SIXTH SPECIES OF DYSTOCIA.

Faulty Labour from a faulty Condition of the expelling Powers.

Although this species includes that condition of the expelling powers, where their action is excessive, we shall defer this portion of the subject until we treat of precipitate labour, with which it is essentially connected.

The agency by which the child is expelled during labour is of two kinds: 1st, involuntary action of the uterus, assisted, secondly, by the partly voluntary and partly involuntary action of the abdominal muscles.

On the approach of labour, the uterus, which hitherto had been merely performing the office of a receptacle and a means of conveying nourishment to the foetus, now assumes a totally different character; from being in a nearly passive state, it assumes an entirely opposite condition, viz. of high irritability and powerful action. We might almost suppose that its connexion with the nervous system was become more close and intimate; for it is now sensible to the influence of impressions which had before produced no effect upon it. Thus, we see, that affections of the mind, even but of moderate intensity, and to which it was, before labour, nearly, if not quite, insensible, are now capable either of rousing its efforts to the utmost violence, or of arresting them in the midst of full activity; and, on the other hand, we see that where its action has been deranged or interrupted, it gives rise to serious affections of the nervous system, or even convulsions.

With all this, it now displays peculiarities of function, which strikingly distinguish it from all other organs of the body; in some cases it appears to annihilate or to absorb, by its all-pervading influence, the functional energies of other organs; and, in spite of its increased nervous power and susceptibility to various impressions, it seems to possess the faculty of continuing its efforts uninfluenced by general disease, unimpaired by exhaustion, and, for a time, almost independent of the life itself of the mother. In convulsions and paralysis, in general fever and inflammation of vital organs, its powers appear to be undiminished: on the contrary, where the patient, from whatever cause, is rendered incapable of assisting its efforts by the abdominal muscles, the uterus will take upon itself the whole task of expelling the child, which will be born apparently without a single effort upon the part of the mother.

We also observe, that organs, the various conditions and derangements of which have exerted little or no influence upon the uterus in its state of quiescence during pregnancy, now affect it powerfully, and are capable of modifying its action very considerably. The stomach, the intestinal canal, and the skin, are remarkable instances of this, and seldom fail to disturb or pervert the natural efforts of the uterus, whenever these organs deviate from a healthy condition. It will be, therefore, of the highest importance to watch their functions narrowly, in order that we may form a correct estimate of their effects upon the uterus.

Derangements in the contractile power of the uterus may arise from a variety of causes, which may be chiefly brought under two heads, viz. functional and mechanical.

The functional derangements may arise from insufficient activity, the result of general or local debility; from a deranged condition of the digestive organs; from passions or affections of the mind; from hereditary temperament, constitution, or peculiarity; from the patient’s age, being either very young or considerably advanced in years, and pregnant for the first time; from plethora, general or local; from rheumatic affection of the uterus; and from uterine inflammation.

The contractions of the uterus may be mechanically impeded, by tumours imbedded in its substance; by organic diseases, as schirrus, cephaloma, and hÆmatoma; cicatrices from former ulcerations or rupture, or by any other circumstances which interrupt the action of the longitudinal fibres upon the os uteri.

From debility. Where uterine action is insufficient from debility, the pains are feeble, and do not appear to act in the right direction; they are frequently attended with much greater suffering than might be expected from their inefficiency; the intervals between the pains are unusually long, the pains themselves are very short, or, after a while, cease altogether.

This condition, when depending on general debility, may be the result of previous disease, loss of blood, or other debilitating evacuations, poverty, with its attendant miseries, depressing passions of the mind, and health broken down by intemperance.

The contractile power of the uterus itself may be injured by previous leucorrhoea or menorrhagia, by abortions, or by attacks of hÆmorrhage during the latter part of pregnancy; it may be weakened by over-distention of the uterus, either from plurality of children or too much liquor amnii, by the patient exerting herself improperly at the commencement of labour, straining violently, and endeavouring to bear down before she is involuntarily compelled to do so by the presence of the head in the vagina. It may also be produced by the membranes giving way too soon, as is so frequently observed in first labours.

