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.
A useful modification has been invented by Professor Naegelé, which supplies a considerable defect in the two above-mentioned instruments, viz. the necessity of using both hands to open the blades, thereby requiring that the hand which guides the instrument in the vagina should be removed at this moment: for this purpose the blades do not cross at the lock as the others do, by which means the grasp of one hand is sufficient to squeeze the handles together, and thus make the blades diverge in order to dilate the opening. A similar one has been invented by the surgical instrument maker, Mr. Weiss, but it does not appear to be quite so safe.
The object of these instruments is not merely to bore through the skull, but to break down the parietal bone to a certain extent, in order to enlarge the opening: a slight curve of the blades is advantageous, because their points thus impinge more directly upon the skull, and enter it at once without running the risk of slipping along the surface.
Indications. "The perforation is indicated, first, in all cases where the labour is dangerous for the mother, and where the antero-posterior diameter, although more than two inches and a half, is so small that the head which presents, cannot be delivered by the forceps. Secondly, it is indicated where the head is much larger than natural, as in hydrocephalus." (Naegelé, MS. Lectures.) For a more detailed and special account of the precise circumstances under which it will be required, we must refer to those different forms of DYSTOCIA, where it is occasionally required, particularly our fourth species, viz. DYSTOCIA PELVICA.
Much discrepancy of opinion has existed as to how far the operation itself was justifiable, and has, therefore, given rise to very different results in the practice of different schools. The most obstinately prejudiced against perforation was the late celebrated Benjamin Osiander, of Göttingen, who asserted, that it was never necessary, for, where others were obliged to open the head, he would deliver the patient by means of his forceps, an instrument which, from its great length and the various hooks &c. for applying additional hands, was capable of exerting a degree of force which nothing could justify. In France, the predilection for using exceedingly powerful forceps to a degree, which in this country and the greater part of Germany would be looked upon as very injurious, if not dangerous, has tended to render the perforation a comparatively rare operation: thus out of somewhat more than twenty thousand labours at the Maternité, of Paris, only sixteen were delivered by this means. Of the ninety-six cases in whom the forceps was applied, no mention is made as to the result with respect to the mothers; but, from the description of a forceps case at the Hôtel Dieu which we have received from an eye-witness, the force used must have been carried to a most unwarrantable extent.
The English practitioners have frequently been accused by their Continental brethren with being too ready in the use of the perforator; but, with one or two exceptions, the charge is not just, for, as already stated, we are not justified in subjecting an adult and otherwise healthy woman to so much suffering and danger for the sake of a child which, after all, will be probably sacrificed by the severity of the labour.[106]
Operation. In performing the operation we introduce two or three fingers along the vagina to the presenting part of the foetal head, and carefully guide up the perforator against it: these fingers will not only protect the soft parts from injury, but steady the point so firmly upon the skull, as to enable the other hand to bore through it without difficulty. Having passed the blades up to the shoulders or rests, we dilate the opening, first one way and then the other, to form a crucial incision: we now insert the instrument up to the basis cranii, breaking down the attachments and structure of the brain, and thus enabling it to come away with greater facility. To favour this object still farther, and make the cranial bones collapse more readily, we must pass a long elastic tube through the opening, and by means of a syringe, throw up a powerful stream of water into the cavity of the skull: if this be introduced to the base of it, the water will necessarily drive out the brain before it, so that with every stroke of the piston, a quantity of brain will be expelled nearly equal to that of the water injected.
When the perforation has been made, it will be desirable to wait a few hours before making any attempt to extract: we thus give the mother an opportunity of getting a little rest; the attachments of the cranial bones after a short time become more yielding, the head collapses more readily, and adapts itself better to the form of the passages. "In all circumstances," says Dr. Osborn, "which admit and require precision, I would recommend the delaying all attempts to extract the child till the head has been opened at least thirty hours: a period sufficient to complete the putrefaction of the child's body, and yet not sufficient to produce any danger to the mother. From such conduct, the beneficial effects of facilitating the extraction of the child, I am firmly convinced, by frequent experience, will much overbalance any possible injury which may reasonably be expected from the putrid state of the child and secundines in so short a time. The propriety, however, of this delay entirely depends upon the head being opened in the beginning of labour: for if we do not perform the first part of this operation till the labour has been protracted so long as that the woman's strength begins to fail, we must expedite the delivery as speedily as possible, otherwise, the danger which we wish to avoid, will infallibly be incurred: no woman can suffer continued labour beyond a certain period without fever, inflammation, and the most imminent danger, if not death ensuing." (Osborn's Essays on the Practice of Midwifery.)
It has been recommended to perforate the head at the sutures, on account of the greater facility in passing the instrument through them: but that part of the head which is lowest in the pelvis, or which, in other words, presents, must necessarily be the most convenient, not only for the introduction of an instrument, but also for the evacuation of the brain. When the perforation is made at a suture, the edges of the bones gradually overlap as the head diminishes in size, and thus close the opening, a circumstance which cannot occur when it is made through a bone. Splintering the bone in making a crucial opening has been objected to on the ground that the sharp edges and spiculæ are apt to wound the soft parts of the mother: of this, however, there will be but little danger so long as they are covered by the scalp, which we should be somewhat cautious of, and not tear or otherwise destroy the cranial integuments unnecessarily, for it has long since been remarked by the celebrated Peter Frank, that inflammation of the uterus produced by wounds from spiculæ of bone or sharp instruments becoming blunt, &c., usually prove fatal: it is also desirable to disfigure the head as little as possible. Still, however, we are far from recommending the trepan-shaped perforators which have been used by Professors Assalini, Joerg, &c. as they cannot make a sufficiently free opening, nor break down the skull to the necessary extent.
Extraction. Where sufficient time has been allowed for the cranial bones to collapse, the finger inserted into the opening and acting as a blunt hook will, if assisted by the pains, be enabled to exert a sufficient degree of force to bring the head down to the pelvic outlet; by which time the action of the vagina and abdominal muscles in aid of the uterine efforts will soon succeed in pressing it through the os externum. By using the finger in this way we pull by that part of the head which is already lowest in the pelvis, and, therefore, run no risk of altering the position of the head and bringing it down in an unfavourable direction; this objection (among others) applies to the hook, whether it be fixed internally or externally, and thus frequently renders the passage of the head through the outlet and os externum more tedious, difficult, and painful, than it otherwise would have been. The craniotomy forceps are still more objectionable in all ordinary cases of perforation, for they not only alter the position of the head, but by tearing away portions of bone from time to time are very liable to wound the soft parts.
From our own experience, we would recommend the application of the common curved forceps in all cases where the pelvic deformity is not of a very unusual degree, for by this means the hand is equally grasped and compressed, the soft parts to a considerable extent are protected by the blades, and the whole mass brought down exactly in the position in which it presented. On several occasions where the craniotomy forceps and crotchet have failed to move the head, the midwifery forceps has been applied, and the delivery easily and quickly accomplished. Dr. Smellie recommends the crotchet to be applied on the outside of the head, and was evidently aware that its position was liable to be altered by this means. He directs the practitioner to "introduce it along his right hand with the point towards the child's head, and fix it above the chin, in the mouth, back part of the neck, or above the ears, or in any place where it will take firm hold. Having fixed the instrument, let him withdraw his right hand, and with it take hold on the end or handle of the crotchet, then introduce his left to seize the bones at the opening of the skull (as above directed) that the head may be kept steady, and pull along with both hands." (vol. i. chap. 3. sect. 7. numb. 4.) Where there was considerable difficulty in bringing down the head, Dr. Smellie used to introduce a second crotchet opposite to the first, like the second blade of the forceps, and having locked them together was thus enabled to apply a greater degree of force.
Crotchet. The usual mode of applying the crotchet at the present day is to pass it into the cranial cavity, and endeavour to fix it upon some portion of the skull, which will afford a sufficiently firm hold for the purpose; the best spot is the petrous portion of one or other of the temporal bones. The plan of passing up the hook on the outside of the head is objectionable, for in most cases where there is much impaction of the head, it will be exceedingly difficult, if not impossible, to push the hook past it without much suffering and probable injury. Not wishing to differ from so great an authority as Dr. Smellie without reason, we have repeatedly tried this mode of using the crotchet, but invariably found that its introduction on the outside of the head was attended with so much difficulty and pain as to make us relinquish the attempt. His objections to passing the hook into the cranial cavity are not valid, for we should never try to fix it upon the "thin bones," nor should we hold it in such a manner that, if it did slip or tear through, it would wound either our hand or the soft parts of the mother.
The common form of the crotchet in general use is but ill adapted for taking hold of any part within the skull: it is, in fact, the very instrument left us by Dr. Smellie for applying on the outside of the skull: and, therefore, that which was intended to take hold of a convex surface cannot possibly be also suited for one of the contrary form, viz. a concavity; for this reason, the shank of the hook requires to be straight, so that the point may project at a considerable angle, by which means it will take hold with much greater ease.
The point of the hook guarded by the finger should be cautiously introduced up the vagina, and passed into the cranial cavity; having fixed it, as above directed, the finger should be applied externally, so as to correspond with the hook inside: by so doing, if the point slips or tears through the bone, the finger is ready to protect the soft parts from it; the operator is equally safe from injury, for, by grasping the shank of the hook with his thumb and other fingers, his whole hand moves with it and gives him instant warning of its going to slip. Where the deformity of the pelvis is very great, it may be necessary to break down the bones of the head still farther, in order to produce greater comminution; but even here, so long as the bones collapse well together, it will be better not to displace them from their attachments, the whole mass will come down better and with less chance of injuring the soft parts. Where, however, this is admissible, we must give the head sufficient time to undergo that process of softening which is one of the early stages of putrefaction; the cranial parietes may be gradually removed, one after the other, until we have nothing remaining but the base of the skull and the face. Dr. Burns recommends us now to convert it into a face presentation with the root of the nose directed to the pubes: "I have carefully measured, (says he,) these parts placed in different ways, and entirely agree with Dr. Hull, a practitioner of great judgment and ability, that the smallest diameter offered, is that which extends from the root of the nose to the chin."
Embryulcia. This is merely a degree farther than the perforation: it consists in evacuating the chest and abdomen of their contents, and thus enabling their parietes to collapse. It is chiefly had recourse to in cases of deformed pelvis, where the arm or shoulder has presented, or where the distortion is so great as to prevent the trunk from passing without its bulk being lessened. Dr. Smellie's perforator with its scissor edges is best suited for this object. Having made an opening into the most presenting part of the thorax, we enlarge it by cutting away portions of the ribs and thoracic parietes, and removing the contents of the chest. The abdominal viscera are brought away in a similar way through a perforation in the diaphragm; and if this be not sufficient to let the trunk pass, the crotchet must be inserted into the brim of the child's pelvis, which must be brought down doubled upon the spine, somewhat like the process of spontaneous expulsion.
The success of this operation, will, in a great measure, depend not only upon its being undertaken sufficiently early before the patient's strength is exhausted, but upon a sufficient length of time intervening between the removal of the thoracic and abdominal viscera and the extraction of the child. The excellent rule of Dr. Osborn, above quoted, is peculiarly applicable here; for when softened by the effects of incipient decomposition, the body will sometimes even be expelled by the unassisted efforts of the uterus.
In a case of this sort, the perforation of the head is the last part of the process to be performed. It will be by all means, desirable not to separate it from the body, but to pass up the curved perforator along the neck, and make an opening behind the ears: this is effected without much difficulty, and the head can be brought away whole, or in portions, according to the nature of the case.
V. DYSTOCIA, OR ABNORMAL PARTURITION
Divisions and species. By the term Dystocia, we understand those labours which either cannot be completed by the natural powers destined for that purpose, or at least, not without injury to the mother or her child.[107] These will, therefore, consist of the two following classes:--
1. Labours that are difficult or impossible to be completed by the natural powers.
2. Labours which are rendered faulty without obstruction to their progress.
The first division of dystocia may either arise from a faulty condition of the expelling powers, or, without any anormality in this respect, it may depend upon the faulty condition either of the child, or of the parts through which it has to pass.
As respects the child it may arise from,
1. Malposition.
2. Faulty form and size of the child.
3. Faulty condition of the parts which belong to the child.
On the part of the mother this division of dystocia may arise from a faulty condition.
4. Of the pelvis.
5. Of the soft passages.
6. Of the expelling powers.
The second condition where labour is rendered dangerous for the mother or her child, without any obstruction to its progress, may arise from,
1. Following too rapid a course.
2. Prolapsus, &c. of the umbilical cord.
3. From accidental circumstances, which render the labour dangerous, viz. convulsion, syncope, dyspnoea, severe and continued vomiting, hæmorrhage, &c.
We propose to consider the different species of dystocia in the order above enumerated.
I. FIRST SPECIES OF DYSTOCIA
Malposition of the child.--Arm or shoulder the only faulty position of a full-grown living foetus.--Causes of malposition.--Diagnosis before and during labour.--Results where no assistance is rendered.-- Spontaneous expulsion.--Malposition complicated with deformed pelvis or spasmodically contracted uterus.--Embryulcia.--The prolapsed arm not to be put back or amputated.--Presentation of the arm and head.-- Presentation of the hand and feet.--Presentation of the head and feet.--Rupture of the uterus.--Usual seat of laceration.--Causes.-- Premonitory symptoms.--Symptoms.--Treatment.--Gastrotomy.--Rupture in the early months of pregnancy.
We have already stated that the presentations of the full-grown living foetus may be brought under three classes, viz. those of the head, of the nates or lower extremities, and of the arm or shoulder: the former two have already been considered under the head of eutocia or healthy parturition, and may be distinguished from the latter, by the great peculiarity that in them the long axis of the child's body is parallel with that of the uterus, whereas, in arm or shoulder presentations this cannot be the case, its body lying across the uterus.
Although malposition of the child, strictly speaking, refers to one species of presentation only, viz. to that of the arm or shoulder, yet it has been rendered a matter of great perplexity by the speculations and theoretical notions of authors. No one has propagated more serious errors upon this subject than the celebrated Baudelocque, the more so as the great authority of his name has tended to silence all doubts as to the accuracy of his views upon this subject. Almost every author since his time has contented himself with copying more or less from him, without ascertaining by personal observation how far they corresponded with the actual course of nature. By forcing a stuffed figure into a pelvis in every possible direction, he succeeded in making actually ninety-four presentations of the child, all of which he described as if they had really occurred in nature.
Few have taken so simple a view of this subject as the late Dr. Denman. "The presentations of children at the time of birth," says this distinguished accoucheur, "may be of three kinds, viz. the head, the breech or inferior extremities, the shoulder or superior extremities; the back, belly, breast or sides, properly speaking, never constitute the presenting part."
The two greatest Continental authorities of modern times, viz. Madame La Chapelle and Professor Naegelé, confirm this opinion: the former points out one of the sources of error which has induced practitioners to suppose that they had met with other species of faulty presentation besides those of the arm or shoulder. "In the greater number of shoulder presentations," says this experienced authoress, "I have very distinctly touched the chest, in some positions of the nates I have been able to reach the loins, the hips, or lower part of the abdomen; but it would require no slight bias from prejudice and theoretical systems to find presentations of the chest, the back, the abdomen, or the loins, the neck or the ear."[108]
We would, therefore, limit the term malposition of the child merely to presentations of the arm or shoulder: other presentations, it is true, occur, but not of the full-grown living foetus; they are only where the child is premature, or has been dead in utero some time. Under such circumstances it will follow no rule whatever; for in the first case it is too small, and therefore the passages can have no effect in directing its course through them; and, in the second, a child which has been dead some time becomes so softened by gradual decomposition, that it may be squeezed by the pressure of the uterus into almost any shape: it is by this cause that we occasionally see in still-born children parts in close contact, which in a living child could not have been brought together.
We do not deny that such presentations may be made by ignorant and awkward attempts to deliver, but it is to be hoped that such cases are daily becoming of rarer occurrence.
Malposition of the child is fortunately not of very frequent occurrence: as a general average we would say that it occurs once in 230 cases, as the following results will show:--At the Westminster General Dispensary (1781) it occurred to Dr. Bland once in 210 cases: at the Dublin Lying-in Hospital, to Dr. Joseph Clarke, once in 212: in private practice, to Dr. Merriman, once in 155: "calculated from a great number of cases," to Professor Naegelé, once in 180: at the Dublin Lying-in Hospital, to Dr. Collins, once in 416: at the Maternité, of Paris, to Madame La Chapelle, once in 230.
In arm and shoulder presentations the back of the child is turned towards the anterior part of the uterus more than twice as frequently as it is in the contrary direction, from which circumstance Professor Naegelé has called this the first position of the shoulder to distinguish it from the other, which, as being rarer, he calls the second.
In investigating the nature of the causes which produce malposition of the child, which, from the above observations, is evidently a circumstance of rare occurrence, the question naturally suggests itself, by what means is the long diameter of the child in so large a majority of cases kept parallel with that of the uterus? This depends in great measure on the form and size of the uterus. Where the uterus is not unduly distended with the liquor amnii, and where it preserves its natural oval figure, it is scarcely possible that the child should present in any other way than with its cephalic or pelvic extremity foremost. There can be no doubt that the first early contractions of the uterus in the commencement of labour have a great effect in regulating the position of the child; for, by the gentle and equable pressure which they exert upon it, they not only maintain it in the proper direction, but tend materially to correct any slight deviations from the right position. Hence, therefore, we find that where any cause has existed to impair or derange the action of these precursory contractions of the uterus, the child is apt to lie across, or, in other words, to present with the arm or shoulder. Thus, for instance, if the uterus be much distended with liquor amnii, the contractions of its parietes can have little influence upon the child's position; this will be particularly the case where the accumulation is very considerable, for here the uterus becomes more or less globular, and presents but little variation as to the length of its diameter in any direction.
The form of the uterus is no less worthy of attention as a cause of malposition, and is also in a great measure influenced by the character of its early contractions. Thus in a uterus for the first time pregnant, they generally act equally on all sides: hence it is why in primiparæ the uterus is so exactly oval, and why we so rarely meet with faulty presentations. Sir Fielding Ould, of Dublin, was the first and almost the only practitioner in this country who noticed the influence which the early contractions of the uterus have in determining the position of the child. "The first labour pains, which are very short, continue their repetition for two or three hours, or perhaps for more, before there is the least effect produced upon the os tincæ, which time must certainly be employed in turning the head towards the orifice." (Treatise of Midwifery, p. 14.)
Wigand, in reasoning upon the physical impossibility of a child presenting wrong, where the uterus is of the natural configuration, says that "the chief cause of faulty position of the child does not depend so much upon the child itself, as upon the deviation of the uterus from its natural elliptical or pyriform shape." (Wigand, vol. ii. p. 107.)
The theory at one time so universally entertained, that the obliquity of the uterus was the chief cause of malposition of the child, has long since been disproved, although it continues to find a few adherents to the present day: the uterus, in fact, towards the end of pregnancy, is scarcely ever quite straight; the upright posture of the human female rendering it almost necessary that the fundus should incline somewhat to one side or to the other, or forwards, and yet we find that it has no influence upon the position of the child when labour comes on. The moment a pain commences, the fundus moves towards the median line of the body, so that its axis corresponds nearly with that of the pelvic brim: as the pain goes off, so does it return towards its former oblique position. Even in those cases where it is strongly inclined forwards, and where the abdomen is quite pendulous, the position of the child is unaffected by it.
Where, however, the uterus has been altered in point of form, where from irregular contractions of its fibres it has been pulled down unequally to one side, while it is quite relaxed in the opposite direction, the position of the child may be seriously affected, for it will now present obliquely as regards its long axis, and become a case of malposition.
We may, therefore, state that the causes of arm or shoulder presentations are of two kinds, viz. where the uterus has been distended by an unusual quantity of liquor amnii; or where, from a faulty condition of the early pains of labour, its form has been altered, and with it the position of the child.
It is a well-known fact that cross births, as they have been called, are frequently preceded by severe spasmodic pains in the abdomen, from which the patient suffers for some days or even weeks before labour has commenced: the uterus is more or less the seat of these attacks, which usually come on towards night-time; and, in some instances, it is felt for the time hard and uneven from irregular contraction. It was the circumstance of this symptom having preceded five successive labours of a patient, in all of which the child had presented with the arm or shoulder, which induced Professor Naegelé, when attending her in her sixth pregnancy, to endeavour to allay these cramp-like pains, which had begun to show themselves as severely as on former occasions. Having tried opium by itself, and also in combination with ipecacuanha or valerian without effect, he ordered her a starch injection with twelve drops of Tinct. Opii every night as long as she continued to suffer from these attacks: the spasms soon ceased, nor did they appear again during the remainder of her pregnancy, and he had the satisfaction of delivering her at the proper time of a living child, which presented in the natural manner.
Many other causes of malposition have been enumerated by authors, which evidently exist only in theory and not in reality: thus, shortness of the umbilical cord, or its being twisted round the child, insertion of the placenta to one side of the uterus, faulty form or inclination of the pelvis, obliquity of the uterus, as above-mentioned, violent exertions or concussions of the body, plurality of children; of all these, we do not believe that there is one which can exert the slightest influence in determining the position of the child. There is no doubt that several of them will render labour difficult or even dangerous, more especially deformed pelvis; but we constantly meet with it under every degree and variety without at all altering the child's position. Indeed, if malformation of the pelvis were to be a cause of malposition of the child during labour, what difficulties would it not add to the process of delivery under such circumstances? And yet we find, with very rare exceptions, that in every case requiring artificial assistance on account of contracted pelvis, the head is resting upon the brim which is too narrow to allow it to pass.
