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diff --git a/40654.txt b/40654.txt deleted file mode 100644 index 30bf7ac..0000000 --- a/40654.txt +++ /dev/null @@ -1,23417 +0,0 @@ -The Project Gutenberg eBook, A System of Midwifery, by Edward Rigby - - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - - - - -Title: A System of Midwifery - - -Author: Edward Rigby - - - -Release Date: September 3, 2012 [eBook #40654] - -Language: English - -Character set encoding: ISO-646-US (US-ASCII) - - -***START OF THE PROJECT GUTENBERG EBOOK A SYSTEM OF MIDWIFERY*** - - -E-text prepared by Bryan Ness and the Online Distributed Proofreading Team -(http://www.pgdp.net) from page images generously made available by -Internet Archive/American Libraries (http://archive.org/details/americana) - - - -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 formulae 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.-- - Nymphae.--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. CAESAREAN OPERATION. - - Indications,--Different modes of performing the operation.-- - History of the Caesarean 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 - nymphae.--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.-- - Haemorrhage.--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.--Anaemic convulsions.-- - Symptoms.--Treatment.--Hysterical convulsions.--Symptoms, 376 - - CHAPTER XII. PLACENTAL PRESENTATION, OR PLACENTA PRAEVIA. - - History.--Dr. Rigby's division of haemorrhages 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 _Geburtshuelfe_ 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 vertebrae; 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. -Med._) These laminae 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 vertebrae of the spinal column, -and from their resemblance to those bones they have been called false -vertebrae. These cartilages, after a time, gradually disappear; bony matter -is deposited in their place; so that by the period of puberty the five -sacral vertebrae 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 alae 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 deg. and -100 deg., whereas in the male it is not more than between 70 deg. and 80 -deg. (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 deg. and 60 deg.; 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 versa_; -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.--Nymphae.--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 fimbriae. - -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, haematoma, 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 rugae. 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 fimbriae 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 fimbriae -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 tincae_ 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 rugae diverging obliquely -in an arborescent form, and hence called the _arbor vitae_. 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 tincae 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 laminae; 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 rugae, 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 tincae 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 rugae, 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 vertebrae, 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 primiparae, or women pregnant for the first time, the margin of the os -uteri thus closed is not only circular but perfectly smooth; whereas in -multiparae, 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 primiparae; 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 primiparae -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 primiparae: 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 multiparae, 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 primiparae 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 multiparae 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 tincae,) 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_, _nymphae_, 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 vaginae,) 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 rugae -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 vitae 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 nymphae, 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 _carunculae 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 vaginae, 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. - -_Nymphae._ The _nymphae_ 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 nymphae 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 nymphae: it is surrounded by several lacunae -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 _fraenulum 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 laminae 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 rugae, 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 Goettingen, 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 versa_. 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_. Sec. 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 fibrillae, 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 _plicae primitivae_ -of Pander, the _laminae 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 vertebrae. - -[Illustration: _a_ Transparent area. _b_ Laminae dorsales. _c_ Cephalic -end. _d_ Rudiments of dorsal vertebrae. _e_ Serous layer. _f_ Lateral -portion of the primitive trace. _g_ Mucous layer. _h_ Vascular layer. _k_ -Laminae 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 portae,) 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 urinae 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 Naturae 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. _e_ Bladder. _f_ -Vesicula umbilicalis. _g_ Communicating canal between the vesicula -umbilicalis and intestine. _h_ Vena umbilicalis. _i i_ Arteriae -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 scapulae 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 -vertebrae, 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 nymphae 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 faeces, and greedily takes the nipple. (Naegele'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 fibrillae: 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 portae, 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 versa_; 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 versa_; 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 haemorrhage; 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_, Sec. 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._ Sec. 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_, -Sec. 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 versa_: 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 tincae, 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 -Academie Royale de Medecine 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 Naegele -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 haemorrhage, where the vessels are -usually distended, or where (Naegele, _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 -Naegele, 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 deg. and 120 deg., 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. (Naegele, _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 -Naegele, 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 Naegele'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 Charite 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-faelle_.) 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 primae viae. - -_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_, Sec. 