From derangement of the digestive organs. We have already described the change which takes place in the relation between the uterus and other organs, as soon as it passes into a state of action. The intestinal canal stands foremost in the influence which it exerts upon the uterus; whether it be from constipation or diarrhoea, irritation from acrid contents, &c., it will greatly modify, and even derange, its contractile power; the pains cease to be genuine uterine contractions, and assume a spasmodic character, producing much painful griping and pinching about the front and lower part of the abdomen, without any of that regularity of interval and duration, and gradual accession and recession, which mark the presence of real labour pains, and, we need scarcely add, with little or no effect upon the progress of the labour itself. These griping colicky pains appear to supersede the true process of parturition, and either to prevent the uterus acting with due regularity and effect so long as they last, or so to pervert its action as to produce a species of metastasis towards other organs. The pains lose their peculiar character as the expelling powers of the uterus; they cease entirely, and the patient is suddenly attacked with dyspnoea, cramps in the extremities, violent shivering, great restlessness, intense headach, delirium, convulsions, or even mania.

Wherever the action of the uterus is deranged by gastric or intestinal irritation, the abdomen is generally more or less tender in front, particularly over the symphysis pubis; the os uteri is thin, tense, and rigid; the vagina is hotter than natural; the secretion of mucus is sparing; and both os uteri and vagina are more than usually tender to the touch.

From mental affections. The mind is capable of influencing the action of the uterus during labour in a remarkable manner, not only where it is suffering from depressing emotions, as grief, great anxiety, or painful anticipations as to the result, but from causes of a much slighter character, which are nevertheless well worthy the attention of the practitioner: his sudden appearance in the room, without the patient having been properly warned of his arrival: the dread of an examination; or annoyances of a much slighter character, as regards his manner, or that of the nurse, &c., will not unfrequently be quite sufficient to stop the progress of the pains.

The age and general temperament of the patient will also affect the character of the pains. When pregnancy occurs for the first time, either at a very early age, or considerably advanced in life, labour is apt to be protracted, from defective uterine contraction; in the first case, she has not yet attained that degree of adult strength which is requisite to undergo a process requiring so much exertion; the pains are weak, of short duration, and inefficient, but very exhausting to the patient. From the irritability both of the nervous and vascular systems, so peculiar to youth, arises a long train of troublesome symptoms, such as congestion of blood to the head, spasms, syncope, convulsions, &c. In the other case, the condition of the system is the reverse, the irritability is diminished, the uterus is sluggish in its action, the pains are weak and inefficient, follow each other very slowly, and the course of the labour is much protracted; besides this, the short passages through which the child advances are now less capable of dilatation, from having that elasticity and suppleness peculiar to youth, and therefore oppose a much greater resistance.

Where the patient is of a slothful phlegmatic habit, the uterus generally indicates a corresponding state, by the slowness of its action and want of excitability during labour. The same condition is manifested during the catamenial periods in the unimpregnated state, by the absence of pain, weight, throbbing, and other symptoms of local congestion, which are usually observed at these times; so that, but for the discharge, the patient has scarcely any guide to mark their recurrence. On the contrary, where the appearance of the menses is preceded and accompanied by severe pain in the back and loins, throbbing, heat, weight, &c., indicating considerable excitement in the uterine system, we usually observe a similar condition in the uterus during labour, the pains being quick, energetic, and efficient. It is probably from some peculiarity of temperament that we can explain the hereditary disposition which some women show in the unusually lingering or rapid character of their labours.

From plethora. A congested or overloaded state of the uterine circulation, whether from general plethora or from other causes, is not an uncommon cause of feeble contractions. The spongy tissue of the uterine parietes is so gorged with blood, as to prevent, in a great measure, the free action of the pains, and may thus seriously impede the progress of labour. We have already pointed out, when speaking of the signs of pregnancy, the disposition which the system manifests for forming a larger quantity of blood than before; the pulse is stronger and more full, the animal heat is increased; this is especially observed in the uterus, and continues so during the whole process. Whilst in the state of inaction which belongs to pregnancy, but little inconvenience, comparatively, is felt; but when labour commences, and it contracts, the blood is driven from its engorged veins and sinuses into the general circulation; if, however, it cannot do this, from the general state of plethora, its contractions are rendered very imperfect and inefficient.