We may also mention another circumstance which has occasionally seemed to produce a faulty position of the child. It sometimes happens that the hand, which is frequently felt lying by the side of the face at the beginning of labour, instead of slipping up out of reach as the head descends, which is usually the case, advances more and more, until it not only prevents the head from engaging farther into the pelvis, but pushes it out, so that the head slips up to one side, and lodges in the cavitas iliaca, allowing the shoulder with the rest of the arm to descend.
Where, however, the pelvis is large or the head small, the arm will not always force it to one side, but the two will come down together and be born in this position. (See case in our Midwifery Reports, Med. Gaz. April 19, 1834.)
Sometimes the two hands present (La Motte, book iii. ch. 26.,) or a hand and foot: this, however, does not long continue so, for when the membranes have ruptured, the liquor amnii flowed away, and the uterus contracted upon the child, one shoulder and arm descend before the rest, and remain in this position.
The complication of two arms presenting with the head we disbelieve entirely, except where it has been made during some awkward and ignorant attempts at delivery.
Although the symptoms of malposition of the child during the last few days before, or at the commencement of labour, are far from being distinct, still, however, when taken collectively, they will be sufficient to excite our suspicion. The abdomen is irregularly distended, and marked with unequal prominences; anteriorly, it is more or less pointed. It is usually much increased in breadth, and this is generally in an oblique direction, forming a globular protuberance at the upper part on one side, and at the lower part on the other: the former is the pelvic extremity of the child; the other, from its size, form, and hardness, may easily be recognised as the head.
"The movements of the child feel differently to what they did before; they are no longer exclusively confined either to one side or the other. Sometimes, as before-mentioned, cramp-like pains are felt in the abdomen, during which it is more or less distorted with violent movements, apparently of the child, as if it were trying to force its way through the abdominal parietes at this spot." (Naegelé, Lehrbuch, p. 223.)
Upon examination per vaginam, either no presentation is to be reached at all, or only small parts can be indistinctly felt, such as the hand, the arm, or the shoulder. The not being able to feel a presenting part in a primipara shortly before or at the commencement of labour, is an unfavourable symptom; for the head at this time ought to be deep in the cavity of the pelvis; still, however, it does not necessarily prove that the child is presenting wrong, for it may be a presentation of the nates, which, as we have before shown, do not descend so low into the pelvis just before labour, as the head does; or it may arise from the unusual size of the child's head, especially in cases of congenital hydrocephalus. It may arise from a large quantity of liquor amnii, and where the head is nevertheless presenting; it may be a case of twins, or lastly of dystocia pelvica, where the head is presenting, but unable to pass through the contracted brim.
In women who have had several children, it is frequently impossible to reach the presentation during the early part of the labour: this arises either from the abdomen in these cases being generally more or less pendulous, or from the circumstance of the uterus having been distended in so many previous pregnancies: its lower part does not become so fully developed as before, but continues more or less funnel-shaped, a considerable portion of the cervix still remaining. Where this is the case, the head will not descend so low as usual at first, but remains out of reach, or nearly so, until the os uteri is fully dilated and the membranes have given way.
"If, upon such an examination, it should be ascertained that the os uteri is considerably dilated, and the child cannot be felt, this affords reason to suspect that the presentation is preternatural. Should the liquor amnii be discharged and the child be out of reach of the finger, the probability of a preternatural position is greater. Should the membranes be found hanging down in the vagina not of the usual globular form, but rather conical and small in diameter, this likewise is a presumptive proof of a cross-birth; especially if there be any part presenting through the membranes which is smaller, feels lighter, or gives less resistance when touched than the bulky heavy head."[109]
The diagnosis of the shoulder is by no means easy: it offers no distinctive marks, and may readily be mistaken for the nates, or even for the head. It feels round, but is smaller and softer than the head. The scapula and clavicle, the neck, the armpit, the arm itself, and the ribs, assist us in our diagnosis. From the direction of these parts, we shall be able to ascertain the position of the rest of the body, and which shoulder presents. If the hand has prolapsed, the direction of the palm and of the thumb will soon show the position of the child.
Labours with malposition are always dangerous; when left without assistance, they are almost always fatal to the child, and generally so to the mother.
When a full-grown child has presented with the arm or shoulder, and nothing has been done to assist the delivery of it, the results are usually as follow:--After the membranes have burst, and discharged more liquor amnii than in general where the head or nates presents, the uterus contracts tighter around the child, and the shoulder is gradually pressed deeper into the pelvis, while the pains increased considerably in violence, from the child being unable, from its faulty position, to yield to the expulsive efforts of nature. Drained of its liquor amnii, the uterus remains in a state of contraction even during the intervals of the pains; the consequence of this general and continued pressure is, that the child is destroyed from the circulation in the placenta being interrupted, the mother becomes exhausted, and inflammation or rupture of the uterus or vagina are almost the unavoidable results.
Another although much rarer consequence of malposition of the child, is that peculiar mode of expulsion which was first noticed by Dr. Denman in 1772. From the supposition that the shoulder receded and the nates came down into the pelvis, in which position the child was born, he called it "the spontaneous evolution of the foetus;" but the term spontaneous expulsion, as proposed by Dr. Douglas in 1811, is much better adapted, it having been shown by that gentleman that the explanation of this process as given by Dr. Denman was not correct. (An Explanation of the real Process of the spontaneous Evolution of the Foetus, by J. C. Douglas, M. D. 2nd ed. 1819, p. 28.,) but that whilst the shoulder rested against the pubes, the side of the thorax and abdomen, followed by the nates, passed in one enormous sweep over the perineum, leaving the head and other arm still to be extricated.
The shoulder and thorax thus low and impacted, instead of receding into the uterus, are at each successive pain forced still lower, until the ribs of that side, corresponding with the protruded arm, press on the perineum, and cause it to assume the same form as it would by the pressure of the forehead in a natural labour. At this period, not only the entire of the arm but the shoulder can be perceived externally, with the clavicle lying under the arch of the pubes. By farther uterine contractions the ribs are forced more forwards, appearing at the os externum, as the vertex would in a natural labour, the clavicle having been by degrees forced round on the anterior part of the pubes with the acromion looking towards the mons Veneris. "The arm and shoulder are entirely protruded with one side of the thorax, not only appearing at the os externum, but partly without it: the lower part of the same side of the trunk presses on the perineum, with the breech either in the hollow of the sacrum or at the brim of the pelvis, ready to descend into it, and, by a few farther uterine efforts, the remainder of the trunk, with the lower extremities, is expelled." (Douglas, op. cit. p. 28. 2nd ed.)
Farther experience has confirmed the correctness of Dr. Douglas's views (Med. Trans. of the Royal Coll. of Physicians, vol. vi. 1820;) and, indeed, the original case as related by Dr. Denman himself tends to prove that nothing like an "evolution" of the foetus takes place. I found the arm much swelled, and pushed through the external parts in such a manner that the shoulder nearly reached the perineum. The woman struggled vehemently with her pains, and during their continuance I perceived the shoulder of the child to descend.
Some years afterwards, the late Dr. Gooch had the opportunity of observing a case of spontaneous expulsion with great accuracy, and came to the same conclusion as Dr. Douglas had done. "Resolved to know what became of the arm, if this (the spontaneous expulsion) should happen, and thus fit myself for a witness on this disputed point, I laid hold of it with a napkin and watched its movements: so far from going up into the uterus when a pain came on, it advanced, as well as the shoulder, still forwarder under the arch of the pubes, the side of the thorax pressing more on the perineum and appearing still more externally; it advanced so rapidly that in two pains, with a good deal of muscular exertion on the part of the patient, but apparently with less suffering than attends the birth of the head in a common first labour, did the side of the chest, of the abdomen, and of the breech, pass one after the other in an enormous sweep over the perineum till the nates and legs were completely expelled." (Ibid.)
The celebrated Boer, has, however, detailed a case where the arm had prolapsed into the vagina, the hand appearing externally; and on introducing his hand for the purpose of turning, he felt the hand distinctly receding, and the breech beginning to occupy the cavity of the pelvis. This is very different to a case of spontaneous expulsion: "the child lay completely across, with its abdomen towards the back of the mother;"[110] it had, in fact, not yet begun to press against the brim, or to assume any definite position, there having been as yet but little uterine contraction, and both rectum and bladder being considerably distended. When these were evacuated the pains increased: the breech being nearest to the brim, descended, and the arm in consequence receded. Dr. Gooch considers it most probable that "it was only a breech presentation, the hand having accidentally slipt down into the vagina."
Although in cases of malposition where turning has become excessively difficult and dangerous, the spontaneous expulsion must be looked upon as a most fortunate process by which nature effects delivery, still, however, we must never venture to wait for it without making such attempts to turn the child as the state of the patient may justify. It is always more or less dangerous to the mother, and almost certainly fatal to the child. Indeed, it is our opinion, that the spontaneous expulsion can rarely, if ever take place, except where the child has been already dead some time, or where it is premature. "Nor can any event," says Dr. Douglas, "ever be calculated upon than that of a still-born infant. If the arm of the foetus should be almost entirely protruded with the shoulder pressing on the perineum, if a considerable portion of its thorax be in the hollow of the sacrum with the axilla low in the pelvis, if with this disposition the uterine efforts be still powerful, and if the thorax be forced sensibly lower, during the presence of each successive pain, the evolution may with great confidence be expected." (Op. cit. p. 42.)
On the other hand, if either from the rigidity, &c. of the child or of the passages, but little material advance is made in the manner above-mentioned, if the soft parts are become swollen and inflamed, and the powers of the patient are beginning to flag, and exhaustion coming on, if turning has been attempted as far as could be done with safety, and still without success, we have no choice left but that of embryotomy; the chest and abdomen must be evacuated of their contents as already directed under the head of PERFORATION, and in this manner the child delivered.
Malposition with deformed pelvis, or rigidity of the uterus.--Where the pelvis is deformed, or the uterus (from the early escape of the liquor amnii) spasmodically contracted upon the child, and the os uteri in a state of rigidity, the difficulties and danger of the case are greatly multiplied: in the former complication the embryotomy must be carried much farther, in the latter we must have recourse to bleeding, opium, warm-bath, &c. as recommended under the head of TURNING.
The prolapsed arm is not to be put back or amputated.--Where the arm has been some time prolapsed, and, from the pressure of the soft parts, much swollen, it fills up the vagina so completely that it would seem almost impossible to introduce the hand, unless we push up the arm first: experience however confirms the valuable rule of La Motte, viz. that we must slide our hand along the arm into the uterus; we shall rarely find, where the passages are in a proper state for undertaking the operation, that the prolapsed arm presents any serious obstruction to the passage of the hand. "An arm presenting," says Chapman, "and advanced as far as the armpit, is not to be returned, but the hand is to be introduced (which, as Deventer justly observes, is often found to penetrate with much more ease when the arm hangs down than when it is thrust back again) and the feet to be sought for, which, when found, the arm will prove no great hindrance in turning the child." (Chapman's Midwifery, p. 46. 2nd. ed., 1735.)
In no case is it necessary to separate the arm at the shoulder, "for I have found it," says Dr. Denman, "a great inconvenience, there being much difficulty in distinguishing between the lacerated skin of the child and the parts appertaining to the mother." (Essay on Preternat. Labours, p. 32.)
Dr. Meigs, of Philadelphia, has added another powerful argument against this practice, viz. that cases have occurred where the arm had been cut off and where the child was nevertheless born alive.
As to how far it is possible or advisable so to alter the position of the child as to make it present with the nates or head, this has already been considered in the chapter upon TURNING.
The presentation of the arm with the head is of very rare occurrence, so much so that some have doubted if it really existed: two cases of this kind have come under our own notice, in both of which the child was born in this position, although with some difficulty.
"Independent of the awkwardness of position which the head may assume, from the circumstance of the hand or arm descending with it into the pelvis, there will be so much increase in the bulk of the part as to render its passage slow and difficult; yet if the case be not interrupted by mismanagement, it will terminate favourably, for this complication of presentation seldom happens but in a wide pelvis." (Merriman's Synopsis, p. 48, last ed.)
It is by no means uncommon to feel the hand lying upon the side of the head or on the cheek; but this produces no impediment to the labour, for as the head descends through the brim of the pelvis the hand usually slips up: in the other case we have felt the arm bent over the head, and pressing the ear on the opposite side.
Presentation of the hand and feet. We sometimes also meet with cases where the hand presents with one or two feet; but these complications merely exist at the commencement of labour, where the uterus has been greatly distended with liquor amnii, and where its contractions have not yet begun to press the child into the brim. Cases of this nature sooner or later are sure to terminate in presentations of the nates or shoulder, unless the process of labour has been interfered with.
Presentation of the head and feet. Presentations of the head and one or both feet have also been described: these, however, have only occurred during the operation of turning, when the feet have been brought down into the pelvis before the head had left it, and, therefore, must be considered as having been made by unskilfulness on the part of the practitioner. Where this is the case it may be necessary to premise blood-letting, &c., on account of the inflamed condition of the parts from the previous unsuccessful attempts to turn: after this, a fillet should be passed round the feet in order to secure them, and then the head may be safely pushed out of the pelvis.
Rupture of the uterus. Of the injurious results arising from protracted or neglected cases of arm or shoulder presentation none can compare in point of danger with those where the uterus has given way or burst. This state may also be produced by deformity of the pelvis, tumours, and other causes of obstruction to the passage of the child, by which the uterus is excited to unusually violent efforts in order to overcome the impediment during which the laceration is effected. It may also arise from injuries to the uterine tissue without undue exertions, as from exostosis of the pelvis, sharp projecting edges of the promontory or brim, and also from organic disease: thus, "when the rent speedily follows the accession of labour, before the pains have become severe, or the uterus has scarcely begun to dilate, its structures will probably be found diseased." (Facts and Cases in Obstetric Medicine, by I. T. Ingleby, p. 176.)
Usual seat of the laceration. The part of the uterus in which laceration is most frequently observed to occur is near to or at the junction of the uterus with the vagina: this happens rather more frequently behind than before, but the difference in this respect is very trifling. Thus in 36 cases which were collected by Mr. Roberton, of Manchester, "in 1 the cervix was separated from the vagina except by a thread: in 11 the laceration was posterior, in 8 it was anterior, in 5 lateral, in 3 anterior-lateral, and in 3 posterior-lateral." (Edin. Med. and Surg. Journal, vol. xlii. 1834, p. 60.) In 34 cases which occurred at the Dublin Lying-in Hospital, "in 13 the injury was at the posterior part; in 12 anteriorly; in 2 laterally; in 1 the mouth of the womb was torn, and in 6 the particular seat of the laceration was not described." (A Practical Treatise on Midwifery, &c., by Robert Collins, M. D., 1835, p. 244.)
The nature and extent of the laceration varies a good deal: in the worst cases the uterus is torn completely through, and the child escapes either partly or wholly into the abdominal cavity; whereas, in many, the peritoneum has not given way, the laceration being confined entirely to the tissue of the uterus itself. Thus, in 9 of the 34 cases recorded by Dr. Collins, "the peritoneal coat of the uterus was uninjured, although the muscular substance of the cervix was extensively ruptured." In other instances the peritoneum has been cracked or torn in numerous places without any injury to the subjacent tissue.
From the greater degree of resistance to the passage of the child, in cases of first labour, we might naturally suppose that rupture of the uterus would be more frequently seen among primiparæ: this, however, is not the case, for of 29 cases mentioned by Mr. Roberton, only one of them was a primipara; a larger (and as an average probably more correct) proportion, viz. 7 in 34, has been given by Dr. Collins: of the multiparæ, 5 were in their sixth pregnancy, 2 in their tenth, and 2 also in their eleventh pregnancy.
Experience also shows that in a large proportion of these cases, the duration of the labour has been very far from being longer than usual; indeed, in a considerable majority, the mischief has taken place very few hours after the commencement of active labour. Thus, the average duration of it in the 36 cases recorded by Mr. Roberton, was 15 hours: in 24 of those by Dr. Collins, it was 17 hours: but if we take merely the majority of them we shall have a much smaller average: thus, in 20 of Mr. Roberton's cases it was 9 hours, and in 15 of Dr. Collins's it was only 6 hours.
Causes. A large proportion of cases where the uterus gives way during labour, are connected with more or less deformity of the pelvis, and where, from previous severe and difficult labours, its structure has been injured, and rendered incapable of bearing that degree of tension, which even the ordinary exertions of the uterine fibres would require. In many others, the impediment produced by the contracted pelvis, or malposition of the child, has roused the uterus to those violent efforts which have produced the laceration. Organic diseases of the uterus, or cicatrisations of the soft passages from extensive injuries in former labours, either render its powers of resistance defective, or, by increasing the resistance, excite it to unusual violence. "The operation of turning is not unfrequently a cause of laceration of the vagina or mouth of the uterus, particularly, where it is performed previous to the soft parts being sufficiently dilated to admit the easy passage of the hand, or where great haste is employed. The same consequences may ensue from rash or violent attempts to remove a retained placenta. I have also known the mouth of the womb to be torn by the imprudent use of the forceps when not sufficiently dilated." (Dr. Collins, op. cit. p. 242.) "The sex of the infant, it would appear, may also have some share in occasioning this very distressing occurrence." (Practical Remarks on Lacerations of the Uterus and Vagina, by Thomas M'Keever, M. D., p. 4.) Thus, of 20 cases reported by Dr. M'Keever, 15 were delivered of boys and 5 of girls; of the 34 cases described by Dr. Collins, "23 of the children were males. This is satisfactorily accounted for by the greater size of the male head, as proved by accurate measurement made by Dr. Joseph Clarke."
Another circumstance which influences to a certain extent the frequency of rupture of the uterus, is the rank of the patient: in private practice, especially among the better classes of society, it is an extremely rare occurrence; but in the lower grades of life several causes concur to render it more frequent. They are "much more exposed to falls, bruises, and other accidental injuries during pregnancy, in consequence of which the uterus may be either ruptured at the time they have sustained the violence, or may be so weakened in structure at some particular point, as readily to give way during its efforts to accomplish delivery. Lastly, they are more liable to fall into the hands of ignorant inexperienced midwives, who not unfrequently, with a view of expediting the process of delivery, rupture the membranes at an early period of the labour; in consequence of which, the firm unyielding head of the child is prematurely brought in contact with the passages, exciting by its pressure, swelling, inflammation, and an interrupted state of the circulation in the uterus and adjacent parts. In such a case should there unfortunately exist any disproportion between the parts of the mother and the head of the infant, or should proper measures not be employed to obviate distressing symptoms, and that the labour pains continue to recur with extreme violence, there is great risk of the uterus giving way, the laceration being of course most likely to occur at that part where the greatest pressure has been sustained." (M'Keever, op. cit. p. 3.)
The premonitory symptoms of rupture of the uterus are not always sufficient to warn us of the impending danger, for in many cases nothing unusual has occurred until the actual injury has been produced, and it has then been inferred by the alarming change observed in the patient's appearance. In many cases, especially where the muscular substance only of the uterus was torn, the pains have continued with a sufficient degree of power to expel the child; in others the mischief has been attended with so little suffering at the moment, and for the time with so little constitutional derangement, as to excite no suspicion, either on the part of the patient, or her attendant. "Farther, as on some occasions, the uterus has been known to give way during the very pain which effected the delivery of the child, instances of which may be found in the works of Crantz and Guillimeau." (Ibid. p. 15.)
Symptoms. "When a rupture of the uterus has really happened, it is generally marked by symptoms which are decisive; but it being a case which occurs so very rarely, they do not immediately create suspicions. When labour has continued violent a considerable time, if a pain expressive of peculiar agony is followed by a discharge of blood, and an immediate cessation of the throes, there is reason to apprehend this mischief. If nausea and languor succeed, with a feeble and irregular pulse, cold sweat, retching, a difficulty of breathing, an inability to lie in a horizontal posture, faintness or convulsions, there is still more reason to suspect the nature of the case. But if the presenting part of the child, which was before plainly to be distinguished, has receded and can be no longer felt, and its form and members can be traced through the parietes of the abdomen, there is evidence sufficient, I believe, to determine that the uterus is ruptured. The labour pain, in consequence of which the rupture is supposed to have happened, is often described by the patient, as being similar to cramp, and as if something was tearing and giving way within them. It has been said likewise, to have produced a noise which could be heard by the people present." (Observations on an extraordinary Case of ruptured Uterus, by Andr. Douglas, M. D., 1785, p. 48.)
Where the peritoneal coat only has been torn, we may have many of the above-mentioned symptoms resulting from laceration of the uterus, without any impediment to the progress of labour. This peculiar species of partial rupture was first noticed by the late Dr. John Clarke, (Trans. for the Improvement of Med. and Surg. Knowledge, vol. iii.,) since which cases have been recorded by Mr. Partridge (Med. Chir. Trans. vol. xix. p. 72.,) Dr. Collins, Dr. Ramsbotham, &c. In Dr. Clarke's case the uterus and vagina "were found to have sustained no injury whatever; but on turning down the fundus uteri over the pubes, between forty and fifty transverse lacerations were discovered in the peritoneal covering of its posterior surface, none of which were in depth above the twentieth of an inch, and many were merely fissures in the membrane itself. The edges of the lacerations were thinly covered with flakes of coagulated blood; and about an ounce of this fluid was found in the fold of the peritoneum, which dips down between the uterus and the rectum."
Where the uterus has been torn quite through, a frequent result is, that the child passes either wholly, or in part, through the rent into the abdominal cavity: this occurrence will, in great measure, be influenced by the situation and extent of the laceration, and also by the degree of the uterine contractions. It is easily recognised by the presenting part having receded, and in all probability by the members of the child being felt with unusual distinctness through the abdominal parietes.