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 sennae, 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. Creta, 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 aphthae; 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] - -Aphthae 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 ou le -chirurgien doive faire plus grande reflexion, et apporter plus de -precaution aux choses qui concernent son art, c'est en celle ou 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 Caesarean 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 Caesarian -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 versa_. 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 primiparae. 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 primiparae, where the head is -advancing slowly, and where it is tightly encircled by the distended -vagina. But in multiparae, 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 -Obstetricae_, 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 haemorrhage 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 haemorrhage 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 haemorrhage: 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 haemorrhage 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, haemorrhage 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 haemorrhage 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 haemorrhage 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 haemorrhage -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 haemorrhage 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 haemorrhage; 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, haemorrhage, 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 haemorrhage 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 haemorrhage. 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, aet. 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 faeculent matter be -passing along the intestine, its course will be obstructed at this point, -and the rectum quickly become distended with an accumulation of faeces -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 faeces 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 faeces 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, (_Anfangsgruende 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 faeces 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 faeces 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 faeces 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._ Sec. -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 faeces; 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. (Naegele, _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 Naegele 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 faeces; 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 Napoleon 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 haemorrhage 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 primiparae 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 haemorrhage 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_, Sec. 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 primiparae 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 -haemorrhage, 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 haemorrhage 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 haemorrhage were necessarily -followed by expulsion. (_Mem. 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 tincae. 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 haemorrhage without pain, which is -the contrary when it takes place near the fundus." (Dewees, _Compend. -System of Midwifery_, Sec. 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. sennae, or a Seidlitz powder; and -thus all sources of irritation in the primae viae 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_, -Sec. 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: anaemia, -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 haemorrhage 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_,) Sec. 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 haemorrhage, 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 haemorrhage going -on, the plug must be returned. It is however by no means a remedy to be -used in every case of haemorrhage, 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 -haemorrhage, 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_, Sec. -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._ Sec. 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 haemorrhage 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 haemorrhage 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 anaemia we -must refer our readers to the chapter on HAEMORRHAGE. - - - - -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 primiparae) 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 -tincae 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 -primiparae, 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_, Sec. 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 faeces, 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 primiparae) 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 Geburtshuelfliche 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, _caeteris 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 versa_, 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 primae viae, -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 primiparae 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 primiparae, 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 primiparae, 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 primiparae, 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 faecal 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 haemorrhoidal 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 placentae 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 placentae the umbilical -arteries of two placentae 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 haemorrhage. - -Moreover, the rectum being distended with faeces, 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 faeces, 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 -faecal 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 versa; 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 primiparae, -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 primiparae, 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 Pare, 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 percee 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 misere_. 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 Naegele, 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 primiparae, 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 primiparae, 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 primiparae, for -the soft parts never having been subjected to such a degree of dilatation -before, do not yield so readily as in multiparae. The anterior margin of -the perineum, called _fraenulum_, 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 fraenulum 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 fraenulum 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 fraenulum; 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 fraenulum 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 fraenulum 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 -fraenulum 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 faeces 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 fraenulum. 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 haemorrhage.