Exostosis of the pelvis.
Perhaps the most remarkable case of pelvic exostosis is that which has been described by Dr. Haber of Carlsruhe, and where also the cause was ascertained to have arisen from a violent fall on the ice when carrying a heavy load upon the head; on coming to herself the woman found that she was unable to move, and in this state was conveyed home; she recovered to all appearances in a few weeks, married, and soon became pregnant. When labour came on it was found impossible to deliver her, from the pelvis being entirely filled with a huge exostosis: the Cæsarean section was performed, but she died, and on examination after death an immense mass of bony growth was found springing from the sacrum, which had been apparently fractured, not only filling up the whole cavity of the pelvis, but arising to a considerable extent above the brim.
In those cases of funnel-shaped pelvis which we have had the opportunity of observing, perforation has been ultimately required, although the head had passed easily through the brim andentered the cavity; in one of these we have subsequently used the artificial premature labour with success.
We have already stated the doubtful utility of arranging cases of deformed pelvis according to their degree of contraction, and of classifying the different modes of treatment by such a scale; still, however, there must be certain limits beyond which it will be impossible to make the child pass, even when diminished by embryotomy. To draw the precise line of demarcation, however, will be nearly if not quite impossible; and, as in cases of slighter deformity, we must take many other circumstances into consideration which we have already mentioned. An inch and a half from pubes to sacrum has been mentioned by many as the extreme degree of contraction through which a full grown child can be delivered by embryulcia; generally, however, in these cases of unusually deformed pelvis, there is much more space on each of the sacrum; and on this, in great measure, will depend the possibility of effecting the delivery. The celebrated case of Elizabeth Sherwood, which Dr. Osborn has recorded, and where he succeeded in delivering the child, although the antero-posterior diameter “could not exceed three-quarters of an inch,” has been looked upon as being of doubtful accuracy, and that Dr. Osborn had unintentionally deceived himself. When, however, we learn that on the right side of the sacrum the antero-posterior diameter was an inch and three-quarters, the incredible nature of the case diminishes considerably, the more as the patient was examined by Dr. Denman and others who fully coincided with Dr. Osborn’s statements. To assert that in this case the antero-posterior diameter was only three-quarters of an inch, as many have done, is evidently incorrect, and tends to throw doubt upon it: the case was evidently the closest possible approach to the limits requiring the Cæsarean operation; its success was mainly attributable to the gradual manner in which it was performed; the child had become completely soft and flaccid from putrefaction, and was thus more capable of being moulded to the contracted passage.
FIRST SPECIES OF DYSTOCIA.
Obstructed Labour from a Faulty Condition of the soft Passages.
Pendulous abdomen.—Rigidity of the os uteri.—Belladonna.—Edges of the os uteri adherent.—Cicatrices and collosities.—Agglutination of the os uteri.—Contracted vagina.—Rigidity from age.—Cicatrices in the vagina.—Hymen.—Fibrous bands.—Perineum.—Varicose and œdematous swellings of the labia and nymphæ.—Tumours.—Distended or prolapsed bladder.—Stone in the bladder.
Pendulous abdomen.—Rigidity of the os uteri.—Belladonna.—Edges of the os uteri adherent.—Cicatrices and collosities.—Agglutination of the os uteri.—Contracted vagina.—Rigidity from age.—Cicatrices in the vagina.—Hymen.—Fibrous bands.—Perineum.—Varicose and œdematous swellings of the labia and nymphæ.—Tumours.—Distended or prolapsed bladder.—Stone in the bladder.
In speaking of the uterus itself as a cause of this species of dystocia, we only mention it here as one of the soft passages, not as the organ by the contractions of which the child is expelled; we merely refer to those faulty conditions of the uterus which produce an impediment to the child’s progress, not to those which interfere with the natural condition of its expelling powers, as this will be considered under the next division of dystocia.
We have already stated our disbelief that an oblique position of the uterus can have any influence in producing malposition of the child. With the exception of extreme anterior obliquity, or pendulous belly, we equally doubt that it can have any effect in retarding the labour when the child presents naturally. The highest authorities in midwifery during the last hundred years unite in asserting that this celebrated opinion of Deventer, was a misconception.
Pendulous abdomen.Where, from great relaxation of the anterior abdominal wall, (a frequent result of repeated child-bearing,) the fundus is inclined so forwards as almost to hang over the symphysis pubis, the child’s head does not readily enter the brim of the pelvis, nor can the uterine contractions act so favourably in dilating the mouth of the womb; and in this manner the first part of labour may be considerably retarded. Pendulous abdomen to this great extent is not very common; and in ordinary cases the horizontal posture, especially upon the back,is quite sufficient to allow the head to engage in the pelvis. “We have found more than once,” says Dr. Dewees, “in cases of extreme anterior obliquity, that it is not sufficient for the restoration of the fundus that the woman be placed simply upon the back; but we are also obliged to lift up and support by a properly adjusted towel or napkin, the pendulous belly until the head shall occupy the inferior strait. To illustrate this, we will relate one of a number of similar cases in which this plan was successfully employed. Mrs. O., pregnant with her seventh child, was much afflicted after the seventh month with pain and the other inconveniences which almost always accompany this hanging condition of the uterus; was taken with labour pains in the morning of the 10th of October, 1820. We were sent for about noon. The pains were frequent and distressing, and, upon examination per vaginam, the mouth of the uterus was found near the projection of the sacrum, dilated to about the size of a quarter dollar, but pliant and soft. During the pain, the membranes were found tense within the os uteri, but did not protrude beyond it.
As this was the first time we had attended this patient, and from the history she gave of her former labours, in which she represented her abdomen being in all equally pendulous, with the exception of the first, we waited several hours (she being placed upon her side) for the accomplishment of the labour. During the whole of this period the head did not advance a single line; nor could it, as the direction of the parturient efforts carried it against the projection of the sacrum. We had several times taken occasion to recommend her being placed upon her back, but to which she constantly objected, until we urged its being absolutely necessary. She at length reluctantly consented to the change of position; when upon her back it was found that it did not advance the os uteri sufficiently towards the centre of the superior strait. The abdomen was therefore raised, and a long towel placed against it, and kept in the position we had carried it by the hands, by its extremities being firmly held by two assistants; at the same time we introduced a finger within the edge of the os uteri, and drew it towards the symphysis pubis, and then waited for the effects of a pain. One soon showed itself, and with such decided efficacy, as to push the head completely into the inferior strait, and three more delivered it.” (Compendious System of Midwifery, § 224.)
This peculiar displacement of the uterus, which has been called by some anteversion of the gravid womb, has occasionally given rise to the suspicion that there was no os uteri, from its being tilted upwards and backwards towards the promontory of the sacrum: it has been said, in some cases, to have even contracted adhesions with the posterior wall of the vagina, fromthe firmness with which it was pressed against it, and thus tended still farther to increase the deception. “Within our knowledge,” says Dr. Dewees in the paragraph preceding the one just quoted, “this case has been mistaken for an occlusion of the os uteri, and where upon consultation it was determined that the uterus should be cut to make an artificial opening for the fœtus to pass through. They thought themselves justified in this opinion, first, by no os uteri being discoverable by the most diligent search for it; and, secondly, by the head being about to engage under the arch of the pubes covered by the womb. Accordingly, the labia were separated, and the uterine tumour brought into view. An incision was now made by a scalpel through the whole length of the exposed tumour down to the head of the child, the liquor amnii was evacuated, and in due course of time the artificial opening was dilated sufficiently to give passage to the child. The woman recovered, and, to the disgrace of the accoucheurs who attended her, was delivered per vias naturales of several children afterwards, a damning proof that the operation was most wantonly performed.” Where, in addition to the anteversion, strong adhesions have taken place between the os uteri and posterior wall of the vagina, no trace of os uteri will be felt, and the operation above-mentioned does become sometimes necessary.