Treatment. Under such an unfortunate complication nothing remains but to effect the delivery in as speedy and gentle a manner as possible. Where the os uteri is fully dilated, the head presenting and but little receded, and the pelvis only slightly contracted, the application of the forceps will be justifiable; but in many instances the circumstances of the case will not warrant it, and the attempt must be made to bring down the feet, which has been most usually had recourse to with success although it occasionally happens that even this is attended with no slight difficulties: the rigid and partially dilated os uteri may be a serious bar to the introduction of the hand; this has been successfully overcome by incisions into its edge;[111] but it is a remedy which no practitioner would use if by any means to be avoided.
Gastrotomy. Where the whole child has passed into the abdominal cavity, and the uterus has evidently contracted, so as to produce a serious, if not insurmountable obstacle to delivering it through the vagina, or at any rate without the risk of increasing the extent of the laceration, the question then remains as to whether we should perform gastrotomy, or leave the foetus in the abdominal cavity to be gradually discharged, like an extra-uterine pregnancy, by abscess and sloughing. There can be no doubt that the former plan is preferable, nor are there wanting upon record successful cases of gastrotomy after rupture of the uterus; one of which is doubly interesting from the operation having been twice performed with a favourable result in consequence of a repetition of the injury in the patient's succeeding pregnancy.[112] Mr. Ingleby, of Birmingham, gives a similar opinion in favour of the operation: "The result of two cases of Cæsarean operation in which I have been engaged, leads me to view the mere abdominal incision with very different feelings. The operation is not half so dangerous as the Cæsarean, whilst the celerity with which it is done, the absence of hæmorrhage, and the facility with which the intestines are confined within the abdomen, tend to divest it of much of its terror." (Op. cit. p. 201.)
Rupture during the early months of pregnancy. Cases of rupture of the uterus have occasionally been observed at an early period of pregnancy; in many of these the foetus has passed into the abdominal cavity, where it has been enclosed in a species of cyst, and afterwards expelled through the rectum or abdominal parietes by an abscess. It may be doubted whether some of these have not been cases of extra-uterine pregnancy. On the other hand, there is reason to believe that those extraordinary cases of ventral pregnancy, to which we have alluded, where the foetus has been found in a sac in the abdomen, which communicated with the uterus, and to which the placenta was attached, were the results of rupture at an early period of pregnancy, in all probability the result of ulceration or organic degeneration of the uterine parietes. In some instances it has been produced by violence: and it is by no means impossible that it might take place during a miscarriage, when the uterine contractions are occasionally very violent. Mr. Ingleby remarks that in a case of premature expulsion at the fifth month, the violence of the pains seemed quite equal to produce a breech of surface.
Dr. Collins has recorded a case of ruptured uterus in about the fifth month. The laceration appears to have taken place imperceptibly: the child was very putrid; and as the os uteri was sufficiently dilated, the head was perforated, and "was brought away almost without any assistance. It was nothing more than a soft mass, being so completely broken down by putrefaction."[113] There was no previous history to explain it; the muscular structure of the uterus at the anterior part of its cervix was torn, leaving the peritoneum entire.
Lastly, we may mention a very singular species of laceration of the uterus, of which we know of but two cases, the one recorded by Mr. P. N. Scott, of Norwich, (Med. Chir. Trans. vol. xi.) the other which occurred under our own notice, where the whole os uteri separated from the uterus during labour.[114] In both cases, the os uteri presented a degree of unnatural rigidity, which was quite peculiar, and which in one case, defied repeated and active bleeding, as well as opiates. In Mr. Scott's case, the laceration took place during a violent pain, when the patient "felt something snap, the noise of which one of the attendants declared she heard." In the other case, the patient was not aware of any thing peculiar having happened: it was a first labour in the eighth month of pregnancy; the os uteri had dilated to nearly the size of half a crown, but would dilate no farther; the child had evidently been some time dead; the cranial integuments gave way from putrefaction, the brain escaped, the bones of the skull collapsed, and the bag of scalp protruded so far that we could lay hold of it, although the basis cranii had not passed. We were thus enabled to use more extractive force than we could have ventured upon with the crotchet: after a little effort, but without even a complaint from the patient, the head descended and passed through the os externum. "On the bed lay a disc of fibrous matter with a circular hole in the middle; in fact, the os uteri separated from the uterus to the extent of near half an inch, the edge of the laceration being as clean and smooth as if it had been carefully cut off by a knife." In both instances the patient recovered. Whether incisions into the os uteri for the purpose of effecting the necessary degree of dilatation would have been justifiable under circumstances of such unusual rigidity, does not belong to the present subject; for the consideration of this, we must refer to the FIFTH SPECIES OF DYSTOCIA.
II. SECOND SPECIES OF DYSTOCIA
Size and form of the child.--Hydrocephalus.--Cerebral tumours.-- Accumulation of fluid and tumours in the chest or abdomen.-- Monsters.--Anchylosis of the joints of the foetus.
In this case the labour is rendered difficult or impossible to be completed by the natural powers on account of the faulty size, form, or condition of the child. In the first instance, it is merely a case of disproportion between the child and the passages, owing to the unusual size of the former. Where the child is well formed throughout, but larger than usual, it rarely happens that the head experiences any serious degree of difficulty in passing through a well-formed pelvis, the greatest resistance being observed during the dilatation of the external passages. Even when the head is born, the shoulders may produce a considerable obstruction to its farther passage, requiring a good deal of careful manipulation, in order to disengage the foremost shoulder from under the pubic arch, and thus diminish the pressure of the child against the parietes of the pelvic cavity. Where the shoulders have been severely impacted in this position, it has been in great measure owing to the practitioner having endeavoured to bring down the wrong shoulder first, viz. that which is directed more or less backwards.
Size of the child. We have already stated that the average weight of the full grown foetus is between six and seven pounds, and its length about eighteen inches; but it is frequently found to exceed these proportions very considerably. Children are not uncommonly observed to weigh 10lbs. at birth. Dr. Merriman once delivered a still-born child, which weighed 14lbs., and the late Sir Richard Crofts is said to have delivered one alive which actually weighed 15lbs.; but by far the largest child which we have yet heard of is recorded by Mr. J. D. Owens, surgeon, at Haymoor near Ludlow; it was born dead, and the weight and admeasurements ten hours after birth were as follow:--
The long diameter from the occiput to the root of the nose 7-1/4 inches. The occipito-mental 8-1/2 From one parietal protuberance to the other 5 Circumference of the skull 15-1/4 Circumference of the thorax over the xiphoid cartilage 14-1/2 Breadth of the shoulders 7-1/4 Extreme length of the child 24 Weight of the child 17 lbs. 12 oz.
(Lancet, Dec. 22. 1838.)
We have already pointed out the difficulty of determining the presence of twins merely from the appearance of the mother's abdomen; the same will necessarily hold good with regard to one large child. The size of the patient must rarely have any influence in forming our prognosis: in most cases she will have many symptoms, which arise either from pressure or weight in the pelvis, such as difficulty in passing water, oedema of the feet and legs, varicose veins of the thighs and labia, or from cramps, the result of pressure upon the absorbents, veins, or nerves; considerable expansion of the inferior segment of the uterus: all these will give us reason to suspect the presence of a large child even although the abdomen may not be remarkably distended.
Where the head is very large, the bones are seldom much ossified; they therefore yield easily, and the head accommodates itself to the shape of the passage: sometimes, however, it is unusually hard, the bones are well ossified and very unyielding, so that even if it be not larger than common, still, from its hardness, it meets with considerable difficulty in passing through the pelvis. Cases have been described where the cranial bones were completely ossified, and the sutures perfect; but this latter is very doubtful. Perfect mentions an instance where the head was "almost one entire ossification, and where it passed through the pelvis with great difficulty." (Perfect's Cases in Midwifery, vol. ii. p. 370.) We have also met with cases requiring perforation on account of deformed pelvis, and where the cranial bones had almost the feel of a hard nut or shell; still, however, as already observed, we seldom see any serious impediment to the passage of a large head, so long as it is naturally formed; and this applies also to the other parts of the child.
Form of the child. On the other hand, where there is an unnatural form of the child, either from a disproportionate size or anormal configuration of certain parts, labour may be rendered not only very difficult but dangerous: thus one of the three great cavities may be distended with an accumulation of fluid, the most common form of which, is the congenital hydrocephalus.
Hydrocephalus. In many cases it produces much less resistance than might be expected from the size of the head; this is, in great measure, owing to the unusual width of the sutures and fontanelles, but chiefly to the almost entire want of ossification in the cranial parietes, which are little else than membranous, and so flexible as to allow the head to be squeezed into almost any shape. In some very rare cases the head has burst, a large quantity of fluid has come away suddenly, and this has been followed almost immediately by the birth of the child:[115] but in the majority the labour has been tedious and severe, and in some instances attended with dangerous results to the patient; thus, Dr. Merriman has "known one hydrocephalic foetus pass entire, the circumference of whose head was 17 inches; another passed alive and lived nearly an hour, whose head measured in circumference nearly 22 inches; both the above labours were long and painful." Perfect relates a case of hydrocephalic head, of which he has given engraved delineations; the labour was attended with extreme difficulty, and the woman expired in less than two hours after delivery; the circumference of this head was 24 inches. (Cases in Midwifery, vol. ii. p. 525.) An interesting case of hydrocephalus, attended with convulsions and laceration of the vagina, has been recorded by Dr. Collins: "the perforator was used, upon the introduction of which into the head fully three half pints of water gushed out; the bones then collapsed, and the delivery was easily completed." (Practical Observations, p. 205.)
Cerebral tumours. The bulk of the head is sometimes increased by tumours or sacs of fluid, which arise from a suture or fontanelle: they are of the same nature as the spina bifida, being formed by a protrusion of the integuments and cerebral membranes from an accumulation of fluid beneath: these are of very rare occurrence, and appear to have retarded labour but little, even although of considerable size. The largest cases on record are those which have been described by Ruysch, where one was as big as the head itself, and another where it was nearly as large as the child's body.[116] A case of fluctuating tumour upon a child's head has been described by Mauriceau, (Case 544,) but the precise nature of it is not very apparent.
Accumulations of fluid, and tumours in the chest or abdomen. It is very rare that the chest is distended by any accumulation of fluid or morbid growth, although this is not unfrequently met with in the abdomen. La Motte has given three cases of ascites which, by the distention of the abdomen, produced considerable obstruction to the delivery of the child. (Cases 331, 332, and 333.) In other cases the liver or the kidneys have been enormously enlarged. A case is described by Dr. Hemmer, where the child was born as far as the shoulders, and there stuck; finding it impossible to extract the child, he perforated the abdomen in two places, but could not extract it; in a few minutes after it came away of itself. The abdomen had been distended with small hydatids; these gradually escaped, and thus diminished the size of the abdomen. (Neue Zeitschrift für Geburtshülfe, band iv. heft 1, 1836.) Where the child has been dead some time in the uterus, the abdomen is frequently tympanic, and thus retards its expulsion.
Monsters. Certain cases of monstrous formation may produce very serious obstacles to the progress of labour: the most considerable is of twins united by the breast. It is difficult to conceive how so large a mass can be forced through the pelvis: we can only suppose it possible where the children have been dead some time before birth, or where they were premature: to this latter circumstance only we can attribute the fact of their having been born alive, as in the celebrated case of the Siamese twins. Where the children have been united by one pelvis, &c., the chances here of the foetus being dead before birth would be even still greater. M. Rath, of Zetterfeld, has lately described a case of extremely difficult labour, in consequence of twins united by the breast. "The children (two girls) weighed 15lbs.; they were 17 inches long. The part by which they were united was 9 inches broad and 3 long, and extended from the upper extremity of the sternum to the navel, into which one umbilical cord, which was common to both, entered. The diameter of the two children when laid together was between 7 and 8 inches from one back to the other. One child had two thumbs on the right hand. The cord was 19 inches long, and unusually thick. After suffering some time from peritonitis, &c., the patient recovered." (Siebold's Journal, band xvii. heft 2. 1833.)
Anchylosis of the joints of the foetus. Lastly, we may mention a very rare cause of this species of dystocia, which has been observed by Professor Busch, where the obstruction to the passage of the child arose from anchylosis of its joints. "The head had been delivered by the forceps, but the body would not follow. As no cause of obstruction could be discovered, a gentle and then more powerful traction was used: this was followed by a cracking sound, and the upper part of the trunk passed through the os externum: here again it stopped, but still, as no cause of obstruction could be discovered, and as the child was dead, another traction was made, with a repetition of the cracking sound, and the child was delivered. On examination it was found that all the joints of the extremities were anchylosed in the usual position of the foetus in utero, so that the ossa humeri and then the ossa femoris had given way. The child had been dead some time." (Neue Zeitschrift für Geburtskunde, vol. xv. 1837; and British and Foreign Med. Rev. April 1838, p. 579.)
No precise rules can be given for the treatment of these cases of malformation of the child; it must be modified according to the peculiarities of each individual case. Whenever a part has undergone considerable increase of size from accumulation of fluid, this can be in most cases removed without much difficulty by perforation, whether it be of the head or abdomen. With monstrous growths the accoucheur must depend upon his own resources, ingenuity and knowledge of the mechanism of parturition. The more careful and correct his diagnosis is, the more efficient will be the means he adopts for delivering the child. In such cases the examination can scarcely be made effectually by the finger alone, but the hand will be required for this purpose.
III. THIRD SPECIES OF DYSTOCIA
Difficult labour from faulty condition of the parts which belong to the child.--The membranes.--Premature rupture of the membranes.-- Liquor amnii.--Umbilical cord.--Knots upon the cord.--Placenta.
In describing this species of dystocia, according to the arrangement of Professor Naegelé, which we have adopted, it will be necessary to observe that serious obstructions to the passage of the child is seldom produced by it, although, at the same time, many slight derangements in the progress of labour are liable to result, which demand the care of the practitioner.
The membranes when too thick or tough (Merriman's Synopsis, p. 217,) may retard the labour occasionally, especially during the second stage, when instead of bursting and allowing the uterus to contract more powerfully upon the child by the evacuation of the liquor amnii, they are pushed down into the vagina, forming a large conical sac, which may even protrude externally. We doubt much, however, if the non-rupture of the membranes at the proper time during labour is of itself sufficient to retard its progress, for it is frequently observed that the head will, nevertheless, advance rapidly and even be born covered by the protruded membranes. Where labour is rendered tedious by the unusual strength of the membranes, it is generally connected with considerable distention of the uterus from liquor amnii; in which case the bag of waters is so spherical that it will not descend readily into the vagina, even although the os uteri is fully dilated, and, therefore, prevents the advance of the head: to this we shall recur immediately. So long as there is no undue accumulation of liquor amnii, we may safely allow the membranes to descend to the os externum before we rupture them. In former times a variety of instruments were employed for this purpose, many of which were dangerous, and all unnecessary, the finger being in most cases sufficient. The most effectual way of doing this is to press the thumb and middle finger upon the membranes during a pain and thus increase their tension, whilst the point of the fore-finger is pushed against them: scratching them with the nail during a pain will be sufficient when they are higher up the vagina.
Premature rupture of the membranes. More frequently the membranes rupture too soon, that is, before the os uteri is fully dilated: this may arise from their being too thin, a condition, however, which it is not very easy to prove: in most instances, it is observed where the uterus is but moderately distended, and where it has that oval or pyriform shape which we have already pointed out as being best adapted for acting efficiently upon the os uteri. This, perhaps, is one reason, why too early rupture of the membranes so frequently occurs in primiparæ; and this may be one cause, among many others, why first labours are generally so much more tedious and severe. The membranes may also be prematurely ruptured by violent exertions, coughing, sneezing, vomiting, &c. by straining immoderately and too soon, by rough and awkward examination, &c. Where this is the case, the patient should preserve the horizontal posture, and keep as quiet as she can until the os uteri has dilated sufficiently and allowed the head to advance.
Liquor amnii. Where the uterus is distended by an unusual quantity of liquor amnii, its contractile power is necessarily much impaired; and until the quantity of its contents be somewhat diminished, the progress of the labour will be more or less retarded. The average quantity of liquor amnii at the full period of pregnancy is about eight ounces; but it frequently exceeds this very considerably, occasionally amounting to several pints or even quarts. The causes of this extraordinary accumulation are still but little known. "M. Mercier has, in some cases, attributed it to an inflammatory condition of the amnion, the foetal surface of this membrane being stated to have been partially coated with false membrane, and the amnion itself crowded with blood-vessels of a rose colour:" in another case "about a quarter of the foetal surface of the amnion was inflamed, being of a deep red colour and double the natural thickness."[117] The results of Dr. R. Lee's observations, after having paid a good deal of attention to the subject, do not tend to confirm this view: he has described six cases of unusual accumulation of the liquor amnii, in one amounting actually to sixteen pints. In five of them "there existed with dropsy of the amnion some malformed or diseased condition of the foetus or its involucra, which rendered it incapable of supporting life subsequent to birth." In two only of the preceding cases was "the formation of an excessive quantity of liquor amnii accompanied with inflammatory and dropsical symptoms in the mother; and in none did the amnion, where an opportunity occurred for making an examination, exhibit those morbid appearances produced by inflammation, which M. Mercier has described, and which led him to infer that inflammation of the amnion is the essential cause of the disease." (Lee, op. cit.) Dr. Merriman has given a similar opinion, and states, that "when the embryo or foetus is diseased, the liquor amnii is sometimes immense in quantity. I once saw at least two gallons evacuated from the uterus: the child was monstrously formed and much diseased."[118]
In these cases the size and globular form of the uterus, the tenseness of its parietes, the more or less distinct feel of fluctuation, the absence of the child's movements and of any prominences arising from the projecting portions of its body, the rapid increase which has been observed in the size of the abdomen, the pain in different parts of the uterus, especially in the groins and pelvis, the oedema or anasarca of the lower extremities, serve to mark this condition. On examination per vaginam we also feel the inferior segment of the uterus much expanded, the cervix probably shorter than might be expected for the period of pregnancy; the ballottement is unusually free and distinct. In some instances the patient has suffered so much, either from the effects of the retarded circulation in the lower extremities, or from the impeded respiration as to require the membranes to be punctured in order to reduce the size of the uterus. The child is usually born dead where the accumulation has gone to so great an extent: in the three cases recorded by La Motte, it was dead before birth in the first two, and died immediately after birth in the third. Many of these cases, which have been complicated with disease or malformation of the foetus, have appeared to arise from a syphilitic taint; but in others, of more common occurrence, where there was merely an unusually large quantity of liquor amnii without any disease either of the mother or her child, the cause must still remain a matter of uncertainty. This latter condition is mostly seen in women who have been frequently pregnant; the os uteri in them is generally yielding, and when once it has attained its full degree of dilatation, we may safely rupture the membranes and thus expedite labour considerably.
There being an unusually small quantity of liquor amnii can scarcely operate as an obstruction to labour, except where the membranes have been prematurely ruptured.
The umbilical cord may obstruct labour, by either being too short, or rendered so from being twisted round some part of the child. Its length varies very considerably. Although we have stated it to average about eighteen or twenty inches,[119] we have met with extreme deviations both within as well as beyond this medium length. The shortest cord which we know of occurred some years ago at the General Lying-in Hospital, "where, after two or three violent pains, the child was suddenly and forcibly expelled the cord was found ruptured at about two inches from the navel of the child, which cried stoutly. After removing the child the matron sought for the other end of the funis, but could not find it; she examined per vaginam but could not feel it; and on introducing her hand into the uterus, found the placenta with the remains of the cord ruptured at its very insertion; so that in this case the cord could not have been much more than two inches long." (Printed Lectures in Renshaw's Lond. Med. and Surg. Journ. May 1835, p. 426.)
We quite agree with Professor Naegelé, that unusual shortness of the cord can rarely if ever retard labour; and that where the cord really produces an impediment to its progress, it is from being twisted round the neck, or some other part of the child. (Lehrbuch, 2d ed. p. 289.) This generally arises from its unusual length, and from its having formed several coils around the child: we have met with it forty-eight inches long, and twisted four times round the child's neck; but Baudelocque mentions a case where it actually measured fifty-seven inches, "forming seven turns round the child's neck." (Heath's Transl. vol. i. § 516.) Mauriceau has given an instance (Obs. 401.,) where the cord had "longueur d'une aune et un tiers de notre mesure de Paris:" which, converted into English measure, amounts to somewhat more than sixty-one inches.
Although nothing is of more common occurrence than the cord being twisted once or twice round the child, it nevertheless, happens, but very rarely, that its advance is thereby obstructed. In a case of this sort, the labour usually commences quite favourably; the os uteri dilates, and the head advances to a certain extent, beyond which it makes no other farther progress; the uterine contractions are attended with much pain in the fundus, during which the head advances somewhat, but retires again during the intervals. Where the head is already near the os externum, this may be easily attributed to the elasticity of the soft parts, until the delay which takes place to the farther progress of the labour warns the practitioner that something more than ordinary is the cause. But where this takes place, and the head is still in the pelvic cavity; where at the same time, although it refuses to advance, it is quite moveable, and allows the finger to be passed freely round it; where any attempt to extract it with the forceps has not only met with great opposition, but has greatly aggravated the sense of painful dragging in the upper parts of the uterus there will be pretty certain evidence of the cord being either too short, or, what is most probable, of its being twisted round the child. In each of the three cases recorded by La Motte, the head had descended to the os externum; whereas, in two others described by Burton, it was evidently much higher up: he ruptured the cord in both instances; La Motte succeeded in cutting the cord with a pair of scissors in one case, in another he appears to have separated the placenta, and in the other to have delivered by little else than force. Where upon introducing the hand we find it impossible to undo the coil of the funis, we should endeavour to slip it first over one and then the other shoulder, as we have recommended under the more ordinary circumstances: should this fail, we must try to cut it through either by a finger nail slightly notched for the purpose, or by the introduction of a Smellie perforator well guarded.