Besides the appearances of general plethora, we shall easily recognise this condition by the following symptoms: “the patient has much heat of surface and yet but little thirst; the face, eyes, and skin, are red and considerably swollen; we can feel vessels pulsating in every direction; she gets but little sleep, and finds the bed and the bedclothes uncomfortable to her; the uterus is large, thick, tense, and very warm: the os uteri swollen and cushiony, and the vagina also warm and spacious; the foetus is very restless, and causes a good deal of pain by its movements. The pains are short and ineffective, and accompanied with a peculiar sensation of painful stretching or tension, without any symptoms of rheumatism, cramp, or other morbid conditions of the uterus being present.” (Wigand, Geburt des Menschen, vol. i. p. 138.) This condition is not unfrequently accompanied with tendency to hÆmorrhoids, inactivity, constipation, varicose veins of the lower extremities, &c.

Rheumatism of the gravid uterus is an affection which, although it has received but little or no notice in this country, has been long known and described by the continental authors. It appears to be a similar condition of the uterine fibres, when developed by pregnancy, to rheumatism in other muscular tissues, arising from the same causes, connected with the same conditions of the system, and producing similar effects; hence, therefore, it must interfere considerably with the healthy action of the uterus, and greatly diminish or entirely destroy, the efficiency of the pains.

The whole uterus is unusually tender to the touch; the contractions are excessively painful from their very commencement, the slightest excitement of the uterus producing a sensation of pain; they come on with a sudden twinge or dragging pain about the pelvis and loins, and where the contractions are still powerful, they sometimes rise to an intolerable degree of intensity. This condition is frequently observed to a slight extent at the commencement of labour; the mild precursory pains which, in a healthy state, are merely attended with a sensation of equable pressure and tightness round the abdomen, now produce much suffering and give rise to one form of spurious pains, to which we have already, under that head, alluded. Where the symptoms are of considerable severity and have been aggravated by improper treatment, this state may easily pass into that of actual inflammation.

On examining into the history of the case, we shall frequently find that for several days, or even more than a week, the patient has remarked the uterus to be unusually tender to the touch, scarcely bearing the pressure of the clothes; and at night-time the uneasiness has increased to such a degree that she could scarcely remain in bed. There is a frequent desire to pass water, which is highly acid, and deposites much red sediment; and in all probability she complains of rheumatic pains in other parts of her body.

The causes of this condition are the same as those of rheumatism under ordinary circumstances: exposure to cold, and alternations of temperature, particularly when heated; derangement of the stomach, with much prevalence of acid, &c.: insufficient clothing, and, upon the Continent, especially in Holland, where it is said to be very frequent, by the use of chauffe-pieds.

Inflammation of the uterus is another condition which can not only greatly impair, but entirely suspend, the activity of the uterus. It is usually brought on by improper treatment during labour, where the real cause of the lingering ineffective pains at the commencement has been entirely overlooked, and a state of uterine irritation aggravated into one of actual inflammation by the abuse of stimuli and other heating drinks, given with the view to increase the pains; it may be produced by external violence, improper attempts to dilate the os uteri, rough and too frequent examination, endeavouring to turn the child or to apply the forceps before the soft passages were in a fit condition for that purpose.

The whole abdomen becomes extremely tender, and even the slightest contractions of the uterus produce intense suffering; the vagina is hot and dry, and very tender to the touch—its mucous secretion suppressed; the os uteri is swollen, tense, and painful, and the anterior lip is sometimes so distended as to have been actually mistaken for the bladder of membranes; the bowels are confined; the urine is suppressed; the abdomen becomes distended from tympanitis; and general, and probably fatal, inflammation of its contents follows.

Treatment. The causes of insufficient uterine action are so numerous that the modifications to which they give rise are almost endless, and demand no little variety of treatment. A great deal may be done to avoid this state by attention to the patient’s health shortly before labour; and by so carefully regulating it as to ensure a healthy condition of the whole system. Lingering labour from feeble uterine activity is seen most frequently in young primiparÆ of delicate form and nervous irritable habit; the pains produce much fruitless suffering, and greatly exhaust the patient. If the cause continues, the case becomes much protracted, and serious consequences may ensue; such as hysterical symptoms, or even convulsions, inflammation of some organ, general fever, or complete and dangerous exhaustion, hÆmorrhage, retained placenta, or hour-glass contraction of the uterus. In a slight degree this condition is not of unfrequent occurrence, whether from an enfeebled uterus or general debility, and requires general, rather than special treatment for its removal. Change of posture, walking about the room, gentle friction of the abdomen, and occasionally taking some refreshing or mildly nutrient drink, as tea, wine and water, or beef-tea, &c., prove serviceable in such cases; friction of the abdomen, if well applied, frequently produces a great alteration in the character of the pains, and greatly assist the progress of labour: if it be still in the first stage (the os uteri not yet fully dilated,) an enema will not only clear the rectum of any fÆcal matter which may be lodging there, but assist in rousing the uterus to greater activity.