Rigidity of the os uteri.The chief way in which the uterus can obstruct the passage of the child, is, by an undilatable state of its mouth: this may arise from a variety of causes, which may be chiefly brought under the two heads of functional and mechanical. Under the first head comes rigidity of the os uteri, either from a spasmodic contraction of its circular fibres, or from irregularity or deficiency in the contractions of the longitudinal fibres of the whole organ. In a slight degree this is frequently met with, especially in first labours, where the patient is young, delicate, and irritable, and where, in all probability, there is some source of irritation in the primæ viæ which tends to disturb and divert the proper and healthy action of the uterus. We see it also in robust plethoric primiparæ; the os uteri dilates to a certain degree, perhaps an inch in diameter, and remains tense and firm, with its edge thin; the contractions of the uterus produce much suffering, and to all appearances are very violent; but they are chiefly in front, and produce little or no effect upon its mouth; the vagina is hot and dry, the patient becomes exhausted with fruitless pains, and fever or inflammation would quickly follow, if nothing be done to relieve this state. As this subject, however, belongs rather to the next species of dystocia, viz. that arising from a faulty condition of the expelling powers, we shall delay the consideration of the treatment.
Belladonna.It has been recommended, and not veryjudiciously, to apply belladonna to the os uteri in cases of great rigidity: it was repeatedly tried by the celebrated Chaussier in the Maternité, at Paris, and, according to his observations, it produced a considerable effect upon it. “The knowledge of the extraordinary powers which this drug possesses in causing dilatation of the iris, led to its employment for the object of enlarging the aperture of the uterus; but there is certainly no similarity in the structure and office of the two organs, and no analogy can be drawn between their functions. It is not likely that this means will produce the relaxation we require; and if no good results from its use, it must be injurious; not in consequence of the poisonous quality resident in the drug itself, but in the friction which is necessary for its efficient application. The mucus which naturally lubricates the part must be wiped away, and this irritation must predispose the tender organ to take upon itself inflammatory action.” (Dr. F. H. Ramsbotham’s Lectures, in Med. Gaz.May 3, 1834.)
For our own part we must confess, that, although we have seen this application tried repeatedly, it has never produced the desired effects, but has invariably brought on very troublesome and distressing symptoms, such as sickness, faintness, headach, vertigo, &c.
There is a condition of the os uteri which is occasionally met with, and which presents a degree of rigidity which we have never seen except where there have been adhesions and callous cicatrices from former injuries. It has nothing of the thin edge put strongly on the stretch during the pains; but it is thick and firm, presenting nothing of the elastic cushiony softness of the os uteri in a favourable state for dilatation; it dilates to about an inch across, tolerably regularly, and without much apparent difficulty, but no efforts of the uterus can dilate it farther. We have already alluded to two extreme cases of this when speaking of ruptured uterus, and where in each instance the os uteri entirely separated from the uterus and came away. Whether there is something peculiar in the structure of the part which renders it thus undilatable, or whether it required even still more powerful measures than those employed, is not very easy to decide.
Edges of the os uteri adherent.—Cicatrices, &c. A serious impediment to the passage of the child may be produced by adhesions of the sides of the os uteri to each other; by hard callous cicatrices resulting from ulcerations, lacerations, &c. in former labours; by abnormal bands, or bridles, as they have been called; and by tumours and other morbid growths. Where the structure of the os uteri has been much injured by previous injuries of this character, the resistance will probably be so great as to require artificial dilatation with the knife. Generally speaking, however, the whole circle of the uterine opening is not involved,portions still remaining of natural structure, and, therefore, capable of dilatation. On examination, it feels irregular both in shape and hardness; a part being soft, cushiony, yielding, and forming the segment of a well-defined circle, the rest of it uneven, knobby, and hard, being evidently puckered up by cicatrisation.
In many cases, these callous contractions give way more or less when the head begins to press powerfully against them; but even where this is not the case, the healthy portion of the os uteri is so dilatable as to yield sufficiently. It would be difficult to estimate how far an os uteri in this state, with perhaps, not more than half, or even a third, of its circle in a healthy condition is capable of dilating. But from cases which have come under our own observation, and others which have been recorded by authors in whom we place the greatest reliance, we are quite confident that with proper treatment a sufficient degree of dilatation can be effected without resorting to artificial means.
Bleeding to fainting, the warm bath, laxatives, and enemata, will assist greatly in promoting our object. Where, however, the contracted portion shows no disposition to yield to this treatment, or to the pressure of powerful pains, but forms a hard resisting bridle or band, which effectually impedes the farther advance of the head, it must be divided by the knife in order to prevent dangerous laceration of the part on the one hand, or protraction of labour on the other. The mode of doing this will be described when these conditions as effecting the vagina are considered.
Artificial dilatation of the os uteri by incision has been practised very rarely, the chief of these operations having had reference to the vagina. F. Ould considered that mere contraction of the os uteri from former lacerations did not require this operation; but that where it was in a state of schirrus, there would be “no chance for saving either mother or child but by making an incision through the affected part.”
We have quoted, on a former occasion, a case of cicatrised os uteri recorded by Moscati, and where, in consequence of injury in a former labour, the opening was nearly closed; fearing the laceration which had occurred in a similar case under his father’s care, in consequence of making merely one incision, he made a number of small incisions round the whole of the orifice until a sufficient dilatation was produced.
Agglutination of the os uteri.Another condition of the os uteri which may produce very considerable impediment to the passage of the child, is that which has been calledagglutination, where by some adhesive process, apparently that of inflammation, the lips of the opening adhere and completely close it. These species of imperforate os uteri may occur in primiparæ as well as in those who have borne children: the agglutination of its edges takes place during pregnancy, probably shortly after conception. Uponexamination we find no traces of hardness, rigidity, or any other morbid condition, either in the os uteri itself, or the parts immediately surrounding it; the os uteri is closed by a superficial cohesion of its edges, and which in some cases seem to adhere by means of an interstitial fibrous substance; this when of a firmer consistence forms a species of false membrane, which in some cases is capable of resisting the most powerful uterine contractions, and in others it appears to cover the os uteri so completely as to conceal it most effectually, and give rise to the erroneous conclusion that the os uteri is altogether wanting. Baudelocque describes this condition (Op. cit.§ 1961;) but from the brief mention which he makes of it, as also from the treatment recommended, it is plain that he had no very distinct notions about it, for he advises that “in all cases the orifice must be restored to its original state, and be opened with a cutting instrument as soon as the labour shall be certainly begun.”
