VII. INVERSION OF THE UTERUS
Partial and complete.--Causes.--Diagnosis and symptoms.--Treatment.-- Chronic inversion.--Extirpation of the uterus.
The uterus is liable, although rarely, to a peculiar displacement called inversion, where the fundus is forced down into the cavity of the uterus, and so through the os uteri into the vagina; or where the whole uterus is turned wrong side outwards, the fundus appearing at the os externum, the former being the partial, the latter the complete inversion: in the latter it is not only the entire uterus which is inverted, but it is also the vagina, so that the whole mass which the uterus forms at the os externum is attached to the inverted vagina as by a hollow pedicle, and is encircled by the os uteri close to the labia; the external surface of the mass is the inner surface of the uterus.
As it is impossible for the fundus to descend through the os uteri when this is not dilated and open, it is evident that, except in certain cases of polypus, inversion of the uterus can only take place immediately after delivery. If, at this moment, especially when the uterus has been too suddenly emptied of its contents, any force be applied to the fundus, it may be easily pushed down into the cavity, or, by the continued action of that force, the fundus may be carried through the os uteri or even through the os externum.
Causes. Where this force has been applied externally, it may be produced by violent straining during the last pains, violent efforts, as coughing, vomiting, sneezing, &c., or by sudden attempts to rise in bed, by which the abdominal muscles are put into powerful action. Where, on the other hand, it has been applied from within, it may arise from improper attempts to extract the placenta before the uterus was sufficiently contracted; where the cord has been unusually short, or twisted round the child, or where the patient has been suddenly surprised with violent pains, and the child dashed upon the floor before she could reach her bed, by which means the cord has received a violent jerk, or has been even broken.
It has been very much the habit to attribute inversion almost solely to these latter causes, and that, except where it takes place from the shortness of the cord, or the sudden expulsion of the child whilst the mother is in the erect posture, it must almost necessarily be a result of improper pulling at the cord on the part of the practitioner: the cases on record, however, go to prove that, in by far the majority of instances, no force of this sort had been applied to the fundus; and in those instances where the child has been dashed upon the floor and the cord broken (some six or seven of which have at different times occurred under our own notice,) the fundus has not once been pulled down, although the force applied to it must have been very considerable, since the very cord which had thus given way to the weight of the child resisted afterwards, on more than one occasion, a considerable effort which we made to break it. In by far the majority of these cases, the cord has given way nearly at the same spot, viz. about three inches distance from the umbilicus, apparently justifying the inference, that it was weaker here than elsewhere. Another reason why the fundus should not have been pulled down by the weight of the child might be stated, viz. that the placenta being at that moment above the brim of the pelvis, the direction in which the strain was made upon the cord (viz. in that of the outlet, or downwards and forwards,) was not much calculated to affect the fundus.
"The practice of pulling too early and violently at the cord," says Dr. Radford, "after the expulsion of the child, before the uterus has contracted, so as to detach and expel the placenta, has been generally considered as the cause of inversion; but we know that the accident happens before any force has been applied to the funis. In case fourth, the descent was so rapid and forcible through the os externum, that it would have been quite impossible to have resisted the unnatural action by which the organ was carried down. It has occurred when the patient was delivered of a dead child, the funis so putrid as to break with a slight effort. It has been found before the cord was separated, and the child given to the nurse. In the practice of Ruysch, this circumstance took place after he had extracted a dead child."[133]
Still, however, it is not the less important to recommend caution, especially to young beginners, against pulling at the cord with too much force, in their hurry to bring the placenta away; the condition of the uterus at this moment is highly favourable if in a state of inertia.
Diagnosis and Symptoms. In cases of partial inversion of the uterus, we distinguish the disease by the absence of the hard spherical tumour of the fundus above the pubes, and by the presence of a globular fleshy body in the os uteri, which is sensible to the touch. This tumour will be found broader at the base than at its extremity; and surrounded by the os and cervix uteri, forming, as it were, a tight ring round it. The patient complains of a sense of dragging amounting to severe pain in the groins and lumbar region, and which compelling her to strain violently, often forces the uterus farther down, and sometimes induces complete inversion; hæmorrhage more or less considerable accompanies it; the pain is more acute in this than in the complete inversion, and the hæmorrhage more violent; the patient suffers under an oppressive sense of sinking, with nausea or vomiting, cold clammy sweats, feeble fluttering or nearly extinct pulse, faintings or even convulsions.
In the complete form we have neither the hæmorrhage nor that frightful train of symptoms produced by the strangulated condition of the inverted uterus; for now that it is fairly turned inside out, it is just, or nearly as capable of contracting as in its natural state, which it is prevented from doing when only partially inverted: complete inversion, however, is not the less to be dreaded, for death may suddenly follow from the shock which the nervous system has sustained, or from dangerous fainting in consequence of the sudden evacuation of the abdominal cavity; this latter circumstance will be aggravated by the inversion of the vagina which is apt to accompany the complete form, and thus give rise to considerable displacement of the intestine.
Treatment. The sooner we endeavour to return the uterus the better, for we shall seldom experience much difficulty in effecting our object, if done immediately upon the occurrence of the accident; indeed, we know of a case where, under these circumstances, it was successfully returned by a midwife. If, on the other hand, some hours are permitted to elapse before the attempt at reduction is made, it will be attended with great difficulty, or even prove entirely abortive; the os uteri contracts powerfully, the uterus swells from the obstructed return of the circulation, inflammation rapidly follows, and diminishes still farther our chances of success. Dr. Denman says, "The impossibility of replacing it, if not done soon after the accident, has been proved in several instances, to which I have been called so early as within four hours, and the difficulty will be increased at the expiration of a longer time." Still, however, we must not despair of success, for numerous cases have been recorded by different authors where the reduction has been effected after a much longer period.
There has been a considerable discrepancy of opinion as to the management of those cases where the placenta is still adhering to the uterus, viz. whether it is not safer to reduce the fundus with the placenta, and excite the uterus to throw it off afterwards in the usual way, or whether we ought not to separate the placenta before making the attempt at reduction. Mr. Newnham, the author of almost the only monograph upon this subject, recommends the former mode of practice. "It has been recommended by several respectable authorities to remove first the placenta, in order to diminish the bulk of the inverted fundus, and thus facilitate the reduction. But it is surely impossible that this proceeding can be attended with any beneficial consequences, whilst the irritation of the uterus will necessarily tend to bring on those bearing down efforts, which would present a material obstacle to its reduction; and would increase the hæmorrhage at a period when every ounce of blood is of infinite importance, besides returning the placenta while it remains attached to the uterus; and its subsequent judicious treatment as a simply retained placenta will have a good effect in bringing on that regular and natural uterine contraction, which is the hope of the practitioner and the safety of the patient." (Essay on the Symptoms, Causes, and Treatment of Inversion of the Uterus, by W. Newnham, Esq. p. 14.)
On the other hand, many authorities, especially of modern times, advocate a very opposite practice, and recommend that the placenta should be removed before attempting to reduce the fundus; as by so doing it will pass back much more easily than where the bulk of the placenta is added to it. There can be no doubt that this practice is correct in cases of complete inversion, where, as we have already observed, there is little or no danger from hæmorrhage, and where it is of the greatest importance to avail ourselves of every advantage by lessening the size of the inverted uterus as much as possible: where, however, it is a case of partial inversion, it is generally accompanied with hæmorrhage; and here, therefore, it becomes a question how far we are justified in detaching the placenta, and therefore increasing the flooding, either before we are certain that we are able to reduce the fundus, or before we have placed the uterus in a condition in which it is capable of contracting. In Mr. Mann's case, quoted by Dr. Radford (op. cit.,) the inversion was evidently complete, for the uterus was found to have "passed externally from the vagina, and the placenta attached to it." "I first peeled the placenta from the fundus uteri, and then grasping the extruded part with my hand, I did not find it very difficult to re-introduce it into the vagina, and to carry it through the os uteri. I followed with my hand, or rather pushed it forward, when I observed it suddenly start from me as a piece of India rubber would."
Dr. Merriman, who candidly owns that he has altered his opinion on this point, since the last edition of his work on difficult parturition, in favour of removing the placenta, distinctly proves that the presence of this mass was the chief cause of the difficulty. "I tried," says he, "to effect the reduction without removing the placenta, but could, by no possibility, accomplish it till I had first separated the placenta: this being effected, I succeeded to my entire satisfaction in re-inverting the fundus." (Synopsis of Difficult Parturition.)
In reducing the fundus, we must not thrust our fingers collected into a cone against the tumour, as has been recommended by most authors; for, by so doing, we only produce a depression in it, and, as it were, re-invert or double the uterus upon itself, and thus add considerably to the bulk of the mass, and the difficulty of the reduction. We should grasp the tumour firmly, and push it bodily upwards in the direction of the pelvic outlet: at first little or no change is produced, until it has ascended so far, that the vagina which had been dragged down is returned again to its natural situation; the hand must follow the tumour, and now that the lower part of the uterus is fixed, by the vagina being put upon the stretch, the pressure which is applied to the fundus will act with so much greater effect. We should endeavour to "return, first, that portion of the uterus which was expelled last from the os uteri." (Newnham, op. cit. p. 616.) As the hand rises into the cavity of the pelvis, and is no longer able to grasp the tumour, so far from contracting the points of our fingers into a cone, it will be desirable to spread them at equal distances round it, and thus apply the pressure over a larger space: it was to attain this object that Leroux recommended the application of a cloth to the fundus, as by this means the force applied to it was more equally divided. (Sur les Pertes de Sang, § 218.) The hand, however, will be far preferable. We must gradually alter the direction in which we press up the tumour as it ascends, guiding our hand in the axis of the pelvic cavity, and lastly bringing it upwards and forwards in that of the superior aperture. When once the fundus has repassed the os uteri, it usually recedes suddenly from the hand, as already described in Mr. Mann's case: if we feel the uterus through the abdominal parietes well contracted, there will be no need of passing the hand into its cavity; but if it be still flaccid and soft, the hand should be introduced, not only for the purpose of guarding against any return of the inversion, but of exciting more active contractions by its presence. The patient should avoid making any sudden efforts to raise herself, or to cough, strain, or by any means excite the abdominal muscles to exert pressure upon the fundus, for it is occasionally observed, that the disposition to inversion continues some time after the reduction has been effected.
Where some little time has elapsed before any attempt is made to reduce the fundus, the inverted portion begins to swell from obstruction to the return of blood, especially where the inversion is partial, and, therefore, tightly girded by the os uteri; the passages grow hot and dry, and the chances of reducing the tumour diminish in proportion. "Is it not reasonable," as Mr. Newnham observes, "to suppose that the first effect of the accident will be to bring on inflammatory action and tension of the parts, and this very state will in itself be a sufficient obstacle to success." (Op. cit. p. 18.) If, under these circumstances, we find that the attempts at reduction is attended with considerable difficulty, or is evidently impossible, it will be necessary to wait until the excitement of the circulation, and the congestion and swelling of the parts are reduced, and the passages duly relaxed by bleeding; besides this, the external parts should be well fomented, the patient should use the warm hip bath, or sit over the steam of hot water, and throw up emollient and sedative enemata as recommended in our treatment of inflammation of the uterus; the operation, which was during the state of inflammation and feverish excitement in which the patient was, strongly contra-indicated, now becomes practicable and safe, and the difficulties, which before would have rendered it nearly or quite impossible, are now in a great measure removed.
Wherever the uterus is completely inverted, and there is reason to expect considerable difficulty in reducing it, we shall find great benefit in adopting the mode of practice recommended by Mr. C. White, of Manchester, viz. of firmly grasping the tumour until we have succeeded in considerably diminishing its size, and thus removing the chief obstacle to its reduction. "I grasped the body of it in my hand," says Mr. W., "and held it there for some time, in order to lessen its bulk by compression. As I soon perceived that it began to diminish, I persevered, and soon after made another attempt to reduce it, by thrusting at its fundus; it began to give way. I continued the force till I had perfectly returned it, and had insinuated my hand into its body: it was no sooner reduced, than the pulse in her wrist began to beat: she recovered as fast as we could wish." (White, on Lying-in Women, case, 19. Appendix, p. 429, 2d edit.)
Where the fundus is partially inverted, and the os uteri girds it very tightly, so as not only to produce very frightful symptoms arising from the strangulated condition of the organ, but also to render its reduction a matter of great difficulty, or even impossibility, Dr. Dewees has advised that, so far from attempting to push up the fundus, we should rather try to bring it down, and thus render the inversion complete; by this means, the "pain, faintness, vomiting, delirium, cold sweats, convulsions, extinct pulse," &c. will not only be relieved, but the farther danger from hæmorrhage prevented.
"The propriety and safety of this plan is, it must be confessed, predicated upon the happy result of a solitary case, but, from its entire and speedy success in this instance, it is rendered more than probable that it will be of equal advantage if employed in others; "all reasoning upon the subject" is certainly in its favour; and experience, so far as a single case may be entitled such, is equally so. The patient is to be placed upon her back near the edge of the bed, and have her legs supported by proper assistants; the hand is to be introduced along the interior part of the vagina, but sufficiently high to seize the uterus pretty firmly; it is then to be drawn gently and steadily downward and outward, until the inversion is completed: this will be known by a kind of jerk, announcing the passing of the confined part through the stricture. Traction should now cease, and the part be carefully examined; if the inversion be complete, the mouth of the uterus will no longer be felt, and there will be an immediate cessation of pain and other distressing sensations." (Dewees, Compendious System of Midwifery, § 1318.)
Chronic inversion. Where some time has already elapsed since the occurrence of the accident, and the more distressing symptoms have subsided, the inversion now passes into a chronic state, which, although not immediately dangerous to life, will ultimately be not less fatal. The form of the tumour gradually alters; it assumes a more polypoid shape, from the increasing contraction of its mouth narrowing the upper part of it; and now the diagnosis from polypus sometimes becomes exceedingly difficult, the more so as the pressure produced by the os uteri diminishes the sensibility of the fundus. Hence, as Mr. Newnham observes, we may conclude, "that it is always difficult and sometimes impossible, with our present knowledge, to distinguish partial and chronic inversion of the uterus from polypus; since, in both diseases, the os uteri will be found encircling the summit of the tumour, and, in either case, the finger may be passed readily around it. And if, in order to remove this uncertainty, the entire hand be introduced into the vagina, so as to allow the finger to pass by the side of the tumour to the extremity of the space remaining between it and the os uteri; and if we find that the finger soon arrives at this point, it will be impossible to ascertain whether it rests against a portion of the uterus which has been inverted in the usual way, or by the long-continued dragging of the polypus upon its fundus. And if, under these embarrassing circumstances, we call to our assistance our ideas concerning the form of polypus, its enlarged base and narrow peduncle, we must also recollect the abundant evidence to prove that the neck of such a tumour is often as large, and sometimes larger, than its inferior extremity, and we shall still be left in inexplicable uncertainty."
The periodical hæmorrhages, with profuse leucorrhoea during the intervals are too common, both to chronic partial inversion and to polypus, to afford any certain means of diagnosis; and the gradually increasing debility, from the constant drain upon the system and ultimate breaking up of the general health, may be as much the result of the one as of the other. The rugged uneven surface of the inverted uterus, the smoothness of a polypus, are distinctions not of long continuance; for, after awhile, the uterus gradually becomes smoother, whereas, a polypus rarely continues long in the vagina without its surface becoming irregular from ulceration.
It might be a question whether it would not be possible to detect the menstrual fluid at the catamenial periods oozing from the surface of the inverted uterus: that this is quite possible in cases of complete inversion, is a well-known fact, but how far it can be detected in the partial form is not so certain, as the position of the tumour pretty high up in the vagina would prevent our ascertaining it, especially when there is more or less hæmorrhage going on. In most cases, the history of the case, and our not being able to pass up a catheter far beyond the os uteri, which completely surrounds the neck of the tumour without adhering to it, are the chief points upon which we must found our diagnosis.
"Whilst the inverted uterus remains in the vagina, the discharge (excepting at the periods of menstruation) will be of a mucous kind; but if the uterus falls lower, so as to protrude beyond the external parts, the exposure of that surface, which in a natural state lined the cavity, to air, as well as to occasional injuries, may induce inflammation and ulceration over a part or the whole of its surface; and the mucous discharge may be changed to one of a purulent kind, so considerable in quantity as to debilitate the constitution, and to cause all the common symptoms of weakness." (Sir C. M. Clarke, on the Diseases of Females, part i. p. 155.)
Although such a length of time has elapsed since the inversion, that it has become of the chronic kind, still we are not justified in giving up all hopes as to the possibility of returning it. Dr. Churchill has given an interesting summary of cases where many days, and in one case even twelve weeks, had intervened, and yet, nevertheless, where the reduction was successfully effected. (On the Principal Diseases of Females, p. 331.) We may also add two very remarkable cases related by Boyer (quoted by Kilian,) viz. where the uterus had resisted every endeavour to reduce the inversion, which in one case had remained fourteen days, in the other more than eight years, and where, in consequence of a sudden and violent fall upon the nates, reduction followed spontaneously and permanently.
Extirpation of the uterus. Where, however, the powers of the system are rapidly breaking, from the profuse hæmorrhages at each menstrual period, and not less profuse discharge during the intervals, the only means of saving the patient is by treating the case as one of polypus, or in other words, removing the uterus by ligature. Numerous cases are on record where this has succeeded perfectly, although during the process the patient suffered from several attacks of pain and even inflammation, occasionally requiring the ligature to be loosened for awhile. In the case recorded by Mr. Newnham, rather more than three weeks were required before the separation of the tumour was effected. When once this source of irritation is removed, the hæmorrhage and other discharges which had so greatly reduced the patient cease, and, as in cases of polypus, a most striking and favourable change is produced, the health and strength return, and the recovery of the patient is complete.