[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 placentae, 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 haemorrhage 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 haemorrhage; but if it be soft and relaxed, she -cannot be considered safe even if their be no haemorrhage; 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 haemorrhage 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 praecordia, darkness before -the eyes, &c. we may be sure that haemorrhage is going on. We refer to the -chapter upon uterine haemorrhage 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 haemorrhage, -but if it does take place, will probably be much more dangerous. We cannot -be too cautious how we extract the placentae 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 placentae -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 placentae 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 haemorrhage, 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 haemorrhage 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 haemorrhage 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, aphthae, 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 axillae, 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. AEth. 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 -haemorrhage 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. Gentianae 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. Creta 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 haemorrhage -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 primiparae. 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 (_caeteris 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 primiparae, -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 multiparae, 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." (Naegele, -_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 primiparae 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 Naegele 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." (_Traite des Accouchemens_, 1770, Sec. -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 _Natuerliche Geburtshuelfe_, 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 Naegele; 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 Naegele, jun., in his new edition of the admirable essay -upon the mechanism of labour, published by his father, in Meckel's -_Archiv. fuer 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. Naegele, -_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." (Naegele, _on the Mechanism of -Parturition_, transl. Sec. 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." (Naegele, _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 axillae, 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 Caesarean -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 fenestrae, 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 fenestrae 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 fenestrae, 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 fenestrae 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: Naegele'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 Brueninghausen of Wuerzburg, first introduced by -ourselves into this country, and commonly known among the -instrument-makers under the name of Professor Naegele'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, _caeteris 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 haemorrhage, 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. (Naegele, _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 versa_, 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 -Caesarean 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 -Boekelman, 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 Boekelman -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. (Naegele, _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, (_Traite des -Accouchemens_, 1770,) Boer, (_Naturliche Geburtshuelfe_, 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. (Naegele, -_Lehrbuch der Geburtshuelfe_, Sec.Sec. 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 praevia and other causes, the haemorrhage -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 praevia, 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 Naegele) 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 Geburtshuelfe_, 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 haemorrhage_. 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, detacher les membranes des parois de ce viscere, et les percer a -l'endroit ou 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 -Naegele. - -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_, Sec. 629.) "The vagina is never so soft, -so dilatable, and capable of admitting the hand as during the presence of -an active haemorrhage, and this is equally the case in primiparae 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 haemorrhage -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_, -Sec. 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 fuer 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 foetus 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 Medicina_, 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 Pare, (Ambr. Paraeus, _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 Pare's mode of turning in haemorrhages 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. - -CAESAREAN OPERATION. - - _Indications.--Different modes of performing the operation.--History - of the Caesarean operation._ - - -The next operation in Midwifery for delivering the full-grown foetus alive -is that of _Hysterotomy_, commonly called the Caesarean 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 Caesarean -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 Pare, 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 Caesarean 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 Caesarean -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, Sec. 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 -Caesarean 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 Caesarean 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, _Anfangsgruende 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 fuer 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 Caesarean 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 haemorrhage: 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 Caesarean 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 Aesculapius; 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 Caesar 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 Naegele, viz. that one of the Julian -family at Rome had been delivered _ex caeso matris utero_, and had been -named Caesar 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 Caesarean 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 Caesarean -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 haemorrhage 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, Sec. 