In by far the majority of cases which have been recorded, the pains have after a time been sufficient to dilate the os uteri. Dr. Campbell has described two of these cases, where no os uteri could be traced for some time after the commencement of labour: both were first pregnancies: in the former, uterine action continued about twelve hours before the os uteri could be distinguished, when it felt like a minute cicatrix; the other patient had regular pains for two nights and a day before the os uteri could be perceived, and she suffered so much as to require three persons to keep her in bed; both these patients were largely bled, gave birth to living children, and had a good recovery.
We may suspect that the protraction of labour arises from agglutinated os uteri, when at an early period of it we can discover no vestige of the opening in the globular mass formed by the inferior segment of the uterus, which is forced down deeply into the pelvis, or at any rate, where we can only detect a small fold or fossa, or merely a concavity, at the bottom of which, is a slight indentation, and which is usually a considerable distance from the median line of the pelvis. The pains come on regularly and powerfully; the lower segment of the uterus is pushed deeper into the cavity of the pelvis, even to its outlet, and becomes so tense as to threaten rupture; at the same time it becomes so thin, that a practitioner who sees such a case for the first time would be induced to suppose the head was presenting merely covered by the membranes. After a time, by the increasing severity of the pains, the os uteri at length opens, or it becomes necessary that this should be effected by art: when once this is attained, the os uteri goes on to dilate, and the labour proceeds naturally, unless the patient is too much exhausted by the severity of her labour. Although the obstacle in some cases is capable of resisting the most powerful efforts of the uterus, a moderate degree of pressureagainst it whilst in a state of strong distention, either by the tip of the finger, or a female catheter, is quite sufficient to overcome it; little or no pain is produced, and the appearance of a slight discharge of blood will show that the structure has given way. Two interesting cases of this kind have been described by the late W. J. Schmitt, of Vienna, under the title of two cases of closed os uteri which had resisted the efforts of labour, and where it was easily dilated by means of the finger.[127]
Contracted vagina.The vagina may be naturally very small, or unusually rigid and unyielding: in the first case serious obstruction to the progress of labour is rarely produced, the expelling powers being generally sufficient ultimately to effect the necessary degree of dilatation; the proper precautions must be taken to avoid every species of irritation and excitement of the circulation; the bowels must be duly evacuated; the circulation controlled either by sedatives, or, if necessary, bleeding, and where it is at hand, a warm bath; if this latter cannot be easily procured, a common hip bath, or sitting over the steam of warm water will be of great service; the great object will be to ensure a soft and cool state of the passage with a plentiful supply of that mucous secretion which is so essential to the favourable dilatation of the soft passages.
Nauseating remedies, and even tobacco injections, have been tried to a considerable extent for the purpose of relaxing the mouth of the uterus; but they produce little or no good effects, and cause much suffering to the patient. In Dr. Dewees’ second case of obstructed labour from the above causes, a sufficient trial of this remedy was used to satisfy all doubts as to its effects. “It produced great sickness, vomiting, and fainting, but the desired relaxation did not take place: we waited some time longer and with no better success. In the course of an hour, or an hour and a half, the more distressing effects of the infusion wore off; and resolving to give the remedy every chance in our power, we prevailed on our patient with some difficulty to consent to another trial of it: its effects were the same as before,—great distress without the smallest benefit, the soft parts remaining as rigid as before its exhibition.” Bleeding was now proposed; the patient became faint after losing ten ounces, and the most complete relaxation followed: the forceps were applied, and a living child delivered.
Rigidity from age.In women pregnant for the first time at an advanced period of life, the vagina and os externum are said to oppose considerable resistance to the passage of the child fromtheir rigid condition, the parts having lost the suppleness and elasticity of youth; the vessels also convey less blood to the mucous membrane and adjacent tissues: hence the secretion of mucus is more sparing; the cellular tissue is more condensed and firm; still nevertheless, although it is constantly mentioned by authors as a cause of this species of dystocia, we cannot help declaring that it exists to a much less degree than has been generally supposed, and that primiparæ at a very early age are much more liable to have tedious and difficult labours than those at an advanced age. Still, however, the circumstance is well worthy of notice; and in such cases we may produce much relief by the warm bath, or hip bath, by sitting over the steam of hot water, by warm water enemata, and great attention to the state of the intestinal canal and of the circulation. Mucilaginous or oleaginous injections into the vagina have been recommended; but we have no experience of their effects: we have frequently used lard, &c. to the edges of the os externum when the head was beginning to distend it, and we think with relief; at any rate it produces a feeling of comfort to the patient, being soft and cooling.
Cicatrices in the vagina.The most serious impediments to the progress of labour connected with the vagina are the contractions of this canal from callous cicatrices, the results of sloughing and other injuries in former labours. The vagina may be contracted throughout its whole length, its parietes hard, gristly, and uneven, and so small as not to admit even the tip of the little finger; the course of the canal from the irregularity of the contractions and adhesions is frequently much distorted; in other cases it is obstructed in different places by bands or septa, which have been produced by similar causes.
Where the condition of the vagina has been ascertained before labour, much may be done to ameliorate the condition of the parts, not only by the treatment already mentioned for rigidity of the vagina under other circumstances, but also by the judicious application of tents, bougies, and other means for dilating the passage. A case of this kind came under our notice some years ago; the patient had been married many years without being pregnant, and was considerably beyond the age of forty. The deranged health and enlargement of the abdomen which took place excited no suspicions of pregnancy either in her mind or that of her medical attendant: the case was suspected to be ovarian dropsy, and a variety of medicines under this supposition were administered, both internally and externally: the commencement of actual labour appears to have been equally mistaken; nor was it until labour had advanced considerably that the real nature of the case was discovered; from its length and severity, violent inflammation and sloughing of the vagina was the result, the canal became much contracted, and was rendered still fartherimpervious by the formation of strong bands or septa which were stretched across it, and which effectually prevented the os uteri from being reached; sponge tents, and oval gum elastic pessaries of different sizes were introduced, and by degrees such a state of dilatation was produced as not only permitted the os uteri to be reached, but restored the vagina in great measure to its natural size.
The action of labour forcing the head of the child against these contractions and adhesions is frequently sufficient ultimately, to effect the necessary degree of dilatation; where, however, this is not the case, they require to be divided by the knife. The proper moment for doing this is during a pain, when the parts are put strongly on the stretch: we can now feel exactly where there is the greatest resistance, and where an incision will produce the most effect. In this state also the incision can be effected with most ease, for the stricture being firmly distended, the knife will more readily divide it than where it is relaxed; the patient also at this moment is not sensible to the cutting of the knife. The lower part of the blade well armed with lint or tow should be cautiously introduced along the side of the finger during an interval of the pains: in this way the necessary number of incisions may be made: this is usually followed by a good deal of bleeding, which tends still farther to relax the parts; and when the head has advanced low enough, a cautious attempt may be made with the forceps to deliver it.
In recommending dilatation by means of the knife, it must be distinctly understood, that a sufficient time should be allowed in order to see how much can be effected by the uterine efforts, for in many of these cases the stricture has at length yielded after severe and protracted suffering.[128]In cases of this kind, also, the effects of bleeding are by no means inconsiderable, and must not be neglected.