VIII. ENCYSTED PLACENTA
Situation in the uterus.--Adherent placenta.--Prognosis and treatment.--Placenta left in the uterus.--Absorption of retained placenta.
By the term encysted placenta, we mean that state of irregular uterine action after the expulsion of the child, where the lower portion of the uterus, particularly the os uteri internum, is closely contracted, while the fundus contains the placenta enclosed in a species of cyst or cavity formed by itself and the body of the uterus.
Upon examination externally, we find the fundus pretty firmly contracted, but probably somewhat higher up the abdomen than usual; the vagina and os uteri externum, or os tincæ, are usually found dilated, the passage gradually tapering like a funnel to the os uteri internum, or upper end of the canal of the cervix.
Situation in the uterus. This state has been very generally considered to arise from a spasmodic contraction in the circular fibres of the body of the uterus, by which it was as if tightly girded by a cord at its middle, and, from the form it was supposed to take, was called hour-glass contraction of the uterus.
From the observations of later years there is much reason to suppose that the true hour-glass contraction, as now described, is of very rare occurrence, even if it does take place at all; and that, in by far the majority of cases, the stricture is either produced by the upper part of the cervix, as we have already mentioned, or resides in the os uteri externum or inferior portion of the cervix.
Baudelocque was the first who pointed out the neck of the uterus as the real seat of the stricture in these cases: "that circle (says he) of the uterus which is round the child's neck, according to the general laws of its contraction, must narrow itself much quicker after delivery than the other circles which compose that viscus, because it is already narrower, and its forced dilatation at the instant of the expulsion of the child's trunk is only momentary, and because it has naturally more tendency to close than the other circles have, since it is that which constitutes the neck of the uterus in its natural state." (Baudelocque, Heath's Trans. vol. ii. § 969.)
Dr. Douglas, of Dublin, also investigated this subject, and came to a similar conclusion: he considered that encysted or incarcerated placenta from hour-glass contraction, resulted either from morbid adhesion of the placenta, or from inactivity of the uterus, and does not occur as a primary affection; his observations lead to the conclusion that the stricture in hour-glass contraction "does not form from the middle circumference of the uterus; it is formed by the lowest verge of its thickly muscular substance, at the line of demarcation of its body and cervix." "Thus, then, it would appear that the upper chamber comprises in its formation the entire of the body of the fundus; whilst the lower chamber engages only the cervix uteri and the vagina." (Medical Transactions of the Col. of Phys. vol. vi. p. 393.)
The late W. J. Schmitt of Vienna considered that the stricture was produced by the os tincæ, or os uteri externum.
From our own experience we would say that the seat of the stricture varies considerably in different cases; that in the simplest form it is nothing more than a contracted state of the os uteri externum; that in others it is formed by the upper portion of the cervix uteri, or os uteri internum; but in other instances it appears to be formed by the inferior segment of the uterus itself. The contraction in this part of the uterus, which, according to the observations of Professor Michaelis, comes on when the os uteri is fully developed, and, by closely surrounding the head, is one chief means by which prolapsus of the cord is prevented, may easily produce a state of stricture after the birth of the child, and thus retain the placenta; it may, however, be questioned whether this portion of the uterus, when fully dilated by pregnancy, and which then forms its inferior segment, would not become the os uteri internum when the uterus is empty and contracted.
Hour-glass contraction of the uterus is liable to occur where the action of the uterus has been much deranged or exhausted, either by the unusual rapidity or excessive protraction of the labour. In all cases where the child has been rapidly expelled before the uterus has had time to contract regularly and uniformly, the disposition in the os uteri to contract, as pointed out by Baudelocque, will manifest itself. This state may also be induced by great previous distention, as from twins, or too much liquor amnii; by irritation, as by improperly pulling at the cord, by having used too much force in artificially delivering the child, by the introduction of the hand or instruments too cold, &c. The most frequent cause, however, is over anxiety to remove the placenta; the cord is frequently pulled at, and at length the os uteri is excited to contract; in this case we generally find the stricture at the os tincæ, which yields without much difficulty, either by gentle friction with the hand over the fundus, and cautiously pulling the placenta in the axis of the superior aperture, or by introducing the hand and bringing it away.
Adherent placenta. When the placenta is still attached either wholly or in part, there are generally some preternatural adhesions to the uterus, which, by keeping its upper portion distended, give rise to partial contractions below. This condition of the placenta is observed to attend nearly every severe case of hour-glass contraction; in some instances its whole surface appears as if grown to the uterus, forming an adhesion so close and intimate as to be overcome with the greatest difficulty: we have met with cases where the placenta tore up into shreds which still adhered to the uterus as strongly as before; in others, however, the adhesions are of smaller extent, varying from the size of a shilling to that of a crown piece, sometimes there being only one, sometimes two or three in the same placenta.
The nature of these adhesions is but little understood; it is generally considered that they have been produced by some inflammatory process taking place between the uterus and placenta; and certainly the firm feel and lighter colour of the part which has been adherent might, perhaps, justify such a conclusion. Cases have occurred where the inflammatory action has extended in the contrary direction (outwards,) producing mischief in the neighbouring parts, viz. abscess and injury of the pelvic periosteum with subsequent pelvic exostosis. (Neue Zeitschrift für Geburtskunde, band v. heft 1.) We may also observe, that these adhesions of the placenta usually occur several times in the same individual.
Prognosis and treatment. The danger in these cases depends chiefly on the presence or absence of hæmorrhage; in the latter case, we may wait safely, and give the uterus the opportunity of contracting upon the placenta, so as ultimately to dilate the stricture and expel it. In most instances, where the os tincæ is the seat of the contraction, and the placenta (as is usually the case here) already detached, a little patience, aided by gentle friction of the fundus, and carefully abstaining from all irritation of the os uteri, will be sufficient to attain this object; the os uteri will gradually relax and the placenta slowly exude into the vagina. Where, from the feel of the fundus, the uterus appears still unable to exert such a degree of contraction as shall overpower the os uteri, we may follow the plan of Dr. Dewees, in his section "On the enclosed and partially protruded Placenta," and rouse its activity by some doses of ergot: "should this not succeed within an hour, the uterus must be gently entered, by slowly dilating the os uteri, and the placenta removed." One finger after the other must be passed through the os uteri, until it has yielded sufficiently: if the placenta be quite detached, two fingers will generally be sufficient for this purpose, by which means it may be gradually brought down into the palm of the hand, and then removed.
Where more or less of it is morbidly adherent, which may be presumed when it continues for some time at the upper part of the uterus without any disposition to descend, we must carefully introduce the whole hand, and endeavour to find the edge of the placenta at which we should begin the process of separation. Where, however, the edge is very thin, and the attachment firm, it is not easy to effect this without risk of injuring the structure of the uterus itself with the nails, nor can we always distinguish the thin and closely adherent edge of the placenta from the uterus itself: in these cases it will be safer to plunge the fingers into the central and thicker portions of the mass, and gradually separate it towards the circumference. Wherever this close adhesion prevails over a considerable extent, it becomes nearly impossible to prevent portions being left adhering to the uterus; thus it not unfrequently happens, where a placenta under these circumstances has been artificially removed, that there are one or more large irregular cavities on its uterine surface, from a portion of its mass having been torn from it, and left adhering. Cases have occurred to us,[134] where the whole central portion has thus remained, the amniotic surface of the placenta having come away entire with the larger umbilical vessels attached to it, and merely a narrow margin of parenchyma at its edge; in others, the whole mass has broken up, the cord, the larger branches of the umbilical vessels, and the membranes have come away, but the greater part of the placenta has remained closely adhering to the uterus. In such a case it becomes a question, whether it be safe to persist in our efforts to remove the remains of the placenta, or whether it will not be better to leave the case to nature: experience shows that the latter plan is the safer, and that a practitioner is not justified in running the risk of severely injuring the uterus by repeated and violent efforts to effect his object.
Placenta left in the uterus. Where a portion of placenta has been thus left in the uterus, the case may terminate in one of three ways: either it may be expelled in the course of from twelve to twenty-four hours, without any perceptible marks of putrefaction, and with but little or no disturbance to the system; or where, after a longer interval, the discharges have become very offensive, and the placenta has been expelled in a putrid state, with serious disturbance of the health; or lastly, where the lochia has been sparing but natural, and where no trace whatever of the placenta has appeared.
In the first mode of termination it may be presumed that the attachment of the placenta has yielded either to the continued contraction of the uterus, or from a slight degree of incipient putrefaction, by which its union with the uterus was weakened; in the second case, from contact with the external air, and being constantly kept at a considerable temperature by the heat of the surrounding parts, the lacerated placenta rapidly putrefies, putrid matter is carried into the system, producing all the effects of a deadly poison, and the patient is placed in a state of the greatest danger; the pulse becomes quick and small, the tongue red and dry, accompanied with great depression of the vital powers, the uterus frequently swells, grows hard, and excessively painful, followed by general peritonitis; it is not, however, the inflammation which necessarily destroys the patient, but the prostrating effects upon the nervous system, produced by the introduction of an animal poison into the circulation.
Absorption of retained placenta. Where the placenta has not been much lacerated, or at any rate where every portion has been removed which could be separated without violence, where also the uterus has contracted firmly and closely, the part which is retained does not pass into putrefaction, little or no inconvenience is experienced by the patient; the lochia, as we before observed, is sparing but natural, and ceases after the usual time, but not a trace of the placenta comes away. This fact has been repeatedly noticed, especially in later years; but the attention of medical men was first called to the subject by Professor Naegelé, of Heidelberg, in 1828. In 1802, and again in 1811, cases of premature expulsion of the foetus occurred to him where the membranes and placenta did not come away, and where no trace whatever of them appeared afterwards. In 1828[135] his assistance was required in a case of unusually firm adhesion of the placenta, and where, from this as well as other circumstances, the extraction was so difficult that he was compelled to leave considerably more than one-third in the uterus. (Med. Gaz. Jan. 10, 1829.) About the same time, a most interesting case was published by Professor Salomon, of Leyden, where the whole placenta of a child only three weeks short of the full time was retained by the firm contraction of the uterus, and, according to Dr. Salomon's view of it, removed by the process of absorption. About the end of the third week, the uterus, which had hitherto been larger than is natural under ordinary circumstances after labour, and more globular, now diminished considerably, and began to assume the usual form as in the unimpregnated state. Besides the cases already alluded to, which we have described in our Midwifery Hospital Reports, we may again refer to one which was mentioned by Dr. Young, formerly professor of Midwifery at Edinburgh: "I could get my hand to the placenta, but no farther, the uterus having formed a kind of pouch for it, so that I at last was obliged to trust to nature; what was very remarkable, the placenta never came away, yet the woman recovered."
Cases have also occurred where the placenta, after having been retained many days in the uterus, has been expelled quite fresh, the edges worn or rather dissolved away by the process of absorption; thus Dr. Denman mentions one where the whole placenta was retained till the fifteenth day after labour, and was then expelled with little signs of putrefaction except upon the membranes, the whole surface which had adhered exhibiting fresh marks of separation. Cases of abortion have occasionally been observed where the embryo has escaped, but the secundines have never come away, although the discharges, &c., have been watched with the greatest attention; after a time the menses have returned, the patient has again become pregnant, and has passed through her labour at the full term without any thing unusual occurring.
The subject has recently been considered very fully, and much interesting knowledge added, by Dr. Villeneuve, of Marseilles. Besides putting the fact beyond all doubt, he shows that cases of total adhesion are rarely if ever fatal; and that, where cases have terminated fatally, the placenta has only partially adhered, and the patient has been either destroyed by hæmorrhage, or by the effects arising from the absorption of putrid matter, or from injury of the uterus in attempting to remove the placenta. He considers that a placenta which is not fixed to the uterus by organic and intimate adhesions cannot be absorbed, though it may perhaps be retained for several days without danger, if there is contraction of the uterus. (Gazette Médicale de Paris, July 8, 1840.) It may, however, be doubted whether this last observation be correct, as it is a well-established fact that cows which had been supposed with calf, and in which the symptoms of pregnancy had again subsided, have afterwards been killed and nothing but the bones of the calf found in the uterus, the soft parts having been removed by absorption. The same fact has been observed also in sheep and other animals; and knowing how abundantly the human uterus is supplied with absorbents, coupled with what has been already stated, there can be little or no doubt but that the placenta in these cases had been acted upon by a similar process. Although we strongly deprecate repeated attempts to remove the adherent portions of placenta, especially where we have brought away a considerable quantity of its foetal part, still we would warn our readers against leaving any loose ragged pieces in the uterus, for these rapidly pass into putrefaction, and produce the alarming symptoms above-mentioned. The safety of our patient mainly depends on the firm contraction of the uterus preventing the access of air, and on our constantly removing, by means of injections, any putrid discharge which may have collected. The sparing quantity of lochia which has generally been observed, especially where the whole surface of the placenta has adhered, can easily be accounted for, the greater portion of the vessels which ordinarily furnish this discharge being closed up by the adherent mass: from the same reason we can explain why cases of total attachment of the placenta are rarely or never attended with hæmorrhage.
Lastly, should any symptoms of fever or abdominal inflammation supervene, they must be treated according to the rules which we have given under these heads.[136]
IX. PRECIPITATE LABOUR
Violent uterine action.--Causes.--Deficient resistance.--Effects of precipitate labour.--Rupture of the cord.--Treatment.--Connexion of precipitate labour with mania.
The second division of Dystocia comprises those species of labour where it becomes dangerous for the mother or child, without obstruction to its progress. Of these we shall first consider precipitate or too rapid labour, not only because it is liable to be followed by a great variety of injurious results, but also because it has received little or no notice by the obstetric authors of this country.
Precipitate labour depends on one of two conditions; either the expelling powers exceed their ordinary degree of activity, or the resistance to the passage of the child is less than usual. "Every normal labour has a certain course, which is neither too slow nor too quick. The passages are thus dilated gradually and without excessive suffering; the uterus is felt alternately hard and soft; and the pains have certain and regular intervals, which become very gradually shorter, during which both mother and child are enabled to recover themselves." (Wigand, Geburt des Menschen, vol. i. p. 68.)
Violent uterine action. In the present case the pains are extremely violent from the very commencement of the labour; they produce great suffering; each pain lasts a considerable time, and the intervals between them are very short. During their presence, the patient is irresistibly compelled to bear down and strain with all her force; the whole body partakes of the general excitement: the patient is more restless and less manageable than usual, her manner is altered and becomes strange; the head is hot, the face flushed, and the pulse quick and full.
In some cases the intervals between the pains are scarcely perceptible, for one pain has scarcely left off before the next has already commenced; or the uterus falls into a state of continued violent contraction, which does not cease until the child is driven into the world. The abdomen is very hard during the pain, the whole body stiff and rigid; the patient expresses her sufferings very loudly, or actually raves with pain. From the constant and irresistible effort to strain, it seems as if she has scarcely time to get her breath, for she continues to hold it so long that respiration might be almost supposed to have stopped altogether. "As long as consciousness remains, the impulse to lay hold of any object within reach and pull by it is extraordinarily strong, until at length, in the midst of a violent scream, or grinding of the teeth, covered with sweat and with simultaneous evacuation of the rectum and bladder, she is suddenly delivered." (Wigand, op. cit. vol. i. p. 71.)
Causes. This storm of uncontrollable uterine action "appears to depend upon an unusually powerful influence of the nervous system upon the contractile fibres of the uterus or upon a morbid degree of irritability." (Ibid.) In some cases it appears as an individual peculiarity, every successive labour of the patient being remarkable for its violence and rapidity. Precipitate labours of this kind are frequently observed to be hereditary, and like an opposite and equally faulty condition of the expelling powers, viz. slow and lingering uterine action, are sometimes peculiar to certain families, the mother and the sisters of the patient having had all their labours peculiarly rapid and violent.
The character of the catamenial periods before pregnancy is frequently observed to bear a considerable relation to that of the labours in the same individual; thus, if she has always suffered much pain and other symptoms of uterine excitement just before or during these times, so much so as even to require slight medical treatment to allay the periodical suffering, the uterus almost invariably manifests a similar degree of energy and irritability during labour. On the other hand, where the menstrual periods produce so little suffering or derangement that, but for the appearance of the discharge itself, the patient has scarcely any means of determining their recurrence, the uterus betrays a similar want of activity when labour comes on, which may therefore, cæteris paribus, be expected to be slow and lingering.
Mental affections, which we have already shown to be capable of retarding labour, occasionally have the opposite effect, and rouse the uterus to violent action. It is well known that the dread of the forceps, which the practitioner has declared would be required, has frequently been followed by so much activity of the uterus as to render its application unnecessary.
Where the patient is stout, robust, and plethoric, or of a nervous hysterical habit, this state of unruly uterine action is frequently attended with great cerebral excitement; during the pains she raves wildly, and for some time becomes quite unmanageable, or in other cases this state passes into actual convulsions.
In febrile diseases, especially of the eruptive kind, the labour is usually of this character; the exertions of the uterus in such cases, especially in scarlet fever, are sometimes quite extraordinary, so that the child seems to be born without any effort on the part of the mother. This is of great importance in inflammation of the lungs, &c. where the patient would be unable to inflate the lungs to that extent which is necessary for any violent efforts.
Deficient resistance. Where the rapidity of the labour arises from want of that degree of resistance to the expelling powers which is natural, it may depend on circumstances connected with the mother or the child; thus, it may arise from too large a pelvis; the head, covered by the inferior portion of the uterus, is forced down deeper into the pelvis than usual, especially if, as is not unfrequently the case, this state be accompanied with violent and powerful pains; the head may thus be actually forced through the os externum before it has passed the os uteri: cases have been recorded where nearly the whole uterus, has been thus protruded. In an "extraordinary case," as Deventer justly terms it, "the head of the child had passed the os externum as far as the shoulders, and only the summit of it was visible, three-quarters at least of the head being still enclosed in the uterus, although the head and neck had already passed." (Novum Lumen, part. ii. chap. 3.)
