This is a section of a Pelvis to show the effect of a corroding
disease of another kind. The whole of this is such a mass of disease
and deformity as to preclude any particular description.
[Illustration: Plate XLIV.
This is another deformity, in which one side is sunk below the other,
and both twisted round the sacrum.]
[Illustration: Plate XLV.
The effect of corroding disease.]
Curvature of the spine sometimes affects the pelvis, when low down, and
therefore if any female is affected with it she should not marry before
being examined. Several diseases and lesions of the hip-joint, and of
the thigh, may also do the same, and should therefore be suspected.
In the great majority of cases, deformities of the pelvis remain
unknown, till the period of delivery, and all that can be then done
is to combat in the best possible way the difficulties they create.
It is evident that the amount of difficulty depends entirely on the
disproportion between the head of the child, and the passage through
which it has to be born. If the head be large and the passage small
the difficulty will be greatest, but if the head be small it may pass
through the pelvis though under its average size. The development of
the head cannot be ascertained however, before birth, except when it is
unusually large from dropsy, and it is therefore always assumed to be
of an average development, and the pelvis is compared accordingly.
The kind of assistance required in these cases depends chiefly on the
measure of the pelvic diameters, though it may be modified somewhat by
other considerations.
When the smallest diameter of the pelvis measures from _three inches
and a half to three inches_, it is customary to leave the expulsion
of the fœtus to nature, and it is generally effected, though slowly
and with difficulty. If however the patient becomes exhausted, or the
head be unusually large, the forceps are generally used after waiting
five or six hours. In these cases the head often becomes firmly fixed
in the upper strait, so that great force is needed to dislodge it. The
upper part passes through, owing to the overlapping of the bones, and
the scalp then bulges out like a large tumor, from being engorged with
blood and serum, but the lower being more unyielding remains behind.
It is therefore impossible for the head to move either way, as it is
formed like a figure 8, and held by the narrow part, as will be seen by
the following plate.
[Illustration: PLATE XLVI.
This Plate represents the head fixed, or impacted, at the upper strait
of a narrow pelvis.]
When the smallest diameter is not more than from _three inches to
two and a half_, the birth is sometimes effected by nature, but with
extreme difficulty. The accoucheur waits four or five hours, as in the
former case, and then if no progress is made he applies the forceps,
using great care in doing so. If the extraction is found impossible,
with reasonable force, the head must be opened and made smaller, even
though the child be living, because it is more proper to sacrifice it
than to risk the life of the mother. In a case like this however, no
one person would like to decide, unless in a great emergency; there
should always be a consultation if possible.
A _dwarf_, named Lepratt, who used to perform at the theatres, was
delivered with the forceps by M. Dubois, though the pelvis only
measured _three inches_. She perfectly recovered, though the child was
born dead: it was of fair average size.
It is contended by some that the delivery may be effected, under
peculiarly favorable circumstances, when the passage measures only two
and a half inches, and at all events the effort should be made; but
for the sake of the mother such cases should not be left long, as the
chance is so small, and the risk of delay so great. When the passage is
_less_ than two and a half inches, spontaneous or artificial delivery
is allowed to be impossible, and the only alternatives then are to
dismember the child or open the mother. Which of these should be done
depends on circumstances. Whenever the child _can_ be brought away by
the natural passages, though it be piecemeal, it always is so brought,
unless the danger to the mother be greater than by the cesarian
operation, in which case that operation is resorted to. By means of
an instrument called the _Cephalotribe_, which crushes the head, the
child may be brought away, unless very large, when the pelvis only
measures _two inches_. When the passage is _less than two inches_, the
only resort is to the cesarean operation, which sometimes succeeds, and
saves both mother and child, though more frequently the mother sinks.
The necessity for all these frightful operations is now much less than
formerly, _and may be done away_ _with altogether_. This important
fact should be known universally, and also the means to be resorted
to. In the first place, every young female should be examined, before
marriage, by a competent person, if there be the slightest reason to
suspect deformity; and in case the deformity is found to exist, the
consequences if she becomes pregnant, must be laid before her. If,
after being told this, she _will marry_, or has already done so, the
means of _avoiding conception_ should be placed at her disposal, so
that she may not be made, of necessity, a helpless victim. These means
need not be described here, though I have no hesitation in referring
to them. When I know that the _life_, or _life-long health_, of a
female, depends on her not becoming pregnant, I consider it my duty to
put such means at her disposal, if she desires it. In many instances I
have known females suffer, several times, the most frightful tortures,
merely to bring into the world the mangled fragments of a dismembered
child, with the greatest risk to their own lives; and in others I have
known them in constant dread of becoming pregnant, because they were
conscious it would be their death warrant. In such cases I leave it to
_humanity_, and _common sense_, as to whether such information should
be withheld? _I_ could not reconcile it with my notions of _duty_ to
withhold it.
In case pregnancy has occurred before the deformity is discovered, and
it is then found that a _full grown_ child cannot be born, premature
delivery must be brought on; or, in other words, the Uterus must be
made to expel the child before the full term, while it is yet small
enough to pass through the Pelvis. This operation is of course only
allowable when needed to preserve life, or to escape great suffering
and danger. It must always be decided upon by the medical man, and
performed by him, so that a description of it is uncalled for here.
In Europe it is quite common, and nothing has tended so much to do
away with those disgusting and horrid operations, on mother and child,
which were formerly absolutely necessary in cases of deformity. If
it is found at the first delivery of a female, or before, that she
cannot bear a living child at full term, artificial delivery is
accomplished at _seven_ or _eight_ months, thus avoiding all the
danger to the mother, and _frequently preserving the child_. In the
case of the _dwarf_ before referred to, when she became pregnant the
second time, M. Dubois brought on premature delivery, and the child
was _born alive_, with but little difficulty. According to statistics
it appears that, when artificial premature delivery has been induced,
in _one hundred and sixty-one cases_ only _eight mothers_ have died,
and all but _forty-six_ of the infants were born alive. Of the whole
number of children _seventy-three_ continued to live; and of the eight
mothers five died from other causes, leaving but _three_ whose death
resulted from the operation. Now when the fearful number of deaths
from instruments, and other operations, necessary at full term, is
recollected, the advantage of this practice will be evident. In the
Cesarian operation for instance, which is often the only remaining
resort, but _one_ female out of _six_ recovers.
The delivery should be postponed as long as possible, so as to give
the best chance for the child living. This must of course be decided
upon after the size of the pelvis is ascertained. Seven months is the
earliest time at which the fœtus is viable, and it is much better left
till eight, if the size of the parts will allow of its birth then. In
case they are so small that it cannot be born even at seven months, we
have our choice, as M. Chailly remarks, _between the dreadful Cesarian
operation at full term, and producing early miscarriage_.
M. Dubois seems to recommend premature delivery in nearly all cases, if
the smallest diameter is _under three inches_; because, as he remarks,
spontaneous delivery at _full term_ is then a very rare exception, and
the danger and suffering to the mother is so great. He also recommends
it when there are tumors, and even when the female is afflicted with
any acute disease. Of course it is always necessary, before operating,
to be sure that the child is alive.
I knew a lady myself who had given birth, at full term, to _seven_
children, all of which were torn from her with instruments, _dead_,
owing to the smallness of the pelvis. When pregnant with the _eighth_,
premature delivery was brought on, at my suggestion, at about _seven
months and a half_. The fœtus was born with comparative ease, and
_lived_. But for this operation she probably would never have been
blessed with a living child at all. Since then she has avoided
conception.
TUMORS IN THE PELVIS.
Tumors of various kinds are met with, both in the bones of the pelvis
and attached to the soft parts. They frequently offer the most serious
impediments to delivery, and baffle the skill of the most experienced
obstetricians. In fact they differ so much in their structure, their
size, and their situation, that but few general directions can be given
as to their management. In every case where one exists pregnancy
should never occur, if possible to be prevented, before it is removed;
for though it may cause no inconvenience at other times, yet during
delivery it may necessitate very serious operations, or even cause
death. Some of these tumors are mere vesicles, or bags, filled with
fluid, and may be punctured and their contents let out, so as to make
them less. Others are more or less solid but moveable, and may often
be supported above the upper strait till after the child is born. When
they are so large as to block up the passage, and are either fixed or
cannot be carried up into the Womb, there is often no other choice than
to either cut them out or open the child's head; the practice being
determined by the circumstances of the case. In some instances the
bladder itself, distended with urine, has impeded delivery, and been
mistaken for a tumor; and in other instances stones in the bladder have
caused the same error.
A specimen of one of these tumors is represented in Plate XLVII, and
one of a Polypus in Plate XLVIII.
PLATE XLVII.
This represents an Ovarian Tumor, which has descended before the head
of the child, and completely blocked up the passage. The delivery, it
will be seen, is utterly impossible in such a case, unless the Tumor
can either be pushed away, or reduced in size.
[Illustration: Plate XLVII.
Case of Tumor.]
PLATE XLVIII.
This Plate represents a case which occurred in the practice of Dr.
Ramsbotham, and which terminated favorably. The polypus had a very
long neck, and was forced _out of the external opening_ by the child,
which was then born with ease. I once saw a case myself, in which the
labor was completely arrested by a large hard tumor about the middle
of the Vagina; it could not be moved, and delivery was evidently
impossible while it remained. In consultation it was decided to cut
it out, as there seemed but little circulation of blood in it, and
its situation was favorable for the operation. This was accordingly
done with but little trouble, and the child was born without
difficulty in about twenty minutes after. The mother perfectly
recovered.
[Illustration: Plate XLVIII.
Case of Polypus.]
TUMORS EXTERNALLY.
Sometimes tumors exist externally, on the lips, or in the Vulva, but
as they seldom offer much obstruction, and are easily detected and
managed, but little need be said about them. They should always however
be attended to, if discovered, before labor comes on, or better still
before pregnancy.
In some instances the veins around the Vulva become much enlarged,
and resemble tumors, and sometimes even impede delivery. It is usual
then to open them, and let out the blood, but not till the head is
sufficiently low to press upon it and prevent dangerous bleeding.
OBSTRUCTIONS IN THE VAGINA, AND NARROWNESS OR OBSTINATE RESISTANCE OF
THE VULVA AND PERINEUM.