Theunruptured hymenhas been said to be capable of impeding the progress of the head, but this can only be where the membrane is of unnatural strength and thickness. It has more than once occurred to us at the commencement of labour, to find the hymen uninjured; but it has broken down under the finger, even during examination, and we are convinced would have produced no obstacle whatever to the child. Where its structure is abnormal, and the advance of the labour is evidently retarded by it, division is the simplest and easiest remedy.
Bands of firm fibrous or almost ligamentous tissue aresometimes found stretched across the vagina or os externum. We described a remarkable case of this sort in theMedical Gazette, Sep. 26, 1835, where it extended from the symphysis pubis backwards to the perineum; it had resisted the pressure of the child’s head so powerfully as to produce a deep indentation along the cranial bones; it was divided by a bistouri, and the head was immediately expelled.
Theperineumcan rarely, if ever, prove a serious hindrance to the labour in primiparæ so long as its structure is healthy, even although it may be unusually broad. With patience and due management the necessary degree of dilatation may be obtained by the pressure of the head; and proposals to dilate it artificially, or even to make a slight incision into it, do not deserve a moment’s consideration. Where, however, it has been extensively lacerated in a previous labour, and has healed again throughout its entire length (by no means a common occurrence) or when there has been much sloughing, the cicatrix thus formed may render it incapable of relaxation, and thus produce much resistance to the passage of the head. Even here we may do a great deal by warm hip baths, fomentations, and especially by bleeding; an incision through the callous portion is by no means desirable where it can be possibly avoided, as it only endangers a farther laceration during the expulsion of the head. Cases nevertheless, occur where the contracted ring of the os externum is so unyielding and gristly as to make this operation necessary.[129]In all these cases, where, either the adhesion and contractions have given away, or have been divided during labour, great care should be taken to prevent them forming again during the process of healing, by using sponge tents well greased, and other appropriate means.
Varicose and œdematous swellings of the labia and nymphæalso deserve mention, although they rarely interfere with the progress of labour to any great extent. Varicose labia seldom annoy the patient during her pregnancy; the veins of the part may have become somewhat dilated and the labium swollen; but it is generally not until the commencement of labour, that they become hard and knotty: at first they feel like a bunch of currants imbedded in the cellular tissue of the labium, and as labour advances, and the return of blood from the part is still more impeded, the swelling continues to increase in size, and frequently obstructs the os externum very considerably. The danger here is not so much from its acting as an obstacle to the passage of the child, as from its bursting during labour and causing loss ofblood and other serious consequences. The tumour seldom bursts directly externally, but first gives way beneath the skin, producing extravasation, after which, in consequence of still farther distention, the labium itself ruptures. In some cases the hæmorrhage is not very profuse externally, while the extravasation internally, amounts to some pounds, extending not only to the vagina and perineum, but also to the groin; and instances have occurred where it has spread to a great distance over the glutæus muscles.
“The extravasation,” says Mr. Ingleby, “usually happens during the pain which expels the child; but sometimes at an early period of labour, as in the example of severe hæmorrhage here annexed. I had just left a patient to whom I had been called, in consequence of the difficult transmission of the child’s head through a distorted pelvis, in connexion with an inordinate varicose enlargement of the labia pudendi (especially the left,) when a messenger overtook me urging my immediate return. It appeared that during the violence of the straining, the tumour on the left side had suddenly burst at the edge of the vagina posteriorly. The patient lay in a little lake of blood; and as the bleeding recurred in gushes with the return of every pain, it became essential to complete delivery, and a child weighing fifteen pounds was extracted with the forceps. A large slough separated at the end of the third week.” p. 109.
Where no laceration has taken place externally, it is seldom that an opening for the purpose of removing the effused blood will be of use; on the contrary, the access of external air cannot but be prejudicial in many cases. The action of the absorbents is generally sufficient for this purpose, and may be increased by friction with stimulating liniments, and most remarkably of all by the application of electricity. Where the extravasation extends beneath the lining membrane of the vagina, so much swelling may be produced as nearly to close the passage; this, however, generally takes place after the birth of the child, the rupture of the varicose vessel having occurred whilst it was passing.
On perceiving, at the commencement of a labour, that there are varicose veins in the labium, which are beginning to increase in size and hardness as the head advances, it will be as well to compress them as much as possible during the intervals of the pains, when there is less impediment to the blood returning from them: we can, by thus squeezing out their contents to a certain degree, lessen the size of the swelling, and thus prevent it from gaining that extent which might endanger laceration. We may instantly know when this injury has taken place, by the livid tumefaction of the parts, and our being no longer able to feel the knotty portions of the varix. In order to check the effusion of blood as much as possible, we must apply cold, and thus favourits speedy coagulation beneath the skin. Where the distention is very great, it may become necessary to evacuate the effused fluid; but, generally speaking, it is deeper beneath the surface than might, at first sight, be expected. “It has been proposed,” says Mr. Ingleby, “that the swelling should be punctured, provided there has been no delay, and the puncture is made whilst the blood is still liquid. On one occasion I promptly carried this suggestion into effect, but without success; and, considering the structure of the labium, it is probable that the greater part of the blood will coagulate almost as rapidly as it is effused.” (Ingleby,op. cit.p. 109.)
A considerable degree of suffering and annoyance to the patient may arise from œdematous swelling of the labia and nymphæ, both previous to and during her labour. The labia are occasionally so distended as not only to close the os externum, but to require that the legs should be kept as wide asunder as possible, to prevent the swollen parts being crushed: the patient is thus rendered very unwieldy and helpless, if she were not already so previously by an anasarcous state of the lower extremities, which frequently accompanies this condition.
Œdema of the labia is of less consequence where the patient has had several children than where she is a primipara, and seldom either retards labour to any serious extent, or is attended with any troublesome consequences afterwards: where, however, it is her first labour, and the swelling is very considerable, laceration may be produced, the results of which may be sloughing and gangrene: a fatal case of this kind has been described by Burton.
Where the labia are much swollen, they not only render the patient incapable of moving, but are apt to become inflamed and excoriated, from being in such close contact, and constantly moistened by the trickling of the urine over them. By preserving the horizontal posture, and thus taking off the pressure of the child from the soft parts of the pelvis, by keeping the bowels open by saline laxatives, and by using saturnine and evaporating lotions to the part, a good deal may be done for the patient’s relief. Where there is no disposition to inflammation, and the parts appear somewhat flabby, warm and gently stimulating applications will be preferable. Mr. Ingleby remarks that, “if the swollen parts are punctured (and a particularly fine curved needle answers best,) a load of serum is drained off, and relief is rapidly obtained. I have not observed any of the reported bad effects (sloughing and gangrene for instance) succeed this little operation; nor are they likely to occur in an unimpaired constitution.” The celebrated Wigand of Hamburgh, who strongly opposed making incisions into the dropsical structure, does not appear to have tried the plan recommended above. Heconsidered that, as these swellings are the result of pressure, the less we do with them the better, merely taking care to keep up the action of the skin.