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 force_ of the -French practitioners, where, on account of the sudden accession of -dangerous symptoms, such as haemorrhage, 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 Geburtshuelfe_, 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 haemorrhages, -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." -(Naegele, _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 -Brueninghausen, Kluge, and others, has, as far as we know, never been -attempted in this country, and resembles much too closely the -_accouchement force_ 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 kuenstliche -Fruehgeburt_.) - -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: Naegele's perforator.] - -A useful modification has been invented by Professor Naegele, 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." (Naegele, _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 -Goettingen, 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 -Maternite, 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 Hotel 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 spiculae 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 spiculae 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, haemorrhage, -&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 Naegele, 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 Naegele, once in 180: at the Dublin Lying-in Hospital, to Dr. -Collins, once in 416: at the Maternite, 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 Naegele 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 primiparae 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 tincae, 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 Naegele, 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." (Naegele, _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 primiparae: 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 multiparae, -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 -Caesarean 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 Caesarean, whilst the celerity with which it is done, -the absence of haemorrhage, 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 -fuer Geburtshuelfe_, 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 fuer 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 Naegele, 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 primiparae; 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 Naegele, 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. Sec. 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 fuer Geburtskunde_, vol. xv. 1837.) - -_Unequally contracted pelvis._ The unequally contracted pelvis (_pelvis -inaequaliter 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 vertebrae 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." (Naegele's _Lehrbuch_, 2te -Ausgabe, p. 247.) - -[Illustration: _From_ Naegele.] - -[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 Caesarean 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." -(Naegele's _Lehrbuch_. Sec. 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 oblique ovata_, which, of late years, has been -pointed out by Professor Naegele. 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 Naegele, 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 Schraeg 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." (Naegele, _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 Naegele is inclined to look upon them as modifications of the -_pelvis oblique 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 fuer 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 oblique 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 -Naegele, 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 Caesarean 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 -Caesarean 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 nymphae.--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_, Sec. -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 primae viae which tends to disturb and -divert the proper and healthy action of the uterus. We see it also in -robust plethoric primiparae; 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 Maternite, 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 primiparae 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._ -Sec. 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 primiparae 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 primiparae 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 nymphae_ 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 -haemorrhage 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 glutaeus 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 haemorrhage 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 nymphae, 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 nymphae, 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 nymphae 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 -aromaticae_" of the Continental pharmacopeiae 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,) haematoma (fungus haematodes,) 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.--Haemorrhage.--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 haematoma; 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 haemorrhage -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 haemorrhoids, 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 primiparae 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, haemorrhage, 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 faecal 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; Sodae 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 haemorrhage. - -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 faecal 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 primiparae, 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 primae viae 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 faeces; -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 -haemorrhage 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. - -_Haemorrhage._ The danger here, chiefly depends upon the occurrence of -haemorrhage: if the placenta be still attached by its whole surface to the -uterus, no haemorrhage 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 haemorrhage 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 praecordia, 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 haemorrhage. 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 haemorrhage, -perhaps, without any blood having issued externally: this is the _internal -uterine haemorrhage_, 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 haemorrhage, 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, haemorrhage 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 haemorrhage 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 haemorrhage, 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 haemorrhage:--"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 haemorrhage, 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 haemorrhage, 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 haemorrhage, 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 haemorrhage than for stopping it in the first -instance: we are _never_ perfectly secure against haemorrhage 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 haemorrhage. 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 haemorrhage 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 -haemorrhage 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 -haemorrhage 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 haemorrhage; 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 haemorrhage 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 haemorrhage 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; -haemorrhage more or less considerable accompanies it; the pain is more -acute in this than in the complete inversion, and the haemorrhage 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 haemorrhage 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 -haemorrhage 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 haemorrhage, 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 haemorrhage; 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_, Sec. 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 haemorrhage 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_, Sec. 