The Vagina may be partly closed by its sides growing together, or it
may be united by bands and membranes stretching across; and these
obstructions may be sufficient to impede or prevent delivery. Most
usually they give way, and are gradually broken down by the pressure
of the child's head; but if they prove too strong, after waiting a
reasonable time, they must be cut through. Cases have even been known
in which the _hymen_ has been found perfect at delivery, and even
offered considerable resistance, so as to necessitate its being cut
through before the child could be born. In such cases this membrane is
unusually strong, and conception occurs without its being broken.
When the perineum or Vulva remains rigid and hard, so that the opening
cannot be enlarged sufficiently for the child to pass, it may also be
necessary to operate with the knife. But this should never be done till
after every means of relaxation has been tried, and the head has been
kept back as long as prudent. It is however, always better to open a
passage than to let one be _torn_, because it may be made in the most
favorable place. When the perineum is allowed to be torn, the most
serious consequences often ensue, and the patient is made a miserable
sufferer for life. The Vagina and Rectum may be torn into one, or the
power of retaining the contents of the intestine, or bladder, may be
for ever lost. When an incision is made none of these evils follow; the
wound speedily heals, and in a little time no trace of it can be seen.
It has even been necessary _to cut the neck of the Womb_, when it would
not open, to prevent the organ from being ruptured; and this has been
done with perfect safety. A celebrated practitioner in this city had to
perform such an operation very recently, on a female who had injured
herself, and made the mouth of the Womb grow together, by violent
attempts to produce abortion. The delivery took place with comparative
ease, and no unpleasant results whatever followed, either to the mother
or the child.
CHAPTER XX.
CAUSES CONNECTED WITH THE CHILD, OR CHILDREN, WHICH MAY IMPEDE
DELIVERY, OR MAKE IT DIFFICULT AND DANGEROUS.
PROCIDENTIA OF THE UMBILICAL CORD.
This means the escape of a portion of the cord before the child itself.
It is most frequent in the irregular presentations, as they do not so
fully close up the mouth of the Womb, and it is most likely to occur at
the commencement of labor, though not impossible at a later stage. Very
often the cord descends when the membranes break, being carried down
by the rush of the waters; and sometimes it is already in the sack, or
bag, before the rupture takes place. This accident is comparatively
frequent, being found to occur as often as once in about three hundred
cases.
The causes which produce procidentia of the cord, are most
likely these:--A large quantity of liquor amnii, and its sudden
discharge,--Unnatural presentations,--Deformities of the superior
strait of the Pelvis,--A very long cord,--and rupturing the membranes
too early. But it may also happen from other causes with which we are
unacquainted.
There is seldom much difficulty in detecting this accident, because
if the membranes are broken it protrudes into the Vagina, and if they
remain whole it can be felt within the sack, and its pulsation will be
quite distinct. Sometimes, it is true, it may be so firmly compressed,
between the fœtus and the walls of the pelvis, that its pulsation may
be very indistinct, or even totally suspended for a time; but this only
necessitates a little extra care.
Procidentia of the cord may be very serious for the child; in fact, it
is a frequent cause of its death. The reason of this will be evident
when the functions of the cord are borne in mind. The circulation in it
is as necessary for the life of the child before birth, as breathing is
after, and when protruded first it can seldom escape being so pressed
upon as to stop its circulation, and hence the danger. To the mother
it makes no difference whatever, unless it be told and alarm her; or
unless violent efforts are made to correct it. She had therefore better
not know if it occurs.
If assistance is not rendered in this accident the consequences are
almost always fatal to the child, though in some instances the cord has
remained hanging from the Vulva several inches, for an hour or more,
and still the infant has been saved.
If the fallen cord is detected before the membranes are broken, it
may frequently be put back into the Womb without much difficulty. The
accoucheur must wait till the mouth of the Womb is fully dilated, and
then watch his opportunity, in an interval between two contractions,
to push the cord upwards, between the fœtus and the uterine walls. If
he succeeds in this, as is usually the case, he must then break the
membranes during the next pain, and this will bring the presenting part
at once into the upper strait, and so block up the passage. To effect
this manœuvre it is requisite to introduce two or three fingers, and
sometimes even the whole hand. It must never be attempted till the
mouth is fully dilated, otherwise the membranes may be ruptured too
soon, and the delivery be delayed, thus increasing the danger.
After the rupture of the membranes the replacing of the cord becomes a
much more difficult matter, and frequently cannot be effected at all;
particularly if the head be descended far down. Every effort however
must be made, and if unsuccessful the delivery should be hastened as
much as possible. In many such cases the _forceps_ are applied, and the
child brought away at once, because every moment's delay increases the
risk to its life.
Several different kinds of instruments have been invented to return the
cord, but they are seldom at hand when needed, and none of them are so
good as the hand itself.
If the return of the cord cannot be effected, and the progress of
the labor will allow of it, the hand is introduced and the child
turned, unless the position of the head will allow of the advantageous
application of the forceps, in which case they are mostly resorted
to. The only general rule is, to terminate the labor as speedily as
possible, consistent with the welfare of the mother. In spite of all
that can be done the pulsation is often found to cease, and when the
child is born it is either quite dead or breathes but a few times.
A very frequent indication that the fœtus suffers from compression of
the cord, is a greenish color of the water discharged, owing to the
discharge of _Meconium_ from the child's bowels. This is brought about,
most probably, by its straining, and its efforts to relieve itself.
SHORTNESS OF THE CORD.
The cord is sometimes too short, and this may operate very unfavorably
in many ways. It may keep the fœtus up in the Womb, and prevent it from
descending to the bottom of the Vagina,--it may cause the placenta to
be torn away too soon, and so lead to serious flooding,--it may pull
down and invert the Womb,--or it may make the labor very tedious, and
cause the death of the child.
Unfortunately there are but few signs of this accident, even after the
rupture of the membranes, and none at all before, that can be depended
upon. If the head has descended properly, and the parts be fully
relaxed, but still the expulsion is delayed from no obvious cause, it
may reasonably be supposed that shortness of the cord exists; and if so
there is very soon given a proof of it by a discharge of blood. This is
owing either to the breaking of the cord, or to the separation of the
placenta, and is frequently the first intimation the assistant has of
the accident. All that can be then done is, to conclude the delivery as
soon as possible, and in the best way that circumstances will allow.
In some cases the cord is not too short absolutely, but is made so by
being twined round the body or limbs of the child, which are often
_cut off_ by it. M. Tasil saw a case where the cord round the neck
had nearly severed the head; and Montgomery gives several instances
in which the limbs had been amputated in this way. Two of these are
represented below:--
[Illustration: PLATE XLIX.
Fig. 1. Fig. 2.
_Limbs cut off by the Cord._
Occasionally the cord can be slipped over the head, or limbs, when
wound round them, and the strain upon it be thus removed. If this
cannot be done however, and the danger increases, relief may be
obtained by _cutting the cord_, particularly if it be absolutely short.
But this must not be done till everything indicates that the labor will
probably soon terminate; and the end connected with the child must be
carefully held, or tied.]
DESCENT OF OTHER PARTS WITH THE HEAD.
_One Arm._--The descent of one arm along with the head may cause
some delay and difficulty, but Nature nearly always overcomes the
impediment. It is seldom that the arm can be reduced, and therefore
but little can be done at first; if the delivery be evidently arrested
by it the accoucheur must at last assist in the most feasible manner.
Sometimes even it is necessary for him to apply the forceps.
_The Two Arms._--Even this difficulty is often overcome spontaneously,
though much more rarely than the former one. As soon as it is detected,
the accoucheur must endeavor to return one or both of the limbs, if the
labor has not proceeded too far; and if he cannot succeed the delivery
must be accomplished as soon as possible, either by turning or with the
forceps, unless there be reasonable ground for delay.
_The Feet._--Either one or both of the feet may also descend with the
head, at first, though they usually recede and allow the head to be
born alone. When they are so impacted as to prevent the delivery being
completed, the accoucheur must interfere. In most cases he will find it
quite easy to push the feet above the head, and allow that to descend
alone; but if this is not possible he must introduce one hand, grasp
the feet with it, and pull them down, while the other pushes the head
up. This will turn the child, and if it be in no immediate danger, and
the mother is not suffering, the rest may be left to nature; but if
the contrary is the case, the delivery must be finished as speedily as
possible. When the head is very low down it may be necessary to use the
forceps, but great care must be observed not to grasp the feet along
with the head when using them.
_A Foot and Arm._--The proceeding is the same as with the foot alone.
If the limbs cannot be returned the head and arm must be pushed up,
while the foot is brought down.
TWINS AND TRIPLETS.
In most cases where there are two or more children the delivery is
easier than with one, because they are generally small, and the first
one so prepares the way that the rest are born without difficulty. It
is also a fact that twins are nearly always born before full term, and
consequently are not quite grown.
The expulsion of the second fœtus usually takes place, immediately
after the first, though sometimes the Womb stops contracting, and it
is not born for half an hour or more, and it may even remain for hours
or days. It is a question whether, in such a case, the second delivery
should be left for Nature to finish, or whether the accoucheur should
terminate it sooner artificially. The most general practice is to wait
only about half an hour, and then, if the Womb is still inert, use
friction, or other necessary means, to excite it, and accomplish the
second delivery as soon as possible. If there be more than two the
proceeding is still the same.
Some difficulties may arise however with twins, which it is necessary
to be prepared for. Thus the two heads may come together, and mutually
impede each other. In this case the one which moves the easiest must be
pushed up till the other is descended sufficiently low. One head may
also descend with one or two feet; in which case, if the feet cannot be
returned, the head must be pushed up, and they must be brought down.
The force exerted however, must not be very great at first, because
_one may belong to each of the children_, and much injury may be done;
a little gentle traction will soon detect this however, with ordinary
care. If two arms, or one arm and a foot descend, the same care is
also required, before pulling upon them, to ascertain that they are
not parts of the _two_ children. Sometimes when the head of one twin
descends along with the feet of the other they may, if small, descend
together. But if this is impossible, and interference is needed, we
must first try to push up the head; and if this cannot be done, _it_
must be drawn upon, not the feet; because if the feet were drawn down
the two children would soon occupy the passage together, body and head,
and would perhaps become firmly wedged. In nearly every case one of the
twins presents by the head and the other by the feet, as formerly shown.
EXCESSIVE SIZE OF THE FŒTUS, OR THE DISEASED DEVELOPMENT OF CERTAIN
PARTS.