Œdema, or rather dropsy, of the nymphæ, is not of common occurrence, and, when it takes place to a considerable extent, produces a singular alteration in the appearance of the external organs. The nymphæ protrude beyond the labia, and depend so much as to rest upon the bed on which the patient lies, forming a soft membranous bag, fluctuating with the fluid which it contains. If labour has not actually commenced, we would prefer endeavouring to excite the absorbents of the part, and thus remove the effused fluid, to its evacuation by puncture: we have perfectly succeeded, by the use of warm aromatic stimulating fomentations. The “species aromaticæ” of the Continental pharmacopeiæ may be used with much advantage in these cases: the mode of its application is, to tie some up in a loose muslin bag, and soak it in hot wine; this forms an excellent warm stimulating application, and appears to excite the absorbents very briskly. A very good imitation of this, is to scald some chamomile flowers, and having squeezed them tolerably dry, to sprinkle some port wine over, and then apply them as a poultice. A swelling of this sort can offer but little obstruction to the passage of the head; and if labour commence before we have been able to reduce its size sufficiently, we may at the last let off the fluid by puncture, should the pressure of the head be such as to threaten laceration.
Tumoursof different sorts may obstruct the passage of the child, and, in some cases, produce an impediment of the most serious character. Fibrous polypi and hard tubercles of the subcartilaginous character (commonly called the fleshy tubercle) are those which may present the greatest resistance, while fungoid growths of malignant disease, whether cephaloma (brain-like tumour,) hæmatoma (fungus hæmatodes,) or carcinoma, rarely oppose much obstruction. Their structure is soft and spongy, they therefore yield to the gradual pressure of the head, become more or less flattened, and thus allow it to pass. But fibrous or chondromatous tumours are of too firm a structure to admit of this, and are capable of rendering the labour not only difficult, but very dangerous. The mass being situated at the lower part of the uterus, or attached to it by means of a pedicle, is perhaps forced down into the cavity of the pelvis, beyond which its attachments do not allow it to advance; if it be a fleshy tubercle imbedded in the structure of the uterus, it will not be able to advance so far, but will obstruct the brim of the pelvis, and thus prevent the head descending into it. In many cases, these tumours are merely covered by the lining membrane of the uterus, which sometimes forms a species of pedicle. In either case, an early diagnosis is of great importance, as we may thushave the opportunity of removing the mass either by the scissors or ligature.
Dr. Merriman has recorded an interesting case of this kind, where the polypus which arose from the inner surface of the right lip of the os uteri was tied, and removed rather more than three weeks before labour came on. A fatal case, communicated to him by the late Dr. Gooch, is equally valuable, inasmuch as it shows the results of a contrary practice.[130]
“The class of tumours which most frequently obstruct labour comprise follicular enlargements and the prolapsed ovarium. The former disease originates in the vagina, and has been shown by Mr. Heming to consist in a dilated state of one of the mucous follicles, which acquires a cyst, and secretes a fluid of varying colour and consistence, from a dark to a straw-coloured serum, or a deposition purely gelatinous. Owing to the density of its walls, and its general tension, the fluid contents of the tumour arenot easily distinguished; but the flaccidity which succeeds a free puncture is very striking.”
“There are two forms of ovarian tumour which obstruct the passage of the child; in the one, a small cyst in connexion with a very bulky cyst; or else a portion of a large cyst passes into the recto-vaginal septum, and bulges through the posterior part of the vagina: in the other, and that which occurs by far the most frequently, the whole ovary, moderately enlarged, prolapses within the septum. The descent is peculiarly liable to happen at two periods; the first near the end of gestation, the second during labour, the prolapsus being promoted by the relaxation of the soft parts. The changes which the ovary undergoes when long detained in the septum, will chiefly depend upon the capacity and yielding state of the parts. If the woman has not previously borne children, it may remain small, and scarcely retard delivery; but under contrary circumstances, it acquires a large size, and nearly fills the vagina. In rare instances, the bulging is said to have appeared at the anterior part of the pelvis.” (Ingleby,op. cit.p. 118.)
The contents of these tumours vary a good deal; the hard ones are usually lipomatous or fatty tumours, not unfrequently containing hair and rudiments of teeth. Numerous cases have been recorded where ovarian tumours, which had been pushed down before the child, have at length burst, discharging their contents, and thus ceasing to act as an obstacle to the labour. We quite agree with Mr. Ingleby in recommending puncture under such circumstances; for, independent of pregnancy, it is a well-known fact, that there is a much better chance of successfully tapping an ovarian dropsy per vaginam, than through the abdominal parietes. The same holds good in operating through the rectum; and he has described two highly interesting cases where this mode of treatment was completely successful; one in his own practice, the other in that of our friend Mr. W. Birch.
Distended or prolapsed bladder, &c. Lastly, the urinary bladder may obstruct the passage of the child, from being prolapsed and distended with water, or from containing a calculus which is forced down below the head. In the first case, a prolapsus of the distended bladder can scarcely take place without much inattention on the part of the practitioner, not having ascertained whether the bladder had been lately evacuated. In case we find, upon examination, that there is a disposition to this displacement, the elastic catheter will enable the tumour of the prolapsed bladder to collapse, and thus remove all farther trouble. The examination in these cases must be conducted with care; for an elastic fluctuating tumour of this kind may be mistaken for the distended membranes, or a hydrocephalic head; and Dr. Merrimanhas given a melancholy case where, in consequence of such an error, the bladder was punctured.
A stone in the bladderis sometimes more difficult to manage. If the head is only just beginning to enter the brim, the stone may be pushed up above it; but if it has already engaged completely in the pelvic cavity, it becomes a question whether it will not be necessary to cut down upon it, and thus remove it. These cases are, however, of very rare occurrence, and we must be entirely guided by circumstances, it being impossible to lay down any precise rules for their treatment.
SIXTH SPECIES OF DYSTOCIA.
Faulty Labour from a faulty Condition of the expelling Powers.
I.Where the uterine activity is at fault—functionally or mechanically—from debility—derangement of the digestive organs—mental affections—the age and temperament of the patient—plethora—rheumatism of the uterus—inflammation of the uterus—stricture of the uterus.—Treatment.II.Where the action of the abdominal and other muscles is at fault.—Faulty state of the expelling powers after the birth of the child.—Hæmorrhage.—Treatment.
I.Where the uterine activity is at fault—functionally or mechanically—from debility—derangement of the digestive organs—mental affections—the age and temperament of the patient—plethora—rheumatism of the uterus—inflammation of the uterus—stricture of the uterus.—Treatment.II.Where the action of the abdominal and other muscles is at fault.—Faulty state of the expelling powers after the birth of the child.—Hæmorrhage.—Treatment.
Although this species includes that condition of the expelling powers, where their action is excessive, we shall defer this portion of the subject until we treat ofprecipitate labour, with which it is essentially connected.
The agency by which the child is expelled during labour is of two kinds: 1st, involuntary action of the uterus, assisted,secondly, by the partly voluntary and partly involuntary action of the abdominal muscles.
On the approach of labour, the uterus, which hitherto had been merely performing the office of a receptacle and a means of conveying nourishment to the fœtus, now assumes a totally different character; from being in a nearly passive state, it assumes an entirely opposite condition, viz. of high irritability and powerful action. We might almost suppose that its connexion with the nervous system was become more close and intimate; for it is now sensible to the influence of impressions which had before produced no effect upon it. Thus, we see, that affections of the mind, even but of moderate intensity, and to which it was, before labour, nearly, if not quite, insensible, are now capable either of rousing its efforts to the utmost violence, or of arresting them in the midst of full activity; and, on the other hand, wesee that where its action has been deranged or interrupted, it gives rise to serious affections of the nervous system, or even convulsions.