The cord being twisted round the child's neck may not only retard labour, it may destroy the child itself by preventing the free return of blood from the head: this may take place some little time before birth, or during the actual process of labour. That suffocation cannot possibly be the cause of death under these circumstances is sufficiently evident.
Knots upon the cord have been mentioned by some authors as a cause of danger to the child shortly before and especially during labour; for the circulation in the umbilical vessels being more or less compressed, the child would either be born dead or in a very weakly state. Experience has, however, shown that these effects have been much over-rated, and that these knots are seldom injurious to the child.[120] Baudelocque has not only met with single, but even triple and very complicated knots tied tightly upon the cord, and yet the child was not only born alive, but remarkably robust and healthy. Circumstances, however, may occur by which the knot is gradually drawn so tight as to destroy the child. Smellie has given a case of this kind; but it is to the late Matthew Saxtorph, of Copenhagen, that we are indebted for an admirable essay on this subject. The result of his observations coincides with those of Baudelocque, viz. that it rarely proves fatal to the child.[121] The manner in which these knots are formed may be easily imagined; when by chance the cord lies in the form of a ring, and the foetus happens to float through it, a noose is made, which, when drawn tight by accident, forms a knot.
The most favourable time for the formation of such knots is in the earlier months of pregnancy, when the quantity of liquor amnii, in proportion to the bulk of the foetus, is so much greater than at an after period, and when its movements are consequently less impeded. The circulation in the knot will be obstructed in proportion as the knot is drawn closer: if it be merely somewhat impeded, the vessels on each side of the knot will be distended and varicose, and the cord itself, where it forms the knot, from the constant gradual pressure of one fold against the other, will become more or less flattened.[122] We believe that in every case the cord has been of unusual length.
The placenta cannot easily obstruct the birth of the child, although it may render the labour exceedingly dangerous in a great variety of ways: these circumstances will be considered under their respective heads.
IV. FOURTH SPECIES OF DYSTOCIA
Abnormal state of the pelvis.--Equally contracted pelvis.--Unequally contracted pelvis.--Rickets.--Malacosteon, or mollities ossium.-- Symptoms of deformed pelvis.--Funnel-shaped pelvis.--Obliquely distorted pelvis.--Exostosis.--Diagnosis of contracted pelvis.-- Effects of difficult labour from deformed pelvis.--Fracture of the parietal bone.--Treatment.--Prognosis.
This may arise from there being either too much or too little resistance to the passage of the child; where, in the one case, labour is rendered difficult or impossible to be completed by the natural powers; in the other, it is unnaturally rapid. The latter condition belongs to the second great division of dystocia, where the faulty character of the labour does not depend upon its progress being deranged, but upon other circumstances: we shall, therefore, delay speaking of precipitate or too rapid labour from unusually large pelvis, until then, and devote the present chapter to the consideration of those cases where the labour is more or less obstructed by the faulty condition of the mother's pelvis.
The pelvis may obstruct the passage of the child in a variety of ways.
1. It may be merely a diminutive or dwarfish pelvis, viz. well formed but smaller than usual in every direction--the pelvis simpliciter justo minor of Continental authors.
2. It may be distorted and deformed.
3. It may be of the natural form and size, but the passage through it more or less obstructed by exostosis.
Equally contracted pelvis. The first species of faulty pelvis (pelvis simpliciter justo minor,) is not of common occurrence, and has received but little notice in this country. It has been said to resemble the pelvis of a girl in its general appearance; but this only holds good in point of size; for, in the relative proportions of its diameter, it presents all the characters of a well formed adult pelvis. From this circumstance, it can scarcely be said to be an arrest of development, the necessary changes in the form of the pelvis having taken place at the time of puberty, as completely as if it had been of the ordinary size. A pelvis of this sort may be not more than a quarter of an inch too small in every direction, or it may be as much as a whole inch: we do not know of any case where the diminution has exceeded this last degree.
The pelvis equaliter justo minor is not accompanied with a corresponding diminutiveness in the rest of the skeleton, most of the patients in whom it has been observed being well formed and of the usual stature. Fortunately, as before stated, it is of rare occurrence, for even a small diminution in the size of the bony passages, which is uniform in every direction, presents a most serious obstacle to the passage of the child. Thus, in three cases of the sort, which have been described by Professor Busch in his report of the Berlin Lying-in Hospital, the labour terminated fatally in two. "The first case was a presentation of the breech; the head was delivered by the forceps; the child was dead; the pelvis measured half an inch too small in every direction. In the second case, which was a head presentation, the delivery was effected by the forceps, but not without the greatest efforts; the child was still-born, and the mother died in a day or two after from peritoneal inflammation. The third case required perforation; this also terminated fatally, the forceps having been previously applied, and considerable efforts made without success. On examination after death, every diameter of the pelvis was three quarters of an inch smaller than usual: in appearance it resembled that of a child." (Neue Zeitschrift für Geburtskunde, vol. xv. 1837.)
Unequally contracted pelvis. The unequally contracted pelvis (pelvis inæqualiter justo minor) may exist under a variety of forms; the most common is where the antero-posterior diameter is defective, or, in other words, where the distance between its anterior and posterior parietes is less than usual. In a slight degree, it is frequently met with among the poorer classes, and arises from the patient having been compelled to carry heavy burdens in early childhood, or otherwise subjected to severe labour. The practice of entrusting a girl of eight or ten years of age with the care of a heavy infant, which she carries about in her arms for many hours every day, is a fruitful source of this species of pelvic deformity; the young and plastic pelvis is unable to bear the additional pressure which is thrown upon the sacrum by the overloaded trunk, without having the just proportions of its growth materially influenced and perverted, especially at a period of life when the whole form of the pelvis is undergoing considerable changes. The constant pressure and counter-pressure to which the pelvis is subjected by the undue weight which is applied to the sacrum above, and supported by the resistance of the femora against the acetabula below, must necessarily tend at this age, even in an ordinary state of health, to impair its symmetry, more or less, and gradually to diminish the distance between its anterior and posterior parietes. Under no circumstances has this cause of pelvic deformity acted to such an extent as in the English manufactories, where young children are compelled to remain standing for twelve or more hours at the machines: the physical powers are unequal to the endurance of so much unceasing labour, the skeleton of the child soon suffers in its growth, and the pelvis almost certainly becomes contracted.
Similar effects may also be produced by undue pressure on the other parts of the pelvis. Thus the outlet may become much contracted by sitting many hours a day on a hard seat, as is frequently the case in schools. The tubera ischii are pressed together, the pubic arch is thereby contracted, and the sacrum becomes strongly curved forwards. Much riding on horseback at an early age is said to be injurious; and it is stated that the females of those American nations who are constantly on horseback bear but few children, and are frequently three or four days in severe labour.
Rickets. Similar effects, only in a much more aggravated form, are produced by rickets in early life; the pelvic bones having become soft from the loss of their earthy matter, gradually give way under the pressure of the superincumbent trunk, to the support of which they were unequal. In this way the sacrum is forced downwards and forwards towards the symphysis pubis, the acetabula are driven upwards and backwards, the pubic arch becomes distorted; and if the disease continues for a considerable period of time, the whole pelvis becomes so squeezed together as entirely to lose its original proportions.
The manner in which the distortion takes place varies exceedingly, and will be more or less influenced by the circumstances under which the child has been placed. The most constant change is the shortening of the antero-posterior diameter at the brim. In severe cases the base of the sacrum has, as it were, sunk down between the illia, so that its promontory occupies the cavity of the pelvis, the fourth, or third, or even the second, lumbar vertebræ occupying its former position. The gradual yielding of the bones seldom takes place with that degree of uniformity as to allow the sacrum to approach the symphysis pubis in a straight line: the more common result of rickets is, that the promontory is, at the same time, wrung more or less to one side.
"If the superior strait does not constantly present the same figure in deformed pelvis; if it is sometimes larger on one side than the other; if one of the acetabula is nearer to the sacrum, while the other approaches less; if the symphysis of the pubes is removed in many cases from a line which would divide the body into two equal parts, it is because the rickets has not equally affected all the bones of the pelvis, nor equally hurt all their junctions; and because the attitude which the child takes in walking or sitting may change a little the direction of the compressing power, which I have just mentioned." (Baudelocque, translated by Heath, vol. i. p. 60.) Nor is it necessary that the degree with which the disease affects the different parts of the pelvis should vary in order to produce these inequalities of distortion, for there is no reason to suppose that the promontory of the sacrum would approach the symphysis pubis in a straight line, even where the softening of the bones was uniform throughout; the attitude of the child, as above-mentioned, and the manner in which it supports itself, will have no inconsiderable influence in determining the direction in which the distortion takes place.
In those instances where the promontory is forced low down into the pelvic cavity, the sacrum becomes bent upon itself, the upper part of it forming a sharp curve backwards, while its lower portion together with the coccyx being confined by their attachments, and more or less compressed by sitting, are directed forwards. This is not seen where the projection of the promontory is but slight; the curve of the sacrum so far from being increased is rather lessened; the sacrum is straighter and flatter than usual, so that, although the brim of the pelvis is contracted, we not unfrequently find the outlet even larger than natural: in other cases, where the softening of the bones has gone to a considerable extent, the outlet is diminished, from the tubera ischii having been forced inwards.
The degree to which the promontory projects, of course, varies considerably. The distortion is occasionally so great as not even to leave an inch of antero-posterior diameter. This excessive deformity, however, is more frequently the result of mollities ossium coming on after puberty, for we seldom find children live through this critical period where it has been the result of rickets. The brim of a deformed pelvis varies considerably in shape: "sometimes it has the form of a kidney, or that of the figure eight ([Symbol: infinity]); sometimes it is triangular or heart-shaped, the sides being curved inwards, from the acetabula having been pressed backwards or inwards, the ossa pubis are bent forwards and outwards, and form at their symphysis a sort of beak-like process, which is the apex of the heart: in this species of deformed pelvis, which is usually the result of mollities ossium, the outlet also is usually much distorted: this arises from the tubera ischii being forced nearer to each other, thus contracting the pubic arch." (Naegelé's Lehrbuch, 2te Ausgabe, p. 247.)
Malacosteon, or mollities ossium. An arthritic, rheumatic, or gouty diathesis is a morbid state, in which softening of the bones may take place at a much later period of life, and to a most extraordinary extent. In almost all the cases of extreme pelvic deformity which have been recorded, the distortion has been owing to this disease, and not to rickets in early life: in a pathological point of view there is a considerable analogy between these two diseases. From a variety of causes there is a superabundant formation of acid in the system, which its excreting organs are unable to throw off. The effects of this condition will vary according to circumstances; among them the softened state of the bones from a deficiency of insoluble bone earth is not the least remarkable. Mollities ossium seldom attacks women who have had no children: sometimes it begins shortly after delivery, and very frequently during pregnancy, during the progress of which it continues to increase. Hence, it occasionally happens, that a woman has given birth to several healthy living children without any unusual difficulty in her labours, and where, after this, the pelvis has gradually become so deformed from mollities ossium, as to render delivery impossible by the natural passages, and, therefore, to require the Cæsarean operation. Pelves of this sort, may be easily distinguished from those which have been deformed in early life by rickets; they have evidently attained their full adult growth before the process of softening had commenced: the ilia, for instance, are of the natural size, but bent across, as if they had been folded like wet pasteboard; whereas, the bones of the ricketty pelvis have not attained their full development, they are stunted in growth as well as distorted in shape, the two processes, viz. of growth and distortion, having evidently, co-existed.
The form of the pelvis in mollities ossium necessarily varies with the peculiar circumstances under which the individual is placed: thus, if her strength allows her to sit up, or even to get about, as is generally the case more or less, the promontory and the pubic bones are gradually pressed towards each other, so that the antero-posterior diameter is greatly diminished:[123] if, however, she is confined entirely to bed for a considerable period, the distortion takes a different and much rarer form. From her lying first on one side and then on the other, the pelvis is laterally compressed; the transverse diameter becomes even shorter than the antero-posterior; and if the disease continues long enough, the pelvis is at length so altered and mis-shapen, that nearly all its original configuration is obliterated. The weight of such a pelvis varies considerably: where the disease has ceased some time before death, and bone earth has been again deposited, there will be little difference in this respect from a natural healthy pelvis; but if the patient has died with the disease in full activity, its weight will be greatly diminished, amounting sometimes only to a few ounces.
Mollities ossium, to a slight extent, we believe, is not very uncommon, although cases of extreme deformity from this cause are of rare occurrence. Mr. Barlow states, that "eight cases of this species of progressive deformity have fallen under my notice, in one of which the projection of the last lumbar vertebra at its union with the angle of the sacrum was so much bent forwards into the cavity of the pelvis, that on the introduction of the fore-finger up the vagina, a protuberance was presented to the touch very much resembling the head of the foetus pretty far advanced into its cavity. On carrying the finger a little anteriorly past the projection, I could with difficulty ascertain the head of the child: but on moving it around, the distortion appeared so great, that the whole circumference did not exceed that of a half-crown piece. This occurrence was on the 29th of April, 1792, at which time I delivered the woman with the crotchet, and the bones of the pelvis receded considerably to the impulsive efforts during the extraction of the head of the foetus; yet, notwithstanding, the flexibility of the bones of the pelvis, and the debilitated state of her constitution, she recovered speedily and without interruption." On the 2d February, 1794, being in the neighbourhood, and learning that she was still alive, Mr. Barlow visited her and requested an examination. "I found her unable to walk without assistance, and as she sat, her breast and knees were almost in contact with each other. The superior aperture was nearly in the same state as when I delivered her with the crotchet, but the outlet appeared more contracted, the rami of the pubes overreached, leaving a small opening under the symphysis barely sufficient to admit the finger to pass into the vagina by that passage, and another aperture below, but rather larger, and parallel with the junction of the tuberosities of the ossa ischii. From what I learned afterwards respecting this decrepit female, she survived this period about two years, at which time she was become still more distorted in the spine; and after her death it was with difficulty she could be put into her coffin; this woman bore nine children, and died in the thirty-ninth year of her age." (Barlow's Essays, p. 329.)
Mollities ossium may be feared when, in addition to the general breaking up of the health and strength, the patient suffers from arthritic pains and swellings of the limbs, the urine is generally loaded with lithic secretion: and most of all, where distinct shortening and gradual distortion of the skeleton is taking place. Where the deformity has been the result of rickets in early life, a little careful observation of the patient's external appearance will quickly lead the experienced eye to suspect the nature of the case.
Symptoms of deformed pelvis. Among the external appearances which would lead us to suspect a deformed pelvis, are "the lower jaw projecting beyond the upper; the chin very prominent; the teeth grooved transversely; unhealthy appearance; pale ashy colour of the face; diminutive statue; unsteady gait; when the woman walks the chest is held back, the abdomen projects, and the arms hang behind; there is deformity of the spine and breast, one hip higher than the other, the joints of the hands and feet are remarkably thick; curvature of the extremities, especially the inferior, even without distortion of the spine is a very important sign; wherever the lower extremities are curved, the pelvis is mostly deformed: it is well to ascertain also if, when a child, it was a long time before she could walk alone; whether she had any fall on the sacrum; whether as a girl she was made to carry heavy weights, or to work in manufactories." (Naegelé's Lehrbuch. § 444.)
Funnel-shaped pelvis. Besides the above-mentioned species of pelvic deformity, others are occasionally met with, the origin of which is but little understood. The funnel-shaped pelvis is of this character, where the brim is perfectly well formed, but where it gradually contracts towards the inferior aperture. There are no evidences of its having been produced by any disease; nor in fact can we assign any satisfactory cause for this peculiar configuration: it appears to have been a congenital formation.
Obliquely distorted pelvis. A still more remarkable species of pelvic deformity is the pelvis obliqué ovata, which, of late years, has been pointed out by Professor Naegelé. In this case the pelvis appears awry, the symphysis pubis being pushed over to one side; and the sacrum to the other; one side of the pelvis is more or less flattened, the other bulges out, so that one oblique diameter is shorter, the other longer than natural; and this applies not only to the brim, but to the cavity and outlet of the pelvis. In most cases the sacro-iliac symphysis on that side which is flattened, and to which the sacrum is inclined, is completely anchylosed, not a trace of the division between the ilium and sacrum to be detected, the two bones being completely united into one. In many, the sacrum on this side is smaller than on the other, as if a portion of it had been removed by absorption during the process of anchylosis, or at least not properly developed. When we consider the form of the pelvis, and the appearances which the sacro-iliac symphysis and the sacrum present, we are almost led to conclude that ulcerative absorption must at one time have existed between the sacrum and ilium at this point, probably at an earlier period, by which means more or less bone had been destroyed before the termination of the disease in anchylosis; indeed, we can to a certain extent imitate this peculiar species of pelvic deformity by sawing off the surfaces of the sacrum and ilium which had formed the symphysis, and then putting the bones together again. Still, however, in the various cases which have been collected by Professor Naegelé, no proofs could be obtained of disease having existed in the pelvis during early life.
"In none of the cases, the particulars of which have come to my knowledge, has there been any trace of rachitis; nor have any of the symptoms, appearances, and morbid changes been observed which characterize mollities ossium coming on after puberty. None of these cases have been traced to the effects of external violence, as falls, blows, &c.; nor has there been any complaint of pain in the region of the pelvis, inferior extremities, &c." (Das Schräg Verengte Becken, p. 12.) "With respect to the strength, colour, structure, &c. of the bones of this species of deformed pelvis, no difference could be observed between them and the bones of young and perfectly healthy subjects; not a trace either in form or other respects could be detected of those changes which usually result from rachitis or mollities ossium; and but for this distortion and some other slight irregularities, which required close inspection to detect, these pelves would have been looked upon as well-shaped, and of sufficient capacity." (Naegelé, op. cit. p. 11.) In some specimens no trace of anchylosis at the sacro-iliac symphysis has been observed; but whether this was the case throughout the union of the two bones we cannot say. Professor Naegelé is inclined to look upon them as modifications of the pelvis obliqué ovata, and certainly in the majority of known cases anchylosis has been found present.
It is scarcely necessary to do more than enumerate other varieties in the form of the pelvis, which are occasionally met with: it is sometimes round, the transverse and antero-posterior diameters being of the same length; in other cases it possesses many of the characters which distinguish the male pelvis, being more or less triangular, deep, and with a contracted angular pubic arch.
Exostosis. Lastly, the pelvis may be perfectly well formed, but the passage through it more or less interrupted by the exostosis: this is, perhaps, the rarest species of dystocia pelvica. It may arise from wounds of the periosteum, from fracture of the bones, callus, &c. and may vary in size from a small protuberance to a large mass, which completely fills up the pelvis.
Diagnosis of contracted pelvis. The difficulty of detecting an abnormal configuration of the pelvis, will depend, in great measure, upon its extent: where it is but slight, it may easily be passed over unobserved by a young practitioner, although it may, nevertheless, be quite sufficient to render labour both difficult and dangerous. In the ordinary form of contracted pelvis, where the antero-posterior diameter is shorter than natural, the being able to reach the projecting promontory of the sacrum with the finger is of itself a sufficient evidence: but the converse of this is not true, for we frequently meet with cases of contracted pelvis, without being able to reach the promontory. The numerous instruments which have been invented at different times for measuring the pelvis are of such doubtful accuracy, as to be nearly useless; the experienced finger is the best pelvimeter; and the power of correctly estimating the dimensions of the pelvis during examination, can only be acquired by constant practice, based on a thorough knowledge of them in the healthy pelvis.
The manner in which labour commences is frequently sufficient to make us suspect the presence of a contracted pelvis. Besides, the general appearance of the patient, we frequently find that the uterine contractions are very irregular; that they have but little effect in dilating the os uteri; the head does not descend against it, but remains high up; it shows no disposition to enter the pelvic cavity, and rests upon the symphysis pubis, against which it presses very forcibly, being pushed forwards by the promontory of the sacrum. It is probably from this circumstance that the os uteri, more especially its anterior lip, shows so little disposition to dilate in these cases, for the lower portion of the uterus being jammed between the head and symphysis pubis in front, and promontory behind, the contractions of the longitudinal fibres can have little effect upon the os uteri. Hence we find, that in cases of diminished antero-posterior diameter requiring perforation, and where the os uteri in spite of violent pains, bleeding, &c. has refused to dilate beyond a certain point, on lessening the head, and thus removing its pressure from the symphysis pubis, it has quickly attained its full degree of dilatation.
Where the pains have been active, and a portion of the head has forced itself through the brim, and now projects to a certain extent into the cavity of the pelvis, it will be still more difficult to reach the promontory before delivery; and if, as is frequently the case, the sacrum is bent strongly backwards, so as to render the cavity and outlet very spacious, the real cause of impediment to the progress of labour may be entirely overlooked. It is here that the position of the head upon the symphysis pubis will prove a valuable means of diagnosis. The straightness of the sacrum will also be a guide in other cases.
In that form of the pelvis which has been called the funnel-shaped pelvis, and where the brim and upper portion of the cavity are of the natural dimensions, but where it gradually diminishes towards the outlet, the appearances are frequently very deceptive, the head advances without impediment, and descends as far as the inferior aperture, with every promise of speedy delivery; but here its progress is arrested, and even in the very last stage may require perforation.