_Fœtus too large._--It is very rarely the case that the Fœtus is so
large as not to pass easily through a well-formed Pelvis, though such
cases have been known. The mode of proceeding is of course precisely
the same as if the pelvis were too small. If no means will succeed in
abstracting the Fœtus whole, it must be made less; but Nature should be
first allowed full time to act with all her force.
_Hydrocephalus._--This consists of an accumulation of water in the
head of the child, and is usually termed watery head. The bones of the
cranium will sometimes be widely separated by it, and the head be made
so large that it cannot possibly be born till made less. The causes
which produce this disease before birth are unknown.
In cases of hydrocephalus the head does not descend into the straits,
owing to its size, and is felt to be full and firm, during a pain, but
soft and yielding during the intervals, especially at the fontanelles
and sutures, which are also very large. The bones are usually very wide
asunder, or even totally separated, as if floating in the fluid.
In some cases, when the quantity of fluid is but small, the delivery
may terminate spontaneously; the head lengthening, from being so soft,
and thus adapting itself to the size and form of the strait. Most
frequently however, assistance is rendered in such cases, either by the
forceps, which will sometimes succeed, or by puncturing the head, and
letting out the fluid. This operation has been performed and the child
saved, though such an occurrence can never be reasonably anticipated.
Such instances however, show that great care should be taken not to
injure the brain, as that would destroy the small chance there is.
Dropsy may also occur in the chest, or abdomen of the child, causing
similar difficulty with dropsy of the head. If the natural or
artificial expulsion of the child cannot be effected without, the part
must be carefully punctured, and the fluid evacuated.
_Tumors on the Fœtus._--Sometimes various kinds of tumors form on the
child's body, but they are rarely so large as to prevent delivery,
though they may delay it. If they should be too large however, it will
be necessary to remove them, as in the case of tumors in the Pelvis.
OSSIFICATION OF THE HEAD.
Occasionally the bones of the head will be so hard, and so closely
united, that they will not overlap, in which case the labor may be
very difficult, unless the head is small, or the pelvis very large.
If after waiting a reasonable time, there be no prospect of the
labor terminating naturally, and the female is exhausted, it must be
terminated artificially, as if it were a case of deformed pelvis. It is
seldom however, that the head does not eventually give way.
VARIOUS PRESENTATIONS AND POSITIONS OF THE FŒTUS, FROM WHICH THE LABOR
MAY BE DIFFICULT OR PROTRACTED.
_Presentations of the Face._--These are usually more difficult, and
longer, than those of the head. They will nearly always however,
terminate spontaneously, or with ordinary assistance; but, if they
should not, artificial delivery must be practised, either by turning,
if the case be not too far advanced, or with the forceps. Some of
the most celebrated authors recommend that all these cases should be
treated like cases of natural labor. Dr. Merriman says that in some
_very favorable_ instances turning may be practised with safety and
advantage; but Dr. Lee says, "My firm belief is, that the child, even
under such favorable circumstances, would have a far better chance
to be born alive if the labor were left wholly to Nature; or, if the
natural powers were inadequate, to be extracted with the forceps."
In such cases there is often too little patience, and too much
interference.
_The forehead inclined against the Pubes._--In this position the labor
may be long delayed, and difficult, and most practitioners endeavor
to turn the head round, if they cannot bring down the feet, or else
apply the forceps at once. Dr. Lee however remarks, and very properly,
"From all that I have seen of these cases, I am disposed to believe
that it is best to leave them to the natural efforts, and to avoid all
interference, all attempts to change the position, while the pains
continue regular, and the head advances, however slowly." If the labor
does not progress at all, or the female becomes exhausted, of course
artificial delivery is necessary.
Several _varieties_ of head and face presentations may also retard
labor considerably, but Nature nearly always overcomes the difficulty;
or if she cannot do so mere ordinary assistance is required.
PRESENTATIONS OF THE LOWER EXTREMITIES.
It has already been remarked, in another place, that breech
presentations mostly terminate spontaneously, and that but few of them
require interference. In some of them even, when the pelvis is large,
or the fœtus small, the delivery is effected quite rapidly. Still such
presentation occasionally causes delay and difficulty, and necessitate
more or less assistance.
As soon as the mouth of the Womb is opened sufficiently, unless the
labor is rapidly progressing without it, one of the fingers may be
introduced and _hooked_ over the groin, and a little gentle force
exerted upon it. This will assist very much, and will often be all
sufficient. If the pelvis is too small, or the fœtus too large, and
the delivery is evidently arrested, the breech must be pushed up, if
possible, and the feet be brought down, as in turning. The remarks of
Dr. Lee on this presentation are so plain and practical, and marked
with such good sense, that I think a better explanation of what should
be done in such cases-could hardly be given, I will therefore quote his
remarks in full:--
"Having ascertained that the nates present, whatever the position
of the fœtus may be, whether the abdomen look backward or forward,
we cannot alter it with safety, and no change can be required to be
made till the nates and lower extremities are expelled. The os uteri
dilates slowly in most cases of nates presentation, but we cannot
employ any means with advantage to accelerate the delivery, and in
most cases, if we do not interfere, but wait patiently, they are
gradually pressed lower and lower into the pelvis, and at last escape
from the vagina without any assistance. If the os uteri and vagina
are imperfectly dilated, and the nates are drawn down or pass rapidly
through the pelvis, the child is often lost. The membranes should not
be ruptured, and the expulsion of the nates should be left entirely
to the natural efforts, unless the labor is protracted and exhaustion
takes place. Except supporting the perineum, nothing is required in a
great proportion of these cases before the nates and lower extremities
have been expelled, when it becomes necessary to ascertain precisely
the relative position of the child to the pelvis, to rectify this if
it is unfavorable, and artificially extract the superior extremities
and head, to prevent the fatal compression of the umbilical cord. If
we find, after the expulsion of the nates and lower extremities, that
the toes are directed forward, or that the child is in the position
represented in the second figure, with its abdomen applied to the
anterior part of the uterus, and that its back lies along the spine
of the mother, we should wrap the nates and sides in a soft napkin,
and turn the child very gently round during a pain, observing to
which side the feet are inclined to turn, till its abdomen is to
the spine of the mother, and the toes are directed backward to the
hollow of the sacrum, or to the side of the pelvis. In many cases
the nates turn round in the passage spontaneously, so that it is not
required artificially to alter the position. It is necessary always
to recollect that it is possible to turn the body of the child round
without turning the face round into the hollow of the sacrum, and
that the chin may be over the symphysis pubis when the front of the
chest and abdomen are turned backward. After the lower extremities and
body of the child have been expelled, and placed in the most favorable
position for the extraction of the superior extremities and head, it
is necessary to proceed without loss of time to draw these through
the pelvis, that the child may not be destroyed by compression of
the umbilical cord. As pressure upon the cord for a very short time
will in some cases kill the child, it is proper to watch closely the
pulsations of its arteries. Draw the body of the child forward as
far as the arm-pits, and place it over the palm of your right hand
and fore-arm, and gently draw the body towards the left thigh of the
mother; then pass the fore and middle fingers of your left hand along
the back part of the left arm of the child to the elbow-joint, and
press down the arm with your lingers along the thorax of the child,
and extract it. Then transfer the body of the child and left arm to
your left hand and fore-arm for support, and with the fore and middle
fingers of your right hand disengage and bring down, in the same way,
the right arm of the child; then pass the fore and middle fingers of
your left hand into the mouth of the child, or rather over the lower
and upper jaw, and at the same time place the fore and middle fingers
of your right hand over the back part of the neck and occiput, and
with the fingers of the two hands thus applied extract the head, in
the line of the axis of the pelvis. The perineum is very rigid in some
cases of nates presentation, where it is the first child, and it will
be torn if the head is extracted hastily, and not drawn forward to the
symphysis pubis. When you feel the pulsations of the cord beginning to
cease, you may be tempted to employ greater extracting force than the
neck of the child and perineum can bear, and both may be destroyed.
The only method of obviating this is to press back the edge of the
perineum, that the air may gain admission into the mouth of the child,
and the respiration go on, when the circulation in the cord has been
arrested, until the perineum is sufficiently dilated to slide back
over the face, and allow the head to pass. I have seen from twenty
minutes to half an hour elapse in some cases, after the cord had
ceased to pulsate, before the perineum would allow the head to escape,
during which time the respiration was regularly performed. This is
not a new practice; it has been alluded to by some of the older
accoucheurs, and some others; and the advantages to be derived from
it were fully pointed out some years ago by Dr. Bigelow, in a paper
published in the American Journal of the Medical Sciences, 'On the
means of affording Respiration to Children in Reversed Presentations.'
The object of Dr. Bigelow in this paper is to show that in many cases
the life of the child may be saved by forming a communication between
the mouth and atmosphere previous to the delivery of the head. If the
head be low down, the fingers alone can give the necessary assistance;
but if it is high in the pelvis, and is reached with difficulty, the
assistance of a tube may be necessary. He recommends a flat tube,
which is to be guarded, and kept within the fingers of the inserted
hand.
"Where the pelvis of the mother is small or distorted, and the
child large and unfavorably situated, the efforts of nature may be
insufficient to expel the child, either alive or dead. The nates may
become so firmly impacted in the pelvis, that they cannot advance
without artificial assistance. A finger should be passed up to one
of the groins, and when a pain comes on a considerable extracting
force may be exerted with it, without injuring the child; or a soft
handkerchief may be passed between the thigh and abdomen, and the
nates drawn down; but this cannot be done unless they have descended
low into the cavity of the pelvis. Where these means fail, and it is
impossible to extract the child alive, the blunt hook or crotchet
must be employed. In cases of nates presentation, where the pelvis
is distorted, after the extraction of the trunk and extremities, it
is necessary to perforate the back part of the head, and complete
the delivery with the crotchet. In presentations of the feet and
knees the treatment does not essentially differ from that required in
presentations of the nates."
PRESENTATIONS OF THE SHOULDER.
These are the most dangerous of all the presentations, and most
frequently require assistance; in fact the delivery can seldom be
terminated naturally when the shoulder presents.
Sometimes the child will pass doubled up, as formerly explained, but
this must not be too confidently expected. Dr. Lee says--
"It is now a general rule, established in all countries where
midwifery is understood, that in cases of preternatural labor, where
the shoulder and superior extremities of the child present, the
operation of turning ought to be performed. But the hand must not
be forced into the uterus, if the orifice is rigid and undilatable;
it should be dilated nearly to the size of half-a-dollar piece or
more, or the margin ought to be very thin, soft, and yielding, if it
is expanded to a smaller extent than this when turning is attempted.