With all this, it now displays peculiarities of function, which strikingly distinguish it from all other organs of the body; in some cases it appears to annihilate or to absorb, by its all-pervading influence, the functional energies of other organs; and, in spite of its increased nervous power and susceptibility to various impressions, it seems to possess the faculty of continuing its efforts uninfluenced by general disease, unimpaired by exhaustion, and, for a time, almost independent of the life itself of the mother. In convulsions and paralysis, in general fever and inflammation of vital organs, its powers appear to be undiminished: on the contrary, where the patient, from whatever cause, is rendered incapable of assisting its efforts by the abdominal muscles, the uterus will take upon itself the whole task of expelling the child, which will be born apparently without a single effort upon the part of the mother.
We also observe, that organs, the various conditions and derangements of which have exerted little or no influence upon the uterus in its state of quiescence during pregnancy, now affect it powerfully, and are capable of modifying its action very considerably. The stomach, the intestinal canal, and the skin, are remarkable instances of this, and seldom fail to disturb or pervert the natural efforts of the uterus, whenever these organs deviate from a healthy condition. It will be, therefore, of the highest importance to watch their functions narrowly, in order that we may form a correct estimate of their effects upon the uterus.
Derangements in the contractile power of the uterus may arise from a variety of causes, which may be chiefly brought under two heads, viz.functionalandmechanical.
The functional derangements may arise from insufficient activity, the result of general or local debility; from a deranged condition of the digestive organs; from passions or affections of the mind; from hereditary temperament, constitution, or peculiarity; from the patient’s age, being either very young or considerably advanced in years, and pregnant for the first time; from plethora, general or local; from rheumatic affection of the uterus; and from uterine inflammation.
The contractions of the uterus may bemechanicallyimpeded, by tumours imbedded in its substance; by organic diseases, as schirrus, cephaloma, and hæmatoma; cicatrices from former ulcerations or rupture, or by any other circumstances which interrupt the action of the longitudinal fibres upon the os uteri.
From debility.Where uterine action is insufficient from debility, the pains are feeble, and do not appear to act in the right direction; they are frequently attended with much greater sufferingthan might be expected from their inefficiency; the intervals between the pains are unusually long, the pains themselves are very short, or, after a while, cease altogether.
This condition, when depending ongeneraldebility, may be the result of previous disease, loss of blood, or other debilitating evacuations, poverty, with its attendant miseries, depressing passions of the mind, and health broken down by intemperance.
The contractile power of the uterus itself may be injured by previous leucorrhœa or menorrhagia, by abortions, or by attacks of hæmorrhage during the latter part of pregnancy; it may be weakened by over-distention of the uterus, either from plurality of children or too much liquor amnii, by the patient exerting herself improperly at the commencement of labour, straining violently, and endeavouring to bear down before she is involuntarily compelled to do so by the presence of the head in the vagina. It may also be produced by the membranes giving way too soon, as is so frequently observed in first labours.
From derangement of the digestive organs.We have already described the change which takes place in the relation between the uterus and other organs, as soon as it passes into a state of action. The intestinal canal stands foremost in the influence which it exerts upon the uterus; whether it be from constipation or diarrhœa, irritation from acrid contents, &c., it will greatly modify, and even derange, its contractile power; the pains cease to be genuine uterine contractions, and assume a spasmodic character, producing much painful griping and pinching about the front and lower part of the abdomen, without any of that regularity of interval and duration, and gradual accession and recession, which mark the presence of real labour pains, and, we need scarcely add, with little or no effect upon the progress of the labour itself. These griping colicky pains appear to supersede the true process of parturition, and either to prevent the uterus acting with due regularity and effect so long as they last, or so to pervert its action as to produce a species of metastasis towards other organs. The pains lose their peculiar character as the expelling powers of the uterus; they cease entirely, and the patient is suddenly attacked with dyspnœa, cramps in the extremities, violent shivering, great restlessness, intense headach, delirium, convulsions, or even mania.
Wherever the action of the uterus is deranged by gastric or intestinal irritation, the abdomen is generally more or less tender in front, particularly over the symphysis pubis; the os uteri is thin, tense, and rigid; the vagina is hotter than natural; the secretion of mucus is sparing; and both os uteri and vagina are more than usually tender to the touch.
From mental affections.The mind is capable of influencing the action of the uterus during labour in a remarkable manner, not only where it is suffering from depressing emotions, as grief,great anxiety, or painful anticipations as to the result, but from causes of a much slighter character, which are nevertheless well worthy the attention of the practitioner: his sudden appearance in the room, without the patient having been properly warned of his arrival: the dread of an examination; or annoyances of a much slighter character, as regards his manner, or that of the nurse, &c., will not unfrequently be quite sufficient to stop the progress of the pains.
Theage and general temperament of the patientwill also affect the character of the pains. When pregnancy occurs for the first time, either at a very early age, or considerably advanced in life, labour is apt to be protracted, from defective uterine contraction; in the first case, she has not yet attained that degree of adult strength which is requisite to undergo a process requiring so much exertion; the pains are weak, of short duration, and inefficient, but very exhausting to the patient. From the irritability both of the nervous and vascular systems, so peculiar to youth, arises a long train of troublesome symptoms, such as congestion of blood to the head, spasms, syncope, convulsions, &c. In the other case, the condition of the system is the reverse, the irritability is diminished, the uterus is sluggish in its action, the pains are weak and inefficient, follow each other very slowly, and the course of the labour is much protracted; besides this, the short passages through which the child advances are now less capable of dilatation, from having that elasticity and suppleness peculiar to youth, and therefore oppose a much greater resistance.
Where the patient is of a slothful phlegmatic habit, the uterus generally indicates a corresponding state, by the slowness of its action and want of excitability during labour. The same condition is manifested during the catamenial periods in the unimpregnated state, by the absence of pain, weight, throbbing, and other symptoms of local congestion, which are usually observed at these times; so that, but for the discharge, the patient has scarcely any guide to mark their recurrence. On the contrary, where the appearance of the menses is preceded and accompanied by severe pain in the back and loins, throbbing, heat, weight, &c., indicating considerable excitement in the uterine system, we usually observe a similar condition in the uterus during labour, the pains being quick, energetic, and efficient. It is probably from some peculiarity of temperament that we can explain the hereditary disposition which some women show in the unusually lingering or rapid character of their labours.
From plethora.A congested or overloaded state of the uterine circulation, whether from general plethora or from other causes, is not an uncommon cause of feeble contractions. The spongy tissue of the uterine parietes is so gorged with blood, as to prevent, in a great measure, the free action of the pains, and may thus seriously impede the progress of labour. We have alreadypointed out, when speaking of the signs of pregnancy, the disposition which the system manifests for forming a larger quantity of blood than before; the pulse is stronger and more full, the animal heat is increased; this is especially observed in the uterus, and continues so during the whole process. Whilst in the state of inaction which belongs to pregnancy, but little inconvenience, comparatively, is felt; but when labour commences, and it contracts, the blood is driven from its engorged veins and sinuses into the general circulation; if, however, it cannot do this, from the general state of plethora, its contractions are rendered very imperfect and inefficient.