In other cases the sudden expulsion of the child appears to depend merely upon the great dilatability of the soft parts, and may occur quite independently of any disease. We recollect a case of this sort where the patient, a healthy woman, had only two pains--the first awoke her out of a sound sleep and ruptured the membranes, the next drove the child with great violence into the bed. Where the patient is weakened by previous disease, and the soft parts are very relaxed and flaccid, they produce no resistance to the advance of the head: this condition is very unfavourable, "as it implies a greater state of relaxation, or want of tone, than is compatible with the welfare of the patient: hence it is seldom found to take place except when the unfortunate subject is sinking under the last stage of debility, as in phthisis," &c. (Power's Midwifery, p. 138.)
The want of due resistance to the expelling powers may depend upon the size and hardness of the head; it is either smaller than usual, from the child being premature, or, if of the full size, the cranial bones are imperfectly ossified, the sutures are wide, the fontanelles large, and the whole head very yielding and soft; or it may depend on some congenital defect, in which the brain and cranial coverings are more or less imperfect.
In the ordinary cases of precipitate labour the case depends generally on a complication of violent pains, wide pelvis, and small child.
Effects of precipitate labour. Besides the mischief which may result from the rapid expulsion of the child causing prolapsus uteri, laceration of the vagina, perineum, and hæmorrhage from inertia coming on in consequence of the uterus being so suddenly emptied, dangerous syncope, or even asphyxia, may follow from the shock which the nervous system has sustained, or in consequence of the sudden removal of that degree of pressure which the gravid uterus had exerted upon the abdominal circulation during pregnancy. Where the patient has been very unruly, and has exerted herself with great violence, "emphysema of the face and neck (says Dr. Reid) may suddenly occur during labour, and cause great alarm to a young practitioner, as it alters and disfigures the countenance in an extraordinary manner. Great straining or screaming may produce it, and it probably depends on some partial rupture of the lining membrane of the larynx. I have seen two or three cases of this description, and one which occurred to a great extent in the case of an out-patient of the General Lying-in Hospital, in whom this tumefaction spread to the shoulders and chest." (Manual of Pract. Midwifery, by James Reid, M. D. p. 231.)
The child also may suffer from a precipitate labour, where the pains are excessively violent and run into each other, so that the whole labour is effected during one continued storm of uterine action. If the membranes have given way at an early period, so that the body of the child is exposed to the immediate pressure of the pains, the abdominal circulation suffers, and the child is destroyed in the same way as by pressure on the cord itself; or it may be suddenly dashed upon the floor before the mother has had time to reach her bed, or even put herself in a recumbent posture upon the floor: in this way it may receive a severe injury upon the head, or the cord may be lacerated, and the child die from hæmorrhage before assistance can arrive: such accidents, however, are not so dangerous to the child as have been supposed, a fact which has been proved by medico-legal investigations. The direction of the pelvic outlet and vagina is such as to expel the child obliquely downwards and forwards when the mother is in the upright posture, so that the force of the blow is in a great measure broken by this circumstance; the head also, as well as the other parts of the body, are soft and yielding, and nearly preclude the chances of injury taking place; the violence of the fall is generally diminished in some measure by the patient being almost always compelled to drop upon her knees at the moment of great suffering, whilst the child is passing; her clothes also surround it more or less, and thus shield it from any severe injury.
Rupture of the cord. The cord is liable to be torn in these cases, showing that a considerable jerk had been applied to it, but neither the child nor its mother have suffered from it. Ten or twelve cases of ruptured cord have come to our own immediate knowledge, and in none of them were any unfavourable effects produced. It can scarcely be imagined possible that so much force could be applied to the cord, at the moment when the uterus is so suddenly evacuated, without inversion or prolapsus being the almost unavoidable result, the more so when we recollect that the cord at the moment of birth requires considerable force to break it. This circumstance may be partly attributed to the firmness with which the uterus contracts at the moment that the child is expelled, but chiefly to the fact that the axis of the brim is nearly at right angles with that of the outlet, more especially if the fundus, as is usually the case, is inclined somewhat forwards; the cord passes round the posterior part of the symphysis pubis as upon a pulley, so that a considerable portion of the force which is applied to it, is spent here before reaching the fundus uteri. It is however remarkable, that the umbilicus of the child should receive no injury from a jerk which breaks the cord, when, if we try afterwards to break the remaining pieces of the cord, we find that it will resist very powerful efforts: this fact, and the circumstance that the cord usually ruptures at about two or three inches from the umbilicus, as in some animals, seems to imply that this part is weaker than elsewhere, as if intended by nature to give way with a moderate degree of force.
Wigand considers that patients are particularly disposed to have quick labours, who are of a scrofulous, rheumatic, or arthritic diathesis; that such patients are very liable to have adhesion of the placenta after the birth of the child, with hour-glass contraction: the observation, however, has not been confirmed by the experience of others, and certainly not by the cases which have come under our own notice.
Treatment. Where, from the smallness of the child or unusual size of the pelvis, the pains are forcing the lower portion of the uterus down to, or through, the os externum, it will be necessary to support it carefully, until the os uteri is sufficiently dilated to let the head pass. A case of this kind occurred to Professor Naegelé, of Heidelberg, where, during the patient's former labour, the pains had been so violent, and the uterus had been detruded to such an extent, that actually the lower half of it appeared between the labia: to prevent a similar accident occurring this time, (as the pains were beginning to show the same disposition to violent action as before,) he applied a broad T bandage very firmly upon her, coming over the os externum, so as to prevent the uterus being prolapsed beyond the labia; he cut a hole in it corresponding to the vagina, and the child was born through this with perfect safety to the mother.
Where we have sufficient warning, opium in effective doses will probably assist in lulling the irritability of the uterus: if the bowels have been previously well opened, an opiate enema will be desirable; if not, a large emollient enema should be premised.
The patient should be made to lie upon her side, and not only strictly forbidden to resist to her very utmost, the urgent impulse which she feels to strain and bear down, but must carefully avoid even holding by or pushing against any fixed body with her hands or feet. Still farther, to quiet the turbulence of the abdominal muscles, a broad bandage should be fastened firmly round the abdomen; it not only gives the patient a comfortable feeling of support, but tends greatly to calm the spasmodic irritability of these muscles. These precautions will be of so much more service if they can be used early, as in cases where we have been already warned by the character of her previous labours: we can thus avoid the premature rupture of the membranes, which is a thing by all means to be avoided; the uterus acts with increased power where its bulk has been diminished by the escape of the liquor amnii, and at the same time becomes still more irritable and unruly from contracting immediately upon the child; and not only is there imminent danger of its giving way in some part, but the child is almost inevitably destroyed by the violence of the pressure to which it is exposed.
In cases where the vehemence of the expelling powers appears to be quite beyond our control, Wigand has recommended a copious bleeding to complete syncope as the only means; in which suggestion, he has been followed by Froreip: neither of these authors, however, appear to have had any experience of this mode of treatment, and knowing how much more active the uterus becomes after a smart bleeding in ordinary cases, and how powerfully the state of syncope promotes the dilatability of the soft parts, we should hesitate exceedingly to employ so doubtful a remedy. Wigand also proposes, in cases of this desperate nature, to use effusion with ice-cold water to the abdomen and lower extremities, and by this powerful species of counter-irritation, produce a temporary calm for a few minutes--a measure we should fear of as doubtful a character as bleeding.
Connexion of precipitate labour with mania. Lastly, we may observe, that the subject of precipitate labour involves a medico-legal question of great importance and interest, which has as yet excited little or no notice in this country, viz. as regards acts of child-murder after labours of this character. The state of mental excitement and frenzy into which a patient is brought, by a labour of such violence and suffering, in many cases falls little short of actual mania. We now and then meet with instances, where, for the first half hour or so after a severe and rapid labour, the patient takes a most insurmountable antipathy to her child, and expresses herself towards it in so unnatural a manner, as to contrast strangely with the tender and affectionate feelings which she had a short time previously expressed for it. Cases have occurred where the patient has been without assistance, during labour, and where, in a state of temporary madness from mental excitement and pain at the moment of the child's birth, she has committed an act of violence upon it, which has proved fatal; a circumstance, which, from obvious reasons, would be more liable to occur with single than with married women. These cases have been very carefully investigated in Germany of late, and in many of them the patient has been, we think, very properly acquitted, on the grounds of temporary insanity, having herself voluntarily confessed the act with the deepest remorse, at the same time declaring her utter incapacity to account for the wild and savage fury which seized her at the moment of delivery.
X. PROLAPSUS OF THE UMBILICAL CORD
Diagnosis.--Causes.--Treatment.--Reposition of the cord.
Although by no means a common occurrence, it every now and then happens that a portion of the umbilical cord falls down between the presenting part of the child and the mother's pelvis either just before or during labour; so that, as the child advances through the passages, its life is placed in imminent danger from the pressure to which the cord is exposed, obstructing the circulation in it.
There is probably no disappointment, which the accoucheur has to meet with more annoying than a case of this kind; every thing has seemed to promise a favourable labour; the presentation is natural, the pains are regular, the os uteri is dilating readily, the mother, and, as far as we can ascertain, her child, are in perfect health, and yet because a minute loop of the cord has fallen down by the side of its head, the labour, unless interfered with by art, will almost necessarily prove fatal to it.
Diagnosis. If the membranes be not yet ruptured, we shall probably be able to feel a small projecting mass like a finger, close to the presenting part, and possessing a distinct pulsation, which, from not being synchronous with the mother's pulse, instantly declares its real nature. When the membranes give way, more of the cord comes within reach, and probably forms a large coil, which passes through the os uteri into the vagina, or even appears at the os externum.
Causes. The earliest writer that we know of who has given a detailed account of cord presention was Mauriceau; few, even in hospital practice, and certainly none in private practice, have exceeded him in the number of cases described, and very few have surpassed him in the success of his treatment. He mentions chiefly three conditions as being liable to produce prolapsus of the cord, viz. a large quantity of liquor amnii, an unusually long cord, and malposition of the child: later authors have enumerated several other causes, many of which are imaginary; of these, by far the most correct list has been given by Boer, of Vienna, who has justly ridiculed the theoretical views which were maintained by his cotemporaries.
"If there be a large quantity of liquor amnii present, and especially, as is not unfrequently the case, the child is at the same time under the usual size; if the head be not firmly pressed against the brim, and does not enter it sufficiently, or when the child's position is faulty, especially if, at the same time, the cord is unusually long; if, under such circumstances, a large bag of membranes has formed, and the brim of the pelvis itself is very spacious; if perchance, the rupture of the membranes takes place at a moment when the patient is moving briskly on in some unfavourable posture, the cord will be very liable to prolapse. Nevertheless, cases are occasionally seen which arise without these predisposing circumstances." (Boer, von Geburten unter welchen die Nabelschnur vorfällt.)
The uterus is the chief means by which the cord is prevented from falling down between the presenting part of the child and the passages, from the closeness with which its inferior portion encircles it: without this, from the erect posture of the human female, there would be a liability to prolapsus of the arm or cord in every labour.
"The contraction of the uterus, which comes on with the rupture of the membranes, and sometimes, where they protrude very much, even before, is of great importance. This contraction takes place in the inferior segment of the uterus; it surrounds the head, and when fully developed extends over the whole head of the child. Thus, for instance, if we attempt to operate at an early stage, it feels more like a hard ring round the head, of about a finger's breadth, and it may be felt to extend itself higher up, in proportion as the stimulus of the hand excites the activity of the uterus." (Michaelis, Neue Zeiteschrift für Geburtskunde, band iii. heft. 1.)
Hence, therefore, whatever prevents the uterus from contracting with its inferior segment upon the presenting part of the child, deprives the cord of its natural support, and, therefore, renders it liable to prolapse. Many of the causes enumerated by Boer act in this way; thus, where the uterus is distended by an unusual accumulation of liquor amnii; where the contractions at the beginning of labour have been exceedingly irregular; where the arm, or shoulder, or feet present; or where a large bladder of membranes is formed, the lower part of the uterus will either not contract at all upon the head, or so imperfectly as to endanger the descent of the cord.
Malposition of the child has been mentioned by many authors as a cause of prolapsus of the cord, and in some cases it may possibly act thus from the inferior segment of the uterus being unable to surround sufficiently close so irregular a mass as the shoulder. In the majority of cases, however, the coincidence of these two circumstances depends upon their being produced by the same causes; thus an unusually large quantity of liquor amnii, or irregular contractions of the uterus, will just as much dispose to the one as the other.
The form or size of the pelvis can have, we think, but little effect upon the cord, so long as the uterine action is of the right character and the child alive. Most authors enumerate a large pelvis or small foetal head as a cause, why should we not, therefore, have prolapsus of the cord in every case of precipitate labour which arises from such circumstances? Nor are we at all disposed to consider deformed pelvis as capable of producing it, so long as the uterus is not immoderately distended and acting naturally: we do not deny that the cord is occasionally found prolapsed in cases of dystocia pelvica, but this is chiefly where the child has died from the severity of the labour, and where the flaccid pulseless cord has gradually slipped down during the intervals of the pains.
So long as the uterus exerts but a moderate degree of pressure round the head, it is impossible for the cord of a living child to descend, particularly as, according to Dr. Michaelis, the circular contraction of the portio vaginalis commences from below upwards, and would rather push back the cord if a portion of it had descended during the moments of uterine relaxation. The pulsating turgor of the cord when the child is alive will also assist much in preventing its descent, even where the uterus does not surround the presenting part so closely as usual.
The unusual length of the cord is also a very doubtful cause of its prolapsus, and will evidently, in great measure, depend upon the causes we have already alluded to.
We may also allude to another cause of prolapsus of the cord, which, although noticed nearly a century ago by Levret, and also by two or three authors after him, had nearly fallen into oblivion until lately, when it excited the attention of Professor Naegelé, junior. Levret, from the result of numerous observations on the insertion of the cord into the placenta, was led to suppose that the lower the situation of the placenta in the uterus, the lower also was the insertion of the cord into the placenta, so that if the edge of the placenta touched upon the os uteri, the cord was usually inserted into that part of its edge which corresponded with the os uteri.
Although it is certain that the situation of the placenta close to the os uteri, is by no means necessarily attended by insertion of the cord into its edge, and, therefore, by prolapsus of it when the membranes give way, inasmuch, as under such circumstances we ought to have every case of partial placenta prævia accompanied with the cord presenting: still, however, there is no doubt that cases of the above-mentioned complication do every now and then occur, and must necessarily incur no inconsiderable danger of prolapsus.
"There is no doubt that the situation of the placenta in the vicinity of the os uteri, may be looked upon as one of the predisposing causes of the cord presenting during labour; an accident which is the more to be feared, the nearer the cord is inserted into the inferior edge of the placenta. If its edge extends quite down to the os uteri, and the cord is inserted into it, or the umbilical vessels divide, as in the cases we have described, at some little distance from it, viz. in the membranes, the cord will present as a necessary result, and prolapse as soon as the membranes give way." (Die Geburtshülfliche Auscultation, von Dr. H. F. Naegelé, p. 114.) The two cases referred to by Professor Naegelé, jun., of prolapsus of the cord from this cause, occurred so near after each other, as to render the circumstance the more remarkable. The fact was noticed by Giffard as early as in 1728, in a case of flooding from partial placenta prævia; but he does not appear then to have drawn any inferences from the position of the placenta, which he did not consider was attached, but was "in part, if not wholly, separated from the uterus."[137]
Prolapsus of the cord is fortunately not a circumstance of frequent occurrence. Dr. Churchill, of Dublin, in a valuable paper, (Edin. Med. and Surg. Journal, Oct., 1838,) has collected the results of no less than 90,983 deliveries, amongst which the cord presented in 322 cases, being in the proportion of one in 282-1/4.[138] That prolapsus of the cord occurs most frequently in foot presentations, as supposed by Professor Naegelé, senior, is disproved by the results of Mauriceau's large experience, as well as of many others since; thus, out of 33 cases which occurred in labour at the full term, (or nearly so,) 17 presented with the head, 1 with the face, 1 with the feet, 9 with the hand or arm, 3 with the hand or foot, 1 with the hand and breech, and 1 with the hand and head. In the 16,652 births which have been recorded by Dr. Collins, at the Dublin Lying-in Hospital, the cord prolapsed in 97 instances. "Twelve of the 97 occurred in twin cases, and in seven of the 12 it was the cord of the second child. Nine occurred where the feet presented, (not including two met with in twin children,) which was in the proportion of one in every fourteen of such presentations. Two only where the breech presented, which was in the proportion of one in every 121 of such presentations: this approaches nearly the proportional average in all deliveries, which is one in 171-1/2. Four occurred where the shoulder or arm presented: this is in the proportion of one in nine of such presentations. Seven occurred where the hand came down with the head. Seven of the children were born putrid; three of the 97 were premature, viz. two at the seventh and one at the eighth month." (Collins's Practical Treatise on Midwifery, p. 346.) We may, therefore, conclude with safety, that presentations of the head are by far the most common.
Treatment. Left to itself prolapsus of the cord is almost certain destruction to the child, for unless the labour comes on very briskly, and the head passes rapidly through the pelvis, the cord is pressed upon so long as to render it impossible for the child to be born alive. Still, however, where the passages are yielding, and the pains active; where the head is of a moderate size, the pelvis spacious, and the cord in a favourable part of it, viz. towards one of the sacro-iliac synchondroses; where also the membranes remain unruptured until the last moment, there will be a very fair chance of the child being born alive. Under no circumstances is it of such paramount importance to avoid rupturing the membranes as in these cases, for the bag of fluid which they form dilates the soft passages and protects the cord from pressure.
"Many methods of relief have been recommended, such as turning, delivering with the forceps, pushing up the funis through the os uteri with the hand, and endeavouring to suspend it on some limb of the child, collecting the prolapsed cord into a bag, and then pushing it up beyond the head, pushing up, the funis with instruments of various kinds, endeavouring to keep it secured above the head by means of a piece of sponge introduced; these and many other similar expedients have been resorted to." (Collins, op. cit. p. 344.)