If the os uteri will not admit the extremities of the fingers and
thumb in a conical form to be introduced without much force, if it is
thick, hard, and unyielding, some delay is necessary, that the parts
may relax, death being almost always the consequence of thrusting the
hand with violence through the orifice of the uterus in a rigid and
undilatable condition, whether the membranes be ruptured or not. But
as soon as it will admit of the safe introduction of the hand, where
you have ascertained that an arm presents, no time should be lost in
completing the delivery, otherwise the membranes may give way, the
liquor amnii be evacuated, and a case of little difficulty and danger
be suddenly converted into one equally hazardous to the mother and
child. In all cases of labor, where the first stage is far advanced
without the nature of the presentation being positively determined, or
a superior extremity is felt through the membranes, the patient should
be kept in the horizontal position, that they may not be ruptured;
and you should remain in constant attendance upon the patient, and be
prepared to interfere the instant the necessity arises."
Speaking of the operation of turning in these cases he remarks as
follows:--
"In some favorable cases of shoulder and arm presentation, the uterus
is widely dilated before the membranes are ruptured and the liquor
amnii discharged; and no difficulty is experienced in passing the
hand into the uterus, laying hold of the feet, and extracting the
child by the operation of turning. If the uterus is not contracting
strongly and at short intervals, little resistance is offered to
the introduction of the hand, and the delivery may be speedily
accomplished with safety both to the mother and child. But if the
membranes have burst, the liquor amnii escaped, and the uterus has
been contracting firmly upon the child many hours before the operation
of turning is attempted, the child is often destroyed by the pressure,
and the coats of the uterus exposed to great danger from contusion
and laceration in passing up the hand and bringing down the feet. The
shoulder and thorax become so strongly impacted in the pelvis, that
great force is required to introduce the hand to grasp the feet, and
much exertion necessary before the position can be changed.
"In other cases of shoulder and arm presentation, the membranes
burst and the liquor amnii escapes at the commencement of labor,
and the os uteri is rigid and undilated, so that the hand cannot be
passed into the uterus after the labor has continued many hours. The
difficulty and danger of these cases is greatly increased when the
uterus is contracting with violence, and the pelvis is distorted, or
a disproportion exists between the child and pelvis from any other
cause. The greater number of women, if abandoned to the efforts of
nature under these circumstances--the uterus having no power to alter
the position of the fœtus--would ultimately die undelivered, from
exhaustion or rupture of the uterus and vagina."
Fortunately these cases are very rare, and when assistance is rendered
_early_, the difficulty is readily overcome. This is a strong reason
why all women especially should know what to do, because a little
timely help may save much suffering, or even life.
SECTION VII.
ACCIDENTS DURING LABOR WHICH MAY COMPROMISE THE MOTHER'S LIFE.
CHAPTER XXI.
UTERINE HEMORRHAGE, OR FLOODING, DURING LABOR.
This is always a troublesome, and frequently a fatal accident. It
should be always watched for, and attended to as early as possible--_a
few minutes_ frequently determining the recovery or death of the
patient.
The chief causes of flooding are, the too early or violent, separation
of the placenta; insertion of the placenta over the mouth or on the
neck of the womb; laceration of the womb or vagina; the bursting of
a swelled vein; rupture of one or more of the blood vessels of the
uterus; and breaking of the cord.
Probably the most frequent of these causes are the premature or violent
separation of the cord, and the bursting of the blood vessels. The
insertion of the placenta over the mouth of the womb, instead of on
the fundus, occurs very seldom, but when it does severe flooding is
nearly certain to follow, because the placenta has then to be torn,
by the expansion of the parts, at the very commencement of the labor,
and probably continues to pour out blood for a long time before the
child is delivered, and it can be expelled. In fact this occurrence,
unless the labor terminates very speedily, is nearly always fatal to
the mother, and frequently to the child also. In most cases there is
more or less hemorrhage from this cause during gestation, particularly
after the sixth month, when the neck of the uterus begins to enlarge
more than the placenta, and consequently tears away from it. Abortion
frequently results also, if the flooding be not stopped. Madame Boivin
tells us that in _twenty thousand three hundred and fifty-seven_
deliveries there were but _eight_ cases in which the placenta grew
over the mouth of the womb; which is equal to _one_ case in every _two
thousand five hundred and fifty-four_. Dr. Churchill has collected the
accounts of _one hundred and seventy-four cases_ of this kind, and he
finds that out of these forty-eight terminated fatally; or nearly _one
out of every three_.
The rupture of the blood vessels may occur when they are too much
engorged with blood, or when their coats are weakened and corroded
by disease. Shortness of the cord may also produce a rupture of the
vessels, by the strain it causes on them and on the membranes.
In many cases the flooding comes on suddenly, without any warning
whatever, though most usually it is preceded by a sensation of
weight, heat, and fluttering in the pelvis, pains in the thighs and
back, flushed face, headache, and dizziness. The pulse also becomes
irregular, the hands and feet grow cold, and the ears often ring, or
buzz. The only certain sign that the hemorrhage has really commenced
is the appearance of the blood itself, and this often occurs, as
previously remarked, without any premonitory sign whatever.
The danger from hemorrhage during labor is greatest when it commences
the earliest, because it has then the longest to last. From any of the
causes mentioned it is evident that it must continue till delivery is
accomplished, and therefore if it appears at the commencement of the
labor it may cause the death of both mother and child, before the
labor can be terminated. The danger is greatest however to the child,
unless the flow be very profuse indeed, and then it is equally so to
both. After delivery the danger is of course only to the mother; and
the rapidity with which it may compromise her life is in some cases
fearful. Dr. Lee thus speaks of such cases.
"But one of the most dangerous varieties of uterine hemorrhage is that
which follows the expulsion of the placenta, or its removal from the
uterus by art. Sometimes the blood escapes in great quantities from
the uterus immediately after the removal of the placenta, and the
pulse ceases at the wrist, and consciousness is entirely lost in a few
seconds. There is no symptom before labor has commenced, or during its
progress, to warn you of what is about to take place. The child has
been safely delivered, the placenta has come away in a short time, and
while you are perhaps congratulating yourself on the happy termination
of the labor the blood begins to trickle over the bed upon the floor,
or the patient suddenly complains of great faintness. In such cases
there may be either a want of uterine contraction, or the contractions
may not be permanent, but be followed by relaxation and the effusion
of a large quantity of blood, which may either appear externally,
or remain to become coagulated, and distend the uterus. For several
hours after delivery, in some cases, this alternate relaxation and
contraction goes on, to the great hazard of the patient, and if her
condition be not clearly ascertained, and the proper remedies be
employed, death may unexpectedly take place."
In regard to the treatment, he gives such excellent and practical
rules, that I cannot do better than quote them.
"By far the most important remedies in these cases of uterine
hemorrhage are constant and powerful pressure over the fundus uteri,
the application of cold around the pelvis, and the free administration
of wine, brandy, and other stimulants: ergot is indicated, but it
most frequently produces no effect. The pressure and cold are always
within our reach, however sudden the attack may be. The hypogastrium
should be strongly compressed with the binder, and a pad of folded
napkins placed under it, and in addition the hand should be firmly
applied over the fundus uteri. I do not know who it was that first
employed compression of the fundus uteri in cases of flooding after
the birth of the child; but it has been often recommended, and there
are few practitioners in this country who are not fully aware of
the importance of the binder and pad, in exciting permanent and
regular uterine contractions. Dr. M'Keevor states, that in 1815 it
was recommended by Dr. Labatt in his lectures, and for a number of
years before this Dr. Labatt was accustomed to recommend a thick firm
pad, or compress over the pubes, previous to the application of the
ordinary binder, where, in former labors, uterine hemorrhage had taken
place. Dr. M'Keevor states, that of 6665 women delivered during the
years 1819 and 1820, only 25 were attacked with hemorrhage after the
birth of the child. Of these, 15 occurred before the expulsion of
the placenta, ten afterwards, and in all the results was favorable.
He saw only two fatal cases during the time he was in the Dublin
Lying-in Hospital, and he attributes this small mortality partly
to the process of parturition being left entirely to the unassisted
gradual efforts of the uterus; partly to the patient having been kept
cool and quiet, free from all sources of disturbance and irritation;
but, above all, to the careful application of the binder immediately
after delivery, by which means the expulsion of the placenta, and
permanent contractions of the uterus, are most effectually secured,
and whenever any tendency to hemorrhage did occur before the removal
of the placenta, the first point invariably attended to was to tighten
the binder, and in the event of this not succeeding, a thick firm
compress, made by folding a couple of large coarse napkins into a
square form, was placed over the region of the uterus, and the binder
again adjusted. In the great majority of instances, these, with the
admission of cool air, checked the discharge; if not sufficient,
additional pressure was made with the hands.
"At the same time that you efficiently compress the fundus uteri
with the binder and pad, cold should be vigorously applied to excite
the contractions of the uterus. The best mode of doing this is
to plunge a large napkin in a pitcher of cold water, and dash it
suddenly against the external parts, the nates and thighs; and this
should be repeated till the uterus contracts, and the violence of
the hemorrhage is controlled. I am satisfied that this is the most
efficacious method of applying cold to excite uterine contractions;
it is far less formidable than pouring water from a height over the
naked abdomen, but it is not less efficacious, and it possesses these
decided advantages over the other method, that while the application
is made to the external parts, nates, and thighs, the pressure of the
binder and pad is not withdrawn from the hypogastrium, the position of
the patient is not changed from the side to the back, the bed is not
inundated with water, and the application can be repeated as often,
and continued as long, as the urgency of the symptoms may require.
The abdomen may be exposed once, and cold water poured over it from
a height, and the uterus made to contract, and the flow of blood be
arrested for a time, but relaxation of the uterus may follow after
a short interval, and the hemorrhage be renewed again with equal
violence as at first; but we cannot with propriety expose the abdomen
a second time, and empty over it from a height the contents of a great
decanter or kettle. Besides, by adopting this practice, we sacrifice
the whole of the effects derived from pressure on the fundus uteri.
The application of a napkin soaked in vinegar and water to the parts
is often sufficient, along with the binder, to restrain the hemorrhage
where it is not very profuse.