Besides the appearances of general plethora, we shall easily recognise this condition by the following symptoms: “the patient has much heat of surface and yet but little thirst; the face, eyes, and skin, are red and considerably swollen; we can feel vessels pulsating in every direction; she gets but little sleep, and finds the bed and the bedclothes uncomfortable to her; the uterus is large, thick, tense, and very warm: the os uteri swollen and cushiony, and the vagina also warm and spacious; the fœtus is very restless, and causes a good deal of pain by its movements. The pains are short and ineffective, and accompanied with a peculiar sensation of painful stretching or tension, without any symptoms of rheumatism, cramp, or other morbid conditions of the uterus being present.” (Wigand,Geburt des Menschen, vol. i. p. 138.) This condition is not unfrequently accompanied with tendency to hæmorrhoids, inactivity, constipation, varicose veins of the lower extremities, &c.
Rheumatism of the gravid uterusis an affection which, although it has received but little or no notice in this country, has been long known and described by the continental authors. It appears to be a similar condition of the uterine fibres, when developed by pregnancy, to rheumatism in other muscular tissues, arising from the same causes, connected with the same conditions of the system, and producing similar effects; hence, therefore, it must interfere considerably with the healthy action of the uterus, and greatly diminish or entirely destroy, the efficiency of the pains.
The whole uterus is unusually tender to the touch; the contractions are excessively painful from their very commencement, the slightest excitement of the uterus producing a sensation of pain; they come on with a sudden twinge or dragging pain about the pelvis and loins, and where the contractions are still powerful, they sometimes rise to an intolerable degree of intensity. This condition is frequently observed to a slight extent at the commencement of labour; the mild precursory pains which, in a healthy state, are merely attended with a sensation of equable pressure and tightness round the abdomen, now produce much suffering and give rise to one form of spurious pains, to which we have already, under that head, alluded. Where the symptomsare of considerable severity and have been aggravated by improper treatment, this state may easily pass into that of actual inflammation.
On examining into the history of the case, we shall frequently find that for several days, or even more than a week, the patient has remarked the uterus to be unusually tender to the touch, scarcely bearing the pressure of the clothes; and at night-time the uneasiness has increased to such a degree that she could scarcely remain in bed. There is a frequent desire to pass water, which is highly acid, and deposites much red sediment; and in all probability she complains of rheumatic pains in other parts of her body.
The causes of this condition are the same as those of rheumatism under ordinary circumstances: exposure to cold, and alternations of temperature, particularly when heated; derangement of the stomach, with much prevalence of acid, &c.: insufficient clothing, and, upon the Continent, especially in Holland, where it is said to be very frequent, by the use of chauffe-pieds.
Inflammation of the uterusis another condition which can not only greatly impair, but entirely suspend, the activity of the uterus. It is usually brought on by improper treatment during labour, where the real cause of the lingering ineffective pains at the commencement has been entirely overlooked, and a state of uterine irritation aggravated into one of actual inflammation by the abuse of stimuli and other heating drinks, given with the view to increase the pains; it may be produced by external violence, improper attempts to dilate the os uteri, rough and too frequent examination, endeavouring to turn the child or to apply the forceps before the soft passages were in a fit condition for that purpose.
The whole abdomen becomes extremely tender, and even the slightest contractions of the uterus produce intense suffering; the vagina is hot and dry, and very tender to the touch—its mucous secretion suppressed; the os uteri is swollen, tense, and painful, and the anterior lip is sometimes so distended as to have been actually mistaken for the bladder of membranes; the bowels are confined; the urine is suppressed; the abdomen becomes distended from tympanitis; and general, and probably fatal, inflammation of its contents follows.
Treatment.The causes of insufficient uterine action are so numerous that the modifications to which they give rise are almost endless, and demand no little variety of treatment. A great deal may be done to avoid this state by attention to the patient’s health shortly before labour; and by so carefully regulating it as to ensure a healthy condition of the whole system. Lingering labour from feeble uterine activity is seen most frequently in young primiparæ of delicate form and nervous irritable habit; the pains produce much fruitless suffering, and greatly exhaust the patient. If the cause continues, the case becomes muchprotracted, and serious consequences may ensue; such as hysterical symptoms, or even convulsions, inflammation of some organ, general fever, or complete and dangerous exhaustion, hæmorrhage, retained placenta, or hour-glass contraction of the uterus. In a slight degree this condition is not of unfrequent occurrence, whether from an enfeebled uterus or general debility, and requires general, rather than special treatment for its removal. Change of posture, walking about the room, gentle friction of the abdomen, and occasionally taking some refreshing or mildly nutrient drink, as tea, wine and water, or beef-tea, &c., prove serviceable in such cases; friction of the abdomen, if well applied, frequently produces a great alteration in the character of the pains, and greatly assist the progress of labour: if it be still in the first stage (the os uteri not yet fully dilated,) an enema will not only clear the rectum of any fæcal matter which may be lodging there, but assist in rousing the uterus to greater activity.
Where we can satisfy ourselves that none of the above-mentioned causes are present to protract the labour, we may proceed to the use of those remedies which are considered to have the power of exciting the uterine contractions, such as secale cornutum, borax, cinnamon, and the several diffusible stimulants. This state of uterine inactivity is, however, rare; and we would earnestly warn young practitioners against too readily concluding that it is present. They will find that the more carefully they investigate such cases, the less frequently will they require these remedies. In using the secale cornutum, we give the preference to the powder: it should be carefully kept from moisture, air, or light: from twenty to thirty grains, mixed in cold water, will be the proper dose, and this may be repeated two or three times, at intervals of half an hour, or rather more. Borax is also another remedy which appears to possess a peculiar power in exciting the activity of the uterus: although it is scarcely ever used for such a purpose in this country, its effects upon the uterus have been long known in Germany; and in former times, both it and the secale cornutum entered largely into the composition of the different nostrums which were used for the purpose of assisting labour. We have combined these two medicines with the best effects, and generally give them in the following manner:—℞ Secalis Cornuti ℈ i—ij; Sodæ Subborat. gr x; Aq. Cinnamomi ℥ jss. M. Fiat haust. Cinnamon, which is a remedy of considerable antiquity, has also a similar action upon the uterus, although to a less degree.
Our own conviction with regard to the use of these remedies is, that they are seldom requiredduringlabour, except in nates, or footling presentations, or in cases of turning, where the head is about to enter the pelvis, and where, at this critical moment, the action of the uterus is apt to fail, when it is important to thesafety of the child that there should be brisk pains to force the head through the pelvis and internal parts with sufficient rapidity. The chief value of these remedies is for the purpose of exciting uterine contractionafterlabour, and thus to promote the safe expulsion of the placenta, where there is a disposition to inertia uteri, and ensure the patient against hæmorrhage.
