presentation_, cranial, 206. + First species of, 200. + Second species of, 203. + Of the face, 206. + Of the nates, 210. See _Nates_. + Of the arm, 272. + Of the arm with the head, 273. + Of the hand and feet, 273. + Of the head and feet, 274. + Of the placenta, 393. See _Placenta Prævia_. + + _Prolapsus_ of the umbilical cord, 368. + + _Pruritis_ pudendi occurring during pregnancy, 105. + Treatment of, 106. + + _Puberty_, state of the pelvis before, 20. + + _Puerperal_ Convulsions, 376. See _Convulsions_. + + _Puerperal_ Fevers, 415. + Nature of, 418. + Varieties of, 418. + Pathology of, 418. + Peritonitis, 420. See _Peritonitis_. + Uterine phlebitis, 436. See _Phlebitis_. + Gastro-bilious, 444. + Causes of, 444. + History of, 444. + Symptoms of, 445. + Anatomical characters of, 446. + Treatment of, 446. + Adynamic, 450. + Symptoms of, 450. + Anatomical characters of, 455. + Supervention of arthritic or rheumatic inflammation, 456. + Contagious nature of, 458. + + _Puerperal_ Mania, 473. + Inflammatory form of, 473. + + _Puerperal_ Mania, treatment of, 474. + Gastro-enteric form of, 475. + Treatment of, 476. + Adynamic form of, 478. + Causes of, 478. + Symptoms of, 478. + Treatment of, 481. + + + _Quickening_, 88. + + + _Retained_ Placenta, absorption of the, 358. + + _Retention_ of the placenta, 337, 356. + + _Retroversion_ of the uterus, 126. + History of, 126. + Causes of, 127. + Symptoms of, 129. + Diagnosis of, 130. + Prognosis of, 131. + Treatment of, 131. + + _Rheumatic_ inflammation after puerperal fever, 456. + + _Rheumatism_ of the gravid uterus, 328. + Symptoms of, 328. + Treatment of, 333. + + _Rickets_, a cause of deformity of the pelvis, 294. + + _Rigidity_ of the uterus, malposition with, 272. + Of the os uteri, 310. + Treatment of, 310. + From age, 314. + + _Rigour_ after the first stage of labour, 162. + + _Rupture_ of the uterus, 274. + Seat of the laceration, 274. + Causes of, 275. + Symptoms of, 276. + Treatment of, 277. + Gastrotomy, 278. + During the early months of pregnancy, 278. + Premature, of the membranes, 287. + Of the umbilical cord, 364. + + + _Sacrum_, anatomical description of the, 16. + + _Salivation_ during pregnancy, 106. + Treatment of, 106. + + _Show_, 163. See _Labour_. + + _Sickness_, morning, in pregnancy, 101. + Treatment of, 102. + + _Signs_ of pregnancy, 80. See _Pregnancy_. + Of the death of the foetus, 107. + + _Size_ of a child at birth, 281. + + _Spasmodic_ cough during pregnancy, 104. + Treatment of, 104. + + _Spontaneous_ evolution, 270. + Expulsion, 271. + + _Stone_ in the bladder, obstructing labour, 323. + + _Stricture_ of the uterus, 335. + Symptoms of, 335. + Effects of, on labour, 335. + Causes of, 336. + Treatment of, 336. + + _Stroma_, 23. See _Ovaria_. + + _Structure_, fibrous, of the uterus, 32. + + _Sulci_ of the placenta, how formed, 57. + Their connexion with the uterine vessels, 59. + + + _Tampon_, 410. See _Plug_. + + _Temperament_, influence of, on uterine contractions, 327. + + _Tetanic_ puerperal convulsions, 381. See _Convulsions_. + + _Toothach_ during pregnancy, 104. + Treatment of, 104. + + _Tumours_, obstructing labour, 320. + + _Turning_, 230. + Indications for, 231. + Mode of performing the operation of, 232. + Rules for finding the feet, 237. + Extraction of the child, 239. + With the nates foremost, 240. + With the head foremost, 241. + History of, 242. + + _Twins_, 168. + Management of the placenta of, 168, 187. + + + _Umbilical_ Cord, 63. See _Cord, umbilical_. + + _Unruptured_ Hymen impeding labour, 316. + + _Urinary_ deposites in pregnancy, 96. + + _Uterine_ Souffle, 90. See _Auscultation_. + Action, violent, 361. + Phlebitis, 436. See _Phlebitis_. + + _Utero-gestation_, anatomy and physiology of, 15. + + _Uterus_, description of the, 30. + Ligaments of the, 31. + Structure of the, 32. + Comparative anatomy of the, 34. + Changes in the, during gestation, 36. + Situations and appearances of the gravid, 39. + Condition of the gravid, after delivery, 44. + Blood-vessels of the, connected with the placenta, 57, 61. + Retroversion of the, 126. See _Retroversion_. + influence of the form and size of the, on parturition, 266. + Rigidity of the, 272. + Anteversion of the, 309. + Derangement in the contractile power of the, 224. + Rupture of, 274. + Rheumatism of the gravid, 328. + Effects of uterine inflammation in labour, 329. + Stricture of the, 335. + Atony of the, 324. + Inversion of the, 345. + Extirpation of the, 352. + Hour-glass contraction of the, 354. + + + _Vagina_, anatomical description of the, 45. + + _Vagina_, contracted, obstructing labour, 314. + Cicatrices in the, 315. + + _Varicose_ swellings of the labia and nymphæ, 317. + + _Ventral_ Pregnancy, 119. See _Extra-uterine Pregnancy_. + + _Vesicle_, germinal, of the egg, 65. See _Egg_. + + _Violent_ uterine action, precipitate labour from, 361. + + + _Wigand's_ views as to the duration of labour, 178. + + _Womb_, 30. See _Uterus_. + + + _Yelk-bag_, 65. See _Egg_. + + + + +THE END. + + + + +FOOTNOTES: + +[1] On the Ova of Man and Mamiferous Animals, &c.: by T. Wharton Jones. +(_Med. Gaz._) + +[2] "Inde vero cum viderum viviparorum testes ova in se continere, cum +eorundem uterum itidem in abdomen, oviductus instar apertum notarim, non +amplius dubito quin mulierum testes ovario analogi sint, quocunque demum +modo ex testibus in uterum, sive ipsa ova, sive ovis contenta materia +transmittatur, ut alibi ex professo ostendam, si quando dabitur partium +genitalium analogiam exponere, et errorem illum tollere quo mulierum +genitalia genitalibus virorum analoga creduntur." (_Nicolai Stenonis +Elementorum Myologiæ Specimen, &c._ Amst. 8vo. p. 145.) + +[3] "Ova in omni animalium genere reperiri confidenter asserimus, +quandoquidem ea non tantum in avibus, piscibus tam oviparis quam +viviparis, sed etiam quadrupedibus ac homini ipso evidentissime +conspiciantur." (_Regner de Graaf de Virorum et Mulierum Organis +Generationi Inservientibus._ Lugd. B. and Roterod. 1668. 8vo. p. 299.) + +[4] Anat. Descript. of the Human Gravid Uterus: by W. Hunter, M. D. + +[5] An Exposition of the Signs and Symptoms of Pregnancy, &c.: by W. F. +Montgomery, M. D. p. 226. + +[6] Phil. Trans. 1797. + +[7] Purkinje and Valentin, de Phoenomeno generali Motus vibratorii. +Wratisl. 1825. + +[8] W. Hunter, Anatomical Description of the Human Gravid Uterus, &c. p. +13. + +[9] Vesalius, Malpighi, Morgagni, Diemerbroeck, Vieussens, Ruysch, Monro, +Heister, Haller, Roederer, Meckel, Hunter, Wrisberg, Lobstein, C. Bell. +(_Meckel's Anat._ vol. iv.) + +[10] C. Bell, On the Muscularity of the Uterus. (_Med. Chir. Trans._, vol. +iv.) + +[11] Leroux, Sur les Pertes de Sang. + +[12] The tortuous serpentine course which the arteries of the uterus take, +is not, as has been generally supposed, a provision of nature against the +increase of size which the uterus has to undergo during pregnancy, but is +the result of the structure in which they ramify, having already undergone +these changes during a previous pregnancy. + +[13] Anatomical Description of the Human Gravid Uterus, &c.: by W. Hunter, +M. D. + +[14] The axis of the brim of the pelvis runs in such a direction, that if +a line were drawn from its centre, it would pass upwards and forwards +through the umbilicus: the gravid uterus has its axis rarely or never +inclined less than this, and usually much more, especially in multiparæ in +whom the fundus is occasionally inclined so strongly forwards as to +receive the name of pendulous belly. + +[15] We are inclined to think that the soft feel of the portio vaginalis +is one of the earliest signs of pregnancy which can be detected by +examination. Our attention was first drawn to it in an obscure case of +early pregnancy, complicated with extensive disease, which we examined +with Mr. Ingleby of Birmingham, and where we gave a wrong diagnosis, not +considering the patient to be pregnant. If we had placed as much +confidence in this symptom as we are now inclined to do, we should +probably have formed a more correct view of the case. Since this we have, +on several occasions, found that attending to this circumstance has +considerably assisted us in determining cases of doubtful pregnancy at an +early period. + +[16] This description is given according to the lunar not calendar months, +of which there are necessarily ten during the forty weeks of pregnancy. + +[17] We are aware that the plan which we follow, in considering the +development of the ovum, is very different to that usually adopted, and +will probably be open to some objections on the score of defective +arrangement; but it must be remembered that this is a work intended for +students, where complete and perfect arrangement must, to a certain +extent, be sacrificed in order to place an acknowledged difficult and +complicated subject in the clearest and most intelligible light. We have, +therefore, preferred describing first the coverings of the ovum during +those periods of pregnancy at which they are most frequently seen, and +shall delay its minute consideration until we come to the description of +the foetus itself, the development of the one being so essentially +connected with that of the other, as to render a separate description of +them impossible. By this means the reader, by having the general details +first brought under his notice, will be enabled to enter with more ease +and advantage upon the consideration of those which are obscure and +difficult. + +[18] Siebold's Journal für Geburtshülfe, vol. xiv. heft. 3. 