"I have very seldom introduced a plug of any kind into the vagina in
these cases, but when there has been a draining of blood from the
uterus, after the practice now described has been employed, a large
soft sponge passed into the vagina, and pressed up against the os
uteri, has appeared in some cases to promote the coagulation of the
blood. The sponge, however, cannot be employed with safety after the
expulsion of the child and placenta, unless the uterus be firmly
compressed above the brim of the pelvis to prevent its becoming
distended with blood. More frequently I have had recourse with good
effect, to the introduction of several pieces of smooth ice into
the upper part of the vagina, and allowing them to remain there, in
contact with the os uteri, and be dissolved, or pieces of ice have
been inclosed in a bladder and laid over the pubes.
"Other means besides those now described have been recommended in
cases of flooding after the expulsion of the placenta. It has been
proposed to inject cold water into the cavity of the uterus by means
of the stomach pump, and favorable reports have been given of the
practice. The effect, I think, would be similar to directing forcibly
a stream of cold water against a stump soon after amputation; the
coagula in the cavity of the uterus and in the orifices of the
vessels would be all washed away: nevertheless, it might perhaps
be advantageous in some desperate cases. Port wine and water, as
cold as possible, Dr. Collins says, injected into the rectum, has
been of service. Some of the earlier writers on midwifery, and many
in the present century, have strongly recommended the introduction
of the hand within the uterus for the purpose of removing the
coagula accumulated within the cavity, and to excite the uterus to
contract. But it is not necessary to pass the hand into the uterus
for the removal of coagula, because if the binder has been properly
applied, and strong pressure made over the fundus uteri, clots cannot
accumulate within the uterus, and if they have been permitted to
collect in consequence of neglect, then expulsion will immediately
follow the use of proper compression of the hypogastrium, without
the introduction of the hand. Nor do I consider it necessary, to
excite uterine contractions, that the hand should ever be introduced
into the cavity of the uterus after the removal of the placenta. I
am fully convinced, from repeated observation, that this practice,
which is so common as to be almost universal in this country at the
present time, is often not only ineffectual for the purpose, in the
worst cases of flooding, but that it is often followed by the most
pernicious effects; the coagula which nature has formed have been
displaced by the hand, and the uterus has not been excited by the
stimulus of it to secure a permanent contraction. In the greater
number of fatal cases of uterine hemorrhage after the expulsion of
the placenta, which have come under my observation, the hand had been
introduced into the cavity, and the closed fist had been pressed for
a longer or shorter time round and round against the lining membrane,
to make the uterus contract. I do not recollect a single fatal case,
where the unfortunate result could be fairly attributed to the want
of the introduction of the hand into the cavity of the uterus, and
the friction of the knuckles against the lining membrane. I have
repeatedly passed the hand into the uterus to produce contraction, but
it has refused to obey the stimulus of the hand; it has remained like
a soft flaccid bag, more like a piece of intestine than uterus, and
the blood has continued to pour down the arm, until the hand has been
withdrawn, and more efficient remedies employed. Leroux was well aware
that the stimulus of the hand would not in all cases excite the uterus
to contract, for he observes, "where the os uteri is contracted,
the means indicated by Levret are very efficacious, and remove the
hemorrhage as if by a charm. But it is not so in complete inertia of
the uterus; often it is widely dilated, and offers no resistance to
the introduction of the hand. The introduction even of the whole hand
excites little sensation, and the woman will promptly perish from
hemorrhage if other means more active and certain are not employed to
prevent it." The tampon or plug is the remedy Leroux recommends in
cases of flooding after delivery, and he affirms that it will often
succeed in stopping the flow of blood when all other means fail. Dr.
Dewees observes, that he has not found it necessary to introduce the
hand for the purpose of stopping an hemorrhage after the expulsion of
the placenta, during the last five-and-thirty years, as he regarded
the practice as always frightful, and oftentimes unnecessary and
pernicious. But it is difficult to subvert an established mode of
practice, however unsound, and probably some of you, without much
reflection, because you have heard this recommended, will pass up
the hand into the cavity of the uterus after the expulsion of the
placenta, on the very first occasion that you have an opportunity of
doing so, remove all the coagula, and rub the inner surface with the
fist till you are tired, without effect. I have seen cases repeatedly
where this has been diligently performed by those who had neglected to
apply the pad and binder, and all the other means now described. If
you pass the hand at all within the parts, which I strongly suspect
you will do, let me entreat you to carry it no farther than the os
uteri, which you may, with much less risk and with greater effect,
press and rub with the fingers and irritate than the inner surface of
the body and fundus of the uterus.
"Mauriceau recommends that women who are subject to flooding after
delivery should be bled twice or thrice from the arm during pregnancy,
and once, or oftener, after labor has commenced. There are cases of
uterine hemorrhage after the delivery of the child and expulsion of
the placenta unconnected altogether with the plethora, or an excited
state of the heart and arteries, and where bleeding and low diet
do not prevent the accident. Rupturing the membranes at the very
commencement of labor is by far the best remedy, the only thing indeed
upon which any dependance can be placed.
"After attacks of uterine hemorrhage, the patient should not be raised
from the horizontal position for several hours, and the strength
should be supported by wine, beef-tea, and light nourishment. Brandy
in gruel sometimes agrees when wine is rejected. A good large dose
of the liquor opii sedativus often produces the most decided benefit
after the hemorrhage has ceased; there are few cases before this
in which opium does good, though it is constantly given in all the
varieties of flooding, even when the great object is to excite uterine
action. Where recovery is to take place after uterine hemorrhage,
says Dr. M. Hall, the pallor of the countenance, the disposition to
syncope, the coldness of the extremities, the feeble state of the
pulse, and uninterrupted respiration, pass gradually away. Where
the case is to terminate fatally, the symptoms gradually assume a
more alarming aspect, the countenance becomes pale and sunk, the
respiration stertorous, and the pulse cannot be felt at the wrist.
There is great restlessness, and before death one or more fits of
convulsions sometimes occur. Where recovery takes place, in some women
it is astonishing how little permanent inconvenience is felt from the
great loss of blood which they have sustained. In the course of ten
days or a fortnight the effects have entirely disappeared; and this
is the most common result. In some women, a violent determination of
blood takes place to the brain, marked by heat, strong pulsations of
the carotid and temporal arteries, intolerance of light, and all the
symptoms of inflammation of the brain or its membranes. A strong
febrile attack is also sometimes experienced, without an increased
determination of blood to any particular organ. These affections of
the brain and nervous system are aggravated by depletion. The patient
should be kept in a cool, dark room, and mild cathartics, anodynes,
and antispasmodics, occasionally given. Where there is much headache
and throbbing, a few leeches should be applied to the temples, and a
cold lotion to the scalp."
These remarks of Dr. Lee, as to bleeding frequently making the after
symptoms worse, should be carefully borne in mind. There is no doubt
but that too copious, or too frequent bleeding, during pregnancy or
labor, disposes the female to many serious dangers afterwards. I have
known some suffer constant headache, dizziness, and loss of memory, for
weeks after from it; and others have even been made light headed.
To the above remedies I would only append one other, which has, on many
occasions succeeded, when all others have failed, namely _Galvanism_.
This has, at the last moment, when the female was sinking, brought
on uterine contractions, stopped the flooding, and saved her life.
The application is very simple; one pole being placed on the back,
immediately between the hips, and the other over the uterus. Or one
of the poles may be coated with wax, all but the end, and introduced
into the vagina, so that the unwaxed part may touch the mouth of the
womb, while the other is placed over the fundus, or on the back, as
found most efficient. The power should be sufficiently strong to
produce contraction, and the application must be continued till the
contraction remains after the pole is withdrawn. No medical man should
give any female up who is flooding, no matter how severely, till he has
tried Galvanism. In my "_Neuropathy_" and "_Practical Facts_" will be
found many cases, with such plain directions that any one could follow
them and apply it.
The presentation of the placenta, or its growth over the mouth of the
womb, is the most serious cause of flooding, and generally makes any
attempt to check it of no avail, except _delivery_. The discharge
however nearly always occurs before the full period, and either causes
miscarriage or necessitates premature delivery. Dr. Lee remarks:
"In the greater number of cases of placental presentation the
discharge of blood takes place spontaneously in the seventh and eighth
months of pregnancy, and cannot be referred either to bodily exertion,
external violence, nor to any unusual determination to the uterine
organs, or congestion of their vessels. The hemorrhage generally comes
on suddenly, when the woman is in a state of rest, and the blood
continues to flow until faintness or even syncope takes place. It
often ceases entirely, and the patient resumes her usual occupations,
and has no dread of another attack. But after an interval of several
days, and sometimes not before two or three weeks, the flooding is
renewed, and perhaps with increased violence, or a constant profuse
discharge takes place, and a decided effect is produced upon the
constitution,--the pulse becomes rapid and feeble, and the countenance
pale. Similar attacks return at longer or shorter intervals, and if
delivery be not accomplished by art, sooner or later death takes
place. The first attack of flooding seldom proves fatal, but it
sometimes does so; for in the second case related in the table, which
occurred in the British Lying-in Hospital, the life of the patient
was at once extinguished by a single gush of blood from the uterus. I
examined the body after death. The centre of the placenta was over the
centre of the os uteri.
"When flooding takes place to an alarming extent in the seventh or
eighth months of gestation, you ought first to ascertain, by a careful
internal examination, whether or not the placenta be situated at the
os uteri. It is impossible, from the manner in which the discharge of
blood takes place, to be certain of the fact; for there are some cases
of hemorrhage from detachment of the placenta from the upper part of
the uterus, where the flooding occurs spontaneously, and to as great
an extent as in cases where the placenta presents. In some cases I
have been induced, from the symptoms, to believe that the placenta was
at the os uteri when it was not. As the treatment and the successful
or fatal result of the case will, in a great measure, depend on the
correctness of the diagnosis, the examination should be conducted with
so much care and circumspection as to leave no room for doubt on the
subject. An ordinary examination, with the fore and middle fingers, is
generally sufficient to enable us to ascertain the true state of the
case, but where the os uteri is very high up, and directed backwards,
it becomes requisite to introduce the whole hand within the vagina.
The finger should then be passed gently through the os uteri, and,
if the placenta adheres to the cervix, it will be distinguished from
coagulated blood, the only substance with which it can be confounded,
by its firmer, fibrous, vascular structure, and, above all, by its
adhering at one part to the uterus, and being separated at another.