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 haemorrhages, 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 haemorrhage 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 haemorrhages 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 haemorrhage 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 tincae, 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. Sec. 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 tincae, 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 tincae, 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 fuer -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 haemorrhage; 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 tincae 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 Naegele, 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 -haemorrhage, 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 Medicale 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 haemorrhage. - -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, _caeteris 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 haemorrhage 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 haemorrhage 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 Naegele, 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 vorfaellt_.) - -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 fuer 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 Naegele, 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 praevia 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 Geburtshuelfliche Auscultation_, von Dr. H. F. Naegele, p. 114.) The -two cases referred to by Professor Naegele, 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 praevia; 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 Naegele, -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.--Anaemic 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 anaemia; 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 anaemic 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 muscae 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 praecordia, 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 -praecordial 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. Sec. 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 -primiparae: 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 multiparae, 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, Sec. 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 primiparae. 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._ Sec. 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._ Sec. 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. - -_Anaemic convulsions._ The next form of epiplectic puerperal convulsions is -the anaemic 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 haemorrhage, whether spontaneous or -artificial. That the same haemorrhage which produces syncope, often at the -same time produces epilepsy, is well known; and from many experiments and -observations it appears, that haemorrhages 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 haemorrhage, 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 haemorrhage 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_, Sec. 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 ammoniae -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 PRAEVIA. - - _History.--Dr. Rigby's division of haemorrhages 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 -haemorrhage 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." (Naegele, _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 haemorrhage, 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 -Haemorrhage 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 -haemorrhage 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 -haemorrhage 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 Pare, and still farther brought into notice by himself, at that -time formed a great aera 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 haemorrhage 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 Haemorrhage 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 haemorrhage 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 praevia 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 haemorrhage 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 haemorrhage 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 haemorrhages, and in all of them he found -the placenta at the mouth of the womb." (_Essay on Uterine Haemorrhage_, 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 haemorrhage. 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 haemorrhage -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 -praevia 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 praevia, -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 -Haemorrhage_, 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 haemorrhage 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 haemorrhage; 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 haemorrhage 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 haemorrhage 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 haemorrhage -under such circumstances is inevitable, and that the safest mode of -remedying this accident is the _accouchement force_. 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 praevia, 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 haemorrhage 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 Haemorrhage_, 1775,[143] in farther proof -of the placenta being implanted over the os uteri, and being the cause of -haemorrhage. - -We are chiefly indebted to Dr. Rigby for a complete exposition of this -important and interesting subject. His well-known essay on the uterine -haemorrhage 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 haemorrhages, 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 haemorrhages, 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 -haemorrhage 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 haemorrhage, 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 haemorrhage: 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 haemorrhages 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 -haemorrhage? 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 haemorrhage. 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 haemorrhage, which is usually more -copious than ordinary haemorrhage, 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 haemorrhage 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 haemorrhage is also different from that of common -haemorrhage, inasmuch as it increases during a pain, and diminishes or -ceases during the intervals, whereas, in haemorrhage under ordinary -circumstances it is the reverse. - -Where the haemorrhage 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, -haemorrhage 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 -Naegele, 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 haemorrhage 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 haemorrhage 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 haemorrhage. 