1835. + +[19] On the Signs and Symptoms of Pregnancy, p. 133.: by W. F. Montgomery, +M. D. In a note to the above quotation, the learned author very properly +calls them _decidual cotyledons_, "for to that name their form, as well as +their situation, appears strictly to entitle them: but from having, on +more than one occasion, observed within their cavity a milky or chylous +fluid, I am disposed to consider them reservoirs for nutrient fluids, +separated from the maternal blood, to be thence absorbed for the support +and development of the ovum. This view seems strengthened when we consider +that, at the early periods of gestation, the ovum derives its support by +imbibition, through the connexion existing between the decidua and the +villous processes covering the outer surface of the chorion." + +[20] Observations by Dr. Baillie, in the posthumous work of Dr. W. Hunter, +on the Anatomy of the Gravid Uterus. + +[21] Observations on Certain Parts of the Animal Economy, p. 134. + +[22] It has lately been supposed that the irregular nodules of wax in the +Hunterian preparations were merely the result of extravasation, a rather +hazardous conclusion against the authority of such men as the Hunters. Mr. +J. Hunter has, however, expressly met this objection in the following +observation:--"this substance of the placenta, now filled with injection, +had nothing of a vascular appearance, or that of extravasation; but had a +regularity in its form which showed it to be a natural cellular structure, +fitted to be a reservoir for blood." (_Observations on Certain Parts of +the Animal Economy_, p. 129.) + +[23] In offering these observations on the placenta, we have purposely +quoted, wherever it was possible, from the admirable essays of the +Hunter's, on this subject. These works, more especially that of Dr. W. +Hunter, are becoming too scarce to be easily attained by the student; and +yet it is more peculiarly important to this class of our readers, that +they should not only be aware how much we are indebted to these +illustrious men for what we know upon the subject; but also that they +should be as familiar as possible with their very words and expressions. +The essays in question are master-pieces of original observation and +correct description, and we may safely assert, that the one by Dr. Hunter +is so complete, as to leave us little or nothing more to be wished for on +this subject. With such feelings we cannot conceal our surprise, to find +that an author like Dr. Burns should have passed over the whole subject of +the placenta without once alluding to the name of Hunter; this omission is +the more marked in the last editions of his work, where he has furnished +the reader with copious references, &c. in the notes. One would have +thought that Dr. Burns would have felt pride in acknowledging the merits +of his distinguished countrymen. + +[24] We said, "_one_ of the earliest changes." Mr. Jones considers that +"the breaking up of the surface of the yelk into crystalline forms," is +the first change which he has observed. + +[25] Allen Thomson on the Development of the Vascular System in the Foetus +of Vertebrated Animal. (_Edin. New Philosop. Journ._ Oct. 1830.) + +[26] Pander. Beiträge zur Entwickelungs-gesechichte des Hünchens im Eie. +Würzburg, 1817. + +[27] In making these observations upon the formation of the ductus +arteriosus, we must request our readers to consider this as still an +unsettled question. + +[28] The vernix caseosa is a viscid fatty matter of a yellowish white +colour, adhering to different parts of the child's body, and in some cases +in such quantity as to cover the whole surface; it seems to be a substance +intermediate between fibrine and fat, having a considerable resemblance to +spermaceti. From the known activity of the sebaceous glands in the foetal +state, and from this smegma being found in the greatest quantity about the +head, arm-pits, and groins, where these glands are most abundant, there is +every reason to consider it as the secretion of the sebaceous glands of +the skin during the latter months of pregnancy. + +[29] Fourcroy, it is true, has shown that the foetal blood is not only of +a darker colour, but incapable of becoming reddened by the contact of +atmospheric air, and that it coagulates very imperfectly. Others have +shown that there is no perceptible difference in the colour of the blood +of the umbilical arteries from that of the umbilical vein. Still, however, +this by no means disproves what we have now stated, and which is now +generally allowed to be the office of the placenta during the latter +periods of pregnancy. + +[30] "A gentleman," says Dr. Montgomery, "lately informed me that, being +afflicted with a stepmother naturally more disposed to practise the +_fortiter in re_ than to adopt the _suaviter in modo_, he and all the +household had learned from experience to hail with joyful anticipations +the lady's pregnancy, as a period when clouds and storms were immediately +changed for sunshine and quietness." (_Exposition of the Signs and +Symptoms of Pregnancy_, p. 9.) + +[31] _Dionis_ says, that "women of a sanguine complexion, who form more +blood every month than is necessary for the nourishment of the foetus +whilst it is small, discharge the overplus by the vessels which open into +the vagina during the first months." + +[32] The menstrual blood is more pale and sparing: it usually comes from +the hæmorrhoidal vessels of the vagina, or at most, from those of the +cervix uteri. (Levret, _Art des Accouchemens_, § 233.) + +[33] Should the vessels of the cervix uteri take upon them the secretion +of the menses, this discharge can thus continue through pregnancy. (Carus, +_Lehrbuch der Gynakologie_, bd. ii. p. 67.) + +[34] L'Art d'Accouchemens, § 369. (note;) also Deventer, Novum Lumen +Obstet. chap. xv.; Perfect's Cases of Midwifery, vol. ii. p. 71. [Meurer, +American Journ. Med. Sc., April 1841, p. 494.] + +[35] This fact was observed so long ago as by Aristotle, also by Schenk, +as quoted by Mauriceau, lib. i. chap. 1. Mauriceau himself mentions having +seen several cases, one of which forms the subject of his 393d +observation. "Le 8 Juin, 1685. J'ai vu une jeune femme agée seulement de +seize ans et demi, marié depuis un an qui était grosse de cinq mois ou +environ, quoiqu'elle n'eut jamais eu ses menstrues, à ce qu'elle me dit +aussi bien que son marie, qui ne pouvait pas se persuader qu'elle cût pû +devenir grosse, n'ayant pas encore eu ce premier signe de fécondité; +m'alleguant, pour soutenir son opinion, qu'on ne voyait jamais de fruit +d'un arbre qui n'eut été précédé de sa fleur. Mais je lui dis qu'il était +certain, comme il reconnut bien par sa propre experience en voyant +accoucher sa femme d'un enfant vivant quatre mois ensuite, que les jeunes +femmes pouvaient bien quelquefois devenir grosses, ainsi qu'il était +arrivé à sa femme, sans avoir jamais eu leur menstrues, si elles usaint du +coit dans le temps méme quelles étaient sur le point d'avoir effectivement +cette evacuation naturelle pour le premier fois." + +[36] Roederer, Elm. Art. Obst. p. 46. The original is a masterly specimen +of description, not less remarkable for its singular comprehensiveness +than the beauty of the style. "Menstruorum suppressionem mammarum tumour +insequitur, quocirca mammæ crescunt, replentur, dolent interdum, +indurescunt; venæ earum coeruleo colore conspicuæ redduntur; crassescit +papilla, inflata videtur, color ejusdem fit obscurior; simili colore +distinguitur discus ambiens qui in latitudinem majorem expanditur, +parvisque eminentiis quasi totidem papillulis tegitur." + +[37] "In women with dark eyes and hair, this discolouration is very +distinct; in women with light hair and eyes, it is often so slight that it +is difficult to tell whether it exists or no."... "In brunettes who have +already borne children, the areola remains dark ever afterwards, so that +this ceases to be a guide in all subsequent pregnancies." (Gooch, _on some +of the more important Diseases of Women_, p. 201 and 203.) + +[38] We had, at the moment of writing the above, a patient just recovered +from her first labour, in whom the discolouration extended nearly over the +whole breast: it was darker in some spots than in others, and presented a +variety of shades not unlike a large bruise of some days' standing. Dr. +Montgomery mentions a case where the areola was almost black, and upwards +of three inches in diameter. A similar case occurred not long since. + +[39] Bibliothèque Universalle, t. ix. p. 248; also in the Isis for 1819, +part iv. p. 542. + +[40] "Mémoir sur l'Auscultation appliquée à l'étude de la Grossesse, ou +Recherches sur deux nouveaux Signes propres à faire reconnaïtre plusieurs +Circonstances de l'Etat de Gestation; lu à l'Academie Royale de Médecine +dans la Séance Générale du 26 December, 1821. Par J. A. Lejumeau de +Kergaradec." + +[41] Dr. Evory Kennedy, Observations on Obstetric Auscultation, &c. 1833. + +[42] H. F. Naegelé, Die Geburtshülfliche Auscultation, 1838; also Dr. +Corrigan, Lancet. + +[43] Die Geburtshülfliche Exploration, von Dr. A. P. Hohl. + +[44] This sign of pregnancy has very recently excited some attention, and +the researches of M. Tanchou of Paris, (see _American Journ. Med. Sc._ +Feb. 1840, p. 483,) Golding Bird, (_Ibid._, Aug. 1840, p. 501,) and Drs. +McPheeters and Perry, (_American Medical Intelligencer_, March 15th, 1841, +p. 350,) conclusively establish, that taken in connexion with other +symptoms, it forms a very valuable aid to diagnosis. + +The following is the description given by M. Tanchou of the changes which +the urine during pregnancy exhibits, and of the characters by which its +peculiar ingredient, named by M. Nauche _Kiesteine_, may be recognised. + +The urine of a pregnant woman, collected in the morning, is usually of a +pale yellow colour and slightly milky in appearance; it is not coagulable +by heat, or by any of the tests which indicate the presence of albumen. +Left to itself and exposed to the air after the first day, there begins to +appear suspended in it a cottony-looking cloud, and, at the same time, a +flocculent whitish matter is deposited at the bottom of the fluid. These +phenomena are not of constant occurrence, and, moreover, healthy urine +sometimes exhibits analogous phenomena. + +From the second to the sixth day, we perceive small opaque bodies rise +from the bottom to the top of the fluid; these gradually collect together +so as to form a layer which covers the surface: this is the _kiesteine_. +It is of a whitish or opaline colour, and may be very aptly compared to +the layer of greasy matter which covers the surface of fat broth, when it +has been allowed to cool. Examined by the microscope, it exhibits the +appearance of a gelatinous mass, which has no determinate form. Sometimes +small cubical crystals can be perceived in it, when it has become stale. + +The _kiesteine_ continues in the state we have now described, for three or +four days; the urine then becomes muddy, and minute opaque bodies detach +themselves from the surface and settle at the bottom of the vessel: the +pellicle thus becomes soon destroyed. + +The characteristic feature, therefore, of the urine during pregnancy +consists in the presence of _kiesteine_. It deserves, however, to be +noticed, that the urine, in some cases of extreme phthisis pulmonalis, and +also of vesical catarrh, will be found to exhibit on its surface a layer +or stratum which is not unlike to that now described as peculiar to the +state of pregnancy. But with proper attention we may easily avoid this +mistake. The stratum, in the cases alluded to, does not appear so quickly +on the surface of the urine as the _kiesteine_ does; and also, instead of +disappearing, as it is found to do, in the course of a few days, it (the +former) goes on increasing in thickness, and ultimately becomes converted +into a mass of mouldiness. + +Of twenty-five cases, in which M. Tanchou detected the presence of +_kiesteine_ in the urine, seventeen occurred in women who were pregnant +from four to nine months, four in women who had not quickened, and who +considered themselves as labouring under disease of the womb, and the +remaining four in patients who had been under treatment for casual +complaints--one for sciatica at the Hôtel Dieu, another for ascites in the +city, a third for an ulcer in the neck at La Pitié, and the last had been +cauterized twice a week for a pretended disease of the uterus. In none of +these cases had the existence of pregnancy been suspected, although in +every one of them the fact was soon placed beyond doubt.