The first two of these means have been chiefly used in cases of prolapsed funis, the others having, for the most part, been found entirely inefficient. Thus Mauriceau, in the 33 cases which he has recorded, turned 19 times: the children were all born alive, except one, which was dead, but required turning as it presented with the arm. In later times, turning or the forceps have been preferred, according to the period of labour at which the prolapsus was discovered or occurred. Thus Madame Boivin has recorded 38 cases, 25 of which occurred at the commencement of, and 13 during labour, the former were all turned; in the latter the forceps was used; 29 children were saved, seven were lost, and the two others were putrid.
Our practice must be in great measure guided by the circumstances of the case: where the os uteri is not fully dilated, where the head is still high and not much engaged in the pelvis, the liquor drained away, and the cord beginning to suffer pressure during the pains, we dare not wait until the case be sufficiently advanced to admit the application of the forceps, but must proceed as soon as possible to turn the child. The operation should be performed with the greatest possible caution; the cord should be guided to one of the sacro-iliac symphyses; the expulsion of the trunk must be very gradual; a dose of secale should be given to ensure the requisite activity of the uterus when the head enters the pelvis, and the forceps kept in readiness to apply the instant that its advance is not sufficiently rapid. On the other hand, where the labour has made considerable progress before the membranes give way, and the head has fairly engaged in the cavity of the pelvis, if the os uteri is fully dilated, it will be no longer advisable to attempt turning; the head is within reach of the forceps, which should be immediately applied, taking care that the cord does not get squeezed between the blades and the head. Where the arm or shoulder presents, this will of itself require that the child should be turned.
Reposition of the cord. Although the reposition of the cord has been recommended from the time of Mauriceau, and by the majority of authors since, it has nevertheless met with so little success as to have fallen into complete disuse until the last few years; one of its strongest opposers was the celebrated La Motte. "The delivery ought to be attempted as soon as we find that the string presents before the head, it being to no purpose to try to reduce it behind the head, which at that time fills up the whole passage, and can only admit you to push it back into the vagina, and it will fall down again at every pain; and if you have done so much as to reduce it into the uterus, what hinders you from finishing the delivery at once, by seeking for the feet? the chief difficulty is then over." (La Motte, English translation, p. 304.) This mode of delivery (turning) has been more adopted by practitioners in such cases than any other, especially in former times, when the forceps was either not at all or imperfectly known; by none has it been so with more success than by Mauriceau himself, having saved every living child in which he attempted the operation. Still, however, he recommended that the attempt should be made to return the cord wherever it was possible, and has recorded four cases of this mode of treatment, all of which proved successful, although one of the children was born so feeble as to die shortly afterwards. Giffard seems to have attempted the reposition of the cord only once, and failed, apparently from the unusual size of the child. In later years Sir R. Croft, "has related two cases in which he succeeded, by carrying the prolapsed funis through the os uteri, and suspending it over one of the legs of the child. In both these cases the children were born alive." (Merriman's Synopsis, p. 99.) It is to Dr. Michaelis of Kiel that we are indebted for much recent and valuable information on the subject of replacing the prolapsed cord. Having pointed out the fact that it is the uterus alone which prevents the cord from prolapsing, he shows that, in order to replace the cord, we must carry it "above that circular portion of the uterus which is contracted over the presenting part." The reposition of the cord may be effected by the hand, or by means of an elastic catheter and ligature. In replacing the cord by means of the hand alone, Dr. Michaelis remarks that we shall effect this more readily by merely insinuating the hand between the head and the uterus, and gradually passing it farther round the head, pushing the cord before it. In this manner we do not require to rupture the membranes when we have felt the cord before the liquor amnii has escaped; a point of considerable importance.
The reposition, by means of the catheter, is effected by passing a silk ligature, doubled, along a stout thick elastic catheter, from twelve to sixteen inches in length, so that the loop comes out at the upper extremity; the catheter is introduced into the vagina, and the ligature is passed through the coil of the umbilical cord, and again brought down to the os externum. A stilet with a wooden handle is introduced into the catheter, the point passed out at its upper orifice, and the loop of the ligature hung upon it; it is then drawn back into the catheter and pushed up to the end. The operator has now only to pull the ends of the ligature, so as to tighten it slightly, passing the catheter up to the cord, which now becomes securely fixed to its extremity. When the reposition has been effected, he has merely to withdraw the stilet; the cord is instantly disengaged.[139] To prevent any injury, the ligature should be brought away first, and then the catheter.
"Dr. Michaelis has recorded eleven cases of prolapsus of the cord, where it has been returned by the above means, in nine of which the child was born alive. In three cases the arm presented also, which was replaced, and the head brought down; in two of these the child was born alive." (British and Foreign Med. Review, vol. i. p. 588.) A similar plan of replacing the cord by means of an elastic catheter has been tried by Dr. Collins, but he had not tried it sufficiently often at the time of publishing his Practical Treatise to be able to give a decided opinion about it.
The plan of introducing a piece of sponge after replacing the cord, in order to prevent its coming down again, is of no use whatever. Dr. Collins tried it in several instances, and considers that "it is quite impossible, however, in the great majority of cases, to succeed in this way in protecting the funis from pressure, as it is no sooner returned, than we find it forced down in another direction." The plan has been recommended by several modern authors, but it is by no means a new invention, having been proposed by Mauriceau; it does not appear, however, that he ever put it in practice.
Where no pulsation can be felt in the prolapsed funis, which is flabby and evidently empty, no interference will be required; the child is dead, and therefore the labour may be permitted to take its course. We should, however, be cautious in examining the cord where it is without pulsation, and yet feels tolerably full and turgid, for a slight degree of circulation may go on nevertheless, sufficient to keep life enough in the foetus, even for it to recover if the labour be hastened. We should especially examine the cord during the intervals of the pains, and after we have guided it into a more favourable part of the pelvis, where it will not be exposed to so much pressure, for then the pulsation will become more sensible to our touch, and prove that the child is still alive.
The following case by Dr. Evory Kennedy is an excellent illustration of what we have now stated:--"The midwife informed me that there was no pulsation in the funis, which had been protruding for an hour; on examination made during a pain, a fold of the funis was found protruding from the vagina, at its lateral part, and devoid of pulsation. As the pain subsided, I drew the funis backwards towards the sacro-iliac symphysis, and thought I could observe a very indistinct and irregular pulsation; I now applied the stethoscope, and distinguished a slight foetal pulsation over the pubes. Fortunately on learning the nature of the case, I had brought the forceps, which were now instantly applied, and the patient delivered of a still-born child, which, with perseverance, was brought to breathe, and is now a living and healthy boy, four years of age. Had I not in this case ascertained by the means mentioned, that the child still lived, I should not have felt justified in interfering; but, supposing the child dead, would have left the case to nature, and five minutes, in all likelihood, would have decided the child's fate." (Dr. Evory Kennedy, on Pregnancy and Auscultation, p. 241.)
XI. PUERPERAL CONVULSIONS
Epileptic convulsions with cerebral congestion.--Causes.--Symptoms.-- Tetanic species.--Diagnosis of labour during convulsions.-- Prophylactic treatment.--Treatment.--Bleeding.--Purgatives.-- Apoplectic species.--Anæmic convulsions.--Symptoms.--Treatment.-- Hysterical convulsions.--Symptoms.
Women are liable, both before, during, and after labour to attacks of convulsions, not only of variable intensity, but differing considerably in point of character. We shall consider them under three separate heads, viz. epileptic convulsions with cerebral congestion; epileptic convulsions from collapse or anæmia; and hysterical convulsions. Other species have been enumerated by authors, but they are either varieties of, or intimately connected with, those of the first species.
No author has more distinctly pointed out the fact that epilepsy may arise from diametrically opposite causes than Dr. Cullen; a circumstance which, in a practical point of view, is of the greatest importance. "The occasional causes," says he, "may, I think, be properly referred to two general heads; the first, being those which seem to act by directly stimulating and exciting the energies of the brain, and the second, of those which seem to act by weakening the same." "A certain fulness and tension of the vessels of the brain is necessary to the support of its ordinary and constant energy in the distribution of the nervous power" (Practice of Physic;) and hence it may be inferred that, on the one hand, an over-distention, and, on the other, a collapsed state of these vessels, will be liable to be attended with so much cerebral disturbance as to produce epilepsy.
Epileptic convulsions with cerebral congestion. Epileptic convulsions connected with pregnancy or parturition, and which are preceded and attended with cerebral congestion, alone deserve, strictly speaking, the name of Eclampsia parturientium (which, in fact, signifies nothing more than the epilepsy of parturient females,) being peculiar to this condition; whereas, the anæmic and hysterical convulsions may occur at any other time quite independent of the pregnant or parturient state.
The term "puerperal convulsions" is employed in a much more vague and extended sense, and applies generally to every sort of convulsive affection which may occur at this period, and as such, it therefore, forms the title of the present chapter.
Causes. The exciting cause of eclampsia parturientium is the irritation arising from the presence of the child in the uterus or passages, or from a state of irritation thus produced, continuing to exist after labour. The predisposing causes are, general plethora, the pressure of the gravid uterus upon the abdominal aorta, the contractions of that organ during labour, by which a large quantity of the blood circulating in its spongy parietes is driven into the rest of the system, constipation, deranged bowels, retention of urine, previous injuries of the head or cerebral disease, and much mental excitement, early youth: also "in persons of hereditary predisposition, spare habit, irritable temperament, high mental refinement, and in whom the excitability of the nervous, and subsequently the sanguiferous system is called forth by causes apparently trivial." (Facts and cases in Obstetric Medicine, by I. T. Ingleby, p. 5.)
Symptoms. From the above-mentioned list of causes it will be evident, that these convulsions will be invariably attended and preceded by symptoms of strong determination of blood to the head. Previous to the attack the patient has "drowsiness, a sense of weight in the head, especially in stooping; beating and pain in the head; redness of the conjunctiva; numbness of the hands; flushing of the face, and twitching of its muscles; irregular and slow pulse; ringing in the ears, heat in the scalp, transient but frequent attacks of vertigo, with muscæ volitantes, or temporary blindness; derangement of the auditory nerve; embarrassment of mind and speech; an unsteady gait; constipation and oedematous swellings." (Ingleby, op. cit. p. 12.)
As the attack approaches, the patient frequently complains of a peculiar dragging pain and sense of oppression about the præcordia, which comes on and again abates at short intervals, and is attended with much restlessness and anxiety: this is followed by intense pain, which usually attacks the back of the head, and upon the accession of which the præcordial affection apparently ceases; the pulse now becomes smaller and more contracted. If the convulsions do not make their appearance by this time, and the headach continues one or more hours, a slight degree of coma supervenes, the patient loses her consciousness more and more, and wanders now and then; after a time she becomes restless and evidently uneasy, the eye becomes fixed and staring, the countenance changes, and the outbreak of convulsive movements follows.
Sometimes the premonitory symptoms are much less marked; indeed, in some cases, there is scarcely a sign to warn us of the impending danger; in the midst of a conversation the patient becomes suddenly silent, and, on looking to see the cause, we find the expression altered, the muscles of the face are twitching, the features beginning to be distorted, and the next moment she falls down in general convulsions.
Wigand (Geburt des Menschen, vol. i. § 102,) considers that the two symptoms which usher in the attack are, the frightful staring followed by rolling of the eyes, with sudden starts from right to left, and twisting of the head to the same side by the same sudden movements; as soon as the convulsions have commenced, the head generally returns to its former position, or rather is pulled more or less backwards; "the eyes are wide open, staring, and very prominent, the eyelids twitch violently, the iris is rapidly convulsed with alternate contractions and dilatations; the face begins to swell and grow purple, the mouth is open and distorted, through which the tongue is protruded, brown, and covered with froth; the lips swell and become purple: in fact, it is the complete picture of one who is strangled." (Op. cit.)
These convulsions, as in common epilepsy under other circumstances, usually if not always commence about the head and face, gradually passing down to the chest and abdomen, and then attacking the extremities. After the above-mentioned changes, they pass into the throat and neck, by which a state of trismus is produced, and the protruded tongue is not unfrequently caught between the teeth and severely wounded. The neck is violently pulled on one side, and from the pressure to which the trachea is subjected, severe dyspnoea is produced. The respiration is nearly suspended, and from the violent rushing of the air as it is forced through the contracted rima glottidis, the breathing is performed with a peculiar hissing sound. The muscles of the chest now become affected, and the thorax is convulsively heaved and depressed with great vehemence; those of the abdomen succeed, and the convulsive efforts are here, if possible, still more violent: such are the contractions of the abdominal muscles, and so powerfully do they compress the contents of the abdomen, that a person who had not previously seen the patient would scarcely believe she was pregnant; the next moment the abdomen is as much protruded as it was before compressed. From the same cause, the contents of the rectum and bladder are expelled unconsciously, the extremities become violently convulsed, and the patient is bedewed with a cold clammy sweat. The duration of such a fit is variable; it seldom lasts more than five minutes, and frequently not more than two, and then a gradual subsidence of the convulsions and other symptoms follow; the swollen and livid face returns to its natural size and colour, the eyes become less prominent, the lips less turgid, the breathing is easier and more calm, the viscid saliva ceases to be blown into foam from the mouth, and the patient is left in a state of comatose insensibility or deep stertorous sleep, from which, in the course of a quarter of an hour or twenty minutes, she suddenly awakes, quite unconscious of what has been the matter; she stares about with a vacant expression of surprise; she feels stiff and sore as if she were bruised: this will be especially the case if it has been attempted to hold her during the fit. The convulsive efforts of the muscles of the body and extremities are not easily resisted, and thus it is that we hear of a delicate woman under these circumstances requiring several strong men to hold her: the result of such treatment is, that her muscles and joints are severely strained, and continue painful for some time after. Patients, on recovering their senses, frequently complain of pain and soreness in the mouth, arising from the tongue having been bitten; in some cases where the tongue has been much protruded, the injury is very severe, the tongue being bitten completely across, and hanging only by a small portion.
The woman may suffer but one attack, and have no return of the fit, or in half an hour, an hour, or longer, the convulsions again appear as at first. If this happens several times, she does not recover her consciousness during the intervals, but remains in a continued state of coma from one fit to another. Although it rarely happens, that the patient dies during a fit, still nevertheless, one fit will in some cases be sufficient to throw her into a state of coma from which she does not recover; in others, the patient may lie for even twenty-four hours in strong convulsions and yet recover.
The character of these attacks appears to vary a good deal with the cause; thus, where plethora has been the predisposing cause, and the fits frequently repeated, they take on more or less of an apoplectic character, the coma is more profound and of longer duration, and is frequently attended with paralysis; the cerebral affection is more severe, the patient does not recover her senses even where the intervals between the attacks have been of considerable duration; and when the fits have ceased and the coma abated, she is occasionally left in a state of imbecility and blindness, which lasts for several hours or even days.
Where it is connected with constipation or deranged bowels, we think that we have seen it more frequently attended with delirium or even temporary mania; the fits are numerous, the convulsions as severe, but the cerebral congestion is not so intense, the coma less profound; instead of being left in a state of torpid stupor, the patient is very restless and at times unmanageable, and when we consider the identity of the causes which produce these convulsions and one form of purerperal mania, it will be easily understood why the symptoms should assume this character. The degree also of determination to the head, will in no slight measure influence the character of the symptoms which attend these attacks. "One circumstance," says Dr. Parry, "of increased impetus deserves to be noticed. The delirium is preceded by a pain in the head, but as the delirium comes on, the pain ceases, though the impetus remains as before, or perhaps increases. Diminish in a slight degree the impetus, and you remove the delirium and renew the pain; diminish the impetus in a greater degree, and the frown on the forehead is relaxed, the features seem to open, and the pain entirely ceases." (Posthumous Medical Writings, vol. i. p. 263.)
By far the majority of cases of eclampsia parturientium occur in primiparæ: thus in thirty cases which occurred to Dr. Collins, during his mastership at the Dublin Lying-in Hospital, "twenty-nine were in women with their first children, and the other single case was a second pregnancy, but in a woman who had suffered a similar attack with her first child." In two instances, under our own notice, where the disease occurred in multiparæ, the fits did not appear until after delivery; the patients were plethoric, and in one especially, the bowels were excessively deranged; in the other, the attack had much of the apoplectic character, and the coma did not at once abate until the fatal termination.
Convulsions usually make their appearance towards evening; and if pains are coming on, they return with every uterine contraction. The patient's danger will, in great measure, depend upon the severity, frequency, and duration of the fits; and although they must ever be looked upon as a disease of the most dangerous character, yet we are justified in saying that in the majority of instances the patient recovers: thus, of the forty-eight cases recorded by Dr. Merriman, thirty-seven recovered; and of the thirty by Dr. Collins, only five died, "three of which were complicated with laceration of the vagina, one with twins, and one with peritoneal inflammation. It is thus evident that the fatal result in these cases, with the exception of the twin birth, was not immediately connected with the convulsions; and the danger in all twin deliveries, no matter what the attack may be, is in every instance greatly increased." (Practical Treatise, p. 210.)
Although puerperal convulsions usually occur at the commencement of labour, it not unfrequently happens that they do not come on until after the child is born; whereas, in other cases they occur several months before the full period: these varieties depend entirely upon the circumstances under which the attack has appeared. "With respect to their occurrence in the last month of gestation, although the paroxysm mostly appears during the actual dilatation of the os uteri, or on the first approach of labour, still when we recollect that in the last week or two of pregnancy the neck of the uterus is fully developed, the subsequent changes being confined to the os internum (the most sensitive part of the organ,) it cannot be surprising that, in very irritable persons, a serious impression should be made upon the brain at those periods." (Ingleby, op. cit. p. 11.)