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 Naegele 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 haemorrhage 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" haemorrhage 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 haemorrhage 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 haemorrhage connected with -abortion. In his forty-third case, the haemorrhage, 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 haemorrhage 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 haemorrhage 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 haemorrhage 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 haemorrhage, 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 haemorrhage, 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 haemorrhage. - -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 haemorrhage 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 haemorrhage 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 haemorrhage 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 haemorrhage 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 Naegele -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 haemorrhage, 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 haemorrhage; 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._ Sec. 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._ -Sec. 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 -haemorrhage 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 praevia, 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 Haemorrhage_, 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 haemorrhage. - -"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._ -Sec. 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 haemorrhage; 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 -haemorrhage 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, haemorrhage 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 haemorrhage. - -_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 haemorrhage 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 haemorrhage 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 haemorrhage; 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 haemorrhage, 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 medicine eclariree 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 praecordia, 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_, Sec. 1329.) -He quotes also an interesting description from Moschion of the changes -which are observed in the evacuations after delivery,--"_Primo sanguis, -secundo faeculentus 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 Schoenlein 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 versa_: 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 Creta, -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. Assafoetidae, &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 haemorrhages," 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 haemorrhage 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 anaemia. 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 anaemia, 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 faeces 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 faeces 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 faecal 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 papillae, 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 haemorrhage, and necessarily tends to aggravate the state of -anaemia 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 anaemic 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 faeculent 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 Creta 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. Creta -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 faecal accumulation, we find the exhibition of -certain purgatives, especially calomel, to be followed by such copious -faeculent 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 faecal 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 -Creta 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 vitae 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 faeces 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 vitae 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 petechiae, 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 haemorrhages 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 -petechiae, 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 vitae 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 debris 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 glutaei, -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 petechiae 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 -acme, 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 Creta 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 sequelae 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 Suillae, [Symbol: ounce]jss; Camphorae, [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 tincae 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 haemorrhage. 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 anaemia. - -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 anaemia. 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 haemorrhage, 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 -haemorrhage, 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 anaemia 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 haemorrhage, 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 haemorrhage: 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 haemorrhage, 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 anaemic 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. Creta, -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. - - _Anaemic_ 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. - - - _Caesarean_ 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. - - _Carunculae_ 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. - Anaemic, 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 praevia, 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 _Haemorrhage_. - - _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 _Caesarian Operation_. - - _Generation_, internal organs of, described, 22. - External organs of, 45. - - _Germinal_ Vesicle, 65. See _Egg_. - - _Graafian_ Vesicles, description of the, 25. - - - _Haemorrhage_, 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 _Caesarian 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. - Caesarian 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_. - - _Nymphae_, anatomical description of the, 47. - Varicose and oedematous swellings of the, 317. - - _Nipples_, excoriated, 193. - Treatment of, 194. - - - _Oedematous_ swellings of the labia and nymphae, 317. - - _Operations_ in midwifery. See _Midwifery_. - - _Operation_, Caesarian. See _Caesarian 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. - Praevia, 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 haemorrhage, 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 Praevia_. - - _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 nymphae, 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 Myologiae 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 multiparae 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 fuer Geburtshuelfe, 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. Beitraege zur Entwickelungs-gesechichte des Huenchens im Eie. -Wuerzburg, 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 haemorrhoidal vessels of the vagina, or at most, from those of the -cervix uteri. (Levret, _Art des Accouchemens_, Sec. 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, Sec. 