It occasionally happens, also, where the deformity is very considerable, that the promonotory projects to such an extent as to be even capable of being mistaken for the head itself; and cases have actually occurred where, under this impression, the bone has been perforated instead of the child's head. So gross an error as this may easily be avoided by care in making the examination; by ascertaining that the projecting mass is immoveable; that the patient is sensible to the pressure of our finger; and that the promontory can be traced to be continuous with the adjacent parts of the pelvis.
The effects which may result from labour protracted by pelvic deformity are very various, both as regards the mother and her child. The most common form of injury which is produced by this cause, is the contusion and consequent inflammation and sloughing of the soft tissues which line the pelvis from the long continued pressure of the head against the symphysis pubis in front, and against the promontory of the sacrum behind. Not only may sloughing of the vagina and lower part of the uterus be the result, but the mischief may extend through the posterior wall of the bladder, and thus render the patient incapable of retaining her urine, and an object of great, and, generally speaking, incurable suffering.
The danger from rupture of the uterus will chiefly depend on the degree of pressure with which the uterine contractions force the head against the brim. Where the pains are violent, and yet insufficient to overcome the obstacle which the contracted pelvis presents to the advance of the head, there is not safety for a minute, and perforation must be immediately had recourse to. Where the edge of the promontory is very projecting and sharp, the structure of the uterus may be seriously injured by the pressure and contusion. In some cases it has evidently been the cause of ruptures, the fibres having given way first at this spot.
The constant severe pressure upon the head will be not less injurious to the child's life; it must inevitably produce a considerable impediment to the cerebral circulation; and where the liquor amnii has escaped, the pressure of the uterus upon the body of the child will scarcely be less prejudicial. The cranial bones frequently become remarkably distorted, so that after a difficult labour a deep furrow is found on that part of the head which corresponded to the projecting promontory.
Fracture of the parietal bone may even be produced, a fact of which practitioners, till lately, have not been sufficiently aware; and cases have occurred where children have been born dead, with the head greatly distorted, and one of the bones fractured, from which circumstances the mothers have been suspected of infanticide. Dr. Michaelis, of Kiel, has lately reported an interesting case of this kind, where the fracture seems to have resulted from the great immobility of the coccyx. The head was much disfigured, and on examining it the frontal bones were uninjured, but so flattened that the frontal and parietal portions of the sagittal suture lay nearly in the same place; the fontanelle and anterior two-thirds of the sagittal suture projected high up, and the sagittal borders of the parietal bones were firm and well formed. In the posterior third of the sagittal suture, where the parietal bones were firm and well formed, and the suture only two lines in width, were seen small livid portions of the longitudinal sinus forced between the bones. The occipital bone was flattened and forced deep under the parietal bones, but not otherwise injured. The right parietal bone, which during birth had been turned towards the promontory of the sacrum, was covered anteriorly and superiorly with effused blood, and on removing the periosteum, was found fractured in five places. (Neue Zeitschrift für Geburtskunde, vol. iv. part 3. 1836.[124])
Where the action of the uterus is not very violent, and the bones yielding, the head gradually adapts itself to the form of the passage without destroying the foetus; it elongates itself more and more until it is enabled to pass, so that after a tedious labour of this sort, we sometimes find the configuration of the head remarkably altered. Baudelocque, has mentioned a case recorded by Solayres de Renhac, where the head was so elongated that the long diameter measured eight inches all but two lines, the transverse being only two inches and five or six lines.
Treatment. Where the pelvic deformity is very considerable, there can be little difficulty in deciding upon the line of conduct to be adopted. It is in those cases where the obstruction is but slight that the indications for treatment are less distinctly marked: nor must we be satisfied with merely ascertaining the relative proportions of the head and pelvis; for the hardness or softness of the cranial bones, the disposition which they manifest to yield to the pressure of the uterus and surrounding parts, the state of the cranial integuments, and though last not least, of the soft tissues which line the pelvis, must all be carefully ascertained before a correct opinion as to the precise mode of treatment can be formed. Nor, if the woman has already had children, can we altogether be guided by the history of her previous labours; for where the above-mentioned circumstances have been favourable, a slight diminution of the pelvis will scarcely be attended with any perceptible delay or increase of difficulty beyond the natural degree; whereas, if the head happens this time to be a little larger, its bones more ossified, the fontanelles smaller, the scalp and soft linings of the pelvis more swollen, &c. a serious obstruction to the progress of labour will be the result. Thus it is that we not unfrequently meet with patients in whom the first labour has been tolerably easy, the second has been attended with much difficulty and required the forceps, in the third, the difficulty was so much increased as to require perforation, and the fourth where the labour was, like the first, perfectly easy and natural.
It is impossible for the head to remain long in the pelvis (except under unusually favourable circumstances) without more or less obstruction to the circulation, both in the scalp itself and in the surrounding soft tissues. The necessary consequence of this is swelling, by which the head increases while the passage diminishes in size; and this must still be more remarkably the case where the pelvis is at all contracted. It is in these cases that we frequently see such relief produced by venesection; and it is also as a topical depletion to the overloaded vessels, that we can explain why a free secretion of mucus is so favourable a symptom.[125]
Prognosis. Where the pains are moderate and equable, the os uteri nearly or quite dilated, the head not large, its bones yielding and overlapping at the sutures; where the greater portion of it has evidently passed through the brim, and, although slowly, advances perceptibly with the pains; where the passages are cool and moist, the pulse good, and the patient not exhausted, we may safely wait awhile and trust to the efforts of nature. On the other hand, where the pains are violent, the os uteri thin and undilatable, the head forced forwards upon the symphysis pubis by the projecting serum, if the greater part of its bulk has not yet passed the brim, if the soft parts are much swelled, the vagina hot and dry, the pulse has become irritable, the abdomen tender, the patient exhausted and much depressed both in mind and body, the powers of nature are evidently incompetent to the struggle, and require the assistance of art.
Such cases seldom permit the application of the forceps; the head is already pressing too firmly against the brim, and its greatest bulk having not yet passed, a still farther increase of pressure will be required to effect this object, which therefore cannot be attained without producing serious mischief. Where, however, the head has fairly engaged in the cavity of the pelvis, and the case is rather becoming one of deficient power, the forceps will be justifiable, and generally quite sufficient to effect the delivery safely.
The young practitioner must be cautious not to mistake an increase in the swelling of the scalp for an actual advance of the head itself--an error which may very easily be committed if he merely touches the middle of the presenting portion: he must carefully examine the circumference of the presenting part, where the head is pressing against the pelvis, and where there is little or no swelling, and he will frequently find to his disappointment, that although the cranial swelling may have even nearly approached the perineum since his last examination, the head itself has remained unmoved.
Where the forceps has been determined upon, we should endeavour to render its action as favourable as possible, viz. by bleeding, by the warm bath, and by evacuating the bladder and rectum before proceeding to the operation: we thus improve the condition of the soft parts, and diminish the chances of its acting injuriously.
From what has now been stated respecting the various circumstances which may tend to aggravate or alleviate the existing degree of pelvic deformity, it will be seen how incorrect and unpractical must be the attempt to classify the means of treatment merely according to the dimensions of the pelvis. To assert that within certain limits of pelvic contraction the child can be delivered by the natural powers, and that beyond these limits the forceps must be used; and that where it proceeds to a certain extent farther, it can only be delivered by perforation, &c. is evidently objectionable: for there are no two cases alike, even supposing that the degree of pelvic contraction is exactly similar; hence, on the one hand, we might (under such fallacious guidance) be induced to trust to the natural powers when they are wholly incompetent to the task, and on the other, to have recourse to art when the real condition of the case justified no such interference.[126]
With regard to the diagnosis and treatment in the case of obliquely distorted pelvis (pelvis obliqué ovata,) our data are still too scanty to enable us to give any decided rules: the immobility of the head, although the antero-posterior diameter appears of its full length, the shortness of one oblique diameter, and consequent undue pressure upon the head in this direction, and the unusual length of the other, are the characteristics which we have observed in the only case of the kind which has come under our notice during life. In all the cases of labour rendered difficult by this condition of the pelvis, which have been collected by Professor Naegelé, the perforation has been strongly indicated; and where the forceps has been used, it has either failed, as with us, or if the delivery has been effected by this means, it has been attended with fatal consequences.
In exostosis of the pelvis we must be guided by our knowledge of the healthy pelvis, and by our carefully ascertaining the form and size of the bony growth, and in what degree it is likely to impede the passage of the child. As in cases of simple projection of the promontory, the head may be capable of passing, but in doing so becomes more or less distorted: thus Dr. Burns quotes a case from Dr. Campbell, where from exostosis within the pelvis, the left frontal bone was so greatly sunk in, as to make the eye protrude. Professor Otto, of Breslau, mentions a woman who had pelvic exostosis being the mother of four children, in each of whom a small portion of the cranium was depressed and not ossified.
An interesting case has been described by Dr. Kyll, of Cologne, where the patient was the mother of seven children; her former labours had been perfectly natural, except that in the last there had been preternatural adhesion of the placenta, which had required to be removed by the hand; in six days after she was seized with feverish symptoms and violent pain at the spot where the placenta had been attached. The attack yielded to proper treatment, but she continued feverish at night with perspirations, frequently deranged bowels, difficulty in passing water, and severe pain in the abdomen, especially when she tried to stand on the right leg. An abscess formed in the right groin, which was opened and discharged a large quantity of pus, from which her recovery was very slow, and in three years afterwards she became again pregnant. When labour came on, no presenting part could be reached; after a long time the feet came down one after the other, but the nates would not advance. Dr. Kyll found the child resting with the hips on the brim of the pelvis, and completely wedged fast by a hard immoveable tumour as large as a hen's egg, springing from the upper part of the right sacro-iliac symphysis, and apparently having been a result of the pelvic abscess; the child was delivered with great difficulty by embryotomy.
Perhaps the most remarkable case of pelvic exostosis is that which has been described by Dr. Haber of Carlsruhe, and where also the cause was ascertained to have arisen from a violent fall on the ice when carrying a heavy load upon the head; on coming to herself the woman found that she was unable to move, and in this state was conveyed home; she recovered to all appearances in a few weeks, married, and soon became pregnant. When labour came on it was found impossible to deliver her, from the pelvis being entirely filled with a huge exostosis: the Cæsarean section was performed, but she died, and on examination after death an immense mass of bony growth was found springing from the sacrum, which had been apparently fractured, not only filling up the whole cavity of the pelvis, but arising to a considerable extent above the brim.
In those cases of funnel-shaped pelvis which we have had the opportunity of observing, perforation has been ultimately required, although the head had passed easily through the brim and entered the cavity; in one of these we have subsequently used the artificial premature labour with success.
We have already stated the doubtful utility of arranging cases of deformed pelvis according to their degree of contraction, and of classifying the different modes of treatment by such a scale; still, however, there must be certain limits beyond which it will be impossible to make the child pass, even when diminished by embryotomy. To draw the precise line of demarcation, however, will be nearly if not quite impossible; and, as in cases of slighter deformity, we must take many other circumstances into consideration which we have already mentioned. An inch and a half from pubes to sacrum has been mentioned by many as the extreme degree of contraction through which a full grown child can be delivered by embryulcia; generally, however, in these cases of unusually deformed pelvis, there is much more space on each of the sacrum; and on this, in great measure, will depend the possibility of effecting the delivery. The celebrated case of Elizabeth Sherwood, which Dr. Osborn has recorded, and where he succeeded in delivering the child, although the antero-posterior diameter "could not exceed three-quarters of an inch," has been looked upon as being of doubtful accuracy, and that Dr. Osborn had unintentionally deceived himself. When, however, we learn that on the right side of the sacrum the antero-posterior diameter was an inch and three-quarters, the incredible nature of the case diminishes considerably, the more as the patient was examined by Dr. Denman and others who fully coincided with Dr. Osborn's statements. To assert that in this case the antero-posterior diameter was only three-quarters of an inch, as many have done, is evidently incorrect, and tends to throw doubt upon it: the case was evidently the closest possible approach to the limits requiring the Cæsarean operation; its success was mainly attributable to the gradual manner in which it was performed; the child had become completely soft and flaccid from putrefaction, and was thus more capable of being moulded to the contracted passage.
V. FIRST SPECIES OF DYSTOCIA
Obstructed Labour from a Faulty Condition of the soft Passages.
Pendulous abdomen.--Rigidity of the os uteri.--Belladonna.--Edges of the os uteri adherent.--Cicatrices and collosities.--Agglutination of the os uteri.--Contracted vagina.--Rigidity from age.--Cicatrices in the vagina.--Hymen.--Fibrous bands.--Perineum.--Varicose and oedematous swellings of the labia and nymphæ.--Tumours.--Distended or prolapsed bladder.--Stone in the bladder.
In speaking of the uterus itself as a cause of this species of dystocia, we only mention it here as one of the soft passages, not as the organ by the contractions of which the child is expelled; we merely refer to those faulty conditions of the uterus which produce an impediment to the child's progress, not to those which interfere with the natural condition of its expelling powers, as this will be considered under the next division of dystocia.
We have already stated our disbelief that an oblique position of the uterus can have any influence in producing malposition of the child. With the exception of extreme anterior obliquity, or pendulous belly, we equally doubt that it can have any effect in retarding the labour when the child presents naturally. The highest authorities in midwifery during the last hundred years unite in asserting that this celebrated opinion of Deventer, was a misconception.
Pendulous abdomen. Where, from great relaxation of the anterior abdominal wall, (a frequent result of repeated child-bearing,) the fundus is inclined so forwards as almost to hang over the symphysis pubis, the child's head does not readily enter the brim of the pelvis, nor can the uterine contractions act so favourably in dilating the mouth of the womb; and in this manner the first part of labour may be considerably retarded. Pendulous abdomen to this great extent is not very common; and in ordinary cases the horizontal posture, especially upon the back, is quite sufficient to allow the head to engage in the pelvis. "We have found more than once," says Dr. Dewees, "in cases of extreme anterior obliquity, that it is not sufficient for the restoration of the fundus that the woman be placed simply upon the back; but we are also obliged to lift up and support by a properly adjusted towel or napkin, the pendulous belly until the head shall occupy the inferior strait. To illustrate this, we will relate one of a number of similar cases in which this plan was successfully employed. Mrs. O., pregnant with her seventh child, was much afflicted after the seventh month with pain and the other inconveniences which almost always accompany this hanging condition of the uterus; was taken with labour pains in the morning of the 10th of October, 1820. We were sent for about noon. The pains were frequent and distressing, and, upon examination per vaginam, the mouth of the uterus was found near the projection of the sacrum, dilated to about the size of a quarter dollar, but pliant and soft. During the pain, the membranes were found tense within the os uteri, but did not protrude beyond it.
As this was the first time we had attended this patient, and from the history she gave of her former labours, in which she represented her abdomen being in all equally pendulous, with the exception of the first, we waited several hours (she being placed upon her side) for the accomplishment of the labour. During the whole of this period the head did not advance a single line; nor could it, as the direction of the parturient efforts carried it against the projection of the sacrum. We had several times taken occasion to recommend her being placed upon her back, but to which she constantly objected, until we urged its being absolutely necessary. She at length reluctantly consented to the change of position; when upon her back it was found that it did not advance the os uteri sufficiently towards the centre of the superior strait. The abdomen was therefore raised, and a long towel placed against it, and kept in the position we had carried it by the hands, by its extremities being firmly held by two assistants; at the same time we introduced a finger within the edge of the os uteri, and drew it towards the symphysis pubis, and then waited for the effects of a pain. One soon showed itself, and with such decided efficacy, as to push the head completely into the inferior strait, and three more delivered it." (Compendious System of Midwifery, § 224.)
This peculiar displacement of the uterus, which has been called by some anteversion of the gravid womb, has occasionally given rise to the suspicion that there was no os uteri, from its being tilted upwards and backwards towards the promontory of the sacrum: it has been said, in some cases, to have even contracted adhesions with the posterior wall of the vagina, from the firmness with which it was pressed against it, and thus tended still farther to increase the deception. "Within our knowledge," says Dr. Dewees in the paragraph preceding the one just quoted, "this case has been mistaken for an occlusion of the os uteri, and where upon consultation it was determined that the uterus should be cut to make an artificial opening for the foetus to pass through. They thought themselves justified in this opinion, first, by no os uteri being discoverable by the most diligent search for it; and, secondly, by the head being about to engage under the arch of the pubes covered by the womb. Accordingly, the labia were separated, and the uterine tumour brought into view. An incision was now made by a scalpel through the whole length of the exposed tumour down to the head of the child, the liquor amnii was evacuated, and in due course of time the artificial opening was dilated sufficiently to give passage to the child. The woman recovered, and, to the disgrace of the accoucheurs who attended her, was delivered per vias naturales of several children afterwards, a damning proof that the operation was most wantonly performed." Where, in addition to the anteversion, strong adhesions have taken place between the os uteri and posterior wall of the vagina, no trace of os uteri will be felt, and the operation above-mentioned does become sometimes necessary.
Rigidity of the os uteri. The chief way in which the uterus can obstruct the passage of the child, is, by an undilatable state of its mouth: this may arise from a variety of causes, which may be chiefly brought under the two heads of functional and mechanical. Under the first head comes rigidity of the os uteri, either from a spasmodic contraction of its circular fibres, or from irregularity or deficiency in the contractions of the longitudinal fibres of the whole organ. In a slight degree this is frequently met with, especially in first labours, where the patient is young, delicate, and irritable, and where, in all probability, there is some source of irritation in the primæ viæ which tends to disturb and divert the proper and healthy action of the uterus. We see it also in robust plethoric primiparæ; the os uteri dilates to a certain degree, perhaps an inch in diameter, and remains tense and firm, with its edge thin; the contractions of the uterus produce much suffering, and to all appearances are very violent; but they are chiefly in front, and produce little or no effect upon its mouth; the vagina is hot and dry, the patient becomes exhausted with fruitless pains, and fever or inflammation would quickly follow, if nothing be done to relieve this state. As this subject, however, belongs rather to the next species of dystocia, viz. that arising from a faulty condition of the expelling powers, we shall delay the consideration of the treatment.
Belladonna. It has been recommended, and not very judiciously, to apply belladonna to the os uteri in cases of great rigidity: it was repeatedly tried by the celebrated Chaussier in the Maternité, at Paris, and, according to his observations, it produced a considerable effect upon it. "The knowledge of the extraordinary powers which this drug possesses in causing dilatation of the iris, led to its employment for the object of enlarging the aperture of the uterus; but there is certainly no similarity in the structure and office of the two organs, and no analogy can be drawn between their functions. It is not likely that this means will produce the relaxation we require; and if no good results from its use, it must be injurious; not in consequence of the poisonous quality resident in the drug itself, but in the friction which is necessary for its efficient application. The mucus which naturally lubricates the part must be wiped away, and this irritation must predispose the tender organ to take upon itself inflammatory action." (Dr. F. H. Ramsbotham's Lectures, in Med. Gaz. May 3, 1834.)
For our own part we must confess, that, although we have seen this application tried repeatedly, it has never produced the desired effects, but has invariably brought on very troublesome and distressing symptoms, such as sickness, faintness, headach, vertigo, &c.
There is a condition of the os uteri which is occasionally met with, and which presents a degree of rigidity which we have never seen except where there have been adhesions and callous cicatrices from former injuries. It has nothing of the thin edge put strongly on the stretch during the pains; but it is thick and firm, presenting nothing of the elastic cushiony softness of the os uteri in a favourable state for dilatation; it dilates to about an inch across, tolerably regularly, and without much apparent difficulty, but no efforts of the uterus can dilate it farther. We have already alluded to two extreme cases of this when speaking of ruptured uterus, and where in each instance the os uteri entirely separated from the uterus and came away. Whether there is something peculiar in the structure of the part which renders it thus undilatable, or whether it required even still more powerful measures than those employed, is not very easy to decide.
Edges of the os uteri adherent.--Cicatrices, &c. A serious impediment to the passage of the child may be produced by adhesions of the sides of the os uteri to each other; by hard callous cicatrices resulting from ulcerations, lacerations, &c. in former labours; by abnormal bands, or bridles, as they have been called; and by tumours and other morbid growths. Where the structure of the os uteri has been much injured by previous injuries of this character, the resistance will probably be so great as to require artificial dilatation with the knife. Generally speaking, however, the whole circle of the uterine opening is not involved, portions still remaining of natural structure, and, therefore, capable of dilatation. On examination, it feels irregular both in shape and hardness; a part being soft, cushiony, yielding, and forming the segment of a well-defined circle, the rest of it uneven, knobby, and hard, being evidently puckered up by cicatrisation.
In many cases, these callous contractions give way more or less when the head begins to press powerfully against them; but even where this is not the case, the healthy portion of the os uteri is so dilatable as to yield sufficiently. It would be difficult to estimate how far an os uteri in this state, with perhaps, not more than half, or even a third, of its circle in a healthy condition is capable of dilating. But from cases which have come under our own observation, and others which have been recorded by authors in whom we place the greatest reliance, we are quite confident that with proper treatment a sufficient degree of dilatation can be effected without resorting to artificial means.
Bleeding to fainting, the warm bath, laxatives, and enemata, will assist greatly in promoting our object. Where, however, the contracted portion shows no disposition to yield to this treatment, or to the pressure of powerful pains, but forms a hard resisting bridle or band, which effectually impedes the farther advance of the head, it must be divided by the knife in order to prevent dangerous laceration of the part on the one hand, or protraction of labour on the other. The mode of doing this will be described when these conditions as effecting the vagina are considered.
Artificial dilatation of the os uteri by incision has been practised very rarely, the chief of these operations having had reference to the vagina. F. Ould considered that mere contraction of the os uteri from former lacerations did not require this operation; but that where it was in a state of schirrus, there would be "no chance for saving either mother or child but by making an incision through the affected part."