--EDITOR. + +[45] Baudelocque wrote an account of it to Professor Naegelé of +Heidelberg, from whom we received the particulars. + +[46] See Treatise on the Diseases of Females, 6th ed. p. 46. Ed. + +[47] Ovum deforme, in quo partes embryonis et secundarum distingui vix +possunt, molam vocabimus. (Roederer, _Elementa Artis Obstetricæ_, § 738.) + +[48] Dr. J. Y. Simpson on the Diseases of the Placenta. (_Edin. Med. and +Surg. Journal_, April 1, 1836.) + +[49] "One must be careful not to mistake these clots of blood, which being +washed by the reddish serosities which flow from the womb, harden in the +vagina, or womb itself, and look exactly like false conceptions." (_La +Motte._) + +"Every mole is a blighted ovum which has been the product of conception. +We are not justified in classing under the head of moles every mass which +is produced and lodged within the uterus." (Froriep's _Handbuch der +Geburtshülfe_, § 180.) + +[50] Our friend, Dr. Nebel, of Heidelberg, has a preparation of a foetus +which was retained for fifty-four years in the abdomen. This is the +longest period on record of a foetus being retained in the cyst of a +ventral pregnancy. Many other cases have been described. (See _Burns_, 9th +edition, where the notes contain very ample references.) + +[51] We had lately a case of this kind. The patient had been under our +care for inflammation of the cervix uteri. There was that general +enlargement of the uterus which attends this condition; and, on +endeavouring to lift a heavy weight, she was seized with violent pain in +the pelvis, great difficulty in passing fæces and urine, and, on +examination, the uterus was found retroverted. The bowels were well opened +with castor oil, and in a day or two it recovered its natural position. + +[52] Dr. W. Hunter has evidently taken the same view of the case, and +invariably considers retention of urine as an effect, not the cause, of +this displacement. (_Med. Observ. and Inq._ vol. iv.) + +[53] We were once misled in a case of this description. The os uteri lay +close behind the symphysis pubis, and its opening, as well as so much of +the neck as we could feel, looked straight downwards. We were unable to +pass the finger sufficiently high to trace the continuity between the neck +of the uterus and tumour in the hollow of the sacrum formed by the fundus; +and the haggard aged appearance of the woman put all suspicion of +pregnancy out of our mind. + +[54] Dr. Burns makes a similar observation. "In most cases the cervix will +be found more or less curved; so that the os uteri is not directed so much +upwards as it otherwise should be." (_Principles of Midwifery_, p. 281. +9th edit.) + +[55] "Sometimes it is perhaps better to introduce the fingers into the +vagina only, and not into the rectum, not merely because, we can act +better and more directly upon the uterus here, but also because if we +press the posterior wall of the vagina upward towards the sacrum, and thus +stretch the upper part of it which is between the fingers and the os +uteri, it will act upon the uterus like a cord upon a pulley, and greatly +favour its rotation." (Richter, _op. cit._ vol. vii. sect. 57.) + +[56] Among others, we may mention an exceedingly interesting case recorded +by Mr. Baynham, in the _Edin. Med. and Surg. Journ._ April, 1830. The real +nature of the case was not ascertained for six weeks, the catheter only +being used night and morning. Even when the bladder was empty, the fundus +resisted every attempt to return it. The most prominent part of the tumour +in the rectum was punctured with a trocar, and about twelve ounces of +liquor amnii, without blood, were drawn off: the reduction followed in +about a quarter of an hour. A full opiate was given, and the patient +passed a better night than she had done before. Twenty-five hours after +the operation, the foetus, was expelled; it was fresh, and about the size +of a six months' child. The patient recovered. + +[57] Dr. Cheston's case, where the child was afterwards carried the full +time, and born alive. (_Med. Communications_, vol. ii. p. 6.) + +[58] Merriman, Med. Chir. Trans. Vol. xiii. p. 338. + +[59] Exposition of the Signs and Symptoms of Pregnancy: by W. F. +Montgomery M. D. p. 253. + +[60] Dewees, Compendious System of Midwifery, sect. 408. A similar case is +recorded by Dr. Montgomery. + +[61] "Qui inter septimi et noni mensis, à prima conceptione, finem +contingit partus, _præmaturus_ vocatur: _abortus_ vero quando ante dictum +tempus embryo excidit; id quod circa tertium graviditatis mensem ut +plurimum accidit. Vitalem esse præmaturum foetum observatio nos docet, +embryonem autem non manere superstitem constat." (Roederer, _Elem. Artis +Obst._ cap. xxiii. § 716.) + +[62] During the great influenza epidemic, abortions were remarkably +frequent. + +[63] This is nearly the same arrangement which has been followed by Dr. +Copland, in the article ABORTION, in the Dict. Pract. Med. + +[64] This crotchet consists of a piece of steel of the thickness of a +small quill at its handle, and gradually tapered off to its other +extremity which is bent to a hook of small size. (See accompanying figure +which represents the instrument one third the natural size.) + +[Illustration] + +This instrument is highly useful in cases in which the flooding continues +after the ovum has been broken and its contents expelled. A portion of the +involucrum sometimes insinuates itself into the neck of the uterus, and +prevents the degree of contraction necessary to interrupt farther +bleeding. This accident most frequently attends the earlier abortions. As +hæmorrhage is maintained by the cause just named it suggests the propriety +of never breaking the ovum; especially before the fourth month. When the +flooding is maintained by this cause, it will not cease but upon the event +of its removal. This condition of the placenta and neck of the uterus is +easily ascertained by an examination; it will readily be felt to be +embraced by the neck of the uterus; and though a portion may protrude a +little distance below the os tincæ, it cannot be extracted by the fingers; +for the os uteri or cavity of the uterus will not be sufficiently large to +permit the fingers to pass into it, that this mass may be removed; the +crotchet should then be substituted; the mode of using it is as +follows:--The fore-finger of the right hand is placed within or at the +edge of the os tincæ; with the left we conduct the hooked extremity along +this finger, until it is within the uterus; it is gently carried up to the +fundus, and then slowly drawn downwards, which makes its curved point fix +in the placenta; when thus engaged, it is gradually withdrawn, and the +placenta with it. + +Dr. Dewees says, that in every case in which he has used this crotchet, +the discharge instantly ceased. See Art. "ABORTION," by Dr. Dewees, in +_American Cyclopedia of Pract. Med. and Surg._ Dr. Dewees "from some late +experience is induced to believe" that "in cases in which we cannot +command the removal of the placenta by the fingers--that is, when this +mass continues to occupy the uterine cavity, or but very little protruded +through the os tincæ," the administration of ergot, will often supercede +the necessity of the crotchet. _Treatise on the Diseases of Females._ +Sixth Edition, p. 351.--ED. + +[65] Dr. Dewees recommends the crotchet only where the flooding continues +_after_ the ovum has been broken. See preceding note. ED. + +[66] "Clysteres injiciantur, quorum irritatione expultrix uteri facultas +excitatur, et depleta intestina ampliorem locum utero relinquat." +(Riverius, _Prax. Med. de Partu difficili_.) + +[67] [Dr. Dewees recommends the woman to be placed for labour on her left +side at the foot of the bed, in such a manner as will enable her to fix +her feet firmly against one of the bed-posts; her hips within ten or +twelve inches of the edge of the bed; her knees bent, her body well flexed +upon her thighs; her head and shoulders will then be near the centre of +the bed, where pillows should be placed to raise them to a comfortable +height. This is the position we believe in which the patient is very +generally placed in the United States.--ED.] + +[68] [See an interesting paper "on Laceration of the Perineum during +Labour; by Wm. M. Fahnestock, M. D.," in American Journal of the Med. Sc. +for Jan. 1841. Editor.] + +[69] See a case of central perforation of the perineum, _Med. Gaz._ p. +782. Aug. 19, 1837. + +[70] "The practice of using force to hurry the shoulders and body of the +child through the os externum as soon as the head was born, is very +generally laid aside. There can be no doubt that this imprudent conduct +often brought on a retention of the placenta." (See White, _on Lying-in +Women_.) + +[71] "A ligature upon the navel string is absolutely necessary, otherwise +the child will bleed to death; and when tied slovenly, or not properly, it +will sometimes bleed to an alarming quantity. As we take such vast care to +secure the navel string, you will naturally ask how brutes manage in this +particular? I will give you an idea of their method of procedure, by +describing what I saw in a little bitch of Dr. Douglas. The pains coming +on, the membranes were protruded; in a pain or two more they burst, and +the puppy followed. You cannot imagine with what eagerness the mother +lapped up the waters, and then, taking hold of the membranes with her +teeth, drew out the secundines; these she devoured also, licking the +little puppy as dry as she could. As soon as she had done I took it up, +and saw the navel string much bruised and lacerated. However, a second +labour coming on, I watched more narrowly, and as soon as the little +creature was come into the world I cut the navel string, and the arteries +immediately spouted out profusely; fearing the poor thing would die, I +held it to its mother, who, drawing it several times through her mouth, +bruised and lacerated it, after which it bled no more. This, I make no +doubt is the practice with other animals." (Dr. W. Hunter's _Lectures, MS. +1752_; from Dr. Merriman's _Synopsis_, p. 21. note.) + +[72] Carus's Gynakologie, vol. ii. p. 138. This assertion, however, must +be qualified, somewhat, as we know of several cases where flooding has +come on after labour during sleep. + +[73] "I have observed," says Dr. Hunter, "in women who do not give suck, +and in nurses after they leave off suckling, that the axillary glands +become painful, swell, and sometimes suppurate. Is not this owing to the +acrimony which the milk has acquired by long stagnation in the breast, and +affecting the gland through which it must pass in absorption? I have +observed that they are at the same time liable to little fevers of the +intermitting kind, which come on with a rigour, and go off with a sweat. +Are not such fevers raised by absorption of acrid milk?" (Hunter's +_Commentaries_, p. 59.) + +[74] [The best application we have ever tried, is the vinegar and water as +is commended by Dr. Dewees. See his admirable chapter on Milk Abscess. +_Treatise on the Principal Diseases of Females._--AM. ED.] + +[75] [Sore nipples is an affection, of so very frequent occurrence, often +so exceedingly obstinate, and sometimes productive of such extreme torture +to the patient, that some additional remarks relative to its treatment may +be acceptable to the practitioner. + +The solution of nitrate of silver, two grains to the ounce of water, is +highly extolled by MR. ALLARD (_American Journ. Med. Sc._ Feb. 1837,) and +DR. CHURCHILL says that he has found it the most effectual application. +(Diseases of _Pregnancy and Child-bed_.) This solution should be applied +every time the child is taken from the breast, care being taken to wash +the nipple previous to the next application of the child. We have +frequently found this treatment very efficacious, but in some cases it +entirely fails. Dr. Hannay says, that the solution is inferior to the +solid nitrate of silver, and asserts that the latter never fails to afford +relief and ultimately effect a cure. He uses it as follows. The nipple is +to be gently and carefully dried, then freely touched with a sharp pencil +of nitrate of silver, care being taken to insinuate the pencil into the +chaps or chinks. The nipple is then to be washed with a little warm milk +and water. The pain though smart soon subsides, and all that is necessary, +according to Mr. H. to heal the sore, is a little simple ointment, or one +made with the flowers of zinc. When the pain from the application is very +severe, relief should be given by the administration of thirty drops of +the solution of morphium. In some cases it is necessary to apply the +caustic more than once. (_Am. Journ. Med. Sc._ Feb. 1835, p. 527.) + +DR. CHOPIN recommends repeated lotions with the solution of Chloride of +Soda, which he says will often cure in one or two days. (_Am. Journ. Med. +Sc._ May, 1836.) + +DR. BARD says that simply keeping a linen cloth _constantly_ wet with rum +over the nipple is frequently very useful, and as it is one of the easiest +remedies, it should be first tried. (_Compendium of the Theory and +Practice of Midwifery._) + +Stimulating ointments, such as ung. hydrarg. rub. diluted with lard, is, +according to BURNS, sometimes of service, as is also touching the parts +with burnt alum, or dusting them with some mild dry powder. Solutions of +sulphate of alumine and of sulphate of copper, of such strength as just to +smart a little, are also recommended as occasionally of service by the +last named practitioner. (_Principles of Midwifery_, 7th Ed. p. 543.) + +We have found Kreosote, three to six drops in an ounce of water, very +efficacious; in some cases affording more speedy relief than any other +application. The mucilage of the slippery elm applied cold is often a most +comfortable application, and its efficacy is sometimes increased by +dissolving in it some borax. + +When all these means fail, the mother must give up suckling for a time, +when the parts heal rapidly. This last resource will not be often +necessary. + +The great number of remedies which have been employed for the cure of this +complaint sufficiently attest its obstinacy. This obstinacy is owing, in +some cases, we conceive, to an irritable condition of the patient's +system, a fact overlooked so far as we know, by most practitioners. In +such cases a mild and nutritious diet, fresh air, keeping the bowels free, +&c. will do more towards effecting a cure than local applications; though +the latter even here are not to be neglected. Editor.] + +[76] [Dr. Dewees regards after-pains as an evil of magnitude, and always +endeavours to prevent them as quickly as possible. For this purpose he +recommends camphor or some preparation of opium. (See his _System of +Midwifery_.) We have always adopted this practice to the great relief of +the patient, and have never had cause to regret it. Dr. Dewees's +observations on this subject should be attentively perused.--ED.] + +[77] See observations on MALPOSITION OF THE CHILD. + +[78] We have no words in the English language like the _schrag_ and +_schief_ of the German to express these different species of obliquity. + +[79] On the other hand, Dr. Merriman observes, that he has "twice known +the presentation of the face converted by the pains alone into a natural +presentation." (_Synopsis_, p. 48.) + +[80] According to the results of Dr. Collins's experience at the Dublin +Lying-in Hospital, the face presented once in about every 504 cases; but +as, in several labours, the presentation was not noted on account of their +rapidity, the proportion is probably larger. + +[81] Madame La Chapelle calls this the _courboure des bords_, to +distinguish it from the head curvature, _courboure des faces_ (p. 61.) + +[82] A Treatise on the Improvement of Midwifery, chiefly with regard to +the Operation: by Edmund Chapman, 2d edit. 1735. + +[83] [Dr. Dewees, prefers, in all cases, the long forceps. See the +chapters on the Forceps in his _System of Midwifery_. Ed.] + +[84] See Midwifery Hospital Reports, case of Mrs. Worsley, May 3, 1834, p. +187. + +[85] Another circumstance is humanely insisted on by Madame la Chapelle +with much propriety: "Je ne manque jamais de fair voir le forceps à la +femme, et de lui expliquer à-peu près son usage, et sa façon d'agir. Il +n'en est aucune que cette démonstration ne tranquillise, et j'en rencontre +souvent qui à leur deuxieme accouchement sollicitent l'application du +forceps qu'elles ont vu mettre en usage pour les débarasser du premier." +(_Pratique des Accouhemens_, p. 64.) + +[86] Madame la Chapelle confirms this mode of introducing the forceps: +"Pour moi, je l'introduis constamment sur le ligament sacro-sciatique." +(_Pratique des Accouchemens_, p. 66.) + +[87] "Quand une fois la tête est hors les parties osseuses, elle ne +retrograde plus, je les dêsarticule (the blades) avec la clef placée entre +elles en forme de lévier; je les extrais en les inclinant graduellement, +car souvent l'extraction un peu brusquée d'une branche produit l'expulsion +de la tête." (_La Chapelle._) + +[88] "Mon avis est que la choix n'est point _nécessaire_ quand l'uterus +est encore rempli d'eau, et que la position est douteuse. En pareil cas je +conseillerais même plutôt de faire usage de la main droite, quoique, pour +mon compte, l'habitude m'ait rendu l'usage aussi familiar que celui de +l'autre." (Mad. la Chapelle, _Prat. des Accouch._ p. 88.) + +[89] "Une chose très importante à observer quand on se trouve contraint +par la perte de sang à en venir à l'opération, et que les eaux ne sont +point encore ouvertes, c'est de couler la main tantôt à droit, tantôt à +gauche le plus haut et le plus doucement qu'il est possible de long les +membranes qui contiennent les eaux sans les rompre, jusqu' à ce qu' on ait +trouvé les pieds de l'enfant pour s'en saisir. Car s'il arrive qu'elles se +rompent avant qu'on ait pris cette précaution, pendant qu'on les cherche, +les eaux s'écoulent, les sang se perd, a la matrice se referme en partie, +et l'opération devient par-là plus difficile et plus dangereuse." +(_Pratique des Accouchemens_, p. 277.) + +[90] Traité des Accouchemens, 1770. § 691. "Pour moi, j'ai toujours au +contraire trouvé un grand advantage à insinuer la main jusqu'aux pieds de +l'enfant, et à n'ouvrir les membranes qu'en saisissant ces derniers." (_La +Chapelle_ p. 90.) + +[91] "We must by no means burst the bag of liquor amnii until the hand has +passed up between the membranes and the uterus. Every movement is easy +whilst there is fluid in the uterus: hence, therefore, we must not +withdraw the hand until we have fairly gained the feet and brought them +down; for otherwise the waters escape, the uterus contracts, and the rest +of the operation is more difficult." (_Boer_, vol. iii. p. 17. note.) + +[92] "Je suis loin de prétendre, avec Puzos, que la traction sur un seul +pied ait les avantages récis." (_La Chapelle_, p. 93.) + +[93] "Dans tous ces accouchemens je laisse le plus souvent agir la nature, +et je le fais avec bien plus de sécurité quand je sçais que la femme a +accouché précédemment et fort aisément d'enfans volumineux, quand je +reconnois son bassin pour avoir toutes les dimensions requises, quand les +contractions de la matrice sont bonnes." &c. (_Traité des Accouchemens_, § +674.) + +[94] Ueber die künstliche Wendung auf den Steiss, in the Heidelberg Klin. +Annalen, vol. ii. part i. p. 142. + +[95] Traité des Hernies, contenant une ample Déclaration, &c., par Pierre +Franco de Turriers en Provence, demeurant à presént à Orange: à Lyon, +1561. + +[96] See DYSTOCIA FROM MALPOSITION OF THE CHILD. [The student who desires +to investigate this subject farther, may consult Dr. Churchill's +_Researches on Operative Midwifery_. Essay ii. on Version.--AM. ED.] + +[97] [Prof. Gibson has operated twice on the same patient, and both times +successfully, for mother and children. See _American Journal_, for May +1838.--ED.] + +[98] [Dr. Churchill has collected the statistics of 409 cases of Cæsarean +section, of which number, 228 mothers were saved; and 181 lost, or about 1 +in 2-1/4: and out of 224 children, 160 were saved, and 64 lost--or about 1 +in 3-1/2. + +Of the above cases, 40 occurred in the practice of British practitioners, +of which, 11 mothers recovered, and 29 died; or nearly three fourths--and +37 cases, in which the result to the child is mentioned, 22 were saved, +and 15 lost--or 1 in 2-1/2. + +Of 369 cases in the practice of Continental practitioners, 217 mothers +recovered, and 152 died, or 1 in 2-1/3--and out of 187 cases, where the +result to the child is given, 138 were saved, and 49 lost; or nearly 1 in +4. _Researches on Operative Midwifery._ By F. Churchill, M. D., Dublin, +1841. Editor.] + +[99] [The propriety of an early resort to the Cæsarean section, in cases +where it is necessary, has been very properly insisted upon; but the +circumstances which render it necessary, are not always readily +determined. M. Castel states, that in a case at the _hospice de +perfectionnement_, in which the operation was determined on, some delay +became necessary in order to find accommodation for the crowd of students +who collected to witness it, and before this could be effected the woman +was delivered naturally. M. Gimelle says, that at the hospital of M. +Dubois, a small woman, who had five times submitted to the Cæsarean +section, was delivered naturally the sixth time. _Am. Journ. Med. Sc._ +Aug. 1838. Ed.] + +[100] For the particulars of this interesting case we must refer our +readers to the British and Foreign Med. Review, vol. ii. p. 270; and also +to vol. iv. p. 521. [Also to _American Journal Med. Sc._, August, 1838, p. +526, and Nov. 1837, p. 244.