Dr. Merriman has called it dystocia epileptica: there is, in fact, no difference between this disease and common epilepsy, beyond that, under ordinary circumstances, epilepsy is a chronic affection, and, generally speaking, not attended with much danger, whereas, in the present case, it is an acute attack, and of a highly dangerous character.
Many phenomena connected with uterine irritation, both in the unimpregnated state and during pregnancy, prove the intimate nature of the consent existing between the brain and uterus. Thus it is well known that menstrual irritation is accompanied with a great variety of nervous and hysterical symptoms, which are merely a part of the same series of results to which epilepsy itself belongs: it is occasionally attended with delirium, spasms, and even coma, and preceded by the oppression at the pit of the stomach and pain of head, which we have already noticed among the immediate precursors of puerperal epilepsy; on the other hand, as Dr. Parry has well remarked, "the beginning and end of each epileptic fit, before total insensibility begins and after it ceases, is often delirium, screaming, false impressions, attempt to annoy others under these impressions," &c. (Op. cit. vol. i. p. 396. &c.) Thus also during labour, either at the termination of the first stage, when the os uteri has attained its full degree of dilatation, or immediately after the birth of the child, the patient is frequently seized with a sudden convulsive rigour so violent as to make her teeth chatter and agitate the whole bed, and which is nothing more than a harmless modification of convulsive action arising from uterine irritation; the surface is perfectly warm, and the patient frequently expresses her surprise to find herself shivering thus violently and yet not feel cold.
It has been a common opinion that epileptic puerperal convulsions are almost certainly fatal to the child, especially if they continue for any length of time: experience, however, proves the contrary, as cases continually occur where the mother has laid for many hours in a constant succession of severe convulsions, and yet has been ultimately delivered of a living child. Still, however, it must be owned, that barely an equal number of the children are born alive under these circumstances. Thus, in Dr. Merriman's 48 cases, as already mentioned, only 17 children were born alive (including the 6 born before the mothers were attacked with convulsions;) in the 30 cases recorded by Dr. Collins, 18 of the 32 children (two of the women having had twins) were born dead; of these, however, it must be observed, that 8 were delivered with the perforator, and two were born putrid.
Tetanic species. There is one modification of eclampsia parturientium, which, from the spastic rigidity of the uterus which accompanies it, is peculiarly dangerous to the child's life: it has been called the tetanic form: the convulsions are incessant, without any apparent interval, and the uterus actively participates in the state of general spasms: under such circumstances, the pressure which it exerts upon the body of the foetus will seriously obstruct the abdominal circulation, and produce the same effects as pressure on the cord.
In most cases, however, the convulsions have no effect upon the process of labour, which continues its course uninterrupted; so that, where there has been no return of consciousness during the intervals between the fits, and the patient has laid in a continued state of coma for some time, the child may actually be born before there has even been a suspicion that labour was present. It is, therefore, of great importance that the practitioner should be on the watch to detect any symptoms of its coming on, not only for the purpose of giving her the necessary support at the moment of expulsion, but also such assistance as may tend to shorten that process.
"By attentively observing what passes in cases of convulsions, we remark that they do not always interrupt the course of the labour pains, whether they had excited those pains, or the pains had preceded them. All authors relate examples of women who have been delivered without help after several fits of strong convulsions; and others while they were actually convulsed, whether there were lucid intervals between, or that the loss of understanding was permanent. The progress of labour in most of these cases seems even more rapid than in others, since we have often found the child between its mother's thighs, though an instant before we could discover no disposition for delivery." (Baudelocque, trans. by Heath, § 1109.)
Diagnosis of labour during convulsions. Where the patient is in a state of insensibility, we may infer the presence of labour by a variety of symptoms; every now and then, from a state of torpor, she becomes restless, and evidently uneasy; she pushes the bed-clothes from the abdomen, and gropes about it as if trying to remove something that is heavy or uncomfortable; she writhes her body, and moans as if in pain; after awhile, she again relapses into her former state of coma. A little attention will soon show us that these exacerbations of restlessness are periodical; and if we examine the abdomen at the moment, we feel the uterus evidently contracting; the os uteri also will be found tense and more or less dilated: if the head has already advanced into the vagina, these contractions will be accompanied by a distinct effort to strain.
It is rare to find convulsions complicated with malposition of the child; indeed, so uncommon is the occurrence of it under these circumstances, that we may feel almost certain, on being summoned to a case of convulsions, that there will be little chance of this additional difficulty being superadded. "There was but one case," says Dr. Collins, "of convulsions during my residence in the hospital, where the child presented preternaturally; there was not one case with a preternatural presentation during Dr. Clarke's residence; and Dr. Labatt has stated the same fact in his lectures while master of the hospital. In these three different periods there were 48,379 women delivered, so that from this we may infer, where the presentation is preternatural, there is little cause to dread the attack." (Practical Treatise, p. 200.)
Prophylactic treatment. Under no circumstances is the old saying of "Prevention is better than the cure," so well illustrated as in the prophylactic treatment of puerperal epilepsy: it is only by carefully watching for and recognising those symptoms which we have already enumerated as threatening an attack, that we are able to adopt such measures as shall either keep it off entirely, or at any rate considerably diminish its violence.
The treatment which we have recommended during the last weeks of pregnancy, is particularly valuable in keeping off any disposition to these attacks: regular, and for her condition even tolerably active, exercise and strict attention to the bowels, should be required, especially in primiparæ. If any distinct symptoms of cerebral congestion make their appearance, such as flushed face, headach, or slight wandering; if, moreover, the pulse be slow and labouring, we must at once relieve the circulation by bleeding; and by an active dose of calomel and James's powder at night with a warm pediluvium, and a brisk laxative the next morning, endeavour to ward off the dreaded attack. Not unfrequently, however, we have no warning of the danger until the fits burst out, and are thus debarred the opportunity of preparing against them.
Treatment. During the fit itself little can be done beyond placing the patient in such a situation that she should not injure herself by her exertions. If she happens to be upon a chair when the attack begins, it will be as well to let her sink gently upon the floor, and lie there until the fit is over; if she is in bed when it comes on, we have merely to watch that she does not roll off during her struggles; her movements should be restrained as little as possible, and by so doing we shall spare her the suffering after the fit from strained muscles and half-wrenched joints, which is so severe where the assistants, from mistaken kindness, have endeavoured to hold her.
It has been recommended by Dr. Denman to have the patient's face frequently dashed with cold water during the fit, a remedy which, as Dr. Merriman observes, is very effectual in ordinary hysterical paroxysms, and which possibly may have a slight effect in moderating the violence of the epileptic convulsions; but from what we have seen we are not inclined to consider it of much use.
Bleeding. As soon as the fit is sufficiently over to render the operation possible, the patient ought to be placed in a half-sitting posture, and bled from a large orifice in the arm; the quantity of blood abstracted must be determined by the appearance of the patient, the severity of the cerebral symptoms, and the condition of the pulse; this latter will usually be found labouring, and even small, but will rise considerably in fulness and volume as we gradually relieve the circulation. Syncope is an effect which, under these circumstances, it would neither be easy nor safe to produce; but at the same time it will be highly desirable to produce a powerful effect upon the circulation by so large and speedy an abstraction of blood as shall be certain of alleviating the cerebral congestion: this is not often attained until after a loss of twenty, or five and twenty ounces. She should be supported in the half-sitting posture by means of a chair turned against the head of the bed, so that its back forms an inclined plane, which should be covered with pillows for her to lean upon.
Purgatives. An active dose of purgative medicine should be given the moment the patient is able to swallow; for in case of the fit returning, it will be sometimes very difficult to make her take any thing. Eight or ten grains of calomel, with fifteen or twenty of jalap, should be mixed into a paste with a little thin gruel and laid upon the back of the tongue, and a few spoonfuls more of gruel, &c. given to carry it down. If this cannot be taken, a few drops of croton oil will seldom fail to produce the necessary effect.
It is of the greatest importance to do this as early as possible, not only for the reason we have just assigned, but also because we find that purgative medicines frequently take a longer time to operate in these cases than they do under ordinary circumstances, and require the repetition of even a powerful dose before the bowels can be made to act. Where the convulsions appear to depend in great measure upon the deranged state of the bowels, the indications for the immediate employment of purgatives become still more urgent, for although we may control the cerebral congestion by means of the lancet, we shall not remove the source of irritation; but when once the bowels have been freely evacuated, the chain of morbid actions is broken, and the disease ceases: hence, in some cases, we observe much more striking relief produced by purgatives than even by bleeding. In order, therefore, to ensure a certain and speedy effect upon the bowels, she should take, about two hours after the powder, repeated doses of salts and senna, and if necessary, have their action still farther assisted by a purgative injection.
In the mean time, the hair must be closely shaven from the crown and back of the head, leaving the front bands, that she may be disfigured as little as possible, and a large bullock's bladder half filled with pounded ice, applied to the bare scalp; in lieu of which, an evaporating lotion of vinegar spirit and water, may be applied until the ice is procured. Sinapisms to the calves of the legs and soles of the feet will also be required, so that, on coming into a room where a patient is lying in puerperal convulsions, the practitioner may quickly find employment for the numerous friends or assistants, who generally crowd round her on such occasions, and convert their officiousness into real utility. The air of the room must be kept as fresh as possible, and no more people allowed to remain in it than are absolutely necessary.
If she be tolerably conscious during the interval, a hot foot bath, rendered still more stimulating by some mustard flour, will be of great service; flannels wrung out of a hot decoction of mustard, and wrapped round the feet and legs, are also useful, and tend still farther to diminish the cerebral congestion.
In all cases of convulsions, especially if the patient be near her full time, it will be necessary to ascertain the state of the bladder; for the pressure of the head frequently produces much difficulty in evacuating it, and sometimes causes so much distention and irritation as to be itself quite capable of exciting the convulsions. Lamotte has given two instances where the fits had been evidently brought on by retention of urine, and where relief was immediately given by evacuating the bladder.
Where the patient has still some time to go, and no appearance of uterine action has been excited, the probability is, that the above-mentioned treatment, will be sufficient to prevent a return of the attack; and, if we have succeeded in calming the circulation, we may combine a little henbane with her medicine to allay irritability. But if she be near her full time, and labour has distinctly commenced, there will be little chance of the convulsions permanently ceasing until she is delivered, as the contractions of the uterus frequently appear to excite a return of them.
The practice in former times of dilating the os uteri, introducing the hand and turning the child, has been long since justly discarded, for the irritation produced by such improper violence would run great risk of aggravating the convulsions to a fatal degree.
"No cases require more prudence, attention, and sagacity, than the accident of convulsions in women, with their first children especially. The state of the os uteri is of immense importance, and when it will admit of your delivering the woman without violence, trouble, or irritation, no doubt it ought to be performed with all prudent expedition, as you never can be sure of her being restored without delivery." (M'Kenzie's Lectures, MS. 1764, quoted by Dr. Merriman.)
Where we are called to a patient, who has been some little time in convulsions, and where bleeding and other necessary measures have been already had recourse to, we may, with a tolerable degree of certainty, expect to find the os uteri fully dilated, and the head in a favourable state for the application of the forceps. The practitioner should be able to apply the forceps whether the patient be lying upon her back or her side, as it is not always possible to choose her position; the former, will generally be the safest, as she will not only lie more quietly upon her back, but can be kept with most facility in this posture. Generally speaking the fits subside immediately after the child is delivered, although not unfrequently they recur during the first twelve or sixteen hours after labour, coming on at increasing intervals.
If, however, the state of the os uteri forbids our interfering with art, we must be content to follow out that plan of antiphlogistic treatment which has been just laid down, bearing in mind, that in proportion as we reduce the power of the circulation we increase the disposition of the os uteri to dilate, and, as Baudelocque justly observes, "while we wait the favourable moment for operating, we should only employ those means which we could use after delivery, if the convulsions should continue." (Op. cit. § 1110.)
By the time that the medicine has begun to operate, a considerable change will usually be observed in all the symptoms--the violence of the convulsions abates, the coma is less profound, and if the child be not yet born, the process of labour much more speedy and favourable; but if we find that the convulsions assume a tetanic character, and that the uterus actively participates in this state of spasmodic rigidity, we must not expect any very favourable change until delivery is effected; and there will be little chance for the child of its being born alive for reasons already mentioned. Under such circumstances, which are fortunately of rare occurrence, it will be our duty to perforate rather than run the risk of losing the mother as well as her child; but before proceeding to this extremity we must satisfy our minds that the state of the os uteri forbids the forceps, and that, from the tetanic action of the uterus, there is little chance of its farther dilatation.
"It does not always happen that the convulsions cease upon the termination of the labour; on the contrary, they often continue after the birth of the child, and sometimes increase in violence, and at length produce death. If, however, the intervals between the fits become longer, a more favourable prognosis may be formed, but it will be expedient to continue our exertions in relieving the symptoms." (Merriman's Synopsis.)
The after treatment will be little more than a continuation of that which has been described during the attack, only in a much milder form: the head must be kept cool by a proper lotion, and the bowels sufficiently open by gentle laxatives; a little gruel, with or without milk, may be given occasionally; and if the child be alive, it should by all means be applied early to the breast, in order to establish a flow of milk as soon as possible. Where the breasts have been very flaccid, and there were little or no signs of milk, we have now and then applied a sinapism over them with very good effect, for the mammary excitement thus produced has been attended with a copious lochial discharge, which has evidently produced much relief.
Apoplectic species. Dr. Dewees has described a species of convulsions by the term "apoplectic," but it is perhaps questionable how far he is correct in calling them "puerperal convulsions;" for, from the cases which have come under our own notice, the disease has been nothing else than genuine apoplexy occurring in the pregnant, parturient, or puerperal state: he justly observes, that "it may be brought on by causes independent of pregnancy, though this process may with propriety be regarded as an exciting cause; for it sometimes takes place when this process is at its height, but is no otherwise accessary to this end, than increasing by its efforts the determination of blood to the head." (Op. cit. § 1238.)
The treatment will in no respect differ from that of the genuine puerperal convulsions, except that, as the danger is still greater, so, if possible, must the treatment be more prompt; indeed, it can scarcely be said that there is a convulsion, for there is merely loss of motion with insensibility. It is fortunately of rare occurrence, as the patient seldom recovers.
Anæmic convulsions. The next form of epiplectic puerperal convulsions is the anæmic form, where, in consequence of serious loss of blood or debility otherwise induced, the due balance of the nervous system has been disturbed, and irregular and convulsive actions have been the result.
We have already shown that cerebral congestion is favourable to that state of irritability, which, by the help of any exciting cause, may easily pass into a state of epilepsy; an opposite condition, viz. that of exhaustion, is capable of acting in a similar way, and thus confirms Dr. Cullen's assertion, "that there are certain powers of collapse, which, in effect, prove stimulants and produce epilepsy."
"That there are such powers which may be termed indirect stimulants, I conclude from hence, that several of the causes of epilepsy are such as frequently produce syncope, which, we suppose, always to depend upon causes weakening the energy of the brain." "The first to be mentioned, which I suppose to be of this kind, is hæmorrhage, whether spontaneous or artificial. That the same hæmorrhage which produces syncope, often at the same time produces epilepsy, is well known; and from many experiments and observations it appears, that hæmorrhages occurring to such a degree as to prove mortal, seldom do so without first producing epilepsy." (Op. cit.) It is a well-known fact, that when once a state of exhaustion or collapse has been carried beyond a certain point, the irritability of the nervous system increases in proportion: the due balance of its various actions becomes more and more unsteady; their equilibrium is disturbed by the slightest impressions, and losing the state of well-adjusted repose which belongs to health, they continually vibrate between the extremes of excitement or collapse, which seldom fail to produce some serious derangement.
"The symptoms of reaction from loss of blood," says Dr. Marshall Hall, "accurately resemble those of power in the system, and of morbidly increased action of the encephalon; and, from these causes, the case is very apt to be mistaken and mistreated by the farther abstraction of blood. The result of this treatment is, in itself, again apt farther to mislead us; for all the previous symptoms are promptly and completely relieved, and this relief, in its turn, again suggests the renewed use of the lancet. In this manner the last blood-letting may prove suddenly and unexpectedly fatal."
Symptoms. A very little attention, however, will discover the real features of the disease; the pale face, the glazy eye, the shrunken features and colourless lip, the cold moist skin, the heaving chest, the quick, weak, small, and irritable pulse, all betoken a condition of exhaustion and collapse. The history of the case will also show that the patient has suffered from profuse hæmorrhage, or some other debilitating evacuation; and the intense pain on the summit of the head, verging into actual delirium, the rambling thoughts and confused mental associations, the restlessness or absolute insomnia, the tinnitus aurium, disposition to strabismus or other derangements of vision, indicate the defective condition of the cerebral circulation.
We have already mentioned, in the congestive form of epilepsy, that where the irritation from gastric derangement is conjoined to a state of body already predisposed to the disease, that this is frequently sufficient to excite it into action; still more will this be the case where the system is rendered irritable by exhaustion; and it will occur under more formidable circumstances, from our means of treatment being confined within still narrower limits. Dr. M. Hall justly observes, that "exhaustion is sooner induced under circumstances of intestinal irritation:" and again, "paralysis has occurred in a state of exhaustion from other causes, as undue lactation; and in various circumstances of debility, as in cases of disorder of the general health, with sallowness and pallor, and a loaded tongue and breath."