If you will take the trouble to pass the finger carefully and
repeatedly over the uterine surface of a recently expelled placenta,
you will never, in actual practice, mistake a placenta at the os uteri
for a clot of blood, however firm. In all cases it is requisite to
proceed at once to determine by an examination, so carefully conducted
as to render a mistake impossible, whether or not the placenta
presents--even though the hemorrhage should be slightly renewed by the
displacement of the coagula; you cannot be too early acquainted with
the precise condition of the patient. You ought, at the same time, to
ascertain whether the placenta adheres partially or completely to the
cervix uteri, and whether the os uteri is in a condition to admit of
the operation of turning being performed.
"The operation of turning, which is required in all cases of complete
placental presentation, is not necessary in the greater number of
cases in which the edge of the placenta passing into the membranes can
be distinctly felt through the os uteri. Sometimes there is profuse
and dangerous hemorrhage where the placenta does not adhere all round
to the neck of the uterus, but only partially. If the os uteri is not
much dilated or dilatable, the best practice in these cases is to
rupture the membranes, to excite the uterus to contract vigorously,
by the binder, ergot, and all other means, and to leave the case to
nature: by adopting this treatment the operation of turning may be
avoided with advantage in the greater number of cases of partial
placental presentation. But, if the hemorrhage is profuse, has
returned at different intervals, and a great quantity has been lost,
and the constitution is really affected, it is the safest practice at
once, if the orifice of the uterus is in a condition to allow the
hand to pass without difficulty, to deliver by turning the child.
"Where the placental presentation is complete, the operation of
turning should be performed, in all cases, as soon as the orifice of
the uterus is so much dilated or dilatable as to allow the hand to be
introduced without the employment of much force. It is seldom safe to
attempt to deliver by turning before the os uteri is so far dilated
that you can easily introduce the points of the four fingers and thumb
within it: however soft and relaxed it may be, until dilatation has
commenced, and proceeded so far, I am convinced there are very few
cases in which the operation of turning will be required, or completed
without the risk of inflicting some injury on the os uteri. This is a
point of the greatest practical importance, but I do not know in what
manner to communicate to you, in words, a more clear and definite idea
of the grounds upon which you ought to proceed.
"In every case, before attempting to turn, make a most careful
examination of the os uteri, and endeavor, from the degree of
dilatation, and the thinness and softness of the orifice, to form
a correct judgment upon this point, before interfering, for the
hemorrhage will be renewed if the attempt is unsuccessful, and the
patient will be placed in a worse condition than she was before. When
you have resolved to turn, let the patient lie on the left side,
with the pelvis close to the edge of the bed, and introduce the
right hand into the vagina as before described, and then pass the
fingers and hand gently and slowly in a conical form through the os
uteri, giving it time to dilate, and onward into the cavity between
the detached portion of the placenta and the uterus: then force the
fingers through the membranes, grasp both feet, and bring them down
into the vagina, and _slowly_ extract the child as in the cases of
nates presentation, and do not afterwards be in a hurry to remove the
placenta, unless it is wholly detached and lying in the upper part
of the vagina. This operation is easily and speedily performed when
the os uteri is widely dilated and dilatable. It is, however, a great
exaggeration of the facility with which turning may be accomplished in
these cases, to represent it as a very simple process--like putting
the hand into the coat-pocket and pulling out your handkerchief.
At the best it is a dangerous operation, and you can never tell
with certainty whether or not the patient will recover after its
performance, however easily it may have been effected.
"But there is not unfrequently most profuse and alarming flooding
from complete placental presentation, where the os uteri is so thick,
rigid, and undilatable, that it is impossible to introduce the hand
into the uterus without producing certain mischief. In thirteen out
of thirty-six recorded cases the os uteri was rigid and undilatable.
The tampon or plug has no power to restrain the hemorrhage in such
cases, nor do I know of any other means--either cold, quietness,
or opium--which effectually have, and it is sometimes absolutely
necessary under such circumstances to deliver by turning, before the
hand can possibly be introduced into the uterus without producing
fatal contusion or laceration of the part. I have found in several of
these cases, however, that the delivery may be safely accomplished
by merely passing the hand into the vagina, and afterwards the fore
and middle fingers between the uterus and detached portion of the
placenta, grasping with them the feet, which are generally situated
near the os uteri, and drawing down the inferior extremities into the
vagina, and delivering. I know that the inferior extremities may often
be brought down in this way where it is impossible to pass the whole
hand through the os uteri."
The same state of things may however result from other causes, and a
very different mode of proceeding may then be needed, as the doctor
very clearly shows.
"Flooding may take place in the latter months of pregnancy, and during
labor, where the placenta does not adhere to the neck of the uterus,
but to the body or the fundus, and is detached by some external or
internal cause. The separation of the placenta from the upper part
of the uterus may be produced by violence, as blows, falls, pressure
over the hypogastrium, and shocks of various kinds; but it arises much
more frequently from internal causes, of which morbid states of the
placenta, and twisting of the umbilical cord once or oftener round
the neck of the child, are the most common and obvious. This variety
of hemorrhage, though usually termed accidental, can rarely, however,
be referred to accident. Sometimes the flooding occurs to a great
extent without any assignable cause; a large portion of the whole of
the placenta, when in a healthy condition, being suddenly detached
from the uterus, when the patient has been exposed to no external
accident, or injury of any kind, and when no symptoms of increased
determination of blood to the uterus have preceded the attack. When
this happens a large quantity of blood is poured out between the
placenta and uterus, a small portion of which only at the time usually
escapes from the vagina, to indicate what is going on within the
uterus. There may be a great internal hemorrhage, accompanied with
the ordinary constitutional effects resulting from loss of blood--as
faintness, sickness, or vomiting, coldness of the extremities, rapid
feeble pulse, hurried breathing; when there is little or no discharge
from the vagina to excite alarm, or to point out the source of danger,
when it is extreme. It is from the general symptoms of exhaustion, and
by the disagreeable sense of uneasiness, weight, or distension of the
uterus, experienced, and not from the quantity of blood which appears
externally in these cases, that we are led to discover the true state
of the patient--to suspect that internal hemorrhage is going on. But
much more frequently only a small portion of the placenta is at first
detached, and the greater part of the blood which is extravasated
between it and the uterus separates the membranes, and descends by its
weight to the orifice, and escapes through the vagina. In all cases,
however, of uterine hemorrhage in the latter months, the danger cannot
be so accurately estimated by the quantity of blood which appears
externally, as by the general symptoms. The portion of placenta which
is detached, never re-unites to the uterus, but when expelled it is
usually seen covered with a dark coagulum adhering to the uterine
surface.
"When the blood escapes in small quantity, and there are no labor
pains present, and no disposition in the os uteri to dilate, and the
constitutional powers are not impaired, an attempt should be made to
prevent a return of the discharge, and the occurrence of labor pains.
For this purpose, if the pulse is full and frequent, some blood may be
taken from the arm, and the patient should be kept in the horizontal
position, surrounded by cool air, cold applications made over the
hypogastrium, and acetate of lead and opium, mineral acids, and other
remedies that diminish the force of the circulation and promote the
coagulation of the blood, should be taken internally. The plug is
here totally inadmissible; it can only convert an external into an
internal hemorrhage. But where the flooding occurs at first profusely,
and is renewed even in a moderate degree, in spite of our efforts to
check it, the continuance of pregnancy to the full period cannot be
expected; it will be of no avail to bleed and administer internal
remedies, except for the purpose of checking the discharge, and thus
averting the immediate danger until the uterus is emptied of its
contents.
"The operation of turning, which is required in all cases of complete
placental presentation, is rarely necessary in uterine hemorrhage
where the membranes are felt at the orifice. In a great proportion of
these cases, where, on making an examination, you can feel the smooth
membranes extending across the neck of the uterus, the flooding will
be arrested, and the labor safely completed, if the membranes are
ruptured, the liquor amnii discharged, and contractions of the uterus
excited by gentle dilatation of the orifice, and other appropriate
means. The only cases in which this treatment fails are those in which
it has not been had recourse to sufficiently early, or where the
whole or a large portion of the placenta has been suddenly separated
from the uterus, and a great internal hemorrhage has taken place.
The uterus will not contract effectually in these cases after the
membranes have been ruptured; the pains, instead of becoming stronger,
become more and more feeble, return at longer intervals, and during
these the blood flows more profusely, and death would take place
before delivery, if the child were not extracted by the forceps,
crotchet, or by the operation of turning. In all cases, then, of
uterine hemorrhage in the latter months of pregnancy, and in the first
stage of labor, where the placenta does not present, and the quantity
of blood discharged is so great as to render delivery necessary, where
it appears improbable that the pregnancy can go on longer with safety,
or to the end of the ninth month, rupture of the membrane with the
nail of the forefinger of the right hand, evacuate the liquor amnii
by holding up the head of the child, dilate very gently the os uteri
with the fore and middle fingers expanded, and occasionally make
pressure with the fingers around the whole orifice; apply the binder,
give ergot and stimulants, and the uterus will, in all probability,
contract upon its contents, and expel them without further trouble.
If the hemorrhage should, however, continue after the employment of
these means, delivery must be accomplished by the forceps, craniotomy,
or by turning, according to the peculiarities of the case. In women
who are liable to attacks of flooding after the expulsion of the child
or placenta, rupture the membranes at the commencement of labor, even
before the os uteri is much dilated, if the presentation is natural,
and you will often succeed in entirely preventing hemorrhage."
The recommendation to bleed may be with good reason objected to, at
least in the great majority of such cases; and I cannot but think that
a timely and persevering use of the ordinary remedies, namely, keeping
quiet, using acid drinks, and cold fomentations to the abdomen, would
do away with any necessity for it at all. I question very much if ever
bleeding really prevented abortion from flooding, and I cannot but
think that it has often brought it on sooner. Nevertheless, if all
other means fail to arrest the discharge, and there are no decided
objections to the contrary, it might be cautiously tried; though the
policy of taking _more_ blood from a person who is already losing _too
much_, is not very evident.
I have often known the most severe flooding stopped, merely by the
female lying on her back, drinking plentifully of lemonade, and
applying cold wet cloths over the abdomen. A small dose of laudanum
occasionally is also useful; and complete rest and tranquillity of
_mind_ is as indispensable as rest of the body. Many females flood
and miscarry merely from worrying and fretting themselves, and from
passion, or strong excitement, _particularly of a certain kind_. This
in short must be carefully avoided, and the patient must live strictly
as if a widow.