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 agee seulement de -seize ans et demi, marie depuis un an qui etait grosse de cinq mois ou -environ, quoiqu'elle n'eut jamais eu ses menstrues, a ce qu'elle me dit -aussi bien que son marie, qui ne pouvait pas se persuader qu'elle cut pu -devenir grosse, n'ayant pas encore eu ce premier signe de fecondite; -m'alleguant, pour soutenir son opinion, qu'on ne voyait jamais de fruit -d'un arbre qui n'eut ete precede de sa fleur. Mais je lui dis qu'il etait -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 etait -arrive a sa femme, sans avoir jamais eu leur menstrues, si elles usaint du -coit dans le temps meme quelles etaient 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 mammae crescunt, replentur, dolent interdum, -indurescunt; venae earum coeruleo colore conspicuae 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] Bibliotheque Universalle, t. ix. p. 248; also in the Isis for 1819, -part iv. p. 542. - -[40] "Memoir sur l'Auscultation appliquee a l'etude de la Grossesse, ou -Recherches sur deux nouveaux Signes propres a faire reconnaitre plusieurs -Circonstances de l'Etat de Gestation; lu a l'Academie Royale de Medecine -dans la Seance Generale du 26 December, 1821. Par J. A. Lejumeau de -Kergaradec." - -[41] Dr. Evory Kennedy, Observations on Obstetric Auscultation, &c. 1833. - -[42] H. F. Naegele, Die Geburtshuelfliche Auscultation, 1838; also Dr. -Corrigan, Lancet. - -[43] Die Geburtshuelfliche 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 Hotel Dieu, another for ascites in the -city, a third for an ulcer in the neck at La Pitie, 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 Naegele 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 Obstetricae_, Sec. -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 -Geburtshuelfe_, Sec. 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 faeces 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, a prima conceptione, finem -contingit partus, _praematurus_ vocatur: _abortus_ vero quando ante dictum -tempus embryo excidit; id quod circa tertium graviditatis mensem ut -plurimum accidit. Vitalem esse praematurum foetum observatio nos docet, -embryonem autem non manere superstitem constat." (Roederer, _Elem. Artis -Obst._ cap. xxiii. Sec. 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 -haemorrhage 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 tincae, 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 tincae; 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 tincae," 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 a la -femme, et de lui expliquer a-peu pres son usage, et sa facon d'agir. Il -n'en est aucune que cette demonstration ne tranquillise, et j'en rencontre -souvent qui a leur deuxieme accouchement sollicitent l'application du -forceps qu'elles ont vu mettre en usage pour les debarasser 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 tete est hors les parties osseuses, elle ne -retrograde plus, je les desarticule (the blades) avec la clef placee entre -elles en forme de levier; je les extrais en les inclinant graduellement, -car souvent l'extraction un peu brusquee d'une branche produit l'expulsion -de la tete." (_La Chapelle._) - -[88] "Mon avis est que la choix n'est point _necessaire_ quand l'uterus -est encore rempli d'eau, et que la position est douteuse. En pareil cas je -conseillerais meme plutot 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 tres importante a observer quand on se trouve contraint -par la perte de sang a en venir a l'operation, et que les eaux ne sont -point encore ouvertes, c'est de couler la main tantot a droit, tantot a -gauche le plus haut et le plus doucement qu'il est possible de long les -membranes qui contiennent les eaux sans les rompre, jusqu' a ce qu' on ait -trouve les pieds de l'enfant pour s'en saisir. Car s'il arrive qu'elles se -rompent avant qu'on ait pris cette precaution, pendant qu'on les cherche, -les eaux s'ecoulent, les sang se perd, a la matrice se referme en partie, -et l'operation devient par-la plus difficile et plus dangereuse." -(_Pratique des Accouchemens_, p. 277.) - -[90] Traite des Accouchemens, 1770. Sec. 691. "Pour moi, j'ai toujours au -contraire trouve un grand advantage a insinuer la main jusqu'aux pieds de -l'enfant, et a 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 pretendre, avec Puzos, que la traction sur un seul -pied ait les avantages recis." (_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 securite quand je scais que la femme a -accouche precedemment et fort aisement d'enfans volumineux, quand je -reconnois son bassin pour avoir toutes les dimensions requises, quand les -contractions de la matrice sont bonnes." &c. (_Traite des Accouchemens_, -Sec. 674.) - -[94] Ueber die kuenstliche Wendung auf den Steiss, in the Heidelberg Klin. -Annalen, vol. ii. part i. p. 142. - -[95] Traite des Hernies, contenant une ample Declaration, &c., par Pierre -Franco de Turriers en Provence, demeurant a present a Orange: a 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 Caesarean -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 Caesarean 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 Caesarean -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 Naegele, that the merit is due for having first pointed out the -advantage of exciting uterine contraction before rupturing the membranes. -(_Programma de Necessitate Partus quandoque praemature, 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 Naegele, -in his _Lehrbuch der Geburtschuelfe_. - -[108] _Pratique des Accouchemens_, p. 21. "Je puis assurer n'avoir jamais -rencontre 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 Geburtshuelfe_, 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 Naegele, 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 Anatomicae, 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. Gen. de Med. 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 fuer -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 etoit extremement -serre: mais cela ne s'etoit fait seulement que dans la sortie de l'enfant; -car s'il eut ete long-temps serre de la sorte dans le ventre de la mere, -l'enfant auroit certainement peri; a cause que le mouvement du sang que -lui etoit necessaire, auroit ete entierement intercepte dans ce cordon. -J'ai encore accouche depuis ce temps la, sept autres femmes, dont les -enfans qui etoient tous vivans, avoient pareillement le cordon noue d'un -semblable noeud qui s'etoit fait de la meme maniere, 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. Sec. 1306.) - -[123] One of the most remarkable cases of extreme pelvic deformity from -mollities ossium is described by Professor Naegele 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 Caesarean 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 Caesarean 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 Caesarean operation. - -[127] For many of the above observations we are indebted to an admirable -article upon the subject by our friend, Professor Naegele, 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 Wuertzburg. - -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 Caesarean 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 -Obstetriciae_, 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 Haemorrhage_, 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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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. 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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 Mueller 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. 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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, APHTHAE, 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. 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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. 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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 Encyclopaedia, 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. 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