Treatment. Our treatment of these cases will not vary essentially from that of exhaustion from hæmorrhage under the ordinary circumstances; the patient must be placed with her head low, and as soon as she is able to swallow, a little hot brandy and water, or ammonia, should be given to rouse the circulation to a sufficient degree of activity. If the uterus be still flaccid and disinclined to contract effectively, a dose of ergot will be advisable, and the abdomen should be tightly bandaged with a broad towel. When the powers of the circulation have rallied somewhat, a little plain beef-tea will frequently prove very grateful and appear to revive her more powerfully than even the stimulants above-mentioned; and now, as it is of the greatest importance to calm the irritability of the brain and nervous system, we must proceed to the use of sedatives. Of these, opium and hyoscyamus have the preference, the latter especially so, from its not being liable, like opium, to derange the stomach, or contract the bowels. Moreover, where the exhaustion is very alarming, it is not always easy to control the sedative action of opium within due bounds; and in such cases we are sometimes apt to produce so much sopor, as to render it even difficult to rouse the patient. For this reason, the combination with a diffusible stimulant is always desirable: five grains of camphor and of extr. hyosc. in two pills, form, perhaps, the best and safest sedative which can be given; these may be repeated every hour, and then at longer intervals of two or more hours, until sleep has been produced. Sleep, in cases of this kind, is of the greatest importance, and produces the most favourable change in the patient's condition; the intense headach and irritability of the mind, of the sight, and of the hearing, all abate; the circulation becomes calmer, the pulse more full and soft, the heat of the body more equable; in short, the whole nervous system is returning to a more natural and regular state of action, the stomach is more capable of receiving and digesting its food, the bowels are more manageable, and we may now venture to remove a state of constipation, if present, or any morbid intestinal contents without running the risk of bringing on diarrhoea and increasing the debility.
We rarely find that the convulsions return when once the patient has enjoyed the calm of a sound and refreshing sleep, and consider the victory as more than half gained when this favourable state has been produced. The laxative should be of the mildest form, such as will merely excite the peristaltic action of the intestines without increasing their secretions; for this purpose a warm draught of rhubarb manna with hyoscyamus, or castor oil guarded by a little liq. opii. sed., will be the safest. Food of the blandest and most nutritious quality should be given in small and frequently repeated doses; it is important not to load the stomach much or suddenly, for vomiting is easily produced, and when once excited, the stomach becomes so irritable as to be scarcely capable of retaining any food whatever.
Where, on the other hand, several hours have passed, not only without sleep but without even a temporary state of quiet; where the headach alternates with restless delirium; where the medicines and nourishment have produced little or no effect, or have been rejected by vomiting; where the pulse becomes quicker, and the debility increases, we have not only to dread a return of the fits, but that the stage of actual sinking is at hand.
"It would perhaps," says Dr. Marshall Hall, "be difficult to offer any observations on the nature and cause of excessive reaction; but it is plain that the state of sinking involves a greatly impaired state of the functions of all the vital organs, and especially of the brain from defective stimulus. The tendency to dozing, the snoring and stertor, the imperfect respiration, the impaired action of the sphincters, the defective action of the lungs, and the accumulation of the secretions of the bronchia, the feeble and hurried beat of the heart and pulse, the disordered state of the secretions of the stomach and bowels, and the evolution of flatus, all denote an impaired condition of the nervous energy." (On the Morbid and Curative Effects of Loss of Blood, p. 54.)
Hysterical convulsions scarcely deserve the name of puerperal convulsions, being liable to occur under circumstances quite independent of the puerperal state; they rarely occur during the process of labour itself, but are chiefly observed during the last few weeks of pregnancy, and the first week or so after labour, especially when the milk is coming on.
Symptoms. The patient is of a nervous hysterical habit; "she is either still very young, or is of a slim and delicate make; the face is pale and interesting; she has full blue eyes and light hair, and was always of a highly sensitive constitution; the pulse is quick, small, and contracted; the temperature of the skin is rather cool than otherwise; her spirits are variable, fretful, and anxious; she starts at the slightest noise, cannot bear much or loud talking, and misunderstands or takes every thing amiss. During her slumbers, which are short, there are slight twitchings of the eyes and mouth, and in her sleep the eyes are in constant restless motion, and she frequently starts. She complains of sickness, and has frequent calls to pass water, which is very pale; slight rigours alternate every now and then with flushing, and she is easily tired, even by trifling pains, and dozes a good deal during the intervals. She is excessively sensitive, even to the most gentle and cautious examination; the os uteri remains thin, hard, tense, and painful to the touch longer than is usually the case. The ordinary tension and stretching of the os uteri at the termination of a regular contraction is attended with much more pain, and with a peculiar feeling of lassitude, although uncomplicated with any rheumatic affection. The pains follow no regular course, being sometimes stronger, at others weaker, and frequently cease entirely for considerable periods. The uterus has a great disposition from the slightest irritation, to partial and spasmodic contractions." (Wigand, Geburt des Menschen, vol. i. p. 164.)
Before the fit the patient usually passes a large quantity of colourless and limpid urine; she has oppression at the stomach, anxiety, difficulty of breathing and palpitation, with globus, sobbing, and other hysterical symptoms. There are not those precursory symptoms of cerebral congestion as mark genuine epileptic puerperal convulsions; the headach is neither so severe, nor is it in the same place, being usually at the temples and across the forehead; the face is rather pale than flushed, and when the fit begins, we see little or none of the convulsive twitching among the small muscles, as is the case with an epileptic attack; the face is less distorted, but the large muscles of the trunk and extremities are much more violently affected; the patient struggles furiously, and in severe cases has more or less of opisthotonos; she screams, and never appears to lose her senses so entirely as in the epileptic form; her raving may generally be controlled to a certain extent by suddenly dashing cold water in her face, and speaking loudly and sharply to her; at any rate it instantly produces a deep and sudden inspiration, which is frequently attended with a prolonged hooping sound; this is followed by sobbing, gasping, choking, and the ordinary phenomena of an hysteric fit, but the convulsions themselves are usually arrested more or less by this application: we hold the effects of cold water to be one of the best diagnostics of the disease from epilepsy, in which the patient is entirely insensible to such impressions.
A similar fact is observed during vaginal examination; the patient seems aware of our intention, and resists in every possible way.
"The patient, after the fit, can for the most part be roused to attention or will frequently become coherent so soon as she recovers from the fatigue or exhaustion occasioned by her violent struggles; and though she may lie apparently stupid, she will nevertheless sometimes talk or indistinctly mutter. After the convulsion has passed over, she will often open her eyes and vacantly look about, and then, as if suddenly seized by a sense of shame, will sink lower in the bed, and attempt to hide her head in the clothes." (Dewees's Compend. Syst. of Midwifery, § 1240.)
When sufficiently recovered to be capable of swallowing, she should sip some cold water, or what is still better, take a dose of spiritus ammoniæ foetidus in water; this soon produces copious eructations from the stomach, which are followed with much relief. Where there is a disposition to vomiting, and other evidences of a deranged stomach, it should be encouraged by some warm water, chamomile tea, &c. The bowels are almost always in an unhealthy state, which frequently produces much irritation, and in plethoric habits so much tendency to cerebral congestion as to endanger even an attack of the epileptic convulsions. One or two doses of a pretty brisk purgative should, therefore, be given, and if there be still heat or pain of head, a bleeding may be required.
Under ordinary circumstances hysterical convulsions are by no means dangerous, and beyond a little fatigue and exhaustion, the patient recovers from them almost immediately.
XII. PLACENTAL PRESENTATION, OR PLACENTA PRÆVIA
History.--Dr. Rigby's division of hæmorrhages before labour into accidental and unavoidable.--Causes.--Symptoms.--Treatment.--Plug.-- Turning.--Partial presentation of the placenta.--Treatment.
There are few dangers connected with the practice of midwifery which are more deservedly dreaded, and which are wont to come more unexpectedly, both to the patient as well as to the practitioner, than that species of hæmorrhage which occurs in cases where the placenta is implanted either centrally or partially over the os uteri. Well has a celebrated teacher observed, that "there is no error in nature to be compared with this, for the very action which she uses to bring the child into the world is that by which she destroys both it and its mother." (Naegelé, MS. Lectures.) In other words, where there is this peculiar situation of the placenta it becomes gradually detached, either in proportion as the cervix expands during the latter months of pregnancy, or as the os uteri dilates with commencing labour, and is thus unavoidably attended with a profuse discharge of blood, which generally increases as the dilatation proceeds.
The peculiar feature of this species of hæmorrhage, necessarily accompanying the commencement of every labour where the placenta is implanted over the os uteri, was first fully described in this country in 1775, by the late Dr. Rigby, in his classical Essay on the Uterine Hæmorrhage which precedes the Delivery of the full-grown Foetus, a work which has been justly looked upon, both in England and the Continent, as the great source to which we are indebted for our practical knowledge in the management of these dangerous cases.
History. There is abundant evidence to prove the sudden attacks of hæmorrhage during pregnancy, attended with circumstances of great danger to the life of the mother and her child, were known from the earliest times, and especially noticed by Hippocrates where he says, "that the after-burden should come forth after the child, for if it come first, the child cannot live, because he takes his life from it, as a plant doth from the earth." (De Morbis Mulierum, lib. i. quoted by Guillemeau.)
Hippocrates, therefore, evidently supposed that this presentation of the placenta at the os uteri was owing to its having been separated from its usual situation in the uterus, and fallen down to the lower part of it.
This view has been closely adopted by Guillemeau, to whom we are indebted for having called our attention to the above passage. He has devoted his fifteenth chapter[140] to the management of a case where the placenta presents, and shows that "the most certain and expedient method is to deliver the patient promptly, in order that she may not suffer from the hæmorrhage which issues from the uncovered mouths of the uterine veins, to which the placenta had been attached; that, on the other hand, the child being enclosed in the uterus, the orifice of which is plugged up by the placenta, and unable to breathe any more by the arteries of its mother, will be suffocated for want of assistance, and also enveloped in the blood which fills the uterus and escapes from the veins in it which are open."
The operation of turning, which had been newly practised by his teacher, Ambrose Paré, and still farther brought into notice by himself, at that time formed a great æra in midwifery, for it furnished practitioners with a new and successful means of delivering the child in cases where urgent danger could only be avoided by hastening labour; hence, therefore, in all cases of profuse hæmorrhage coming on before delivery, it was a general rule, if the case became at all dangerous, to turn the child.
Guillemeau's explanation of the nature of placental presentations was still more explicitly adopted by Mauriceau, La Motte, and many others. Mauriceau invariably speaks of the placenta, when at the os uteri, as "entirely detached;" and adds that "even a short delay will always cause the sudden death of the child if it be not quickly delivered; for it cannot remain any time without being suffocated, as it is now obliged to breathe by its mouth, for its blood is no longer vivified by the preparation which it undergoes in the placenta, the function and use of which cease the moment it is detached from the uterine vessels with which it was connected: the result of this is the profuse flooding which is so dangerous for the mother; for if it be not promptly remedied she will quickly loose her life by this unfortunate accident." (Vol. i. p. 332, 6th ed.) He also adds, "it must be observed that the placenta, which presents, is nothing more than a foreign body in the uterus when it is entirely separated," (p. 333,) "for when it comes into the passage before the infant, it is then totally divided from the womb." (Chamberlen's Transl. p. 221. 8th ed.) In the sixteen cases which he has detailed, he has distinctly mentioned the fact in thirteen that the placenta was entirely separated from the uterus, and presented at the os uteri. In two of these he has expressly stated his conviction that the placenta had been detached from the uterus, by the mother having been exposed to a violent shock, when the cord was shortened from being twisted round the child.
These facts prove that Mauriceau, considered presentations of the placenta to arise solely from its having been separated by some accident from the fundus, and fallen down to the os uteri.
Dr. Robert Lee, in his "Historical Account of Uterine Hæmorrhage in the latter Months of Pregnancy," (Edin. Med. and Surg. Journal, April 1839,) has omitted all mention of this circumstance, and from the account which he has given of Mauriceau's observations, would infallibly lead his readers to suppose that Mauriceau was fully acquainted with the real nature of these peculiar cases. Thus, he commences with saying, "The symptoms and treatment of cases of placental presentation are here accurately described, and in all cases of hæmorrhage from this cause he recommends immediate delivery;" and again, he observes, "The rules for the treatment of these cases are laid down with the greatest precision. When the placenta was entirely separated, then only did he consider it as a foreign body, and recommend its extraction before the child." The student would be led by such a statement to suppose that Mauriceau did not consider the entire separation of the placenta as the most usual occurrence in these cases, and will therefore naturally infer that in the majority of cases of placental presentation, he recognised the implantation of the placenta upon the os uteri. That such was very far from the case, we have already shown by quotations from various editions of his work. Dr. Lee has collected sixteen, (not seventeen,) cases of placenta prævia from Mauriceau, and has given a short summary of them. Out of the thirteen cases in which Mauriceau has distinctly mentioned that the flooding had been caused by the entire separation of the placenta which presented, Dr. Lee has noticed it in only three; and in one of these he has reversed the expression by saying, "placenta presenting and entirely detached:" thus leading his reader to infer that the placenta had presented at the os uteri, but had become detached from it. Nor is the case (No. 423,) to which Dr. Lee has referred "as a proof that Mauriceau, was aware of the fact, that the placenta had not been wholly detached from the uterus," at all tend to show that he had any idea of the placenta being implanted upon the os uteri.
By stating that "Mauriceau has also recorded the histories of thirty-seven cases of uterine hæmorrhage in which the placenta did not present, but had adhered to the upper part of the uterus and been accidentally detached," Dr. Lee has confirmed the erroneous inference that the implantation of the placenta upon the os uteri was known to this valuable author; whereas, we have proved by numerous quotations, that Mauriceau distinctly supposed that in all cases of hæmorrhage before labour, whether the placenta was found presenting or not, it had been originally attached "to the upper part of the uterus."
Paul Portal was the first, as far as we are acquainted, who describes the placenta as adhering to the os uteri. He has recorded eight cases, "in which," as Dr. Rigby observes, "he was under the necessity of delivering by art, on account of dangerous hæmorrhages, and in all of them he found the placenta at the mouth of the womb." (Essay on Uterine Hæmorrhage, p. 22, 6th ed.) In these he distinctly mentions the placenta adhering to the os uteri. In several of these he separated it from the os uteri and brought it away; and in seven he turned the child. In the other (Case 39,) the head burst its way through the placenta. In one case only (51,) does he attempt to make any practical inference whatever, having in all the others contented himself with merely stating the fact of the placenta adhering to the os uteri. In this instance, however, he has described the real nature of the case, and pointed out the cause of the hæmorrhage. On introducing his hand he "found the after-burden placed just before and quite across the whole inner orifice, which had actually been the occasion of the flux of blood; for by the opening of the orifice the said after-burden then being loosed from that part where it adhered to before, and the vessels containing the blood torn and opened, produced this flooding, which sometimes is so excessive as proves fatal to the woman unless it be speedily prevented." (Portal's Midwifery, transl. p. 167.)
There is no doubt, as Dr. Renton has very justly observed, "that Portal in 1672 (not 1683) knew as much on the subject of uterine hæmorrhage occasioned by the displacement of the placenta from the os uteri, and the practice necessary for its suppression, as we do at the present time." (Edin. Med. and Surg. Journ. July, 1837.) But we cannot coincide with him in the passage which follows, viz. "It is to him unquestionably that we are indebted for our knowledge on the subject," because, as Dr. Renton himself has shown, all the authors in midwifery up to the time of Roederer and Levret (1753) were ignorant of Portal's explanation. We do not even except Giffard, as there is sufficient evidence to show that he, for some time, entertained the prevailing erroneous opinions of Mauriceau, until he at last discovered the real nature of the case himself. We attribute the omission solely to the above observation of Portal being so short and isolated, and to its having been entirely unaccompanied by any other practical remarks or inferences which might have been expected from so remarkable a fact. To this reason alone can we attribute the circumstance of its not having been expressly mentioned by Dr. Rigby when alluding to Portal's cases. In a similar way we can explain why Portal has not had the merit of a valuable improvement in the operation of turning which has been attributed to Peu, viz. the passing the hand between the membranes and uterus up to the fundus before rupturing them, solely because he mentions it as a cursory observation, without any farther notice or practical inference.
The next author who has at all alluded to the real nature of placenta prævia is Giffard, whose posthumous work was published in 1734. The value of his evidence on this subject is considerably modified by his having made no allusion to the implantation of the placenta upon the os uteri in the first ten cases of flooding, where he found the placenta presenting, but repeatedly describes the placenta as being wholly separated and lying in the passage, and in some, he expressly mentions that the placenta had fallen down to the os uteri. In cases 115, 116. and 224. he gives a perfectly correct explanation of the cause of flooding, but the opinion is expressed with such a degree of hesitation, and so cursorily, that we doubt much if it attracted more notice than the observations of Portal, above alluded to, more especially as in the six cases of placenta prævia, which occur between the last two above-mentioned (viz. 120, 121. 158. 160. 185. and 209.,) he returns again to his former mode of describing them. We, therefore, regret that Dr. Renton has not mentioned this circumstance, and that in quoting from "two of the numerous cases which he relates," he has not stated that these were two out of the only three cases which Giffard had described correctly.[141]
It is, therefore, to the above-mentioned circumstances of Giffard having given what is now recognised as the correct explanation, in only three out of nineteen cases, that we can explain why so little notice was taken of the subject at that time; why Dr. Smellie, when speaking of it, makes no allusion to Giffard; and why Dr. Rigby, in his Essay on Uterine Hæmorrhage, was led to suppose that he was ignorant of the real nature of these cases: certain it is that his opinion could scarcely be called a decided one.
Smellie mentions that "the edge or middle of the placenta sometimes adheres over the inside of the os internum, which frequently begins to open several weeks before the full time; and if this be the case, a flooding begins at the same time, and seldom ceases entirely until the woman is delivered; the discharge may, indeed, be intermitted by coagulums that stop up the passage, but when these are removed it returns with its former violence, and demands the same treatment that is recommended above." His cases contain no observation beyond the recital that a considerable hæmorrhage had occurred, the placenta had been found presenting, and that he had turned the child. In his sixth case (Collect. 33, No. 2.) which is dated 1752, it is evident that he was ignorant of what had been said on the same subject by Giffard and Portal; for he observes, "This case being uncommon, I was uncertain at first how to proceed; but at last considering with myself, if I broke the membranes to evacuate the contained waters, so as to allow the uterus to contract and restrain the flooding, the foetus would be lost by the pressure of the head against the funis (which presented) in the time of delivery. I resolved in order to prevent this misfortune to turn the child, and bring it along in the preternatural way, which would give it a better chance to restrain the one, and save the other, if the operation could be performed in a slow cautious manner." This forms the amount of his observations on this important subject, and, therefore, justifies the observation which Dr. Rigby has made, viz. that there are no practical inferences drawn from the cases; nor in his directions about the management of floodings, are there any rules given relative to this situation of the placenta.