We have quoted, on a former occasion, a case of cicatrised os uteri recorded by Moscati, and where, in consequence of injury in a former labour, the opening was nearly closed; fearing the laceration which had occurred in a similar case under his father's care, in consequence of making merely one incision, he made a number of small incisions round the whole of the orifice until a sufficient dilatation was produced.
Agglutination of the os uteri. Another condition of the os uteri which may produce very considerable impediment to the passage of the child, is that which has been called agglutination, where by some adhesive process, apparently that of inflammation, the lips of the opening adhere and completely close it. These species of imperforate os uteri may occur in primiparæ as well as in those who have borne children: the agglutination of its edges takes place during pregnancy, probably shortly after conception. Upon examination we find no traces of hardness, rigidity, or any other morbid condition, either in the os uteri itself, or the parts immediately surrounding it; the os uteri is closed by a superficial cohesion of its edges, and which in some cases seem to adhere by means of an interstitial fibrous substance; this when of a firmer consistence forms a species of false membrane, which in some cases is capable of resisting the most powerful uterine contractions, and in others it appears to cover the os uteri so completely as to conceal it most effectually, and give rise to the erroneous conclusion that the os uteri is altogether wanting. Baudelocque describes this condition (Op. cit. § 1961;) but from the brief mention which he makes of it, as also from the treatment recommended, it is plain that he had no very distinct notions about it, for he advises that "in all cases the orifice must be restored to its original state, and be opened with a cutting instrument as soon as the labour shall be certainly begun."
In by far the majority of cases which have been recorded, the pains have after a time been sufficient to dilate the os uteri. Dr. Campbell has described two of these cases, where no os uteri could be traced for some time after the commencement of labour: both were first pregnancies: in the former, uterine action continued about twelve hours before the os uteri could be distinguished, when it felt like a minute cicatrix; the other patient had regular pains for two nights and a day before the os uteri could be perceived, and she suffered so much as to require three persons to keep her in bed; both these patients were largely bled, gave birth to living children, and had a good recovery.
We may suspect that the protraction of labour arises from agglutinated os uteri, when at an early period of it we can discover no vestige of the opening in the globular mass formed by the inferior segment of the uterus, which is forced down deeply into the pelvis, or at any rate, where we can only detect a small fold or fossa, or merely a concavity, at the bottom of which, is a slight indentation, and which is usually a considerable distance from the median line of the pelvis. The pains come on regularly and powerfully; the lower segment of the uterus is pushed deeper into the cavity of the pelvis, even to its outlet, and becomes so tense as to threaten rupture; at the same time it becomes so thin, that a practitioner who sees such a case for the first time would be induced to suppose the head was presenting merely covered by the membranes. After a time, by the increasing severity of the pains, the os uteri at length opens, or it becomes necessary that this should be effected by art: when once this is attained, the os uteri goes on to dilate, and the labour proceeds naturally, unless the patient is too much exhausted by the severity of her labour. Although the obstacle in some cases is capable of resisting the most powerful efforts of the uterus, a moderate degree of pressure against it whilst in a state of strong distention, either by the tip of the finger, or a female catheter, is quite sufficient to overcome it; little or no pain is produced, and the appearance of a slight discharge of blood will show that the structure has given way. Two interesting cases of this kind have been described by the late W. J. Schmitt, of Vienna, under the title of two cases of closed os uteri which had resisted the efforts of labour, and where it was easily dilated by means of the finger.[127]
Contracted vagina. The vagina may be naturally very small, or unusually rigid and unyielding: in the first case serious obstruction to the progress of labour is rarely produced, the expelling powers being generally sufficient ultimately to effect the necessary degree of dilatation; the proper precautions must be taken to avoid every species of irritation and excitement of the circulation; the bowels must be duly evacuated; the circulation controlled either by sedatives, or, if necessary, bleeding, and where it is at hand, a warm bath; if this latter cannot be easily procured, a common hip bath, or sitting over the steam of warm water will be of great service; the great object will be to ensure a soft and cool state of the passage with a plentiful supply of that mucous secretion which is so essential to the favourable dilatation of the soft passages.
Nauseating remedies, and even tobacco injections, have been tried to a considerable extent for the purpose of relaxing the mouth of the uterus; but they produce little or no good effects, and cause much suffering to the patient. In Dr. Dewees' second case of obstructed labour from the above causes, a sufficient trial of this remedy was used to satisfy all doubts as to its effects. "It produced great sickness, vomiting, and fainting, but the desired relaxation did not take place: we waited some time longer and with no better success. In the course of an hour, or an hour and a half, the more distressing effects of the infusion wore off; and resolving to give the remedy every chance in our power, we prevailed on our patient with some difficulty to consent to another trial of it: its effects were the same as before,--great distress without the smallest benefit, the soft parts remaining as rigid as before its exhibition." Bleeding was now proposed; the patient became faint after losing ten ounces, and the most complete relaxation followed: the forceps were applied, and a living child delivered.
Rigidity from age. In women pregnant for the first time at an advanced period of life, the vagina and os externum are said to oppose considerable resistance to the passage of the child from their rigid condition, the parts having lost the suppleness and elasticity of youth; the vessels also convey less blood to the mucous membrane and adjacent tissues: hence the secretion of mucus is more sparing; the cellular tissue is more condensed and firm; still nevertheless, although it is constantly mentioned by authors as a cause of this species of dystocia, we cannot help declaring that it exists to a much less degree than has been generally supposed, and that primiparæ at a very early age are much more liable to have tedious and difficult labours than those at an advanced age. Still, however, the circumstance is well worthy of notice; and in such cases we may produce much relief by the warm bath, or hip bath, by sitting over the steam of hot water, by warm water enemata, and great attention to the state of the intestinal canal and of the circulation. Mucilaginous or oleaginous injections into the vagina have been recommended; but we have no experience of their effects: we have frequently used lard, &c. to the edges of the os externum when the head was beginning to distend it, and we think with relief; at any rate it produces a feeling of comfort to the patient, being soft and cooling.
Cicatrices in the vagina. The most serious impediments to the progress of labour connected with the vagina are the contractions of this canal from callous cicatrices, the results of sloughing and other injuries in former labours. The vagina may be contracted throughout its whole length, its parietes hard, gristly, and uneven, and so small as not to admit even the tip of the little finger; the course of the canal from the irregularity of the contractions and adhesions is frequently much distorted; in other cases it is obstructed in different places by bands or septa, which have been produced by similar causes.
Where the condition of the vagina has been ascertained before labour, much may be done to ameliorate the condition of the parts, not only by the treatment already mentioned for rigidity of the vagina under other circumstances, but also by the judicious application of tents, bougies, and other means for dilating the passage. A case of this kind came under our notice some years ago; the patient had been married many years without being pregnant, and was considerably beyond the age of forty. The deranged health and enlargement of the abdomen which took place excited no suspicions of pregnancy either in her mind or that of her medical attendant: the case was suspected to be ovarian dropsy, and a variety of medicines under this supposition were administered, both internally and externally: the commencement of actual labour appears to have been equally mistaken; nor was it until labour had advanced considerably that the real nature of the case was discovered; from its length and severity, violent inflammation and sloughing of the vagina was the result, the canal became much contracted, and was rendered still farther impervious by the formation of strong bands or septa which were stretched across it, and which effectually prevented the os uteri from being reached; sponge tents, and oval gum elastic pessaries of different sizes were introduced, and by degrees such a state of dilatation was produced as not only permitted the os uteri to be reached, but restored the vagina in great measure to its natural size.
The action of labour forcing the head of the child against these contractions and adhesions is frequently sufficient ultimately, to effect the necessary degree of dilatation; where, however, this is not the case, they require to be divided by the knife. The proper moment for doing this is during a pain, when the parts are put strongly on the stretch: we can now feel exactly where there is the greatest resistance, and where an incision will produce the most effect. In this state also the incision can be effected with most ease, for the stricture being firmly distended, the knife will more readily divide it than where it is relaxed; the patient also at this moment is not sensible to the cutting of the knife. The lower part of the blade well armed with lint or tow should be cautiously introduced along the side of the finger during an interval of the pains: in this way the necessary number of incisions may be made: this is usually followed by a good deal of bleeding, which tends still farther to relax the parts; and when the head has advanced low enough, a cautious attempt may be made with the forceps to deliver it.
In recommending dilatation by means of the knife, it must be distinctly understood, that a sufficient time should be allowed in order to see how much can be effected by the uterine efforts, for in many of these cases the stricture has at length yielded after severe and protracted suffering.[128] In cases of this kind, also, the effects of bleeding are by no means inconsiderable, and must not be neglected.
The unruptured hymen has been said to be capable of impeding the progress of the head, but this can only be where the membrane is of unnatural strength and thickness. It has more than once occurred to us at the commencement of labour, to find the hymen uninjured; but it has broken down under the finger, even during examination, and we are convinced would have produced no obstacle whatever to the child. Where its structure is abnormal, and the advance of the labour is evidently retarded by it, division is the simplest and easiest remedy.
Bands of firm fibrous or almost ligamentous tissue are sometimes found stretched across the vagina or os externum. We described a remarkable case of this sort in the Medical Gazette, Sep. 26, 1835, where it extended from the symphysis pubis backwards to the perineum; it had resisted the pressure of the child's head so powerfully as to produce a deep indentation along the cranial bones; it was divided by a bistouri, and the head was immediately expelled.
The perineum can rarely, if ever, prove a serious hindrance to the labour in primiparæ so long as its structure is healthy, even although it may be unusually broad. With patience and due management the necessary degree of dilatation may be obtained by the pressure of the head; and proposals to dilate it artificially, or even to make a slight incision into it, do not deserve a moment's consideration. Where, however, it has been extensively lacerated in a previous labour, and has healed again throughout its entire length (by no means a common occurrence) or when there has been much sloughing, the cicatrix thus formed may render it incapable of relaxation, and thus produce much resistance to the passage of the head. Even here we may do a great deal by warm hip baths, fomentations, and especially by bleeding; an incision through the callous portion is by no means desirable where it can be possibly avoided, as it only endangers a farther laceration during the expulsion of the head. Cases nevertheless, occur where the contracted ring of the os externum is so unyielding and gristly as to make this operation necessary.[129] In all these cases, where, either the adhesion and contractions have given away, or have been divided during labour, great care should be taken to prevent them forming again during the process of healing, by using sponge tents well greased, and other appropriate means.
Varicose and oedematous swellings of the labia and nymphæ also deserve mention, although they rarely interfere with the progress of labour to any great extent. Varicose labia seldom annoy the patient during her pregnancy; the veins of the part may have become somewhat dilated and the labium swollen; but it is generally not until the commencement of labour, that they become hard and knotty: at first they feel like a bunch of currants imbedded in the cellular tissue of the labium, and as labour advances, and the return of blood from the part is still more impeded, the swelling continues to increase in size, and frequently obstructs the os externum very considerably. The danger here is not so much from its acting as an obstacle to the passage of the child, as from its bursting during labour and causing loss of blood and other serious consequences. The tumour seldom bursts directly externally, but first gives way beneath the skin, producing extravasation, after which, in consequence of still farther distention, the labium itself ruptures. In some cases the hæmorrhage is not very profuse externally, while the extravasation internally, amounts to some pounds, extending not only to the vagina and perineum, but also to the groin; and instances have occurred where it has spread to a great distance over the glutæus muscles.
"The extravasation," says Mr. Ingleby, "usually happens during the pain which expels the child; but sometimes at an early period of labour, as in the example of severe hæmorrhage here annexed. I had just left a patient to whom I had been called, in consequence of the difficult transmission of the child's head through a distorted pelvis, in connexion with an inordinate varicose enlargement of the labia pudendi (especially the left,) when a messenger overtook me urging my immediate return. It appeared that during the violence of the straining, the tumour on the left side had suddenly burst at the edge of the vagina posteriorly. The patient lay in a little lake of blood; and as the bleeding recurred in gushes with the return of every pain, it became essential to complete delivery, and a child weighing fifteen pounds was extracted with the forceps. A large slough separated at the end of the third week." p. 109.
Where no laceration has taken place externally, it is seldom that an opening for the purpose of removing the effused blood will be of use; on the contrary, the access of external air cannot but be prejudicial in many cases. The action of the absorbents is generally sufficient for this purpose, and may be increased by friction with stimulating liniments, and most remarkably of all by the application of electricity. Where the extravasation extends beneath the lining membrane of the vagina, so much swelling may be produced as nearly to close the passage; this, however, generally takes place after the birth of the child, the rupture of the varicose vessel having occurred whilst it was passing.
On perceiving, at the commencement of a labour, that there are varicose veins in the labium, which are beginning to increase in size and hardness as the head advances, it will be as well to compress them as much as possible during the intervals of the pains, when there is less impediment to the blood returning from them: we can, by thus squeezing out their contents to a certain degree, lessen the size of the swelling, and thus prevent it from gaining that extent which might endanger laceration. We may instantly know when this injury has taken place, by the livid tumefaction of the parts, and our being no longer able to feel the knotty portions of the varix. In order to check the effusion of blood as much as possible, we must apply cold, and thus favour its speedy coagulation beneath the skin. Where the distention is very great, it may become necessary to evacuate the effused fluid; but, generally speaking, it is deeper beneath the surface than might, at first sight, be expected. "It has been proposed," says Mr. Ingleby, "that the swelling should be punctured, provided there has been no delay, and the puncture is made whilst the blood is still liquid. On one occasion I promptly carried this suggestion into effect, but without success; and, considering the structure of the labium, it is probable that the greater part of the blood will coagulate almost as rapidly as it is effused." (Ingleby, op. cit. p. 109.)
A considerable degree of suffering and annoyance to the patient may arise from oedematous swelling of the labia and nymphæ, both previous to and during her labour. The labia are occasionally so distended as not only to close the os externum, but to require that the legs should be kept as wide asunder as possible, to prevent the swollen parts being crushed: the patient is thus rendered very unwieldy and helpless, if she were not already so previously by an anasarcous state of the lower extremities, which frequently accompanies this condition.
Oedema of the labia is of less consequence where the patient has had several children than where she is a primipara, and seldom either retards labour to any serious extent, or is attended with any troublesome consequences afterwards: where, however, it is her first labour, and the swelling is very considerable, laceration may be produced, the results of which may be sloughing and gangrene: a fatal case of this kind has been described by Burton.
Where the labia are much swollen, they not only render the patient incapable of moving, but are apt to become inflamed and excoriated, from being in such close contact, and constantly moistened by the trickling of the urine over them. By preserving the horizontal posture, and thus taking off the pressure of the child from the soft parts of the pelvis, by keeping the bowels open by saline laxatives, and by using saturnine and evaporating lotions to the part, a good deal may be done for the patient's relief. Where there is no disposition to inflammation, and the parts appear somewhat flabby, warm and gently stimulating applications will be preferable. Mr. Ingleby remarks that, "if the swollen parts are punctured (and a particularly fine curved needle answers best,) a load of serum is drained off, and relief is rapidly obtained. I have not observed any of the reported bad effects (sloughing and gangrene for instance) succeed this little operation; nor are they likely to occur in an unimpaired constitution." The celebrated Wigand of Hamburgh, who strongly opposed making incisions into the dropsical structure, does not appear to have tried the plan recommended above. He considered that, as these swellings are the result of pressure, the less we do with them the better, merely taking care to keep up the action of the skin.
Oedema, or rather dropsy, of the nymphæ, is not of common occurrence, and, when it takes place to a considerable extent, produces a singular alteration in the appearance of the external organs. The nymphæ protrude beyond the labia, and depend so much as to rest upon the bed on which the patient lies, forming a soft membranous bag, fluctuating with the fluid which it contains. If labour has not actually commenced, we would prefer endeavouring to excite the absorbents of the part, and thus remove the effused fluid, to its evacuation by puncture: we have perfectly succeeded, by the use of warm aromatic stimulating fomentations. The "species aromaticæ" of the Continental pharmacopeiæ may be used with much advantage in these cases: the mode of its application is, to tie some up in a loose muslin bag, and soak it in hot wine; this forms an excellent warm stimulating application, and appears to excite the absorbents very briskly. A very good imitation of this, is to scald some chamomile flowers, and having squeezed them tolerably dry, to sprinkle some port wine over, and then apply them as a poultice. A swelling of this sort can offer but little obstruction to the passage of the head; and if labour commence before we have been able to reduce its size sufficiently, we may at the last let off the fluid by puncture, should the pressure of the head be such as to threaten laceration.
Tumours of different sorts may obstruct the passage of the child, and, in some cases, produce an impediment of the most serious character. Fibrous polypi and hard tubercles of the subcartilaginous character (commonly called the fleshy tubercle) are those which may present the greatest resistance, while fungoid growths of malignant disease, whether cephaloma (brain-like tumour,) hæmatoma (fungus hæmatodes,) or carcinoma, rarely oppose much obstruction. Their structure is soft and spongy, they therefore yield to the gradual pressure of the head, become more or less flattened, and thus allow it to pass. But fibrous or chondromatous tumours are of too firm a structure to admit of this, and are capable of rendering the labour not only difficult, but very dangerous. The mass being situated at the lower part of the uterus, or attached to it by means of a pedicle, is perhaps forced down into the cavity of the pelvis, beyond which its attachments do not allow it to advance; if it be a fleshy tubercle imbedded in the structure of the uterus, it will not be able to advance so far, but will obstruct the brim of the pelvis, and thus prevent the head descending into it. In many cases, these tumours are merely covered by the lining membrane of the uterus, which sometimes forms a species of pedicle. In either case, an early diagnosis is of great importance, as we may thus have the opportunity of removing the mass either by the scissors or ligature.
Dr. Merriman has recorded an interesting case of this kind, where the polypus which arose from the inner surface of the right lip of the os uteri was tied, and removed rather more than three weeks before labour came on. A fatal case, communicated to him by the late Dr. Gooch, is equally valuable, inasmuch as it shows the results of a contrary practice.[130]
"The class of tumours which most frequently obstruct labour comprise follicular enlargements and the prolapsed ovarium. The former disease originates in the vagina, and has been shown by Mr. Heming to consist in a dilated state of one of the mucous follicles, which acquires a cyst, and secretes a fluid of varying colour and consistence, from a dark to a straw-coloured serum, or a deposition purely gelatinous. Owing to the density of its walls, and its general tension, the fluid contents of the tumour are not easily distinguished; but the flaccidity which succeeds a free puncture is very striking."
"There are two forms of ovarian tumour which obstruct the passage of the child; in the one, a small cyst in connexion with a very bulky cyst; or else a portion of a large cyst passes into the recto-vaginal septum, and bulges through the posterior part of the vagina: in the other, and that which occurs by far the most frequently, the whole ovary, moderately enlarged, prolapses within the septum. The descent is peculiarly liable to happen at two periods; the first near the end of gestation, the second during labour, the prolapsus being promoted by the relaxation of the soft parts. The changes which the ovary undergoes when long detained in the septum, will chiefly depend upon the capacity and yielding state of the parts. If the woman has not previously borne children, it may remain small, and scarcely retard delivery; but under contrary circumstances, it acquires a large size, and nearly fills the vagina. In rare instances, the bulging is said to have appeared at the anterior part of the pelvis." (Ingleby, op. cit. p. 118.)
The contents of these tumours vary a good deal; the hard ones are usually lipomatous or fatty tumours, not unfrequently containing hair and rudiments of teeth. Numerous cases have been recorded where ovarian tumours, which had been pushed down before the child, have at length burst, discharging their contents, and thus ceasing to act as an obstacle to the labour. We quite agree with Mr. Ingleby in recommending puncture under such circumstances; for, independent of pregnancy, it is a well-known fact, that there is a much better chance of successfully tapping an ovarian dropsy per vaginam, than through the abdominal parietes. The same holds good in operating through the rectum; and he has described two highly interesting cases where this mode of treatment was completely successful; one in his own practice, the other in that of our friend Mr. W. Birch.
Distended or prolapsed bladder, &c. Lastly, the urinary bladder may obstruct the passage of the child, from being prolapsed and distended with water, or from containing a calculus which is forced down below the head. In the first case, a prolapsus of the distended bladder can scarcely take place without much inattention on the part of the practitioner, not having ascertained whether the bladder had been lately evacuated. In case we find, upon examination, that there is a disposition to this displacement, the elastic catheter will enable the tumour of the prolapsed bladder to collapse, and thus remove all farther trouble. The examination in these cases must be conducted with care; for an elastic fluctuating tumour of this kind may be mistaken for the distended membranes, or a hydrocephalic head; and Dr. Merriman has given a melancholy case where, in consequence of such an error, the bladder was punctured.
A stone in the bladder is sometimes more difficult to manage. If the head is only just beginning to enter the brim, the stone may be pushed up above it; but if it has already engaged completely in the pelvic cavity, it becomes a question whether it will not be necessary to cut down upon it, and thus remove it. These cases are, however, of very rare occurrence, and we must be entirely guided by circumstances, it being impossible to lay down any precise rules for their treatment.
VI. SIXTH SPECIES OF DYSTOCIA
Faulty Labour from a faulty Condition of the expelling Powers.
I. Where the uterine activity is at fault--functionally or mechanically--from debility--derangement of the digestive organs-- mental affections--the age and temperament of the patient--plethora-- rheumatism of the uterus--inflammation of the uterus--stricture of the uterus.--Treatment. II. Where the action of the abdominal and other muscles is at fault.--Faulty state of the expelling powers after the birth of the child.--Hæmorrhage.--Treatment.