This accident is likely to occur in subsequent pregnancies, at nearly
the same time, and should therefore be guarded against by a careful
avoidance of all excitement, or violent bodily exertion, during the
whole time. Keeping the bowels gently open, and practising a regular
diet, are also requisite. A good supporting bandage is also of frequent
service. For much more valuable information on this subject however,
I refer to my work on "_The Diseases of Women_," in which it is fully
treated.
CHAPTER XXII.
ECLAMPSIA, OR CONVULSIONS DURING LABOR.
Convulsions are to be looked upon as very serious indications of
derangement, during either pregnancy or labor, and are frequently
followed by fatal results to both mother and child. They may be of
several different kinds, _epileptic_, _hysteric_, or _cataleptic_,
though the epileptic form is most common. They often occur during
pregnancy, but not usually before the seventh month, though
occasionally met with much earlier. According to observations it
appears that there is not above one case of convulsions in six hundred
deliveries.
The principal cause of this disease appears to be the strong sympathy
between the womb and other organs, owing to which they are continually
disturbed by the changes it undergoes. Certain temperaments also
dispose to it, particularly the lymphatic, and also dropsy, rickets,
and other diseases. Strong moral impressions may also have a
predisposing effect, such as sudden frights, joy or anger, and also
acute pain, or the dread of it.
In most cases, and particularly during pregnancy, the convulsions are
preceded, and indicated, by severe headache, and spasm at the stomach,
with dimness of sight, bright sparks before the eyes, buzzing in the
ears, and partial difficulty in speaking. Occasionally however the fit
comes on quite suddenly, without any warning whatever.
There are few exhibitions of suffering more frightful than one of
these attacks, and none that call for more prompt and decided action.
In general females are perfectly helpless when one is attacked in
this way, and instead of being able and disposed to render proper
assistance, they either run away alarmed, or fall into hysterics
themselves. It is however of the utmost consequence that the sufferer
should be attended to instantly, and therefore every female should know
what to do in such an emergency, at least till better aid can arrive.
At the first commencement of convulsions the features become gradually
fixed, the eyes are expanded and distorted, the breath is drawn with
difficulty, and all consciousness appears to cease. The body then
begins to twitch, the mouth opens, usually on one side, the tongue
protrudes, the head turns on one side, and the blood rushes to it and
the face in great quantities. In a short time the jaws close again with
great force, and the tongue is bitten if proper care has not been taken
to prevent it. At last the eyes began to twinkle, the mouth moves as
if the patient were muttering, and the nostrils expand; the arms are
thrust straight down by the sides of the body, with the hands firmly
closed; the legs are stiffened straight out, and the body is bent
back like a bow. In short every muscle is affected with spasms, which
are sometimes fearfully violent, and may endure for a considerable
time. When they subside, the fit gradually terminates and passes off.
During the whole time the breathing is difficult, the mouth froths
very much, and the heart palpitates quickly, but irregularly. When the
spasm is over the patient falls into a perfect stupor, during which
she remains unconscious, but with all the limbs soft and moveable,
except the fingers, which appear to grasp. The jaws generally remain
closed, and so do the eyes, but they may be easily opened, and will
sometimes remain open; the breathing becomes powerful and loud, and the
pulse beats with rapidity. At last slight motions are observed, and
consciousness gradually returns, but the memory is generally gone for
some time. This state of stupor usually lasts from ten minutes to half
an hour, but has been known to continue for many hours, or even a whole
day. The spasm seldom continues more than from one to ten minutes,
though it has lasted for an hour or more.
These convulsions might be mistaken for ordinary hysteria by those
not acquainted with the difference. In hysteria however the female
moves about and struggles more; she also cries out, and retains both
sensibility and consciousness, so perfectly even sometimes that
she requests those around to hold her, which is never the case in
convulsions.
During the stupor it might be supposed, by any one not aware of
the previous fit, that the patient was suffering from apoplexy, or
intoxication, the appearance being so similar to that exhibited in
those states. This shows the necessity for careful inquiries as to what
has previously occurred.
During pregnancy convulsions generally cause abortion, either by
bringing on uterine contractions or by causing the death of the child.
Some few patients have suffered from them however, and yet gone their
full time, but this must never be expected. A gradual extinction of
the vital spark, during the stupor is the ordinary termination, though
sudden death is not unfrequent, during the fit. Gradual recovery is
occasionally witnessed, but seldom without partial loss of memory, or
some other affliction. Madame Lachapelle says that _one-half_ of the
females attacked with convulsions die, and of their children many more.
There is no doubt but that the _tendency_ to this fearful affliction
may be very much lessened in many females, by proper attention to diet
and regimen. Those who are of a full habit, and disposed to headache,
and rush of blood to the head, should live low, and carefully avoid
everything of a heating or stimulating character, and also every kind
of excitement or agitation. The bowels should be kept free, and the
skin well rubbed and kept warm, and the head cool.
_Treatment._--While the patient is in the fit, care must be taken that
she does not fall off the bed, or bite her tongue, to prevent which
the jaws must be kept apart, by putting something between, as a piece
of soft wood, or the handle of a spoon covered with cloth, or even a
knotted napkin. The face should be sprinkled with cold water, and the
whole body well chafed, particularly the hands and feet, which should
also be made warm as soon as possible. As soon as the spasm is over it
is customary to bleed, either at the arm, or by leeches to the temples
and behind the ears. Mustard poultices should also be applied to the
feet, and inside the thighs, and an enema should be given of warm water
and a table-spoonful of salt. Ice, or cold water, should be applied
to the head constantly, and if possible the body should be immersed
in a hot bath, which will, in many instances, bring the patient round
immediately without any other treatment. The bladder should be also
looked to, as well as the bowels, and if necessary the catheter should
be used. As soon as she can swallow a few drops of laudanum may be
given, or a little ether, but not a full dose by any means.
The propriety of bleeding, even in these cases, is denied by many, and
I am almost inclined to think myself, that a prompt and persevering use
of the other remedies mentioned, would be fully as successful without
it. At all events, the fearful mortality in spite of it proves that it
has not much power, and may well raise a doubt of its utility.
Convulsions however are so fearful and violent, that few practitioners
can resist the temptation to bleed, because it seems so well calculated
to give prompt relief; and besides it has popular prejudice in its
favor. Some authors however assert that it makes the danger greater of
paralysis, and loss of memory, afterwards.
When convulsions occur during pregnancy they seldom cease entirely till
the uterus is emptied of its contents. It is therefore necessary to
bring on labor, and terminate it as soon as possible, after the parts
are in a proper condition. When they occur during labor it must also
be finished in the shortest time possible, to afford the best chance
of saving the child, and also because no treatment will prevent the
attack while the patient remains undelivered. All means of bringing
on dilatation of the mouth of the womb, mentioned in the article on
_Rigidity_, may be resorted to, excepting _Ergot_, which should never
be used in these cases.
M. Chailly tells us, that in thirteen cases of convulsions _nine_ were
first pregnancies, and _seven_ of the females were dropsical. Only
_one_ was attacked during pregnancy, _ten_ while in labor, and _two_
after. Only _two_ died, and _ten_ of the children.
It is worthy of remark that where pregnant females have had
convulsions, apparently from living too high, the children have also
had them after delivery.
CHAPTER XXIII.
RUPTURE OF THE WOMB OR VAGINA.
Rupture of the womb arises from various causes, but most usually from
powerful contractions when the pelvis is small, or the fœtus large, or
when it presents unfavorably. It not unfrequently results also from
force being used, particularly with _instruments_. In fact there is
no doubt but that _numerous_ females die from this accident, brought
on by the violence, haste, and want of skill of their attendants. Few
injuries are more serious, or more beyond the reach of any remedy than
this, though it is sometimes suffered with impunity.
The symptoms of rupture of the womb are strongly marked, and fearfully
evident. When it occurs, which is most usually during a powerful
contraction, the female shrieks, and instantly complains of an
agonizing pain over the seat of the rupture; her face grows deadly
pale, her pulse falls, and she faints. In general _death_ is almost
instantaneous, though sometimes life may be preserved for an hour or
two, but very seldom. There have even been cases of recovery, but they
are very few, and regarded almost as miracles.
In most cases, directly the rupture happens the fœtus escapes through
the rent into the abdomen, and most of the fluid with it; but sometimes
it still remains in the womb, and then if the liquor amnii is
discharged there may little or nothing pass through the opening, and
the danger will be much lessened in consequence. In all cases the only
proceeding which offers any chance of recovery is, _to deliver as soon
as possible_, because when the fœtus is expelled the uterus begins to
contract, so as to close the wound, and when that is effected, if but
little fluid has passed into the cavity of the abdomen, all may yet
go well. It may frequently happen, when the hand is passed into the
womb, to turn and deliver, that nothing can be found, the fœtus having
passed through the opening into the abdominal cavity, in which case the
hand must be passed through the opening also, and the fœtus be brought
back if possible. If however the rent is too much closed, or the child
cannot be reached, the _Cesarean_ operation is the only resort.
M. P. Dubois tells us of a case of this kind which occurred in his
own practice. The female had only been in labor about an hour when
she uttered a piercing cry, and sank as if suddenly mortally wounded.
The head of the child, which was previously at the mouth of the womb,
could not be felt, and on introducing his hand M. Dubois found its feet
were passed through the opening into the mother's abdomen; he brought
them back however, and effected delivery by turning with comparative
ease. Strange to say this woman was discharged _cured_, in fifteen days
after, though the uterus was so torn that the intestines had forced
themselves through the opening into its cavity, and M. D. put them back
with his hand, which also passed clear into the peritoneal cavity. In
all cases, after the delivery is effected, the womb should be again
explored, so that if any parts have come through they may be returned
before the opening closes, which it may do very soon.
Cases are even mentioned where the child passed clear out of the womb
into the abdominal cavity, and remained there till absorbed, or
escaped through a fistulous opening many years after; while the wound
healed up, and otherwise the patient perfectly recovered. Recovery
however, in any way, is a rare occurrence.
Some females seem more disposed to this accident than others; possibly
from a peculiar tenderness in the substance of the womb. All are
however liable to it, and this liability should beget a proper caution
in all manipulations, and forbid uncalled for violence in any way.
Rupture of the vagina is much less serious than rupture of the womb,
unless it occurs at the upper part, when it may give rise to similar
symptoms and results. At the lower part the danger is much less, though
still sufficient to excite apprehension.
The treatment is the same as in the former case. Delivery must be
effected as soon as possible, and the patient kept still and cool to
avoid inflammation.