Where we can satisfy ourselves that none of the above-mentioned causes are present to protract the labour, we may proceed to the use of those remedies which are considered to have the power of exciting the uterine contractions, such as secale cornutum, borax, cinnamon, and the several diffusible stimulants. This state of uterine inactivity is, however, rare; and we would earnestly warn young practitioners against too readily concluding that it is present. They will find that the more carefully they investigate such cases, the less frequently will they require these remedies. In using the secale cornutum, we give the preference to the powder: it should be carefully kept from moisture, air, or light: from twenty to thirty grains, mixed in cold water, will be the proper dose, and this may be repeated two or three times, at intervals of half an hour, or rather more. Borax is also another remedy which appears to possess a peculiar power in exciting the activity of the uterus: although it is scarcely ever used for such a purpose in this country, its effects upon the uterus have been long known in Germany; and in former times, both it and the secale cornutum entered largely into the composition of the different nostrums which were used for the purpose of assisting labour. We have combined these two medicines with the best effects, and generally give them in the following manner:—? Secalis Cornuti ? i—ij; SodÆ Subborat. gr x; Aq. Cinnamomi ? jss. M. Fiat haust. Cinnamon, which is a remedy of considerable antiquity, has also a similar action upon the uterus, although to a less degree.

Our own conviction with regard to the use of these remedies is, that they are seldom required during labour, except in nates, or footling presentations, or in cases of turning, where the head is about to enter the pelvis, and where, at this critical moment, the action of the uterus is apt to fail, when it is important to the safety of the child that there should be brisk pains to force the head through the pelvis and internal parts with sufficient rapidity. The chief value of these remedies is for the purpose of exciting uterine contraction after labour, and thus to promote the safe expulsion of the placenta, where there is a disposition to inertia uteri, and ensure the patient against hÆmorrhage.

Where the contractile power of the uterus is so enfeebled that it becomes nearly powerless, we deem it much safer and better to apply extractive force to the head by means of the forceps, and thus overcome the natural resistance of the soft parts, to using medicines which excite uterine action, and thus stimulate the exhausted organ to still farther efforts. The mere cessation of uterine action, however, where the labour has been tedious and fatiguing, is no proof that the uterus is exhausted, and incapable of farther efforts: so far from its sinking into a state of quiescence, being a symptom of exhaustion, experience shows that, in labours of this character, it indicates a very opposite condition, being nothing more than a state of temporary repose, during which nature affords it an opportunity of recruiting its own powers, as also those of the whole system. The interval of ease which is thus given to the patient is accompanied by refreshing sleep; the skin grows moist; a gentle diaphoresis creeps over her; the circulation becomes calm; and after a time, the uterus awakes again to renewed and astonishing exertions; thus, Wigand has remarked, “the pains during the same labour may cease once, twice, or even oftener, and yet after a little rest will return with renewed strength.” (Geburt des Menschen, vol. ii. p. 242.) On the other hand, where the pains, in spite of their becoming more and more ineffective, continue to exhaust the patient with fruitless suffering, and prevent her from enjoying that repose which is so desirable under such circumstances; when the uterus, from increasing irritability, scarcely ceases to contract even for a moment, but continues tense and more or less tender during the intervals of the pains, we can have little or no reasonable expectation that such a labour can be terminated by the natural powers. If the head be not far advanced in the pelvis, or the passages fully dilated, if the bowels have been relieved before labour, and there is no febrile excitement of the circulation, a mild diaphoretic sedative, like Dover’s powder, will be of great service: it calms the irritability of the system, and induces that state of quiet or actual repose to which we have just alluded. If, on the other hand, the labour be much farther advanced, the head approaching the pelvic outlet, and the soft parts well dilated, a little assistance, by means of the forceps, will quickly terminate the case, and free the mother and her child from farther suffering and danger.

Where the uterus is enfeebled by lesion or change of structure, it becomes very difficult to decide as to what course ought to be pursued: in some cases, the soft passages partake in the loss of tone, and offer but little resistance to the advance of the child; in others, however, the uterus is so powerless as to give us no choice but of employing artificial delivery.