Roederer decidedly stands pre-eminent, as being the first author who gave a distinct and complete description of this species of hæmorrhage; he points out the cause of it, and accurately describes its symptoms and mode of attack; he shows that the placenta may be entirely or partially attached to the os uteri; that in the one case the hæmorrhage will be very profuse, and artificial assistance will be required; in the other it will be slighter, and in many cases it may be left to nature.[142]
Levret cotemporaneously with the first edition of Roederer's work, published at Paris, a valuable paper on placental presentation, which, with the above-mentioned chapter of Roederer, must be looked upon as the first observations in which this form of hæmorrhage was made a distinct subject of consideration. Although Levret has in no wise claimed the merit of being the first who had noticed the fact of the placenta being implanted upon the os uteri, still there can be no doubt that to him and Roederer we are indebted for having first investigated the subject and called the attention of the profession to its peculiar characters.
Levret has reduced his observations under three heads, viz. that the placenta is occasionally implanted over the os uteri, that hæmorrhage under such circumstances is inevitable, and that the safest mode of remedying this accident is the accouchement forcé. He has also added a few valuable remarks, but by far the greater part of the essay is occupied with theoretical arguments to prove that it is impossible for the placenta, which had been attached to the fundus, to sink down to the os uteri. Indeed, beyond stating the three above-mentioned positions, which are undeniably of great practical value (although by no means original,) Levret has added but little which is not contained in Giffard, his chief merit being that of making it a subject of distinct consideration, and establishing it as a matter beyond doubt.
Levret cannot, however, be looked upon as the first who considered that the flooding, in cases of placenta prævia, was "inevitable," although, from his not having quoted Giffard, we willingly concede to him the merit of originality, as far as he himself was concerned: it was Giffard, however, as far as we know, who first pointed out that hæmorrhage was the necessary consequence of placental presentation, as is shown from what we have already quoted from him, although, to a certain extent, it was hinted at by Portal, in his fifty-first case. Levret's memoir was afterwards reprinted in his large work, entitled L'Art des Accouchemens: the third edition, which appeared in 1766, was quoted by Dr. Rigby in the first edition of his Essay on Uterine Hæmorrhage, 1775,[143] in farther proof of the placenta being implanted over the os uteri, and being the cause of hæmorrhage.
We are chiefly indebted to Dr. Rigby for a complete exposition of this important and interesting subject. His well-known essay on the uterine hæmorrhage which precedes the delivery of the full-grown foetus has stood the test of time, and will ever remain, not less remarkable for its practical value, than "for the perspicuity and simplicity of its style." (Renton, op. cit.) To Dr. Rigby, without doubt, is due the merit of having first distinguished hæmorrhages, which occur before delivery, into accidental and unavoidable, a division so truly practical and appropriate, as to have placed this subject in the clearest and simplest possible light. "He was," as Dr. Collins has justly observed, "the first English author who fully established this most important practical distinction in the treatment of uterine hæmorrhages, although Levret had many years before published a somewhat similar statement." Dr. Rigby's arrangement has been adopted by Dr. Merriman, Dewees, and every other modern author of any note; and the medical world have amply testified their sense of its value, as well as of the work itself in general, by the numerous editions which it has undergone in this, and translations and reprints in other countries.
We have entered into an historical detail of the literature of this subject, from its having been asserted that Dr. Rigby "published an abstract of the doctrines of Puzos and Levret with the addition of some cases from his own practice," (Burns, Principles of Midwifery, 9th ed., 1837, p. 364;) that he availed himself of the discoveries of Dr. Smellie and M. Levret, while he contrived to make the profession believe that his doctrines were original, (Hamilton, Practical Observations, &c., 1836, vol. ii. p. 238;) and that "no fact of the slightest importance has since (Smellie) been discovered relating to the causes and treatment of uterine hæmorrhage in the latter months of pregnancy." (Dr. R. Lee, Edin. Med. and Surg. Journ., 1839, vol. li. p. 389.) We, therefore, deem it only just to our readers, and also to the author, to lay before them his own account of what, at the time, he supposed to be a discovery, and how far he considered himself justified in laying claim to its originality.
"A case of hæmorrhage, in which I found the placenta attached to the os uteri, occurred at a very early period of my practice; but not finding such a circumstance recorded in the lectures which I had attended, or taken notice of in the common elementary treatises on midwifery, I considered it at first merely as a casual and rare deviation from nature. In a few years, however, so many similar instances fell under my notice, as to convince me, that it was a circumstance necessary to be inquired after in every case of hæmorrhage: and this conviction was confirmed by the perusal of cases in midwifery; for I then found that the fact of the placenta being thus situated had been recorded by many writers, though in no instance which had then reached me, had any practical inferences been deduced from it. It appeared to me, indeed, most extraordinary that such a fact, known to so many celebrated practitioners, should not long before have led to its practical application, and in consequence to more fixed principles in the treatment of hæmorrhages from the gravid uterus; and I may, perhaps, be allowed to say, that I congratulated myself, young in years and practice as I was, in being, probably, the first to suggest an important improvement in the treatment of one of the most perplexing and dangerous cases in midwifery; and that I committed my observations on the subject to paper, not only under a conviction of their practical utility, but certainly also under an impression that my suggestions were original.
"Not long after the first edition was at press, indeed before the first sheet was printed, Levret's dissertation on this subject fell into my hands, and in a note I referred to it as additional testimony in proof of the placenta, in these cases, being originally attached to the os uteri.
"I have been led into this little detail, because it has been suggested that I have borrowed my theory from Levret. After remarking the gross folly I should have been guilty of in quoting Levret, had I furtively adopted his opinions, it will, I trust, be sufficient for me unequivocally to declare that my original ideas on the subject were derived solely from my own personal observation and experience; and that having previously neither read nor heard of the placenta being ever fixed to the os uteri, the knowledge of such a circumstance, derived as before observed, came to me and impressed me as a discovery.
"I was, certainly, afterwards struck with the coincidence of the sentiments of Levret and myself on the subject, with the similarity of our practical deductions, and, allowing for the difference of language, even with the sameness of our expressions. I am farther not reluctant to acknowledge, that after reading Levret's dissertation, I felt less entitled to the claim of absolute originality on the subject; and I now rest perfectly satisfied to divide with him the credit arising from the mere circumstance of communicating a new physiological fact. But were I even denied all claim to originality, I should still not be without the satisfaction of having, at least, materially contributed to diffuse the knowledge of an important fact, and of having established its practical utility on the unequivocal testimony of experience; for, had I seen Levret's dissertation sooner, or had even my attention been first directed to the subject by its perusal, ought it to have superseded my publication? Was the practice in this country, at that time, at all influenced by Levret's dissertation? or has it even since been translated into the English language? Was it, at that time, generally known that the attachment of the placenta to the os uteri was a frequent cause of hæmorrhage? and were any directions for our conduct in these cases, founded on the knowledge of the fact, given by those who there lectured on the art of midwifery?
"Levret's facts, moreover, though they proved that the placenta might be originally attached to the os uteri, (and a single instance would establish this,) were scarcely sufficient to prove the frequency of its occurrence, from which alone arises the necessity of practically attending to it in every case of hæmorrhage. His observations (perhaps even more creditable to him for being founded on such scanty materials) were derived from four cases only, and of these, but two were under his own immediate cognizance; whereas, in the first edition of this essay my opinions were supported by 36 detailed cases, in 13 of which the placenta was found at the os uteri; and in the fourth edition the number was increased to 106, 43 of which were produced by this peculiar original situation of the placenta." (Preface to the 5th ed.)
The causes of this peculiar deviation from the usual situation of the placenta are little if at all known. The condition of the decidua shortly after the entrance of the ovum into the cavity of the uterus, will probably influence the situation of the placenta considerably. Under the ordinary circumstances, this effusion of plastic lymph has already attained such a degree of firmness and coherence as to prevent the ovum from passing beyond the uterine extremity of the Fallopian tube from which it has emerged; but in cases of placental presentation it may be presumed that at this period the decidua was still in a semi-fluid state, had formed little or no attachment to the walls of the uterus, and had, therefore, no effect in preventing the ovum gravitating to the lower part, or even to the mouth of the uterus itself. We state this, of course, as a mere matter of theory, since the difficulty of investigation at such early periods, and the comparative rarity of placental presentations, will probably ever prevent our ascertaining the real cause.
Symptoms. The first symptom which warns us that the placenta is presenting, is the sudden appearance of hæmorrhage, which is usually more copious than ordinary hæmorrhage, and apparently comes on without any assignable reason: it is usually the more profuse the nearer the patient is to the full term of pregnancy, for not only now are the ruptured vessels larger, but the separation of the placenta is generally greater. If she has still some time to go, the discharge will be probably slight, and with rest and quiet, &c., will cease, to return again in ten days or a fortnight with increased violence: this usually happens at what would have been a catamenial period. The suddenness of its attack, the profuseness of the discharge, and its coming on without any evident cause, are peculiarly suspicious.
It has been stated that the abdomen is less distended in these cases than usual, from the placenta not being in the upper parts of the uterus: it is an observation, however, which requires to be confirmed, and certainly our own experience, as yet, has not led us to such a conclusion.
On examination, the os uteri is found to be larger and thicker than ordinary: it has a loose spongy feel, for its vessels are now as immensely distended as those of the fundus, when the placenta has its usual situation. If the placenta be partially attached over the os uteri, it is generally upon the anterior lip, which is much thicker. In this case we shall feel the edge of the placenta projecting at one side of the os uteri, and the bladder of membranes, and probably the presenting part of the child at the other. Whereas, if the placenta be centrally attached, we shall find it attached to the whole circumference, except perhaps where the separation is, from which the hæmorrhage proceeds. We shall distinguish the placenta by its spongy mass, by its soft irregular surface, and by the stringy feel which it communicates where it has been torn.
The character of the hæmorrhage is also different from that of common hæmorrhage, inasmuch as it increases during a pain, and diminishes or ceases during the intervals, whereas, in hæmorrhage under ordinary circumstances it is the reverse.
Where the hæmorrhage takes place at some distance of time from the full period of utero-gestation, it probably arises from the gradual development of the cervix during the latter months of pregnancy: where, on the other hand, it does not appear till just before labour, the separation of the placenta will have been produced by the incipient dilatation of the os uteri itself. It might therefore be supposed, that the period of the attack would, in great measure, depend upon whether the placenta was centrally, or only partially, attached to the os uteri; that in the former case the placenta would be more liable to be separated by the gradual development of the inferior segment of the uterus; and that, therefore, hæmorrhage would come on several weeks before the full term; whereas, if only a portion of it cover the edge of the os uteri, the patient would probably go to the very end of pregnancy before any flooding appeared. Although this view is supported by the high authority of Professor Naegelé, still we can scarcely agree with it, since not only do a considerable majority of recorded cases show that a patient with central presentation of the placenta may go to the full time without an attack of flooding, but also several of those which have come under our own observation lead to a similar conclusion.
The most alarming attacks of hæmorrhage are doubtless at the full term, when the os uteri is beginning to dilate from commencing uterine contractions, and the placenta is centrally attached over it: in these cases the discharge experiences little or no abatement beyond an occasional short remission, but returns with the pains, increasing in profuseness as the gradually dilating os uteri produces a still farther separation of the placenta. Such cases, if left to themselves, would almost necessarily prove fatal. The first fainting fit or two would probably produce a temporary cessation of the discharge, and favour the formation of coagula in the upper part of the vagina; but with returning contractions of the uterus, the hæmorrhage would be renewed with increased violence, and quickly reduce the vital powers. In such cases the patient will probably die undelivered, or soon after the birth of a dead child. In some rare instances, the pains have been sufficiently powerful to force the head through the placenta, and thus enable the mother to be delivered by the natural means, although with little chance of the child being born alive, from the injury which the foetal vessels in the placenta have received. Portal's twenty-ninth case terminated in this way. A similar and very interesting case was lately communicated to us by Mr. W. White, of Heathfield, in Sussex, where the placenta appears to have been centrally attached to the os uteri, and where, in consequence of two or three powerful pains, the head was forced through, tearing it quite across. The child was born dead, but the mother did well.
In a few rare cases the placenta has been entirely separated and expelled before the child, but these have usually been attended with a most alarming loss of blood. In almost all the cases related by Mauriceau, and in the majority of those by Giffard, the placenta is stated to have been entirely detached from the uterus, but this was evidently under the mistaken supposition of the placenta having been originally separated from the fundus. "It is extremely rare to meet with a total separation of the placenta. Dr. Clarke informed me that he met with but one case of total separation; the patient dying before he reached the house." (Collin's Pract. Treatise, p. 92.) A still more remarkable instance is recorded by Dr. Collins, where the placenta had been expelled many hours (probably about 18) before the birth of the child. "The membranes had ruptured, and the waters been discharged a fortnight previous to admission, from which time, until the evening before she was brought to the hospital, she had more or less hæmorrhage. It was now ascertained that the placenta had been expelled the evening before her admission, and separated by the midwife in attendance. She left the hospital well on the thirteenth day."[144] (Op. cit. p. 103.) In all these cases the child has been born dead, and must ever be so, where any period of time has elapsed between the expulsion of the placenta and that of the child. The only case we know of where a living child was born after the expulsion of the placenta is recorded by F. Ould. "I found this woman in imminent danger, being seized with faintings and hiccough, having her face pale and Hippocratic. Upon examination, I found the placenta presented to the orifice of the womb, which I immediately extracted; and although the head was far advanced in the passage, I put it back into the womb, and taking hold of the feet brought a living though very weakly child into the world. The mother also recovered, though with much difficulty." (Treatise on Midwifery, p. 77.) La Motte has described a similar case, but where the child died immediately after birth. (Obs. 238.)
The irregularity with which cases of placental presentation have appeared at different times, have more than once excited notice: thus it frequently happens to ourselves that several years have elapsed without our meeting with a single case, although connected with a large lying-in hospital; whereas, at other times two or three cases have followed each other at comparatively short intervals. In selecting ten successive years from the period during which Dr. Rigby observed the numerous cases recorded in his essay, we see this irregularity remarkably exemplified.
In 1779 three cases. In 1780 four cases. In 1781 none. In 1782 five cases. In 1783 one case. In 1784 five cases. In 1785 two cases. In 1786 two cases. In 1787 one case. In 1788 two cases.
A still more remarkable variation has been described by the celebrated Matthias Saxtorph, of Copenhagen. Having stated that placental presentation had occurred only once in 3600 cases, he adds, "the reader will be astonished when I assure him that this case, which is so rare that I had only seen it twice in so many years, and that I had met with it but once out of so many thousand labours at our lying-in hospital, occurred to me in the last six months, eight times." (Collect. Soc. Med. Havn. 1774, vol. i. p. 310.) Professor Naegelé has made a similar remark in his lectures, and states, that in some years placental presentation was so frequent that it seemed as if it were almost epidemic.
Experience proves beyond doubt, that, of the serious floodings which occur during the last weeks of pregnancy, the majority arise from the attachment of the placenta to the os uteri. Dr. Rigby also states "that this attachment of the placenta to the os uteri is much oftener a cause of floodings than authors and practitioners are aware of, I am from experience fully satisfied; and so far am I convinced of its frequent occurrence, that I am ready to believe that most, if not all, of those cases which require turning the child, are produced by this unfortunate situation of it."
The period of pregnancy at which hæmorrhage may come on from placental presentation, varies very considerably. Although, in by far the majority of these cases, it does not come on until the last four or six weeks, it now and then occurs at a much earlier period, viz. the sixth or even the fifth month, and sometimes even earlier. Where this is the case, it must rather be looked upon as one of "accidental" hæmorrhage or abortion, for it can scarcely be supposed that any changes about the os or cervix uteri could have been sufficient to have produced an "unavoidable" separation of the placenta at this time. Thus, for instance, in Dr. Rigby's seventy-fifth case, the first attack of hæmorrhage had appeared when the patient "was about three months gone with child;" and at that early period could hardly have been attributed to the peculiar situation of the placenta, but to the more common causes of hæmorrhage connected with abortion. In his forty-third case, the hæmorrhage, which came on about the twenty-sixth week, appears at first to have been purely "accidental," although it was afterwards produced by "unavoidable" attachment of the placenta. "We very seldom meet with unavoidable hæmorrhage before the sixth month of pregnancy; it is not until the cervix uteri begins to distend freely, and the changes that take place previous to the approach of labour commence, any suspicions are observed; consequently, it will be in the last three months of utero-gestation that hæmorrhage of this nature is found to occur." (Collins, op. cit. p. 93.)
The examination of a case where the placenta presents is not always easy; the natural position of the os uteri during the latter months of pregnancy in the upper part of the hollow of the sacrum makes it very difficult for the finger to reach so completely as to afford us the means of ascertaining satisfactorily whether the placenta be attached to it or not. "For this purpose, however, the usual method with one finger will not always suffice, but the hand must be introduced into the vagina, and one finger insinuated into the uterus; for in several of the following cases it will appear, that though the women were frequently examined in the usual way, the placenta was not discovered till the hand was admitted for the purpose of turning the child." (Essay, 6th ed. p. 35.)
Treatment. We have already stated that the earlier the period at which the flooding comes on, the less profuse it will be; the treatment, therefore, where the hæmorrhage is inconsiderable, differs but little from that in an ordinary case of abortion or miscarriage. The indications, in fact, are the same, viz. to stop the discharge, and allay any disposition to uterine contraction.