--ED.] + +[101] [Those who desire farther information on this subject, may consult, +with advantage, Dr. Churchill's Researches, already quoted.--ED.] + +[102] Dr. Macauley was physician to the British Lying-in Hospital, in +Brownlow Street, and colleague of Dr. W. Hunter. + +[103] Barlow, Medical Facts and Observations, vol. viii. Although we are +in great measure indebted to Dr. Denman for having brought this operation +into general notice, it is to the late Professor May, the father-in-law of +Professor Naegelé, that the merit is due for having first pointed out the +advantage of exciting uterine contraction before rupturing the membranes. +(_Programma de Necessitate Partûs quandoque præmature, vel solo +Instrumentorum adjutorio promovendi._ Heidelberg, 1799.) + +[104] [The student who desires to investigate this subject farther, is +referred to Dr. Churchill's Researches on Operative Midwifery, and a +copious analysis of his Essay on Premature Labour, in the _American Journ. +Med. Sc._ for Nov. 1838, p. 172, also to the Nos. of the Journal just +named, for Feb. 1838, p. 516, November 1839, p. 237, and July 1841, p. +226. Editor.] + +[105] "The scissors ought to be so sharp at the points as to penetrate the +integuments and bones when pushed with moderate force, but not so keen as +to cut the operator's fingers or the vagina in introducing them." +(_Smellie_, vol. i. chap. 3. sect. 7. numb. 2.) + +[106] [Dr. Churchill who has collected the statistics of this operation, +states, that in 334,258 cases of labour, the crotchet has been used in +343, or 1 in 974-1/2. + +Of this number, 41,434 cases of labour occurred to British practitioners; +in which, there were 181 crotchet cases, or about 1 in 228. + +Among the French, 36,169 cases of labour; of which there were 30 crotchet +cases, or 1 in 1,205-2/3. + +And among the Germans, 132 crotchet cases, in 256,655 labours, or 1 in +1,944-1/3. Of 251 cases, in which the result to the mother is given, the +mortality was 52, or about 1 in 5. (_Op. Cit._) Editor.] + +[107] The above arrangement is that which is given by Professor Naegelé, +in his _Lehrbuch der Geburtschülfe_. + +[108] _Pratique des Accouchemens_, p. 21. "Je puis assurer n'avoir jamais +rencontré aucune position du col, ni du tronc proprement dit." (p. 19.) + +[109] Merriman's Synopsis of difficult Parturition, last edition, p. 69. +The elongated form of the protruded bag of membranes is, however, by no +means a constant occurrence, as cases frequently occur where nothing of +the kind has appeared. + +[110] Boer's _Naturliche Geburtshülfe_, b. iii. p. 64. A case of actual +evolution has also been described by Mr. Barlow, p. 399. + +[111] Med. Chir. Trans., case by Dr. Smith, of Maidstone. See also an +interesting case by Professor Naegelé, in the British and Foreign Medical +Review, where the uterus was ruptured by sudden violence, part of the +child was delivered per vaginam, the rest by an abscess through the +abdominal parietes. No. x. April, 1838. + +[112] Lassus, Pathologie Chirurgicale, tom. ii. p. 237, quoted by Dr. +M'Keever, _op. cit._ p. 27. + +[113] Collins, _op. cit._ p. 277. An interesting case of rupture at the +sixth month, is recorded by Mr. Ilot, of Bromley, in the seventh volume of +the Medical Repository, and quoted by Dr. Merriman, who has also given +another at the eighth month by Mr. Glen, p. 268. See also an interesting +case in the Brit. and For. Med. Rev. for October, 1838, p. 539. + +[114] [Another case is recorded by Dr. Carmichael, of Dublin. See _Amer. +Journ. Med. Sc._, May 1840, p. 236.--ED.] + +[115] The late Professor Young, of Edinburg, has described a case of this +sort in his lectures: he distinctly "heard the head crack, and a large +quantity of fluid came away." + +[116] Observationes Anatomicæ, 52. A similar case has been recorded by Dr. +Wrangel, in the Archiv. der Gesellschaft der Correspondirenden Aerzte zu +St. Petersburg. + +When called to the case, the forceps had been already applied by a +colleague, but could not be locked, owing to the enormous tumour of the +head. A doughty swelling was felt between the blades of the forceps, of +such a size that he could only just reach the cranial bones. He made +pretty strong traction twice, when unluckily the instrument slipped off; +it seemed, however, to have brought the head so much lower, that the child +was delivered in ten minutes afterwards by the natural efforts: it was +dead. A sac filled with serous fluid, and as large as the head itself, was +attached to the occiput; it was covered by the cranial integuments, and in +ten hours afterwards, as the fluid had found its way through the open +sutures into the cranial cavity, the tumour had the appearance of a +hydrocephalus. + +[117] Quoted by Dr. Lee in the Med. Gazette, Dec. 25, 1830, from the +Journ. Gén. de Méd. tom. xliii. xlv. + +[118] Merriman's Synopsis, p. 216.; also Dr. J. Y. Simpson's fifth case of +fatal peritonitis, in Edin. Med. and Surg. Journ. No. cxxxvii. The patient +had suffered under four different attacks of venereal disease. Some +interesting cases have been published in the Neue Zeitschrift für +Geburtskunde, band vii. heft 1. by Dr. Bunsen of Frankfort and Dr. Kyll of +Cologne. In almost every case of great accumulation of liquor amnii, the +child was dead, hydrocephalic, or with ascites and in many the placenta +was diseased. + +[119] [Dr. Churchill has given a table of the length of the umbilical cord +in 500 cases. In 127 of these, the cord was 18 inches long, in 77 cases 24 +inches, and in 45 cases 20 inches long. The extremes were 12 and 54 +inches. _Op. Cit._--ED.] + +[120] In a case of this sort Mauriceau says, "Ce noeud étoit extrémement +serré: mais cela ne s'etoit fait seulement que dans la sortie de l'enfant; +car s'il eût été long-temps serré de la sorte dans le ventre de la mère, +l'enfant auroit certainement peri; à cause que le mouvement du sang que +lui étoit nécessaire, auroit été entièrement intercepté dans ce cordon. +J'ai encore accouché depuis ce temps la, sept autres femmes, dont les +enfans qui étoient tous vivans, avoient pareillement le cordon noüé d'un +semblable noeud qui s'étoit fait de la même manière, par l'extraordinaire +longueur de leur cordon." (_Obs._ 133.) + +[121] [Dr. Zollickoffer, of Middleburg, Md., relates two cases, in each of +which there was a knot upon the cord without any injury to the children. +_American Journal, Med. Sc._ July 1841, p. 109.--ED.] + +[122] Van Swieten, in his Commentaries on Boerhaave, gives a remarkable +instance of its occurring twice in the same patient, so as to destroy the +child. "I had occasion to see two instances of the birth of a dead child +in one lady of distinction, where every thing was exactly and rightly +formed; only the navel string was, towards the middle, twisted into a firm +knot, so that all communication between the mother and foetus had been +intercepted. The umbilical rope seems to have formed by chance a link, +through which the whole body of the foetus passed, and afterwards, by its +motion and weight, had drawn the knot, already formed, into such a degree +of tightness, that the umbilical vessels were entirely compressed; for +when the knot was loosened out, all that part of the navel string which +was taken into the knot was quite flattened." (Vol. xiii. § 1306.) + +[123] One of the most remarkable cases of extreme pelvic deformity from +mollities ossium is described by Professor Naegelé in his Erfahrungen und +Abhandlungen. The patient was the mother of six living children when she +was attacked with the disease: the seventh, after great difficulty, was +born dead, and the eighth was delivered by the Cæsarean operation, which +proved fatal. The spine was pressed so downwards, that the third lumbar +vertebra was opposite to the superior edge of the symphysis pubis; the +distance of the left ramus of the pubes from the fourth lumbar vertebra +was only 2-1/2 lines; the transverse diameter of the inferior aperture +only 1 inch 9 lines. For the farther details of this interesting case we +may refer to our published lectures on this subject. A similar and highly +interesting case has been recorded by Mr. Cooper, and communicated by Dr. +Hunter in the Medical Observations and Inquiries, vol. v. The patient's +first three labours were rather easy; in the beginning of her fourth +pregnancy she had a violent rheumatic fever, which continued about six +weeks; from this time she never enjoyed good health and suffered +constantly from rheumatic pains over her whole body: these were followed +by laborious respiration, and gradual distortion of spine: her fourth +labour was accomplished with much difficulty. During her fifth pregnancy +the distortion continued to increase. In her sixth and seventh labours the +pelvis was found much contracted, so much so in the last as to require +perforation. In her eighth labour the pelvis then appeared to be somewhat +less than 2-1/2 inches from the symphysis of the ossa pubis to the +superior and projecting part of the os sacrum, and otherwise badly formed. +Embryotomy was again performed. She had become much more deformed and +helpless, but in three years afterwards she was again pregnant. "She now +appeared to be little more than an unwieldy lump of living flesh." The +antero-posterior diameter was now only 1-1/4 inch, becoming gradually +narrower at each side. The Cæsarean operation was performed with a fatal +result. On examination after death, the rami of the ischium were found +"little more than half an inch asunder." + +[124] [A second case has been recorded by Dr. Schultzen, see _American +Jour. Med. Sc._ July 1841, p. 238.