Situation in the uterus.—Adherent placenta.—Prognosis and treatment.—Placenta left in the uterus.—Absorption of retained placenta.
Situation in the uterus.—Adherent placenta.—Prognosis and treatment.—Placenta left in the uterus.—Absorption of retained placenta.
By the termencystedplacenta, 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 ofcystor 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 calledhour-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 dilatationat 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 theplacenta; 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 theos 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 thelochia 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 doesnotpass 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 fœtus 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 thewholeplacenta 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 ordinarycircumstances 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 ofplacenta, especially where we have brought away a considerable quantity of its fœtal 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 thewholesurface 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]
PRECIPITATE LABOUR.
Violent uterine action.—Causes.—Deficient resistance.—Effects of precipitate labour.—Rupture of the cord.—Treatment.—Connexion of precipitate labour with mania.
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 constantand 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’sMidwifery, 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 suddenlyemptied, 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.)
Thechildalso 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 theuterus 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 onlystrictly 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 ofviolence 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.
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 liquoramnii, 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 fœtal 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 thevicinity 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 282¼.[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. “Twelveof the 97 occurred in twin cases, and in seven of the 12 it was the cord of the second child.Nineoccurred where the feet presented, (not including two met with in twin children,) which was in the proportion ofonein everyfourteenof such presentations.Twoonly where the breech presented, which was in the proportion ofonein every 121 of such presentations: this approaches nearly the proportional average in all deliveries, which isonein 171½.Fouroccurred where the shoulder or arm presented: this is in the proportion ofoneinnineof such presentations.Sevenoccurredwhere the hand came down with the head.Sevenof the children were bornputrid;threeof the 97 were premature, viz.twoat the seventh andoneat the eighth month.” (Collins’sPractical 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 shouldbe 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’sSynopsis, 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 portionof 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 hisPractical Treatiseto 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, havingbeen 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 fœtus, 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 fœtal 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.)
PUERPERAL CONVULSIONS.