Although this species includes that condition of the expelling powers, where their action is excessive, we shall defer this portion of the subject until we treat of precipitate labour, with which it is essentially connected.
The agency by which the child is expelled during labour is of two kinds: 1st, involuntary action of the uterus, assisted, secondly, by the partly voluntary and partly involuntary action of the abdominal muscles.
On the approach of labour, the uterus, which hitherto had been merely performing the office of a receptacle and a means of conveying nourishment to the foetus, now assumes a totally different character; from being in a nearly passive state, it assumes an entirely opposite condition, viz. of high irritability and powerful action. We might almost suppose that its connexion with the nervous system was become more close and intimate; for it is now sensible to the influence of impressions which had before produced no effect upon it. Thus, we see, that affections of the mind, even but of moderate intensity, and to which it was, before labour, nearly, if not quite, insensible, are now capable either of rousing its efforts to the utmost violence, or of arresting them in the midst of full activity; and, on the other hand, we see that where its action has been deranged or interrupted, it gives rise to serious affections of the nervous system, or even convulsions.
With all this, it now displays peculiarities of function, which strikingly distinguish it from all other organs of the body; in some cases it appears to annihilate or to absorb, by its all-pervading influence, the functional energies of other organs; and, in spite of its increased nervous power and susceptibility to various impressions, it seems to possess the faculty of continuing its efforts uninfluenced by general disease, unimpaired by exhaustion, and, for a time, almost independent of the life itself of the mother. In convulsions and paralysis, in general fever and inflammation of vital organs, its powers appear to be undiminished: on the contrary, where the patient, from whatever cause, is rendered incapable of assisting its efforts by the abdominal muscles, the uterus will take upon itself the whole task of expelling the child, which will be born apparently without a single effort upon the part of the mother.
We also observe, that organs, the various conditions and derangements of which have exerted little or no influence upon the uterus in its state of quiescence during pregnancy, now affect it powerfully, and are capable of modifying its action very considerably. The stomach, the intestinal canal, and the skin, are remarkable instances of this, and seldom fail to disturb or pervert the natural efforts of the uterus, whenever these organs deviate from a healthy condition. It will be, therefore, of the highest importance to watch their functions narrowly, in order that we may form a correct estimate of their effects upon the uterus.
Derangements in the contractile power of the uterus may arise from a variety of causes, which may be chiefly brought under two heads, viz. functional and mechanical.
The functional derangements may arise from insufficient activity, the result of general or local debility; from a deranged condition of the digestive organs; from passions or affections of the mind; from hereditary temperament, constitution, or peculiarity; from the patient's age, being either very young or considerably advanced in years, and pregnant for the first time; from plethora, general or local; from rheumatic affection of the uterus; and from uterine inflammation.
The contractions of the uterus may be mechanically impeded, by tumours imbedded in its substance; by organic diseases, as schirrus, cephaloma, and hæmatoma; cicatrices from former ulcerations or rupture, or by any other circumstances which interrupt the action of the longitudinal fibres upon the os uteri.
From debility. Where uterine action is insufficient from debility, the pains are feeble, and do not appear to act in the right direction; they are frequently attended with much greater suffering than might be expected from their inefficiency; the intervals between the pains are unusually long, the pains themselves are very short, or, after a while, cease altogether.
This condition, when depending on general debility, may be the result of previous disease, loss of blood, or other debilitating evacuations, poverty, with its attendant miseries, depressing passions of the mind, and health broken down by intemperance.
The contractile power of the uterus itself may be injured by previous leucorrhoea or menorrhagia, by abortions, or by attacks of hæmorrhage during the latter part of pregnancy; it may be weakened by over-distention of the uterus, either from plurality of children or too much liquor amnii, by the patient exerting herself improperly at the commencement of labour, straining violently, and endeavouring to bear down before she is involuntarily compelled to do so by the presence of the head in the vagina. It may also be produced by the membranes giving way too soon, as is so frequently observed in first labours.
From derangement of the digestive organs. We have already described the change which takes place in the relation between the uterus and other organs, as soon as it passes into a state of action. The intestinal canal stands foremost in the influence which it exerts upon the uterus; whether it be from constipation or diarrhoea, irritation from acrid contents, &c., it will greatly modify, and even derange, its contractile power; the pains cease to be genuine uterine contractions, and assume a spasmodic character, producing much painful griping and pinching about the front and lower part of the abdomen, without any of that regularity of interval and duration, and gradual accession and recession, which mark the presence of real labour pains, and, we need scarcely add, with little or no effect upon the progress of the labour itself. These griping colicky pains appear to supersede the true process of parturition, and either to prevent the uterus acting with due regularity and effect so long as they last, or so to pervert its action as to produce a species of metastasis towards other organs. The pains lose their peculiar character as the expelling powers of the uterus; they cease entirely, and the patient is suddenly attacked with dyspnoea, cramps in the extremities, violent shivering, great restlessness, intense headach, delirium, convulsions, or even mania.
Wherever the action of the uterus is deranged by gastric or intestinal irritation, the abdomen is generally more or less tender in front, particularly over the symphysis pubis; the os uteri is thin, tense, and rigid; the vagina is hotter than natural; the secretion of mucus is sparing; and both os uteri and vagina are more than usually tender to the touch.
From mental affections. The mind is capable of influencing the action of the uterus during labour in a remarkable manner, not only where it is suffering from depressing emotions, as grief, great anxiety, or painful anticipations as to the result, but from causes of a much slighter character, which are nevertheless well worthy the attention of the practitioner: his sudden appearance in the room, without the patient having been properly warned of his arrival: the dread of an examination; or annoyances of a much slighter character, as regards his manner, or that of the nurse, &c., will not unfrequently be quite sufficient to stop the progress of the pains.
The age and general temperament of the patient will also affect the character of the pains. When pregnancy occurs for the first time, either at a very early age, or considerably advanced in life, labour is apt to be protracted, from defective uterine contraction; in the first case, she has not yet attained that degree of adult strength which is requisite to undergo a process requiring so much exertion; the pains are weak, of short duration, and inefficient, but very exhausting to the patient. From the irritability both of the nervous and vascular systems, so peculiar to youth, arises a long train of troublesome symptoms, such as congestion of blood to the head, spasms, syncope, convulsions, &c. In the other case, the condition of the system is the reverse, the irritability is diminished, the uterus is sluggish in its action, the pains are weak and inefficient, follow each other very slowly, and the course of the labour is much protracted; besides this, the short passages through which the child advances are now less capable of dilatation, from having that elasticity and suppleness peculiar to youth, and therefore oppose a much greater resistance.
Where the patient is of a slothful phlegmatic habit, the uterus generally indicates a corresponding state, by the slowness of its action and want of excitability during labour. The same condition is manifested during the catamenial periods in the unimpregnated state, by the absence of pain, weight, throbbing, and other symptoms of local congestion, which are usually observed at these times; so that, but for the discharge, the patient has scarcely any guide to mark their recurrence. On the contrary, where the appearance of the menses is preceded and accompanied by severe pain in the back and loins, throbbing, heat, weight, &c., indicating considerable excitement in the uterine system, we usually observe a similar condition in the uterus during labour, the pains being quick, energetic, and efficient. It is probably from some peculiarity of temperament that we can explain the hereditary disposition which some women show in the unusually lingering or rapid character of their labours.
From plethora. A congested or overloaded state of the uterine circulation, whether from general plethora or from other causes, is not an uncommon cause of feeble contractions. The spongy tissue of the uterine parietes is so gorged with blood, as to prevent, in a great measure, the free action of the pains, and may thus seriously impede the progress of labour. We have already pointed out, when speaking of the signs of pregnancy, the disposition which the system manifests for forming a larger quantity of blood than before; the pulse is stronger and more full, the animal heat is increased; this is especially observed in the uterus, and continues so during the whole process. Whilst in the state of inaction which belongs to pregnancy, but little inconvenience, comparatively, is felt; but when labour commences, and it contracts, the blood is driven from its engorged veins and sinuses into the general circulation; if, however, it cannot do this, from the general state of plethora, its contractions are rendered very imperfect and inefficient.
Besides the appearances of general plethora, we shall easily recognise this condition by the following symptoms: "the patient has much heat of surface and yet but little thirst; the face, eyes, and skin, are red and considerably swollen; we can feel vessels pulsating in every direction; she gets but little sleep, and finds the bed and the bedclothes uncomfortable to her; the uterus is large, thick, tense, and very warm: the os uteri swollen and cushiony, and the vagina also warm and spacious; the foetus is very restless, and causes a good deal of pain by its movements. The pains are short and ineffective, and accompanied with a peculiar sensation of painful stretching or tension, without any symptoms of rheumatism, cramp, or other morbid conditions of the uterus being present." (Wigand, Geburt des Menschen, vol. i. p. 138.) This condition is not unfrequently accompanied with tendency to hæmorrhoids, inactivity, constipation, varicose veins of the lower extremities, &c.
Rheumatism of the gravid uterus is an affection which, although it has received but little or no notice in this country, has been long known and described by the continental authors. It appears to be a similar condition of the uterine fibres, when developed by pregnancy, to rheumatism in other muscular tissues, arising from the same causes, connected with the same conditions of the system, and producing similar effects; hence, therefore, it must interfere considerably with the healthy action of the uterus, and greatly diminish or entirely destroy, the efficiency of the pains.
The whole uterus is unusually tender to the touch; the contractions are excessively painful from their very commencement, the slightest excitement of the uterus producing a sensation of pain; they come on with a sudden twinge or dragging pain about the pelvis and loins, and where the contractions are still powerful, they sometimes rise to an intolerable degree of intensity. This condition is frequently observed to a slight extent at the commencement of labour; the mild precursory pains which, in a healthy state, are merely attended with a sensation of equable pressure and tightness round the abdomen, now produce much suffering and give rise to one form of spurious pains, to which we have already, under that head, alluded. Where the symptoms are of considerable severity and have been aggravated by improper treatment, this state may easily pass into that of actual inflammation.
On examining into the history of the case, we shall frequently find that for several days, or even more than a week, the patient has remarked the uterus to be unusually tender to the touch, scarcely bearing the pressure of the clothes; and at night-time the uneasiness has increased to such a degree that she could scarcely remain in bed. There is a frequent desire to pass water, which is highly acid, and deposites much red sediment; and in all probability she complains of rheumatic pains in other parts of her body.
The causes of this condition are the same as those of rheumatism under ordinary circumstances: exposure to cold, and alternations of temperature, particularly when heated; derangement of the stomach, with much prevalence of acid, &c.: insufficient clothing, and, upon the Continent, especially in Holland, where it is said to be very frequent, by the use of chauffe-pieds.
Inflammation of the uterus is another condition which can not only greatly impair, but entirely suspend, the activity of the uterus. It is usually brought on by improper treatment during labour, where the real cause of the lingering ineffective pains at the commencement has been entirely overlooked, and a state of uterine irritation aggravated into one of actual inflammation by the abuse of stimuli and other heating drinks, given with the view to increase the pains; it may be produced by external violence, improper attempts to dilate the os uteri, rough and too frequent examination, endeavouring to turn the child or to apply the forceps before the soft passages were in a fit condition for that purpose.
The whole abdomen becomes extremely tender, and even the slightest contractions of the uterus produce intense suffering; the vagina is hot and dry, and very tender to the touch--its mucous secretion suppressed; the os uteri is swollen, tense, and painful, and the anterior lip is sometimes so distended as to have been actually mistaken for the bladder of membranes; the bowels are confined; the urine is suppressed; the abdomen becomes distended from tympanitis; and general, and probably fatal, inflammation of its contents follows.
Treatment. The causes of insufficient uterine action are so numerous that the modifications to which they give rise are almost endless, and demand no little variety of treatment. A great deal may be done to avoid this state by attention to the patient's health shortly before labour; and by so carefully regulating it as to ensure a healthy condition of the whole system. Lingering labour from feeble uterine activity is seen most frequently in young primiparæ of delicate form and nervous irritable habit; the pains produce much fruitless suffering, and greatly exhaust the patient. If the cause continues, the case becomes much protracted, and serious consequences may ensue; such as hysterical symptoms, or even convulsions, inflammation of some organ, general fever, or complete and dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass contraction of the uterus. In a slight degree this condition is not of unfrequent occurrence, whether from an enfeebled uterus or general debility, and requires general, rather than special treatment for its removal. Change of posture, walking about the room, gentle friction of the abdomen, and occasionally taking some refreshing or mildly nutrient drink, as tea, wine and water, or beef-tea, &c., prove serviceable in such cases; friction of the abdomen, if well applied, frequently produces a great alteration in the character of the pains, and greatly assist the progress of labour: if it be still in the first stage (the os uteri not yet fully dilated,) an enema will not only clear the rectum of any fæcal matter which may be lodging there, but assist in rousing the uterus to greater activity.
Where we can satisfy ourselves that none of the above-mentioned causes are present to protract the labour, we may proceed to the use of those remedies which are considered to have the power of exciting the uterine contractions, such as secale cornutum, borax, cinnamon, and the several diffusible stimulants. This state of uterine inactivity is, however, rare; and we would earnestly warn young practitioners against too readily concluding that it is present. They will find that the more carefully they investigate such cases, the less frequently will they require these remedies. In using the secale cornutum, we give the preference to the powder: it should be carefully kept from moisture, air, or light: from twenty to thirty grains, mixed in cold water, will be the proper dose, and this may be repeated two or three times, at intervals of half an hour, or rather more. Borax is also another remedy which appears to possess a peculiar power in exciting the activity of the uterus: although it is scarcely ever used for such a purpose in this country, its effects upon the uterus have been long known in Germany; and in former times, both it and the secale cornutum entered largely into the composition of the different nostrums which were used for the purpose of assisting labour. We have combined these two medicines with the best effects, and generally give them in the following manner:--[Symbol: Recipe] Secalis Cornuti [Symbol: scruple] i--ij; Sodæ Subborat. gr x; Aq. Cinnamomi [Symbol: ounce] jss. M. Fiat haust. Cinnamon, which is a remedy of considerable antiquity, has also a similar action upon the uterus, although to a less degree.
Our own conviction with regard to the use of these remedies is, that they are seldom required during labour, except in nates, or footling presentations, or in cases of turning, where the head is about to enter the pelvis, and where, at this critical moment, the action of the uterus is apt to fail, when it is important to the safety of the child that there should be brisk pains to force the head through the pelvis and internal parts with sufficient rapidity. The chief value of these remedies is for the purpose of exciting uterine contraction after labour, and thus to promote the safe expulsion of the placenta, where there is a disposition to inertia uteri, and ensure the patient against hæmorrhage.
Where the contractile power of the uterus is so enfeebled that it becomes nearly powerless, we deem it much safer and better to apply extractive force to the head by means of the forceps, and thus overcome the natural resistance of the soft parts, to using medicines which excite uterine action, and thus stimulate the exhausted organ to still farther efforts. The mere cessation of uterine action, however, where the labour has been tedious and fatiguing, is no proof that the uterus is exhausted, and incapable of farther efforts: so far from its sinking into a state of quiescence, being a symptom of exhaustion, experience shows that, in labours of this character, it indicates a very opposite condition, being nothing more than a state of temporary repose, during which nature affords it an opportunity of recruiting its own powers, as also those of the whole system. The interval of ease which is thus given to the patient is accompanied by refreshing sleep; the skin grows moist; a gentle diaphoresis creeps over her; the circulation becomes calm; and after a time, the uterus awakes again to renewed and astonishing exertions; thus, Wigand has remarked, "the pains during the same labour may cease once, twice, or even oftener, and yet after a little rest will return with renewed strength." (Geburt des Menschen, vol. ii. p. 242.) On the other hand, where the pains, in spite of their becoming more and more ineffective, continue to exhaust the patient with fruitless suffering, and prevent her from enjoying that repose which is so desirable under such circumstances; when the uterus, from increasing irritability, scarcely ceases to contract even for a moment, but continues tense and more or less tender during the intervals of the pains, we can have little or no reasonable expectation that such a labour can be terminated by the natural powers. If the head be not far advanced in the pelvis, or the passages fully dilated, if the bowels have been relieved before labour, and there is no febrile excitement of the circulation, a mild diaphoretic sedative, like Dover's powder, will be of great service: it calms the irritability of the system, and induces that state of quiet or actual repose to which we have just alluded. If, on the other hand, the labour be much farther advanced, the head approaching the pelvic outlet, and the soft parts well dilated, a little assistance, by means of the forceps, will quickly terminate the case, and free the mother and her child from farther suffering and danger.
Where the uterus is enfeebled by lesion or change of structure, it becomes very difficult to decide as to what course ought to be pursued: in some cases, the soft passages partake in the loss of tone, and offer but little resistance to the advance of the child; in others, however, the uterus is so powerless as to give us no choice but of employing artificial delivery.
We have already pointed out the importance of paying the strictest attention to the bowels shortly before and during labour, and how frequently a neglect of this precaution acts as a means of perverting the due action of the pains, and giving them that character, already described under the head of False Pains. "After the labour has made much progress, the rectum, if loaded, should be emptied by clysters; indeed, the utility of clysters in almost every stage of labour is so apparent that it is to be lamented they are not more frequently employed." (Synopsis of difficult Parturition, p. 19.) We have seen cases where, although the bowels had been opened at the commencement of labour, after a time, the pains have gradually lost their dilating effect upon the os uteri, although they have increased in severity; the os uteri has remained tense and hard, and the labour has become very tedious and exhausting; the administration of an enema, and removal of a quantity of fæcal matter from the rectum, has been followed by an instantaneous change in all the symptoms; the pains have become powerful and effective, the os uteri has quickly dilated, and the whole labour has been completed in a very short space of time. In like manner, vomiting during the early part of labour produces the best effects; for it not only assists to relax the parts, by the nausea which usually precedes it, but, by emptying the stomach of unhealthy contents, it tends not a little to restore the uterus to its natural activity.
Where the bowels are distended with flatus, and loaded with acrid and unhealthy contents; we rarely see the pains become regular and effective until these sources of irritation are removed: the abdomen is painful with spasmodic colicky griping, and excites the uterus to partial and very painful contractions of a cramp-like character, which entirely supersede the regular pains, and thus exhaust the patient with protracted suffering without at all advancing the labour itself. If this condition be allowed to continue uninterfered with, the tenderness of the abdomen increases, the circulation becomes excited, and inflammation, and fever of a most serious kind will be the result.
In the management of primiparæ, who are pregnant either at a very early age or considerably advanced in life, our chief attention must be directed to the management of them for some little time before labour is expected, in order that we may place them in as favourable a state of health as possible, and thus enable them to meet the coming trial with safety.
Where the patient is very young, we should endeavour, by early hours, regular exercise, good air, and simple nourishing diet, &c., to increase her strength, and the general tone of health, and thus diminish that irritability of the nervous system peculiar to females of this early age. She should lead a country life, be as much as possible in the open air, enjoy the absence of restraint and excitement, which are almost necessary consequences of a residence in town, and, by agreeable occupation and cheerful society, train herself, as it were, to that state of moral as well as bodily health best adapted to ensure a favourable result. It is in cases of this kind where the bodily powers have not yet ripened into adult womanhood, that so much good may be effected by using the tepid or (if the season permit) cold salt water bath; and we would beg to refer our readers to our observations on this subject in the chapter on PREMATURE EXPULSION. In a case which has recently come under our notice, we have had reason to attribute the remarkably healthy and favourable labour of a young and delicate primipara solely to the invigorating effects of regular exercise and the daily use of sea-bathing, which she continued to within a very few days of her confinement.
It is commonly supposed that women pregnant for the first time, and advanced in years, always have severe labours: this is not necessarily the case, although, at the same time, the greater rigidity of the soft parts considerably increases the resistance to the expelling powers. It will be equally important in this case, also, to improve her health and strength as far as possible, and, by exercise, warm hip baths, &c., to give the parts a greater degree of suppleness and elasticity.
Where the labour is protracted by a state of general plethora or local congestion, the expelling powers are not only enfeebled by the engorged state of the uterine circulation preventing effective pains, but the resistance to the passage of the child is increased by a similar condition of the soft passages, which are swollen and turgid with blood. It is in these cases that bleeding effects such a sudden and complete change; the pulse loses its oppressed character, and rises in point of strength, the uterus loses the thick solid feel which it had before; its contractions become active and powerful, the os uteri dilates, the passages become soft and yielding, and the whole process assumes a different character. By careful observation, this state can easily be discovered before labour has actually commenced; in which case much useless suffering may be prevented by previously reducing the circulation to a proper standard, and thus fitting the uterus for the exertions it has to undergo: besides bleeding, mild saline laxatives, with or without antimonials, will be of great service. The nitrate of potass in these cases has the best effects, either in farthering the effects of the bleeding, or removing the necessity of using so powerful a remedy.
In treating rheumatism of the gravid uterus, our practice will differ but little from that in cases of ordinary rheumatism in other parts: this condition, we believe, is rarely excited, until the system had been already predisposed to it by deranged digestion, and that general prevalence of acid diathesis, which manifests itself in different individuals and under different circumstances so variously; hence, therefore, it will always be important to unload the primæ viæ effectually by an active dose of calomel or some other mercurial, before prescribing for the immediate symptoms of the complaint: beyond producing a little occasional nausea, five grains of calomel will act much more comfortably to the patient's feelings than a smaller dose; there will be less griping and intestinal irritation, but the effect will be more complete and general; not only will the bowels be thoroughly evacuated, but the liver relieved of a large quantity of unhealthy acrid bile, the removal of which cannot but be highly advantageous. We may now proceed to the use of diaphoretics and opiates: of these, Dover's powder stands foremost; and if given in doses of from ten to fifteen grains, accompanied with warm diluent drinks, rarely fails to induce sleep and a pretty active perspiration, which gives great relief. As the abdomen is usually more or less tender on pressure, it should be covered with a piece of soft flannel, or, still farther to ensure the full diaphoretic effect of the remedies, a warm bath may be had recourse to. Where calomel in the above dose has been premised, we seldom fail in procuring a free action of the skin, and, according to our own experience, with far greater relief to the system than where the perspiration has been induced merely by diaphoretics and external warmth.