Where the contractile power of the uterus is so enfeebled that it becomes nearly powerless, we deem it much safer and better to apply extractive force to the head by means of the forceps, and thus overcome the natural resistance of the soft parts, to using medicines which excite uterine action, and thus stimulate the exhausted organ to still farther efforts. The mere cessation of uterine action, however, where the labour has been tedious and fatiguing, is no proof that the uterus is exhausted, and incapable of farther efforts: so far from its sinking into a state of quiescence, being a symptom of exhaustion, experience shows that, in labours of this character, it indicates a very opposite condition, being nothing more than a state of temporary repose, during which nature affords it an opportunity of recruiting its own powers, as also those of the whole system. The interval of ease which is thus given to the patient is accompanied by refreshing sleep; the skin grows moist; a gentle diaphoresis creeps over her; the circulation becomes calm; and after a time, the uterus awakes again to renewed and astonishing exertions; thus, Wigand has remarked, “the pains during the same labour may cease once, twice, or even oftener, and yet after a little rest will return with renewed strength.” (Geburt des Menschen, vol. ii. p. 242.) On the other hand, where the pains, in spite of their becoming more and more ineffective, continue to exhaust the patient with fruitless suffering, and prevent her from enjoying that repose which is so desirable under such circumstances; when the uterus, from increasing irritability, scarcely ceases to contract even for a moment, but continues tense and more or less tender during the intervals of the pains, we can have little or no reasonable expectation that such a labour can be terminated by the natural powers. If the head be not far advanced in the pelvis, or the passages fully dilated, if the bowels have been relieved before labour, and there is no febrile excitement of the circulation, a mild diaphoretic sedative, like Dover’s powder, will be of great service: it calms the irritability of the system, and induces that state of quiet or actual repose to which we have just alluded. If, on the other hand, the labour be much farther advanced, the head approaching the pelvic outlet, and the soft parts well dilated, a little assistance, by means of the forceps, will quickly terminate the case, and free the mother and her child from farther suffering and danger.
Where the uterus is enfeebled by lesion or change of structure, it becomes very difficult to decide as to what course ought to bepursued: in some cases, the soft passages partake in the loss of tone, and offer but little resistance to the advance of the child; in others, however, the uterus is so powerless as to give us no choice but of employing artificial delivery.
We have already pointed out the importance of paying the strictest attention to the bowels shortly before and during labour, and how frequently a neglect of this precaution acts as a means of perverting the due action of the pains, and giving them that character, already described under the head ofFalse Pains. “After the labour has made much progress, the rectum, if loaded, should be emptied by clysters; indeed, the utility of clysters in almost every stage of labour is so apparent that it is to be lamented they are not more frequently employed.” (Synopsis of difficult Parturition, p. 19.) We have seen cases where, although the bowels had been opened at the commencement of labour, after a time, the pains have gradually lost their dilating effect upon the os uteri, although they have increased in severity; the os uteri has remained tense and hard, and the labour has become very tedious and exhausting; the administration of an enema, and removal of a quantity of fæcal matter from the rectum, has been followed by an instantaneous change in all the symptoms; the pains have become powerful and effective, the os uteri has quickly dilated, and the whole labour has been completed in a very short space of time. In like manner, vomiting during the early part of labour produces the best effects; for it not only assists to relax the parts, by the nausea which usually precedes it, but, by emptying the stomach of unhealthy contents, it tends not a little to restore the uterus to its natural activity.
Where the bowels are distended with flatus, and loaded with acrid and unhealthy contents; we rarely see the pains become regular and effective until these sources of irritation are removed: the abdomen is painful with spasmodic colicky griping, and excites the uterus to partial and very painful contractions of a cramp-like character, which entirely supersede the regular pains, and thus exhaust the patient with protracted suffering without at all advancing the labour itself. If this condition be allowed to continue uninterfered with, the tenderness of the abdomen increases, the circulation becomes excited, and inflammation, and fever of a most serious kind will be the result.
In the management of primiparæ, who are pregnant either at a very early age or considerably advanced in life, our chief attention must be directed to the management of them for some little time before labour is expected, in order that we may place them in as favourable a state of health as possible, and thus enable them to meet the coming trial with safety.
Where the patient is very young, we should endeavour, by early hours, regular exercise, good air, and simple nourishing diet, &c., to increase her strength, and the general tone of health,and thus diminish that irritability of the nervous system peculiar to females of this early age. She should lead a country life, be as much as possible in the open air, enjoy the absence of restraint and excitement, which are almost necessary consequences of a residence in town, and, by agreeable occupation and cheerful society, train herself, as it were, to that state of moral as well as bodily health best adapted to ensure a favourable result. It is in cases of this kind where the bodily powers have not yet ripened into adult womanhood, that so much good may be effected by using the tepid or (if the season permit) cold salt water bath; and we would beg to refer our readers to our observations on this subject in the chapter onPremature Expulsion. In a case which has recently come under our notice, we have had reason to attribute the remarkably healthy and favourable labour of a young and delicate primipara solely to the invigorating effects of regular exercise and the daily use of sea-bathing, which she continued to within a very few days of her confinement.
It is commonly supposed that women pregnant for the first time, and advanced in years, always have severe labours: this is not necessarily the case, although, at the same time, the greater rigidity of the soft parts considerably increases the resistance to the expelling powers. It will be equally important in this case, also, to improve her health and strength as far as possible, and, by exercise, warm hip baths, &c., to give the parts a greater degree of suppleness and elasticity.
Where the labour is protracted by a state of general plethora or local congestion, the expelling powers are not only enfeebled by the engorged state of the uterine circulation preventing effective pains, but the resistance to the passage of the child is increased by a similar condition of the soft passages, which are swollen and turgid with blood. It is in these cases that bleeding effects such a sudden and complete change; the pulse loses its oppressed character, and rises in point of strength, the uterus loses the thick solid feel which it had before; its contractions become active and powerful, the os uteri dilates, the passages become soft and yielding, and the whole process assumes a different character. By careful observation, this state can easily be discovered before labour has actually commenced; in which case much useless suffering may be prevented by previously reducing the circulation to a proper standard, and thus fitting the uterus for the exertions it has to undergo: besides bleeding, mild saline laxatives, with or without antimonials, will be of great service. The nitrate of potass in these cases has the best effects, either in farthering the effects of the bleeding, or removing the necessity of using so powerful a remedy.
In treating rheumatism of the gravid uterus, our practice will differ but little from that in cases of ordinary rheumatism in other parts: this condition, we believe, is rarely excited, untilthe system had been already predisposed to it by deranged digestion, and that general prevalence of acid diathesis, which manifests itself in different individuals and under different circumstances so variously; hence, therefore, it will always be important to unload the primæ viæ effectually by an active dose of calomel or some other mercurial, before prescribing for the immediate symptoms of the complaint: beyond producing a little occasional nausea, five grains of calomel will act much more comfortably to the patient’s feelings than a smaller dose; there will be less griping and intestinal irritation, but the effect will be more complete and general; not only will the bowels be thoroughly evacuated, but the liver relieved of a large quantity of unhealthy acrid bile, the removal of which cannot but be highly advantageous. We may now proceed to the use of diaphoretics and opiates: of these, Dover’s powder stands foremost; and if given in doses of from ten to fifteen grains, accompanied with warm diluent drinks, rarely fails to induce sleep and a pretty active perspiration, which gives great relief. As the abdomen is usually more or less tender on pressure, it should be covered with a piece of soft flannel, or, still farther to ensure the full diaphoretic effect of the remedies, a warm bath may be had recourse to. Where calomel in the above dose has been premised, we seldom fail in procuring a free action of the skin, and, according to our own experience, with far greater relief to the system than where the perspiration has been induced merely by diaphoretics and external warmth.