The patient must be placed upon a mattress, and covered as lightly as possible with safety and tolerable comfort to herself. If the circulation be active, the pulse strong, with more or less heat of surface, it may even be desirable to reduce this by means of the lancet. "Under any kind of active hæmorrhage, when the pulse is vigorous, the taking away blood from the arm has uniformly been found useful, by producing contraction by the mere unloading of the vessels, and more especially in diminishing the velocity of blood within them." (Dewees, Compend. Syst. of Midw. p. 441.) Cold cloths must be applied to the vulva, loins, and over the symphisis pubis; gentle saline laxatives with nitrate of potass should be given if the bowels are confined; and if there be the slightest appearance of the pains, an injection of twenty or thirty drops of Liq. Opii Sedat. into the rectum will be necessary. This may be given immediately where the bowels are not confined, or, if they are, after the rectum has been washed out by a large domestic enema. If necessary, she should also take an opiate by the mouth. Her food must consist of little else than plain drinks, as tea, milk and water, &c., all of which must be taken cold; and she must preserve the most perfect quiet of body as well as mind. We cannot agree with Dr. Dewees in permitting "our patients, under treatment for uterine hæmorrhage, to be five or six days without a discharge from the bowels;" as a loaded state of the lower bowels cannot fail in our opinion to obstruct seriously the free return of the circulation from the pelvic viscera, and thus greatly increase the disposition to congestion and hæmorrhage.
The longer the patient has still to go, the more desirable is it that we should, if possible, control the symptoms, and prevent them from proceeding to such extent as to require artificial delivery. It is of the utmost consequence that we should take such measures as will enable the pregnancy to go on safely, if not to the full time, at least to a later period, for by this means the uterus will have attained such a degree of development as will enable the turning to be undertaken with ease to the practitioner and with safety to the mother; the child also will have so far advanced towards maturity as to give it a better chance of surviving the operation.
Wherever hæmorrhage has occurred during the last three months of pregnancy, which has come on suddenly and without any assignable reason, we should earnestly warn the patient and her friends to summon the practitioner the moment there are any symptoms of its return; for if it be a case of placental presentation, it assuredly will return, and as certainly much more profusely than at first.
Where the patient has gone nearly or quite to her full time, the first attack is much more alarming; the hæmorrhage frequently appears with a sudden gush, and in a few minutes a serious and even dangerous quantity of blood is lost; thus a patient whom we had seen but a few hours previously in perfect health, was suddenly seized with profuse flooding as she was standing at the door of her house speaking to a person, and before she could move, a large pool of blood had formed at her feet; in another case, the patient while standing at her tea-table was attacked in a similar manner, and in a moment the floor was deluged with the discharge.
Although artificial delivery by turning the child is required in every case of central presentation of the placenta during the latter periods of pregnancy, it is evident that this will not apply during the earlier months, when the uterus from its size will preclude the possibility of such an operation. Dr. Rigby has established a valuable axiom on this point, viz. "that when the uterus is too small for the admission of the hand, the expulsion of the placenta and foetus will happily be timely effected by nature. It is well known that in the early months, instances of fatal termination by floodings have been very rare, as abortion sooner or later puts a stop to the discharge. It has been likewise before observed, that in floodings at any period of pregnancy, women seldom die, at least not in the first instance, unless a considerable quantity of blood has been suddenly lost. Now, as the danger of a great and sudden loss must obviously depend upon the size of the uterine vessels, and as the enlargement of the vessels is in exact proportion to the increased size of the uterus, it becomes probable that when the vessels have acquired such a magnitude, that when detached from the placenta they would bleed largely and suddenly, the uterus itself must have attained to such a capacity as to admit the hand for artificial delivery." (Op. cit. p. 48, 6th ed.) He farther observes, "that as the most material increase of the uterus does not take place until the end of the sixth month of pregnancy, a hæmorrhage before that period will seldom require artificial delivery; and after that period, should it become necessary, that it is probable the hand may then be admitted for that purpose." (Ibid. p. 51.)
In almost every case where the patient is some time short of her full time, the os uteri will be found unyielding and but little dilated; it will, therefore, seldom be possible, and scarcely ever proper, to introduce the hand into the uterus under such circumstances; the os uteri either entirely resists our efforts, or if we do overcome it, the degree of force required to effect this has been so great, as will in all probability have been attended with serious injury to the part itself. In no case is it proper or safe to force delivery by artificially dilating the os uteri, when it is contracted and unyielding (see TURNING;) but where the placenta is presenting, it is peculiarly dangerous, for even slight laceration of the os uteri will be followed by serious consequences. Where the placenta is situated in the upper part of the uterus, it is of very little consequence if the edge of the os uteri has been torn somewhat during labour; but in the present case it is very different; the os uteri now plays the part of the fundus, its vessels are immensely dilated, and large ones are ruptured, which cannot be closed by the firmest contraction of the uterus.
"In recommending early delivery, I think it right, however, to express a caution against the premature introduction of the hand, and the too forcible dilatation of the os uteri before it is sufficiently relaxed by pain or discharge; for it is undoubtedly very certain that the turning may be performed too soon as well as too late, and that the consequences of the one may be as destructive to the patient as the other." (Rigby, op. cit. p. 37.) Cases have occurred where the os uteri has been artificially dilated, where the child was turned and delivered with perfect safety, and the uterus contracted into a hard ball; in fact, every thing seemed to have passed over favourably; a continued dribbling of blood has remained after labour, which resisted every attempt to check it; friction upon the abdomen and other means for stopping hæmorrhage by inducing firm contraction of the uterus were of no use, for the uterus was already hard and well contracted; the patient has gradually become exhausted, and at last died; on examination after death, Professor Naegelé has invariably found the os uteri more or less torn.
"It must be acknowledged, indeed," says Dr. Rigby, "that it may sometimes happen that at the very first coming on of the complaint, if the discharge be small, and more especially, if it be the patient's first child, and the parts be close and unyielding, the admission of the hand into the vagina, as I have directed, will be attended with the utmost difficulty, and, perhaps, be almost impracticable: in this case let us wait (but let it be with the patient) till the discharge increases, and has continued long enough to relax the parts; for certainly, if the woman be able to bear losing a little blood, which at first she may safely do, the examination will be thereby rendered more easy, and the turning of the child, if necessary, be more practicable and safe." (Op. cit. p. 36.)
We have already shown (see TURNING, p. 236.) that there is no means of rendering a rigid os uteri yielding and capable of admitting the hand equal to the relaxation produced by loss of blood: wherever the powers of the system have already suffered from the effects of hæmorrhage, we may feel almost certain that we shall find the os uteri capable of dilating, even if it be so little open as barely to admit the finger. Where the patient has become faint or fallen into actual syncope, the relaxation of the soft parts is very striking, and frequently to an extent which could scarcely be believed by those who have not felt it; all resistance seems to be at an end for the time, and the hand enters the flaccid passages with scarcely a sensation of pressure from them, but rather (as has been aptly compared, to that of some wet bladder wrapped around it.)
"It has been advised (observes Dr. Rigby) never to introduce the hand till nature has shown some disposition to relieve herself by the dilatation of the os uteri to the size of a shilling, or a half-crown; and this rule is certainly founded on a rational principle, for when it is so much dilated, there is no doubt but the turning may be easily and safely effected; but from some of the annexed cases it appears that a dilatation to this degree sometimes does not take place at all; and that even when the woman is dying from the great loss of blood, the uterus is very little open; the reason for which, seems to be, that when the discharge has been considerable, and more particularly when much blood has been suddenly lost, such a faintness is brought on, that though the uterus be totally relaxed, and might, therefore, be opened by the most gentle efforts, yet nature is unable to make use of these efforts; and, moreover, if there be slight pains, the adhesion of the placenta to the internal surface of the mouth of the womb, counteracts their influence, and thereby hinders its giving way to a power, which would otherwise, probably, very easily open it." (Op. cit. p. 39.)
Plug. Where, however, the case is at that doubtful period of early pregnancy, when even under the most favourable circumstances, as above-mentioned, the hand must experience considerable difficulty in entering the os uteri, and yet the expulsion of the child cannot be safely trusted to the natural powers, it becomes necessary, as in certain cases of premature expulsion, to have recourse to such means as shall enable the os uteri to go on dilating without the danger of farther hæmorrhage; in other words, we must plug the vagina. "If, after the commencement of a flooding, we favour the formation of a coagulum by means of a plug, are we not aiding nature? It brings on labour much sooner, and the os uteri has time to dilate without farther loss of blood." (Leroux, Sur les Pertes de Sang. § 309.) By means of the plug, we enable the patient to go on with perfect security until the pains have produced a sufficient dilatation of the os uteri to admit the hand; after a time we may withdraw it, and if then not satisfied with the state of the os uteri, it must be again introduced until our object be effected. (For directions as to the use of the plug we must refer to p. 152.)
"This remedy should be early employed, as it will, by proper management, save a prodigious expenditure of blood. We gain by its application important time; time that is essential for the successful delivery of the foetus; for, by it, the woman's strength is preserved; pain is permitted to increase; and, eventually, though tardily, the os uteri is dilated, the placenta and foetus thrown off, and the flooding almost immediately controlled. The other means which we have constantly pointed out, should also be tried: they may aid the general intentions, and render the operation of the tampon more certain." (Dewees, Compend. Syst. of Midw. § 1142.)
Although Dr. Rigby has given a short account of Leroux's views respecting the use of the plug in these cases, we cannot but agree with Dr. Dewees, in regretting that he either did not "put his plan in execution," or that if he did, he has not given us the details of his experience upon it. From what Dr. Gooch, however, has stated in his Account of some of the more important Diseases peculiar to Women, there is every reason to suppose that Dr. Rigby was latterly in the frequent habit of using the plug, and that he thought highly of it. The plug is not only useful in keeping the hæmorrhage under due control until the os uteri be sufficiently dilated, but may occasionally prove of the greatest value in cases of extreme exhaustion from loss of blood, where the patient is too much reduced to undergo the act of delivery, without running the risk of dying during the operation; the plug will enable us to wait with safety until the system has had time to rally its powers and be recruited by the administration of proper nourishment. "Mr. Grainger, of Birmingham, on visiting a poor woman with placenta prævia, and apparently in a moribund condition, immediately filled the vagina and os uteri with linen cloths, and waited two days before he durst hazard delivery, which he accomplished with an auspicious result." (Ingleby, on Uterine Hæmorrhage, p. 155.)
Turning. The operation of turning the child will, in no wise, differ from that under more ordinary circumstances, and will require to be conducted according to the rules which we have already given. In no case is it more important to preserve the membranes unruptured until the hand has fairly entered the uterus than here; the hand should be carefully insinuated between the os uteri and placenta; if possible, this should be done at the part where the separation which has caused the flooding has already taken place, in order to avoid all unnecessary detachment of the placenta; the pressure of the hand prevents any great discharge of blood; and as it gradually makes its way between the membranes and the uterus, the arm which now occupies the vagina will effectually act as a plug. Portal, was, probably the first who practised this mode of operation, viz. passing his hand between the os uteri and placenta, and then between the uterus and membranes before rupturing them: in this respect he anticipated Peu, whose work appeared nine years after, (see TURNING, p. 234.) and would have undoubtedly been looked upon as the originator of this improvement in turning, had he given any reasons for this mode of practice, or deduced any inferences from it.
Some discrepancy of opinion has existed as to whether it is better to perforate the placenta, or to follow the plan we have just recommended. Dr. Rigby's authority has rather tended to confirm the former opinion, although he afterwards modifies it so much so as to make us almost suppose that he must have preferred the other method. He states, "that by this means, (perforating the placenta,) not more of the placenta may be separated than is necessary for the introduction of the hand, and, consequently, that as little increase of bleeding as possible may be produced by the operation; but if it be impracticable, as I have more than once found it, and it must ever be when the middle of the placenta presents to the hand, from the thickness of it near the funis, it must be carefully separated from the uterus on one side, and the hand passed till it gets to the membranes." (Op. cit. p. 61.)
To Dr. Dewees are we chiefly indebted for having put the inexpediency of perforating the placenta in the strongest possible light. "We are advised by some," says he, "to pierce the placenta with the hand; but this should never be done, especially as it is impossible to assign one single good reason for the practice, and there are several very strong ones against it.
"1. In attempting this, much time is lost that is highly important to the patient, as the flooding unabatingly, if not increasingly, goes on.
"2. In this attempt we are obliged to force against the membranes, so as to carry or urge the whole placentary mass towards the fundus of the uterus; by which means the separation of it from the neck is increased, and consequently, the flooding augmented.
"3. When the hand has even penetrated the cavity of the uterus, the hole which is made by it is no greater than itself, and consequently much too small for the foetus to pass through without a forced enlargement, and this must be done by the child during its passage.
"4. As the hole made by the body of the child is not sufficiently large for the arms and head to pass through at the same time, they will consequently be arrested; and if force be applied to overcome this resistance, it will almost always separate the whole of the placenta from its connexion with the uterus.
"5. That when this is done, it never fails to increase the discharge, besides adding the bulk of the placenta to that of the arms and head of the child.
"6. When the placenta is pierced, we augment the risk of the child; for in making the opening, we may destroy some of the large umbilical veins, and thus permit the child to die from hæmorrhage.
"7. By this method we increase the chance of an atony of the uterus, as the discharge of the liquor amnii is not under due control.
"8. That it is sometimes impossible to penetrate the placenta, especially when its centre answers to the centre of the os uteri; in this instance much time is lost that may be very important to the woman." (Op. cit. § 1153.)
We have already stated why it is so particularly important not to use any force in passing the hand through the os uteri: the less we separate the placenta, the less also will be the hæmorrhage; and even this will be in great measure controlled by the presence and pressure of the hand itself. In no case of turning is it so important to have all the circumstances connected with the operation as favourable as possible, for the case itself is sufficiently dangerous without being increased by other unfavourable causes. To hurry the delivery would be only to increase the danger: the operation must be performed slowly and with caution: every rule which we have given, (see TURNING,) for ensuring its safe and successful termination, must now be adhered to with double vigilence. "Should the woman," says Dr. Dewees, "be very much exhausted before we commence our operations, we should use additional caution in the delivery. It should be very slowly performed, and we should have at each step of the progress assurances, if possible, that the uterus has not lost, or rather that it possesses, sufficient contractility to render the completion of the operation eventually safe, if performed with due and necessary care." (Op. cit. p. 463.)
When once the os uteri is sufficiently dilated to admit the hand, there will not be much fear of the patient losing much blood during the turning, for during the first part of the operation the hand and arm act both as a compress and plug; and afterwards, when the body of the child is advancing, this will act in a similar manner. There is little danger of hæmorrhage coming on after the child is delivered, for the contraction of that part of the uterus to which the placenta has been attached is much greater in these cases than it is where the placenta is situated in the upper parts of the uterus under ordinary circumstances. The placenta, which is already separated to a certain extent by the introduction of the hand, usually comes away without any trouble as soon as the child is delivered. We once met with a case where it was firmly adherent to the os uteri on one side, and required to be artificially removed, which was effected without difficulty. In this instance, hæmorrhage returned after the labour from uterine inertia, and was checked by the means already recommended. (Med. Gaz. Sep. 2, 1837.) The after treatment should be conducted upon the same principles as in other cases of hæmorrhage.
Partial presentation of the placenta. Where this is the case, the danger is rarely so alarming, nor is it always necessary to effect artificial delivery by turning. The edge of the placenta frequently projects but a very little over that of the os uteri, feeling, as it were, like a second lip; at other times it covers a third or more of the opening, and is usually attached upon the anterior portion of it. Our own observations have rather led to the conclusion, that where the placenta is but partially attached over the os uteri, the first attack of flooding is rarely delayed until the full term of pregnancy, but makes its appearance some weeks earlier. We are inclined to attribute this to the os uteri being only in part covered with placenta; that its other portion, being free, is more capable of dilatation from slight causes, than it would be were the placenta centrally attached: from a similar reason we may understand why the hæmorrhage is seldom so profuse in these cases as to be dangerous, and why the os uteri usually dilates sufficiently soon to allow the head to descend and be born by the natural powers. We are confirmed in this view by what we have already quoted from Dr. Rigby respecting the os uteri being prevented dilating by the close adhesion of the placenta--an opinion which is, moreover, approved of by Dr. Dewees as being "both ingenious and probable." Hence, also, we may reverse our position, and say, that in a case of partial presentation of the placenta, we shall seldom find the hæmorrhage very profuse, until the os uteri has attained a considerable degree of dilatation. Besides the portion of placenta which presents, there will be also a bag of membranes occupying the remaining portion of the opening; we shall rarely, if ever, meet with those difficulties connected with a contracted and unyielding state of the os uteri, which we described in cases of central presentation; and if the hand requires to be introduced, which is not often the case, it will seldom experience much opposition.
Treatment. In our treatment of partial presentation of the placenta, we must be guided, in a great measure, by the strength of the pains and the degree of dilatation which the os uteri has attained; the extent to which it is covered by the edge of the placenta, must also be taken into consideration. Where the pains are strong and active, the pressure of the membranes distended by liquor amnii against the mouth of the womb will be sufficient to check the hæmorrhage; if not, by rupturing them we shall be enabled to let off the liquor amnii, and thus allow the head to press directly upon the os uteri, and act in the double capacity of a plug and compress. Where the pains are slow and inactive, the rupture of the membranes will diminish the size of the uterus, and thus excite it to more powerful contraction; if not, a dose of secale cornutum, repeated according to circumstances, will be of great assistance. If the patient has suffered a good deal by the loss of blood, a little beef-tea, in small quantities frequently repeated, will rouse the powers; wine or a little brandy, may also be given at intervals; but unless the prostration be very serious, we have not found stimulants so useful as beef-tea, which is usually, also, much more grateful.