If this condition of the uterus has been neglected, and the contractions are beginning to produce intense suffering; if the abdomen is rapidly becoming more tender to the touch, it should be covered with a hot poultice of linseed meal, made more stimulating by the addition of mustard flour, and this should be continued until the skin is considerably reddened. In the slighter cases of this affection, where the bowels have been opened, friction upon the abdomen frequently produces the happiest effects. We presume it is to these cases that Dr. Power alludes when he says, "in some, the improper action will be removed almost instantly, and, as it were, by a miracle; so that a case which has been protracted for the greater part of a week, under the most intense suffering, without the least progress, has been happily terminated in fifteen or twenty minutes from the first commencement of the friction." (Power's Midwifery, 1819.)
Where inflammation of the uterus takes place during labour, the case becomes one of the most serious character; for not only is the suffering, which is produced by every contraction, of the most intense description, but the presence of the child aggravates the state of inflammatory action, and excites the uterus to still more violent efforts, while the swollen and unyielding state of the os uteri, &c., precludes the chance of speedy delivery. Under such circumstances, we must trust almost entirely to the lancet in aiding this important object; for, until the circulation has received an effectual check by fainting, the dilatation of the parts cannot proceed, nor can any attempt be made to give artificial assistance. The abdomen should be covered with a hot linseed meal poultice, as above described, in the treatment of rheumatism of the uterus; warm decoction of poppies should be thrown up the vagina, or, if this cannot be procured at the moment, some thin gruel mixed with a little laudanum, or in which a few grains of Extr. Conii or Hyoscyami have been suspended; the bowels should be opened by a simple enema, after which a small opiate injection will be desirable, in order still farther to allay irritation.
Stricture of the uterus. We have already had occasion to allude more than once to that species of violent and continued contraction which we have denominated stricture of the uterus, but have chiefly considered it where it affects the os uteri; a somewhat similar condition of spastic rigidity is occasionally, though rarely, seen in other parts of this organ, and is capable of producing a most serious obstacle to delivery. The uniform and regular action of the uterus disappears; its contractions become partial, both in extent and effect, one part alone contracts whilst the rest of the uterus is relaxed; its shape thus becomes altered; for, by these partial contractions of its fibres, it may become elongated, shortened, flattened, &c.: the spasmodic action frequently varies its seat, and successively attacks different portions; thus, where it affects the body of the uterus, it becomes contracted almost like an hour-glass, having a transverse circular indentation, as if it had been tied with a cord. Where the contraction affects one side of the organ, it alters the shape of it materially; the fundus is pulled down equally, and the position of the child, as we have shown in the first species of dystocia, may be seriously affected. If the stricture has its seat in the os uteri, this becomes tightly contracted, hard, unyielding, and painful upon pressure: it does not dilate sufficiently, and the inferior segment of the uterus is generally pushed downwards, whilst the os uteri itself is drawn upwards. In cases of this kind, we find that although the uterus contracts, the child does not advance, but rather retracts, during a pain; the contractions are never general, but partial, and even where they are general, the fundus does not attain its due preponderance over the os uteri, so that the one contracts as much as the other does; in severe cases, also, the uterus continues in a state of spasmodic action during the intervals of the pains: this is frequently accompanied with a painful and harassing sensation of tension and stretching, very different to that produced by the action of regular pains upon the os uteri; and in the worst cases we occasionally observe a peculiar state of the brain, which manifests itself by attacks of insensibility, faintings, or even convulsions.
Although the head does not advance in spite of the strongest pains, yet, upon examination, we find no want of proportion between it and the pelvis; if the intervals of uterine action be of sufficient duration to allow it, we shall feel the head quite moveable in the pelvis, or, at any rate, with plenty of room for the finger to pass round it, and yet when a pain comes on, the head remains fixed, or if it does descend somewhat, it returns again to its former situation as soon as the pain is over. This state of things is usually seen where the body of the uterus is the seat of the stricture, and is contracted transversely upon that of the child, which it tightly encircles, and renders all farther advance impossible.
This state of spasmodic action is produced by whatever tends to irritate the uterus and excite it to irregular action; thus, premature rupture of the membranes, especially when it has been suddenly drained of a large quantity of liquor amnii; the irritation arising from acrid matter in the intestines, or from their being loaded with accumulations of fæces; improper examination, and more especially, attempts to dilate the os uteri by the fingers or hand; endeavouring to strain and bear down during the early part of labour, and when the patient is not involuntarily compelled to do so; attempting to apply the forceps when the os uteri is not fully dilated, or whilst the instrument is very cold: malposition of the child, especially after rupture of the membranes; and lastly, anxiety, fear, and other affections of the mind. The circulation is generally in an irritable state, the patient is of a delicate excitable habit, and is apt to be nervous and hysterical.
The treatment in these cases will be precisely on the same general rules as we have above described; the bowels must be relieved by a laxative or by an enema; if necessary, the circulation must be reduced to the proper standard by bleeding, and the irregular uterine action controlled by opiates. Besides these means, the warm bath is of the utmost service, and seldom fails to produce a favourable change. Where the action of the uterus is impeded, or otherwise rendered faulty by organic disease, lesions of its structure, &c., we shall in all probability be compelled to use artificial assistance.
II. Where the action of the abdominal and other muscles is at fault. Where the faulty character of the labour arises from a faulty state of the partly voluntary, partly involuntary, action of the abdominal muscles which is destined to aid the uterus in expelling the child, this may equally be a result of general debility from previous disease, exhaustion from the long duration of the labour, from the abuse of spirituous liquors, &c. It may also arise from various causes which tend to impede the respiration; such as excessive corpulence, great deformity of the spine, bronchocele, spasmodic asthma, rheumatism of the diaphragm, ascites, hydrothorax, phthisis, pneumonia, aneurism of the aorta, dilatation of the heart, &c.
Where the size is such as renders the patient very unwieldy, or the spine is much deformed, we must place her in that position in which she can exert herself with greatest effect, and at the same time experience the least possible obstruction to her breathing: with deformed people, this is of great importance; she should be propped up with pillows, &c. into whatever posture she can lie with most comfort, and the practitioner must manage to deliver her in this position. Patients suffering from pluerisy or pneumonia are unable to bear the continued strong inflation of the lungs which is necessary during the second stage: under these circumstances, the pain and inflammation are greatly aggravated; venesection must be used with great promptness, but it does not always bring relief or remove the danger; for the disease is kept up by the presence of labour, which, therefore, in all probability, will require to be terminated by art. In some cases, however, as we have already mentioned, especially where the disease is of an acute character, the uterus appears to take upon itself the whole exertion of the labour, so that the child is born apparently without any effort on the part of the mother.
Faulty state of the expelling powers after the birth of the child. The last stage of labour, which comprehends the expulsion of the placenta, may also be retarded by a faulty state of the expelling powers. This not only arises from the causes which we have already mentioned, but from those connected with the labour itself; as from premature and immoderate straining during the pains, misuse of medicines given to increase the pains; also, where the uterus has been exhausted by the length and severity of the labour, or where it has been thrown into a state of inertia by the sudden evacuation of its contents, especially when previously much distended. This condition is frequently induced by not supporting the child sufficiently when the shoulders are about to pass through the os externum; the main bulk of the child is therefore suddenly expelled, and the uterus is at once thrown into irregular action by the sudden shock of so great a change, or falls into a state of inertia. The separation and expulsion of the placenta may be also retarded where the labour has required the forceps, turning, or perforation, especially the latter, on account of considerable pelvic deformity; the more so if there has been considerable delay in giving assistance. Irregular and partial action of the uterine fibres, after the expulsion of the child, may easily render the last stage of labour dangerous; for, under such circumstances, the portion of the uterus to which the placenta is attached may be in a state of firm contraction in one part, while the other is quite relaxed, so that incomplete separation of the placenta will be the result, and hæmorrhage follow: hence we cannot be too cautious in avoiding every cause which may at all influence the regular action of the uterus during the last stage of labour, which is far more dangerous than the two others put together.
In a case of this kind, we do not feel the uterus contracting into the firm globular mass above the symphysis pubis, as might have been expected; but if inertia uteri be present, it remains soft and large, the peculiar pains of the last stage which indicate the speedy separation and expulsion of the placenta do not make their appearance, or only in a very insufficient degree. If it be contracting irregularly and only in part, we shall feel this distinctly, from the unequal shape and hardness of the uterus, which in some cases will have almost a lobulated feel; in others, it presents a considerable depression either upon the fundus or anterior wall.
Hæmorrhage. The danger here, chiefly depends upon the occurrence of hæmorrhage: if the placenta be still attached by its whole surface to the uterus, no hæmorrhage can ensue; but if the contractions have been of sufficient power to detach more or less of it from the uterus, large trunks, which have hitherto conveyed maternal blood into the placental cells, are torn through, and a profuse discharge must be the result. The degree of the hæmorrhage will in most instances furnish us with a tolerable estimate of the extent to which the separation has taken place; but it is far from easy to ascertain correctly the quantity of blood which has been lost, and we must rather try to ascertain what are the effects produced upon the system of the patient. The pulse becomes smaller and quicker, the column of blood is evidently diminished, and the heart for a time drives on its contents more rapidly; but as the loss increases, so does it become enfeebled, and although beating with a very frequent stroke, it now becomes so weak as to be scarcely or no longer capable at the wrist of producing such a resistance to the finger as will give the sensation of a pulse; the necessary consequence of this is, that the patient at first complains of great weakness, the face becomes pale, the lips white, the breathing anxious; this is followed by a sense of great prostration, the perspiration breaks out upon the face and forehead, tinnitus aurium, confusion of ideas, and sense of darkness before the eyes succeed; the load at the præcordia, and the oppression of breathing, become more insupportable; she tosses her arms about, and in some instances has a sensation that the room is going round with her, or that she is sinking through the bed; in other cases, the breathing becomes gradually more feeble, until it is almost imperceptible; she every now and then takes a deep sobbing grasp, which seems to rouse her to consciousness for a moment, and then she relapses into a state verging upon insensibility; the pulse is probably now no longer perceptible at the wrist, the face is undergoing a rapid change, the features are contracting, and there is a general expression of death-like collapse which shows too truly the urgency of the danger. The alterations which are taking place in the state of the brain and nervous system, vary in different individuals: in some, there is strabismus; in others, temporary mania, or at least, delirium; and in more unfavourable cases, even convulsions; these last are especially formidable, as they not only show that the system has been severely affected by the loss of blood, but are apt, from their violence, to extinguish the little spark of life which is left, or, in other words, to be followed by sudden death.
These are some of the many symptoms indicating a sudden and extensive loss of blood; others also occur, depending on the external or internal character of the hæmorrhage. The want of contraction and general flaccidity of the uterus, as felt through the abdominal parietes, have been already noticed; if the blood be prevented escaping by the contracted state of the os uteri, by coagula, or the detached placenta, it begins to collect in the cavity of the uterus, which therefore swells as the accumulation continues to increase, so that it may even equal the size which it had before labour, containing many quarts of blood, and the patient may be in the most imminent danger of dying from hæmorrhage, perhaps, without any blood having issued externally: this is the internal uterine hæmorrhage, a form which is justly looked upon as peculiarly to be dreaded, from the insidious character of its attack. In most cases, the uterus fills to a certain extent only, and then, as if excited to contraction by the distention of its parietes, or any slight concussion, produced by coughing, &c. it expels a large quantity of coagula and half coagulated blood, and returning to its former state of atony, again begins to swell from fresh accumulation of blood in its cavity.
Treatment. So long as the inertia or atony of the uterus continues without any symptoms either of external or internal hæmorrhage, we are not justified in interfering directly, either for the purpose of exciting the uterus, or still less of removing the placenta. This condition chiefly occurs where the uterus has been previously much distended, or suddenly emptied of its contents, where it has been exhausted by long and difficult parturition, and also, as Leroux has observed, "in women of a phlegmatic temperament and lax fibre, who, during pregnancy, have suffered much ill-health, by which the tone of the solids has been weakened; who have very large pelves, and a soft dilatable os uteri." (Sur les Pertes de Sang, 1776.)
We must therefore give the uterus time to recover from the great and sudden change which it has undergone, to collect its strength, to remodel and arrange its forces, until it is at length able, not only to resume its efforts, but to contract to that extent which shall both ensure the expulsion of the placenta and the safety of the patient. Whilst this state of inertia lasts, the patient should be kept as quiet as possible; she should be placed in a comfortable posture, take a little cool drink from time to time (as cold tea, toast and water, &c.,) in order to refresh her;[131] or, if she has been much exhausted by her labour, a glass of wine may be given with good effect. If, however, hæmorrhage appears, this shows that a separation of the placenta from the uterus must have taken place: our great object should now be to excite contraction of the uterus, for by this means alone can we stop the discharge.
In ordinary cases, a little circular friction with the tips of the fingers over the fundus will generally be sufficient. If the uterus begins to swell, we may grasp it with a sudden but moderate degree of force; or we may give the fundus every now and then a smart jog with our hand. Whilst these measures are pursuing, a dose of secale cornutum (see DYSTOCIA, p. 330,) will be of great service; for even if it does not act soon enough to aid the expulsion of the placenta, it contributes greatly to ensure the contraction of the uterus afterwards. If the hæmorrhage nevertheless continues profuse, it will be necessary to introduce the hand into the uterus and remove the half-separated placenta: its contractions are too feeble for that purpose of itself, and the presence of the hand in its cavity, and the artificial separation of the placenta, act as a stimulus, and rouse it to greater activity. The opinion that we only increase the danger by thus increasing the bleeding surface does not hold good, when, from the profuseness of the hæmorrhage, it has become evident that the greater part of the placenta is already separated from the uterus; on the other hand, where there is but a slight discharge, the case is very different, and would not justify our having recourse to so strong a measure.
If the contraction which has been excited by the artificial removal of the placenta be but temporary, we must proceed to the use of other means for the purpose of rousing the activity of the uterus. The sudden application of cold is a most valuable means; it acts here solely by the shock which it produces at the moment, and not by lowering the circulation and favouring coagulation. Thus we find that a cold wet napkin suddenly flapped upon the abdomen has an immediate effect upon the uterus; but it ought not to remain on long, and the skin should be dried with a warm towel, in order that a fresh application of the cold may produce the greater effect. A series of such shocks may be produced by using another wet napkin to the vulva, and a third to the sacrum and loins; an assistant should remove them in the order in which they have been applied, and dry the skin, for a repetition of the remedy, if necessary.
A still more powerful mode of producing a sudden shock, and thus rousing the uterus to activity, is by a douche of cold water upon the abdomen. This may easily be effected by a teapot or kettle held at some height above, and slowly emptied upon the lower part of the abdomen; the uterus will seldom refuse to obey such a stimulus as this, however great may be the inertia into which it has fallen. The inefficiency of a prolonged application of cold to the abdomen, however severe, and the efficiency of the contrary practice, is admirably expressed by Dr. Gooch, in his description of a dangerous case of hæmorrhage:--"Finding the ice so inefficient, I swept it off, and taking an ewer of cold water, I let its contents fall from a height of several feet upon the belly: the effect was instantaneous; the uterus, which, the moment before, had been so soft and indistinct as not to be felt within the abdomen, became small and hard; the bleeding stopped, and the faintness ceased--a striking proof of the important principle that cold applied with a shock is a more powerful means of producing contraction of the uterus than a greater degree of cold without the shock." (An Account of some of the more important Diseases belonging to women, by Robert Gooch, M. D.)
Another mode of applying cold to induce uterine contraction, and little, if at all, inferior to that above-mentioned, is the injection of cold water into the uterus itself: this can only be effectually employed after the removal of the placenta and membranes, and frequently proves of the greatest assistance, being capable of rousing the uterus when many other means have failed. If, from the sultriness of the weather, water cannot be procured of sufficient coldness, or if the case be very urgent, vinegar and water in equal parts may be used; but the injections of spirit and water, which some have recommended, can scarcely be considered as a safe proceeding.
These various means frequently require to be repeated several times before the contraction of the uterus becomes permanent, nor must we be discouraged by finding the uterus becoming soft again in a minute or two after ceasing to use them; for we may feel assured, with few exceptions, that if we can only keep the uterus, by this means, in a state of tolerable contraction for half an hour, it will ultimately become permanent, and remain so of itself.[132]
It is, in these cases, where pressure is of so much importance, not for the purpose of producing uterine contraction, as of maintaining it when once excited. By pressure applied at this moment, we may frequently keep the enfeebled uterus in a state of contraction, which, but for this support, would have yielded to the general force of the circulation, and have again expanded. For the same reason, whenever the uterus begins to swell again from internal hæmorrhage, and by the renewal of the above remedies, it becomes hard, but does not diminish in size: this shows that the contraction has not been powerful enough to expel the blood, which, in all probability, has already begun to coagulate in its cavity: where this is the case, the hand, or at least two fingers, should be passed, to dislodge the clots, and assist in their expulsion; after which, a cloth folded into a thick compress should be placed over the fundus, and firmly bandaged upon the abdomen by a broad towel.
Where every means has failed to induce a sufficient or permanent degree of contraction, we believe that the only certain means which remains, is putting the child to its mother's breast. Under no circumstances do we see the sympathy between the uterus and the breast so beautifully displayed as here, and we may most truly affirm that we have never known it fail where the mother was sufficiently conscious to know that it was her own child. To a by-stander, ignorant of what was taking place, the sudden gush of blood mixed with coagula, which follows the application of the child, would be nothing less than a sign of renewed danger, while, in fact, it is a proof that the uterus is beginning to contract and expel its contents.
If the pulse has been seriously reduced by the loss of blood which the patient has sustained, a glass of wine, or a spoonful or two of brandy, will be of great service in rousing the vital powers; and this must be repeated or increased, according to the urgency of the circumstances; a little weak beef-tea, given from time to time, frequently appears to rouse the system, even more than the brandy, and is more refreshing to the patient; it can also be taken in larger quantities, for when the exhaustion is very great, stimuli appear to excite vomiting, which is by all means to be avoided. Where, however, it occurs spontaneously, it need not be looked upon in so formidable a light: thus Dr. Denman observes, "when patients have suffered much from loss of blood, a vomiting is often brought on, and sometimes under circumstances of such extreme debility that I have shrunk with apprehension lest they should have been destroyed by a return or increase of the hæmorrhage, which I concluded was inevitable, after so violent an effort: but there is no reason for this apprehension; for, though vomiting may be considered as a proof of the injury which the constitution has suffered by the hæmorrhage, yet the action of vomiting contributes to its suppression, perhaps by some revulsion, and certainly by exciting a more vigorous action of the remaining powers of the constitution, as is proved by the amendment of the pulse, and of all other appearances immediately after the vomiting."
When a slight trickling of blood continues, although the uterus is tolerably hard and contracted, it will be desirable to make an examination, for we shall frequently find a long slender coagulum hanging through the os uteri into the vagina, upon the removal of which, the discharge will cease.
The application of the child to the breast is not less valuable for preventing any return of the hæmorrhage than for stopping it in the first instance: we are never perfectly secure against hæmorrhage coming on during the first few hours after delivery, even where every thing has turned out as favourably as possible: the exhaustion from the length or severity of the labour, the warmth of the bed, and in some cases, it would even seem, the relaxing effects of deep sleep, are all liable to be followed by inertia uteri and hæmorrhage. In no way can we ensure our patient so completely against this kind of danger as by putting the child to the breast; the uterine contraction which it excites is not only powerful, but permanent; nor do we consider that a practitioner is justified in leaving a patient in whom the uterus has shown a disposition to inertia without having ensured her safety by this simple but effectual safeguard.
There is a form of hæmorrhage after the birth of the child, which seems to depend upon an over-distended state of the circulation, and where its activity appears too great for the contractile power of the uterus; so that, in spite of the uterus being tolerably firm and hard, a profuse hæmorrhage is almost sure to follow the separation of the placenta. This condition has been described by the late Dr. Gooch, and still more recently by Professor Michaelis, of Kiel; to the former, especially, we are indebted, not only for having first pointed out this important fact, but for having placed it before us in the simplest and clearest light. "I had now witnessed," says Dr. Gooch, "two labours in the same person, in which, though the uterus contracted in the ordinary degree, profuse hæmorrhage had nevertheless occurred: let me be understood--after the birth of the child, I laid my hand on the abdomen, and felt the uterus within, of that size and hardness, which is generally unattended by, and precludes hæmorrhage; in both instances, the labour had been attended by an excessively full and rapid circulation. I could easily understand that a contraction of the uterus, which would preclude hæmorrhage in the ordinary state of circulation, might be insufficient to prevent it, during this violent action of the blood-vessels; and the inference I drew was, that, in this case, the hæmorrhage depended not on a want of contraction of the uterus, but on a want of tranquillity of the circulation; and that if ever she became pregnant again, a mode of treatment which would cause her to fall in labour with a cool skin and a quiet pulse, would be the best means of preventing a recurrence of the accident." This will be effected by an occasional venesection during the last weeks of pregnancy, by the use of saline laxatives; and if there be still much disposition to heat the surface, and excitement of circulation, by doses of nitre three times a day, and by strict antiphlogistic regimen.