_It is generally thought that the greater part of these accidents
result from improper treatment, and particularly from using
instruments._
SECTION VIII.
OPERATIONS WITH THE HAND AND WITH INSTRUMENTS.
CHAPTER XXIV.
OPERATIONS WITH INSTRUMENTS.
The use of instruments in effecting delivery is a last resort to save
life, and ought to be intrusted only to persons of skill; it may
therefore be thought unnecessary to treat of them in the present work,
and indeed I should not have done so but for the purpose of satisfying
the natural curiosity of females themselves. The greater part of the
dread they now experience where instruments are needed, arises from
ignorance of their nature and mode of action. At the present time
nearly all the instruments used, in competent hands, are comparatively
safe and harmless, and if females generally understood how they
operated, much less fear would be excited by their use. Years ago, when
cutting and tearing instruments were employed, in nearly every case of
difficulty, the lamentable results which followed fully justified the
fears experienced, but at the present day such things are seldom seen,
except in medical museums, the same purpose being much better effected
by simpler and more harmless apparatus. I wish therefore simply to
give a brief explanation of the structure, and mode of action, of the
instruments now chiefly employed, and to show the extent of their
application and the results which have followed from it.
THE FORCEPS.
The forceps are intended to take hold of the fœtus, and assist us to
draw it into the world when the natural forces are inadequate, and no
hold can be obtained by the hands. They were first invented about the
year 1650, by an English surgeon named Chamberlin, who made a secret
of his invention and realized a large fortune from it. Since that time
they have been modified in various ways, by different practitioners,
but still remain essentially the same as when first used.
The most usual form, and probably the best, is that represented below:
[Illustration: PLATE L.
Fig. 1. Fig. 2.]
It consists of two blades articulated by a button, or screw joint, so
that they can be easily separated and again adjusted,--Fig. 1. Each
blade is cut out in the middle, and curved, as seen in Fig. 2.
The only part to which the forceps are intended to be applied is the
head, to the dimensions and form of which they are specially adapted.
Some practitioners have used them on the breech, but the practice is
not generally sanctioned, because they seldom retain their hold on this
part and are nearly sure to seriously injure the child when so applied.
With properly constructed forceps, rightly applied to the head, there
is but little danger either to the mother or the child; but in the
hands of an unskillful or careless person the consequences of their use
may be deplorable to both.
It is scarcely necessary to remark that the forceps are neither
_cutting_ nor _crushing_ instruments, but are simply intended to _lay
hold_, like the hand itself, and enable us to draw down the head, or
change its position. Most usually they are made long and curved, as
shown in the above plate, but sometimes they are made much shorter
and straight. They may be used upon the head when it is either at the
upper or the lower straits, or while it is in the passage; but on no
account should they be applied till the parts are fully dilated, and
everything indicates that the child _can_ pass. Thus they should never
be used when the head is too large, or the pelvis too small, nor when
there are tumors in the way. In short no attempt should be made with
them to _force_ the fœtus through a passage which will not admit it
by reasonable efforts. M. Dubois says they should never be used when
the pelvic diameter is less than _three inches_, because with such
dimensions the child is nearly certain to be crushed to death, and the
mother can scarcely escape serious bruises and lacerations. In like
manner, if they are thrust into the womb before the mouth of it is
naturally dilated they are sure to tear and injure it.
It is not necessary here to give directions for using the forceps in
every variety of presentation and position, but simply to show the mode
of applying them as they are most frequently required. The two blades
are adjusted separately, one to each side of the head, and then locked
together, so that the head is firmly inclosed between them, but not
crushed. Dr. Denman gives perhaps the best and simplest directions on
this point, and I therefore quote from his work.
"The first part of the operation consists in passing the forefinger
of the right hand behind the ossa pubis and the head of the child to
the ear; then taking the part of the forceps to be first introduced
by the handle in the left hand, the point of the blade is to be
slowly conducted between the head of the child and the finger till
the instrument touches the ear: there can be no difficulty or hazard
in carrying the instrument thus far, because it will be guided, and
in some measure shielded, by the finger. But the further introduction
must be made with a slow semi-rotatory motion, keeping the point of
the blade not rigidly, yet closely, to the head of the child, by
raising the handle toward the pubes. In this manner the blade must
be carried gently along the head till the lock reaches the external
parts near the anterior angle of the pudendum. The point of the blade,
while introducing, sometimes hitches upon the ear of the child, and
it then requires a little elevation. But when it has passed the ear,
and is beyond the guidance of the finger, should there be any check
to the introduction either of this or the other blade, it should
be withdrawn a little, to give us an opportunity of discovering
the cause of the obstacle, which we must never strive to overcome
by violence, though we must proceed with firmness. When the first
blade is properly introduced, it must be held steadily in its place
by pressing the handle towards the pubes, and it will be a guide in
the introduction and application of the second blade. Let the second
blade be introduced in this manner. Keep the blade first introduced
in its place with the two lesser fingers of the left hand, and carry
the fore-finger of the same hand between the perineum and head of the
child as high as you can reach. Then take the second blade of the
forceps by the handle in the right hand, and, conveying the point
between the finger placed within the perineum and the head of the
child, conduct the instrument, with the precautions before mentioned,
so far that the lock shall touch the interior part of the perineum, or
even press it a little backwards. In order to fix the two blades thus
introduced, that which was placed towards the pubes must be slowly
withdrawn, and carried so far backwards that it can be locked with the
second blade retained in its first position; and care must be taken
that nothing be entangled in the lock, by passing the finger round it.
When the forceps are locked, it will be convenient to tie the handles
together with sufficient firmness to prevent them from sliding or
changing their position when they are not held in the hand, but not
in such a manner as to increase the compression upon the head of the
child. Should the blades of the forceps be introduced so as not to be
opposite each other, they could not be locked; or if, when applied,
the handles should come close together, or be at a great distance from
each other, they would probably slip, or there would be a failure
of some kind in the operation, as the bulk of the head would not be
included, or they would be fixed on some improper part of the head;
though allowance is to be made for the difference in the size of the
heads of children. But if a case be proper for the forceps, if they be
well applied, and we were to act slowly with them, there would not be
much risk of failure or disappointment. The difficulty of applying the
forceps is most frequently occasioned by attempting to apply them too
soon, or by passing them in a wrong direction, or by entangling the
soft parts of the mother between the instrument and the head of the
child, against all which accidents we are to be on our guard.
"When the forceps are first locked, they are placed backwards, with
the lock close to, or just within, the internal surface of the
perineum; and they can have no support backwards, except the little
which is afforded by the soft parts. The first action with them
should therefore be made by bringing the handles, grasped firmly in
one or both hands, to prevent the instrument from playing upon the
head of the child, slowly towards the pubes till they come to a full
rest. Having waited a short interval with them in that situation, the
handles must be carried back in the same slow but steady manner to the
perineum, exerting, as they are carried in the different situations,
a certain degree of extracting force; and after waiting another
interval, they are again to be carried towards the pubes, according
to the direction of the handles. Throughout the operation, especially
the first part, the action of that blade of the forceps originally
applied towards the pubes must be stronger and more extensive than
the action with the other blade, this having no fulcrum to support
it, and chiefly answering the purpose of regulating the action of
the other blade. If there were any labor pains when the operation
was begun, or should they come on in the course of it, the forceps
should only be acted with during the continuance of the pains; the
intention being, not only to supply the want or insufficiency of the
pains, but to follow them, and imitate also the manner in which they
return. By a few repetitions of this alternate action and rest before
described, we shall soon be sensible of the descent of the head; and
it will be proper to examine very frequently, to know the progress
made, that we may not use more force than needful, nor go on with
more haste than may be expedient or safe. In every case we ought to
proceed slowly and circumspectly, not forgetting that a small degree
of force, continued for a long time, will in general be equivalent to
a greater force hastily exerted, and with infinitely less detriment to
the mother or child. But after some time, should we not perceive the
head to descend, the force hitherto used must be gradually increased,
till it be sufficient to overcome the obstacles to the delivery of the
patient. It was before observed, as the head of the child descended,
that the face would be accordingly turned towards the hollow of the
sacrum, without any aim or assistance on our part. Of course the
position of the handles of the forceps, and the direction in which we
ought to act with them, should alter; for they becoming first more
diagonal or oblique with respect to the pelvis, and then more and more
lateral, every change in their position will require a differently
directed action, because the handles should ever be antagonists to
each other. In proportion also to the descent of the head the handles
of the forceps should approach nearer to the pubes; so that, in the
beginning of the operation, though we acted in the direction of the
cavity of the pelvis, towards the conclusion we should act in that
of the vagina. When we feel that we have the command of the head, by
its being cleared of the pelvis, and the external parts begin to be
distended, we ought to act yet more slowly, especially in the case
of a first child, or there would be great danger of a laceration
of the soft parts; and this can only be prevented by acting very
deliberately in the direction of the vagina--by giving the parts time
to distend--by duly supporting the perineum, which is the part chiefly
in danger, with the palm of the hand--by soothing and moderating the
hurry and efforts of the patient--and, in some cases, by absolutely
resisting for a certain time the passage of the head through the
external parts."
[Illustration: PLATE LI.
_The head being drawn through a narrow Pelvis by the Forceps._
The manner in which the forceps draw the head is well shown in the
above plate, and also the compression of the head itself, which is
seen to be squeezed almost to a point at its presenting part. This
compression, however, is not likely to do serious injury, unless it be
excessive. The child may be convulsed a little from it, but usually
recovers, and suffers nothing afterwards.]
It is merely necessary to remark, in conclusion, that the forceps
should never be used till it is manifestly impossible for the child to
be born without them; and it should be remembered that nature alone
frequently effects delivery under the most unfavorable circumstances,
by giving her time. We should wait therefore as long as the safety of
the mother will allow, but never delay a moment when that safety is
compromised.
The accidents which have followed from the use of the forceps are
numerous and terrible, and I could give a most horrifying account of
them if it were necessary. It must be recollected however, that these
accidents have chiefly followed from want of skill in managing the
instrument, or from its being used under improper circumstances. It is
true that there is always more or less of pain and injury to be dreaded
from the forceps, even in the most favorable cases, and with the most
competent operators, but this is no argument against their employment
altogether. In every case where they are really called for, the female
would, most probably, die undelivered, or have to be cut open, so that
it is simply a choice of evils, of which the forceps are the least.