--Ed.] + +[125] "Mechanical obstruction to the progress of labour, is sometimes +produced by thus fatiguing the woman with continual walking. I have known +the whole of the cellular substance lining the pelvis so much distended by +oedematous tumefaction, as to make the pelvis greatly narrowed in its +capacity, which repose for some hours has diminished, or entirely +removed." (Merriman's _Synopsis_, p. 18. last edit.) + +[126] Mr. Barlow has attempted to form a synoptical table of pelvic +distortion. Thus, he says, where the antero-posterior diameter of the brim +is from 5 to 4 inches, delivery can be effected by the efforts of nature +alone; where from 4 to 3 or 2-3/4 inches, delivery may take place by the +efforts of nature, or assisted by the crotchet, or lever; from 2-3/4 to +2-1/2 inches, it requires artificial premature delivery; from 2-1/2 to +1-1/2 inches, embryulcia; and from 1-1/2 inch to the lowest possible +degree of distortion, the Cæsarean operation. + +[127] For many of the above observations we are indebted to an admirable +article upon the subject by our friend, Professor Naegelé, jun., in the +_Medicenischen Annalen_, band ii. heft 2. + +[128] Dr. Merriman has detailed two interesting cases, which were +terminated by the natural powers. In the first (p. 59,) the patient died +afterwards, a small laceration having taken place in the vagina; the other +appears to have arisen from an unruptured state of the hymen, which was of +unusual thickness; (see Appendix II.) The case did well. + +[129] For much valuable information on this subject, as also for several +interesting cases, we gladly refer to Facts and Cases in Obstetric +Medicine, by our friend Mr. Ingleby, of Birmingham; a practical work of +great value. + +[130] [The following very singular case of tumour of the pelvis is +recorded by Professor D'OUTREPONT, of Würtzburg. + +A woman, twenty-six years old and well made, gave birth when twenty-five +years of age to her first child without difficulty. Towards the end of her +second pregnancy she again applied at the hospital in consequence of +experiencing pain in the pelvic region. Vaginal examination discovered a +hard and painful tumour, extending from the inner surface of the left +ischium nearly to the corresponding point on the opposite side. It was +hard, globular, even on its surface, and occupied the ascending ramus of +the ischium and the descending ramus of the pubis, and extended over the +obturator foramen. It was impossible to reach the lower segment of the +uterus, or to feel any part of the child. + +The size and hardness of the tumour seemed to leave no chance of the birth +of a living child, even by the induction of premature labour. Professor +D'Outrepont, who doubted whether the tumour was fibro-cartilaginous, or a +true bony exostosis, asked the opinion of many eminent men who saw the +case. They did not express themselves with certainty as to its nature, and +the patient refused to allow an experimental incision to be made into the +tumour. + +A short time before labour began, the tumour was thought to have become +slightly compressible. When labour commenced, the professor called a +consultation in which it was determined that unless a great change had +taken place in the character of the tumour, an attempt should be made to +remove it, or to cut away the bone if that should be found to be +implicated, and as a last resource, to perform the Cæsarean section. + +On an examination being made, the right foot of the child was found to +present, the cord was prolapsed, and did not pulsate. The tumour, however, +was found to be so much softened that it was possible to pass three +fingers through the outlet of the pelvis. Professor D'Outrepont brought +down the foot, in doing which, he found that the hips had compressed the +tumour still more. The chief difficulty was experienced in extracting the +head by means of the forceps, which gave the patient considerable pain. +The child was still-born, but was speedily recovered. After the birth of +the child, the tumour regained its former size, so that the placenta could +not be expelled by the natural efforts, and it was necessary to introduce +the hand in order to remove it. + +The patient recovered rapidly, and returned ten weeks after her delivery, +in order to have the tumour removed, which operation was performed by +Professor Textor. The growth was found to be fibro-cartilaginous, and was +connected neither with the bone nor the periosteum. It weighed 11-1/2 +ounces, and was so hard that none but they who were present at the +patient's delivery, could have believed its previous softening possible. +The patient was completely cured.--ED.] + +[131] A sudden drink of cold fluid will generally excite contractions of +the uterus, owing to the close sympathy which exists between it and the +stomach. A couple of ounces, at most, will be sufficient for this purpose, +if swallowed quickly; a larger quantity not only fails of its effect, by +oppressing the stomach, but, by filling it with fluid, renders almost +inert any stimuli or medicines which may afterwards be required. + +[132] "Cold injections," says Dr. Young, "should be thrown into the +uterus, and repeated ten or twelve times; as on this the success depends." +(_MS. Lectures._) + +[133] Essay on Inversion of the Uterus. Dublin Journal for September and +November, 1837, quoted by Dr. Churchill on Diseases of Females, p. 317. + +[134] Midwifery Hospital Reports. Med. Gazette, May 31, 1834; also Aug. +26, 1837. + +[135] "I have reason to believe that a placenta which is entire and +uninjured, which is enclosed in the uterus, adherent to it, and shut out +from access of air, _never becomes putrid_." (Matthias Saxtorph, _Gesamm. +Schriften_.) + +[136] [An interesting memoir on retained placenta, by Dr. Edward Warren, +of Boston, will be found in the _American Journal of Med. Sc._ May, 1840, +p. 71.--ED.] + +[137] Dr. Churchill observes, "I have found, in several cases of prolapse, +that the placenta was situated low down on the side of the uterus, and in +some few others that the funis was inserted into the lower edge of the +placenta." (_Edin. Med. and Surg. Journal_, Oct., 1838.) + +[138] [Dr. Churchill in his _Researches on Operative Midwifery_, +subsequently published, has collected the results of 92,017 deliveries, in +which there was prolapse of the cord, in 333 cases, or 1 in every +276-2/3.--ED.] + +[139] [A figure of this instrument is given in Dewees' Midwifery, Pl. +XVIII. and the method of using it fully described.--ED.] + +[140] In the edition which has been translated into English, A. D. 1612, +it is the _twelfth_ chapter. + +[141] We subjoin the passages to which we have referred in the three above +mentioned cases:-- + +Case 115. "I cannot implicitly accede to the opinion of roost writers in +midwifery, which is, that the placenta always adheres to the fundus uteri; +for in this, as well as many former instances, I have good reason to +believe that it sometimes adheres to or near the os internum, and that the +opening of it occasions a separation, and consequently a flooding." + +Case 116. "The first thing I met with was the placenta, which I found +closely adhering round the os internum of the uterus, which, among other +things, is a proof that the placenta is not always fixed to the bottom of +the uterus, according to the opinion of some writers in midwifery. Its +adhering to the os internum was, in my opinion, the occasion of the +flooding; for as the os internum was gradually dilated, the placenta at +the same time was separated, from whence proceeded the effusion of blood." + +Case 224. "It is generally believed that the ovum, after its impregnation +and separation from the ovarium, and its passing through the tuba +Fallopiana, always adheres, and is fixed, after some time, to the fundus +uteri; in this case the placenta adhered, and was fixed close to and round +about the cervix uteri, as I have found it in many other cases, so that +upon a dilatation of the os uteri a separation has always followed, and +hence a flooding naturally ensues." + +[142] The second edition of Roederer's admirable _Elementa Artis +Obstetriciæ_, which was published by his distinguished successor, +Wrisberg, in 1766, three years after his death, is that which is chiefly +known, although it never had an extensive circulation in this country. The +means of communication with the Continent at that time were very different +to what they are at present; and although none can regret more than +ourselves that Roederer's work should have passed unnoticed in Dr. Rigby's +_Essay on Uterine Hæmorrhage_, still we feel assured that the liberal +portion of the medical world, whether in this or other countries, will not +attribute this omission to a disingenuous suppression of his name, but +rather to the more probable circumstances that, residing in a provincial +town, and actively engaged in the arduous duties of an extensive country +practice, Dr. Rigby had not enjoyed an opportunity of consulting the work; +at any rate, we have good reasons to know that he never possessed it. + +[143] Not 1776, as stated by Dr. R. Lee. + +[144] Dr. Merriman has also recorded three cases of this kind, one of +which occurred to himself; in this case "the placenta was expelled many +hours before the child was born;" the mother died from puerperal fever. + +[145] [A very interesting account of puerperal peritonitis, as it +prevailed in the Pennsylvania Hospital in 1833, is given by Professor H. +L. Hodge, in the _American Journal Med. Sc._, for August, 1833, p. 325, et +seq.--ED.] + +[146] This condition of parts bore the closest analogy to the state of the +cellular membrane, so constantly observed in fatal cases of phlegmonoid +erysipelas, or diffuse cellular inflammation. + +[147] [The student may consult, with advantage, Dr. Dewees's chapter on +Phlegmasia Dolens, in his "Treatise on the Diseases of Females," also the +observations of Dr. Mann, in the "Massachusetts Medical Communications," +vol. ii., and the interesting paper, by Professor Walter Channing, in the +same work, vol. v. p. 46.--EDITOR.] + + + + +MEDICAL AND SURGICAL BOOKS. + +PUBLISHED BY LEA & BLANCHARD, PHILADELPHIA. + + +THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, EDITED BY ISAAC HAYS, M. D. +SURGEON TO WILLS HOSPITAL, &c. &c. + +TERMS. + +Each number contains 260 pages, or upwards, and is frequently illustrated +by coloured engravings. It is published on the first of November, +February, May and August. 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Published in one of the most literary cities in + our country, and supported by a number of her most gifted and best + educated physicians, its reputation is deservedly high as well abroad + as at home."--_Transylvania Journal._ + + +MANUAL OF MATERIA MEDICA AND PHARMACY, By H. M. EDWARDS, M. D. and P. +VAVASSEUR, M. D. + + +CHEMICAL MANIPULATION. Instruction to Students on the Methods of +performing Experiments of Demonstration or Research, with accuracy and +success. By MICHAEL FARRIDAY, F. R. S. First American, from the second +London edition, with additions by J. K. MITCHELL, M. D. + + +A FLORA OF NORTH AMERICA, with 108 coloured Plates. By W. P. C. BARTON, M. +D. In 3 vols. 4to. + + +A MEDICAL ACCOUNT OF THE MINERAL SPRINGS OF VIRGINIA. By Professor Gibson. +(In preparation.) + + +A MANUAL OF MEDICAL JURISPRUDENCE. By Professor R. E. Griffith. In one +volume. (Now preparing.) + +THE PRINCIPLES AND PRACTICE OF MEDICINE. By professor Dunglison. In two +volumes, octavo. (In preparation.) + + +A NEW DICTIONARY, OF MEDICAL SCIENCE AND LITERATURE. + +A NEW EDITION, Completely Revised, with Numerous Additions and +Improvements, OF DUNGLISON'S DICTIONARY OF MEDICAL SCIENCE AND LITERATURE: + +CONTAINING + +A concise account of the various Subjects and Terms, with a vocabulary of +Synonymes in different languages, and formulæ for various officinal and +empirical preparations, &c. + +IN ONE ROYAL 8vo. VOLUME. + + "The present undertaking was suggested by the frequent complaints, + made by the author's pupils, that they were unable to meet with + information on numerous topics of professional inquiry,--especially of + recent introduction,--in the medical dictionaries accessible to them. + + It may, indeed, be correctly affirmed, that we have no dictionary of + medical subjects and terms which can be looked upon as adapted to the + state of the science. In proof of this the author need but to remark, + that he has found occasion to add several thousand medical terms, + which are not to be met with in the only medical lexicon at this time + in circulation in the country. + + The present edition will be found to contain many hundred terms more + than the first, and to have experienced numerous additions and + modifications. + + The author's object has not been to make the work a mere lexicon or + dictionary of terms, but to afford, under each, a condensed view of + its various medical relations, and thus to render the work an epitome + of the existing condition of medical science." + + "To execute such a work requires great erudition, unwearied industry, + and extensive research, and we know no one who could bring to the task + higher qualifications of this description than Professor + Dunglison."--_American Medical Journal._ + + "This is an excellent compilation, and one that cannot fail to be very + much referred to. It is the best medical lexicon in the English + language that has yet appeared. We do not know any volume which + contains so much information in a small compass. The Bibliographical + notices, though so short, are very important and useful; and + altogether we can recommend to every medical man to have this work by + him, as the cheapest and best dictionary of reference he can + have."--_London Medical and Surgical Journal._ + + "So far as we have been able to examine this Dictionary, it is + exceedingly thorough and correct, not only in matters purely medical, + but in whatever can fairly be arranged in the various branches of + science, collateral or contributary to Medicine and + Surgery."--_Medical Magazine._ + + "So well known are the merits of this valuable work, that, in noticing + a second edition of it, it will suffice to extract the remark of the + author in the preface, 'that it will be found to contain many hundred + terms more than the first, and to have experienced numerous additions + and modifications.' It has been got up by the publishers in very + handsome style, and must command, as it deserves, an extended + circulation."--_Medical Examiner._ + + "It is wholly unnecessary, we apprehend, to enter into a long or + formal statement of the fact, that Dr. Dunglison's Dictionary, from + the first day of its appearance, has been regarded with peculiar + favour. And we have now a revised edition, constructed under the + immediate eye of the author, who is most favourably circumstanced for + adding to the previous edition whatever could give it additional + claims on the score of accuracy. Here are eight hundred and twenty-one + pages, large octavo, in double colums, distinct type, of which no one + ought to complain. Finally, although most of our readers may be owners + of the first edition, we cordially and conscientiously recommend to + all future purchasers to procure this in preference to any medical + lexicon extant. Its true and sterling value as a key to medical + science, and its moderate price, are so many common-sense + recommendations which should not be forgotten."--_Boston Medical and + Surgical Journal._ + + +A NEW AND VALUABLE WORK FOR PHYSICIANS, APOTHECARIES, AND STUDENTS. + + +NEW REMEDIES, _The Method of Preparing & Administering them_; THEIR +EFFECTS UPON THE HEALTHY AND DISEASED ECONOMY, &c. &c. + +BY ROBLEY DUNGLISON, M. D. + +_Professor of the Institutes of Medicine and Materia Medica in Jefferson +Medical College of Philadelphia; Attending Physician to the Philadelphia +Hospital, &c._ + +IN ONE VOLUME, OCTAVO. + + "The value of this book is hardly to be estimated; to be without it, + would be very much like obstinacy, and amount to the same thing as + saying, like the Austrians in regard to their government, nothing can + be improved, for we already live in a state of perfection. Dr. + Dunglison, the author, has done an essential service to all classes of + practitioners. It is creditable to the industry and wise + discrimination of the author, and quite necessary to the libraries of + those who feel the necessity of keeping pace with the improvements and + discoveries in the broad but imperfectly exploded domain of + medicine."--_Boston Medical and Surgical Journal._ + + +_A Third Edition, Improved and Modified, of_ DUNGLISON'S HUMAN PHYSIOLOGY: +_Illustrated With Numerous Engravings_. + +IN TWO VOLUMES, OCTAVO. + + "We are happy to believe that the rapid sale of the last edition of + this valuable work may be regarded as an indication of the extending + taste for sound physiological knowledge in the American schools: and + what we then said of its merits, will show that we regarded it as + deserving the reception it has experienced. Dr. Dunglison has, we are + glad to perceive, anticipated the recommendation which we gave in + regard to the addition of references, and has thereby not only added + very considerably to the value of his work, but has shown an extent of + reading which, we confess, we were not prepared by his former edition + to expect. He has also availed himself of the additional materials + supplied by the works that have been published in the interval, + especially those of Müller and Burdach. So that as a collection of + details on human physiology alone, we do not think that it is + surpassed by any work in our language: and we can recommend it to + students in this country (England) as containing much with which they + will not be likely to meet elsewhere."--_British and Foreign Medical + Review._ + + "This work exhibits another admirable specimen of American industry + and talent, and contains an account of every discovery in Europe up to + the period of a few months prior to its publication. Many of the + author's views are original and important."--_Dublin Journal of + Medical Sciences._ + + +GENERAL THERAPEUTICS; OR, PRINCIPLES OF MEDICAL PRACTICE. + +_With Tables of the Chief Remedial Agents and their Preparations, and of +the Different Poisons and their Antidotes._ + +BY ROBERT DUNGLISON, M. D., &c., &c. + +One Volume, large 8vo. + + "There being at, present before the public several American works on + Therapeutics, written by physicians and teachers of distinction, it + might be deemed unjust in us, and would certainly be invidious, to + pronounce any of them superior to the others. We shall not, therefore, + do so. If there be, however, in the English language, any work of the + kind more valuable than that we have been examining, its title is + unknown to us. + + "We hope to be able to give such an account of the work as will + strengthen the desire and determination of our readers to seek for a + farther acquaintance with it, by a candid perusal of the volume + itself. And, in so doing, we offer them an assurance that they will be + amply rewarded for their time and labour."--_Transylvania Journal_, + Vol. IX, No. 3. + + +THE MEDICAL STUDENT; or, Aids to the Study of Medicine. Including a +Glossary of the Terms of the Science, and of the Mode of Prescribing; +Bibliographical Notices of Medical Works; the Regulations of the Different +Medical Colleges of the Union, &c. By Robley Dunglison, M. D., &c., &c. In +one volume, 8vo. + + +ELEMENTS OF HYGIENE; on the Influence of Atmosphere and Locality; Change +of Air and Climate, Seasons, Food, Clothing, Bathing, Sleep, Corporeal and +Intellectual Pursuits, &c., on Human Health, Constituting Elements of +Hygiene. By Robley Dunglison, M. D. &c., &c. In 1 vol. 8vo. + + +MEDICAL ESSAYS. + +THE CYCLOPEDIA OF PRACTICAL MEDICINE AND SURGERY, + +_Or Essays on ASTHMA, APHTHÆ, ASPHYXIA, APOPLEXY, ARSENIC, ATROPA, AIR, +ABORTION, ANGINA-PECTORIS, and other Subjects Embraced in the Articles +from A to Azote, prepared for the Cyclopedia of Practical Medicine by_ + + Dr. Chapman, + Dr. Jackson, + Dr. Horner, + Dr. Hodge, + Dr. Wood, + Dr. Dewees, + Dr. Hays, + Dr. Dunglison, + Dr. Mitchell, + Dr. Bache, + Dr. Coates, + Dr. Condie, + Dr. Emerson, + Dr. Geddings, + Dr. Griffith, + Dr. Harris, + Dr. Warren, + Dr. Patterson, + + Each article is complete within itself, and embraces the practical + experience of its author, and as they are only to be had in this + collection will be found of great value to the profession. + + [Symbol: Asterism] The two volumes are now offered at a price so low, + as to place them within the reach of every practitioner and student. + + +GIBSON'S SURGERY. + +A NEW EDITION OF GIBSON'S SURGERY. + +THE INSTITUTES AND PRACTICE OF SURGERY; being the Outlines of a Course of +Lectures. By William Gibson, M. D., Professor of Surgery in the University +of Pennsylvania, &c. &c. Fifth edition, greatly enlarged. In 2 vols. 8vo. +With thirty plates, several of which are coloured. + + "The author has endeavoured to make this edition as complete as + possible, by adapting it to the present condition of surgery, and to + supply the deficiencies of former editions by adding chapters and + sections on subjects not hitherto treated of. And, moreover, the + arrangement of the work has been altered by transposing parts of the + second volume to the first, and by changing entirely the order of the + subject in the second volume. This has been done for the purpose of + making the surgical course in the university correspond with the + anatomical lectures, so that the account of surgical diseases may + follow immediately the anatomy of the parts." + + +DEWEES'S WORKS. + +A PRACTICE OF PHYSIC, comprising most of the diseases not treated of in +Diseases of Females and Diseases of Children. By W. P. Dewees, M. D., +formerly adjunct professor in the University of Pennsylvania. In one +volume, octavo. + + +A COMPENDIOUS SYSTEM OF MIDWIFERY. + +By DR. DEWEES. + +Chiefly designed to facilitate the Inquiries of those who may be pursuing +this branch of Study. Illustrated by occasional cases and with many +plates. The ninth edition, with additions and improvements. In one vol. +8vo. + + +DEWEES ON THE DISEASES OF FEMALES. + +The seventh edition. Revised and Corrected. With additions, and Numerous +plates. In one vol. 8vo. + + +DEWEES ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. + +With Corrections and Improvements. The seventh ed. In one volume, 8vo. + + The objects of this work are, 1st, to teach those who have the charge + of children, either as parent or guardian, the most approved methods + of securing and improving their physical powers. This is attempted by + pointing out the duties which the parent or the guardian owes for this + purpose, to this interesting but helpless class of beings, and the + manner by which their duties shall be fulfilled. And 2d, to render + available a long experience to these objects of our affection when + they become diseased. In attempting this, the author has avoided as + much as possible, "technicality;" and has given, if he does not + flatter himself too much, to each disease of which he treats, its + appropriate and designating characters, with a fidelity that will + prevent any two being confounded together, with the best mode of + treating them, that either his own experience or that of others has + suggested. + + +HORNER'S SPECIAL ANATOMY. + +A Treatise on Special and General Anatomy. By W. E. Horner, M. D., +Professor of Anatomy in the University of Pennsylvania, &c. &c. Fifth +edition, Revised, and much improved. In two volumes, 8vo. + + +ELLIS' MEDICAL FORMULARY. + +The Medical Formulary, being a collection of prescriptions derived from +the writings and practice of many of the most eminent Physicians in +America and Europe. To which is added an appendix, containing the usual +Dietetic preparations and Antidotes for Poisons, the whole accompanied +with a few brief Pharmacuetic and Medical observations. By Benjamin Ellis, +M. D., Fifth edition, with additions. In one vol. + + Broussais on Inflammation, 2 vols. 8vo. + Broussais' Pathology, 1 vol. 8vo. + Colles' Surgical Anatomy, 1 vol. 8vo. + Costers' Physiological Practice, 1 vol. 8vo. + Greys' Chemistry applied to the Arts, 2 vols. with numerous plates. + + +ELEMENTS OF PHYSICS, OR NATURAL PHILOSOPHY, GENERAL AND MEDICAL, explained +independently of TECHNICAL MATHEMATICS, and containing New Disquisitions +and Practical Suggestions. By NEIL ARNOTT, M. D. In two volumes, octavo. + + "Dr. Arnott's work has done for Physics as much as Locke's Essays did + for the science of mind."--_London University Magazine._ + + "We may venture to predict that it will not be surpassed."--_Times._ + + "Dr. A. has not done less for Physics than Blackstone did for the + Law."--_Morning Herald._ + + "Dr. A. has made Natural Philosophy as attractive as Buffon made + Natural History."--_French Critic._ + + "A work of the highest class among the productions of + mind."--_Courier._ + + +ROGET'S PHYSIOLOGY AND PHRENOLOGY. + +OUTLINES OF PHYSIOLOGY; WITH AN APPENDIX ON PHRENOLOGY; + +BY P. M. ROGET., M. D. + +Professor of Physiology in the Royal Institute of Great Britain, &c. &c. + +FIRST AMERICAN EDITION, Revised, with numerous notes, In one volume, 8vo. + + From the American Preface.--"Of the Author's qualifications as a + physiological writer it is scarcely requisite to speak. The fact of + his having been selected to compose the Bridgewater Treatise on Animal + and Vegetable Physiology, is sufficient evidence of the reputation + which he then enjoyed; and the mode in which he executed the task + amply evinces that his reputation rested on a solid basis. + + "The present volume contains a concise, well-written epitome of the + present state of Physiology--human and comparative--not, as a matter + to be expected, the copious details and developments to be met with in + the larger treatises on the subject; but enough to serve as an + accompaniment and guide to the physiological student. + + "The attention of the American Editor has been directed to the + revision and correction of the text; to the supplying, in the form of + notes, of omissions; to the rectification of some of the points that + appeared to him erroneous or doubtful, and to the furnishing of + references to works in which the physiological inquirer might meet + with more ample information. + + "In Phrenology, the Author is a well-known unbeliever, and his + published objections to the doctrine have been regarded as too cogent + to be permitted to pass unheeded. It will be seen on farther + examination in the interval of many years, which has elapsed since the + publication of the sixth edition of the Encyclopædia, has not induced + him to modify his sentiments on this head. On the contrary, he appears + to be as satisfied at this time, of the fallacy of the positions of + the Phrenologist, as he was at any former period." + + [Symbol: Pointing hand] This work will be introduced into many of the + Medical Colleges of the union as a Text Book, it being a cheap volume, + and well fitted as an introduction to the larger works on Physiology. + + +COATES POPULAR MEDICINE: + +POPULAR MEDICINE; OR, FAMILY ADVISER. + +Consisting of outlines of Anatomy, Physiology, and Hygiene, with such +Hints on the Practice of Physic, Surgery, and the Diseases of Women and +Children, as may prove useful in families when regular Physicians cannot +be procured: Being a Companion and Guide for intelligent Principals of +Manufactories, Plantations, and Boarding Schools: Heads of Families, +Masters of Vessels, Missionaries, or Travellers, and a useful Sketch for +Young Men about commencing the Study of Medicine. + +BY REYNELL COATES, M. D. + +Fellow of the College of Physicians of Philadelphia--Honorary Member of +the Philadelphia Medical Society--Correspondent of the Lyceum of Natural +History of New York--Member of the Academy of Natural Sciences of +Philadelphia--Formerly Resident Surgeon of the Pennsylvania Hospital, &c. + +Assisted by several Medical friends. In One Volume. + + "It is with great satisfaction that we announce this truly valuable + compilation, as the most complete and interesting treatise on Popular + Medicine ever presented to the public. Simple and unambitious in its + language, free from the technicalities, and embracing the most + important facts on Anatomy, Physiology and Hygiene, or the art of + preserving health; and the treatment of those affections which require + immediate attention, or are of an acute character, this should be in + the hands of every one, more particularly of those who, by their + situations are prevented from resorting to the advice of a physician, + nor would the careful perusal of its pages fail to profit the + inhabitants of our cities, by giving them a more accurate knowledge of + the structure of the human frame, and the laws that govern its various + functions; whose perfect integrity is absolutely essential to health, + and even to existence; the various systems of medical charlatanry, + daily imagined to take advantage of the credulity and ignorance of + mankind, would be rendered far less prejudicial to the community than + they now are. We would particularly direct attention to the Chapter on + Hygiene, a science in itself of the utmost importance, and ably + treated in the small space allowed to it in this volume."--_New York + American._ + + +DR. CLARK ON CONSUMPTION. + +A Treatise on Pulmonary Consumption, comprehending an inquiry into the +Nature, Causes, Prevention, and Treatment of Tuberculous and Scrofulous +Diseases in General. By James Clark, M. D., F. R. S. + + "As a text-book and guide to the inexperienced practitioner we know + none equal to it in general soundness and practical utility--to the + general as well as to the professional reader, the work will prove of + the deepest interest, and its perusal of unequivocal + advantage."--_British and Foreign Medical Review._ + + "The work of Dr. Clark may be regarded as the most complete and + instructive Treatise on Consumption in the English + Language."--_Edinburgh Medical and Surgical Journal._ + + +CHITTY'S JURISPRUDENCE. + +A Practical Treatise on Medical Jurisprudence, with so much of Anatomy, +Physiology, Pathology, and the Practice of Medicine and Surgery, as are +essential to be known by Members of the Bar and Private Gentlemen; and all +the laws relating to Medical Practitioners; with explanatory plates. By J. +Chitty, Esq. Second American edition: with Notes and Additions, adapted to +American works and Judicial Decisions. 8vo. + + +A TREATISE ON THE PRACTICE OF MEDICINE, or a Systematic Digest of the +Principles of General and Special Pathology and Theraputics. By E. +Geddings, (now preparing.) + + +SMITH ON FEVER. + +A Treatise on Fever. By Southwood Smith, M. D., Physician to the London +Fever Hospital. Fourth American edition. In 1 volume 8vo. + + +FITCH'S DENTAL SURGERY. + +A Treatise on Dental Surgery. Second edition, revised, corrected, and +improved, with new plates. By S. S. Fitch, M. D. 1 vol. 8vo. + + +ABERCROMBIE ON THE BRAIN. + +Pathological and Practical Researches on Diseases of the Brain and Spinal +Cord. Second American, from the third Edinburgh edition, enlarged. By John +Abercrombie, M. D. In 1 volume 8vo. + + +ABERCROMBIE ON STOMACH. + +Pathological and Practical Researches on Diseases of the Stomach, the +Intestinal Canal, the Liver, and other Viscera of the Abdomen. By John +Abercrombie M. D., third American from the second London edition enlarged. +In 1 vol. 8vo. + + +EWELL'S MEDICAL COMPANION. + +The Medical Companion or Family Physician: treating of the Diseases of the +United States, with their symptoms, causes, cure, and means of prevention. + + +BERTIEN ON THE HEART. + +A Treatise on Diseases of the Heart and Great Vessels. By J. R. Bertien. +Edited by G. Bouillaud. Translated from the French. 8vo. + + +BOISSEAU ON FEVER. + +Physiological Pyretology; or a Treatise on Fevers, according to the +Principles of the New Medical Doctrine. By F. G. Boisseau, Doctor in +Medicine of the Faculty of Paris, &c. &c. From the fourth French edition. +Translated by J. R. Knox, M. D. 1 vol. 8vo. + + +HUTIN'S MANUAL. + +Manual of the Physiology of Man; or a concise Description of the Phenomena +of his Organization. By P. Hutin. Translated from the French, with notes, +by J. Togno. In 12mo. + + +BELL ON THE TEETH. + +The Anatomy, Physiology, and Diseases of the Teeth. By Thomas Bell, F. R. +S., F. L. S. &c., third American edition. In 1 vol. 8vo. With numerous +plates. + + +WILLIAMS ON THE LUNGS. + +A Rational Exposition of the Physical Signs of Diseases of the Lungs and +Pleura; Illustrating their Pathology and facilitating their Diagnosis. By +Charles J. Williams, M. D. In 8vo. with plates. + + +THE BRIDGE WATER TREATISES, COMPLETE IN SEVEN VOLUMES, OCTAVO. Embracing. + +I. The Adaptation of External Nature to the Moral and Intellectual +Constitution of Man. By the Rev. Thomas Chalmers. + +II. The Adaptation of External Nature to the Physical Condition of Man. By +John Kidd, M. D., F. R. S. + +III. Astronomy and General Physics, Considered with References to Natural +Theology. By the Rev. Wm. Whewell. + +IV. The Hand: Its Mechanism and Vital Endowments as Evincing Design. By +Sir Charles Bell, K. H., F. R. S. With numerous wood cuts. + +V. Chemistry, Meteorology, and the Function of Digestion. By Wm. Prout, M. +D., F. R. S. + +VI. The History, Habits and Instincts of Animals. By the Rev. Wm. Kirby, +M. A., F. R. S. Illustrated by numerous Engravings on Copper. + +VII. Anatomy and Vegetable Physiology Considered with Reference to Natural +Theology. By Peter Mark Roget, M. D. Illustrated with nearly Five Hundred +Wood Cuts. + +VIII. Geology and Mineralogy, Considered with Reference to Natural +Theology. By the Rev. Wm. Buckland, D. D. with numerous engravings on +copper, and a large coloured map. + +[Symbol: Asterism] The work of Buckland, Kirby and Rojet may be had +separate. + +*** END OF THE PROJECT GUTENBERG EBOOK 40654 *** |