We have already pointed out the importance of paying the strictest attention to the bowels shortly before and during labour, and how frequently a neglect of this precaution acts as a means of perverting the due action of the pains, and giving them that character, already described under the head of False Pains. “After the labour has made much progress, the rectum, if loaded, should be emptied by clysters; indeed, the utility of clysters in almost every stage of labour is so apparent that it is to be lamented they are not more frequently employed.” (Synopsis of difficult Parturition, p. 19.) We have seen cases where, although the bowels had been opened at the commencement of labour, after a time, the pains have gradually lost their dilating effect upon the os uteri, although they have increased in severity; the os uteri has remained tense and hard, and the labour has become very tedious and exhausting; the administration of an enema, and removal of a quantity of fÆcal matter from the rectum, has been followed by an instantaneous change in all the symptoms; the pains have become powerful and effective, the os uteri has quickly dilated, and the whole labour has been completed in a very short space of time. In like manner, vomiting during the early part of labour produces the best effects; for it not only assists to relax the parts, by the nausea which usually precedes it, but, by emptying the stomach of unhealthy contents, it tends not a little to restore the uterus to its natural activity.

Where the bowels are distended with flatus, and loaded with acrid and unhealthy contents; we rarely see the pains become regular and effective until these sources of irritation are removed: the abdomen is painful with spasmodic colicky griping, and excites the uterus to partial and very painful contractions of a cramp-like character, which entirely supersede the regular pains, and thus exhaust the patient with protracted suffering without at all advancing the labour itself. If this condition be allowed to continue uninterfered with, the tenderness of the abdomen increases, the circulation becomes excited, and inflammation, and fever of a most serious kind will be the result.

In the management of primiparÆ, who are pregnant either at a very early age or considerably advanced in life, our chief attention must be directed to the management of them for some little time before labour is expected, in order that we may place them in as favourable a state of health as possible, and thus enable them to meet the coming trial with safety.

Where the patient is very young, we should endeavour, by early hours, regular exercise, good air, and simple nourishing diet, &c., to increase her strength, and the general tone of health, and thus diminish that irritability of the nervous system peculiar to females of this early age. She should lead a country life, be as much as possible in the open air, enjoy the absence of restraint and excitement, which are almost necessary consequences of a residence in town, and, by agreeable occupation and cheerful society, train herself, as it were, to that state of moral as well as bodily health best adapted to ensure a favourable result. It is in cases of this kind where the bodily powers have not yet ripened into adult womanhood, that so much good may be effected by using the tepid or (if the season permit) cold salt water bath; and we would beg to refer our readers to our observations on this subject in the chapter on Premature Expulsion. In a case which has recently come under our notice, we have had reason to attribute the remarkably healthy and favourable labour of a young and delicate primipara solely to the invigorating effects of regular exercise and the daily use of sea-bathing, which she continued to within a very few days of her confinement.

It is commonly supposed that women pregnant for the first time, and advanced in years, always have severe labours: this is not necessarily the case, although, at the same time, the greater rigidity of the soft parts considerably increases the resistance to the expelling powers. It will be equally important in this case, also, to improve her health and strength as far as possible, and, by exercise, warm hip baths, &c., to give the parts a greater degree of suppleness and elasticity.

Where the labour is protracted by a state of general plethora or local congestion, the expelling powers are not only enfeebled by the engorged state of the uterine circulation preventing effective pains, but the resistance to the passage of the child is increased by a similar condition of the soft passages, which are swollen and turgid with blood. It is in these cases that bleeding effects such a sudden and complete change; the pulse loses its oppressed character, and rises in point of strength, the uterus loses the thick solid feel which it had before; its contractions become active and powerful, the os uteri dilates, the passages become soft and yielding, and the whole process assumes a different character. By careful observation, this state can easily be discovered before labour has actually commenced; in which case much useless suffering may be prevented by previously reducing the circulation to a proper standard, and thus fitting the uterus for the exertions it has to undergo: besides bleeding, mild saline laxatives, with or without antimonials, will be of great service. The nitrate of potass in these cases has the best effects, either in farthering the effects of the bleeding, or removing the necessity of using so powerful a remedy.

In treating rheumatism of the gravid uterus, our practice will differ but little from that in cases of ordinary rheumatism in other parts: this condition, we believe, is rarely excited, until the system had been already predisposed to it by deranged digestion, and that general prevalence of acid diathesis, which manifests itself in different individuals and under different circumstances so variously; hence, therefore, it will always be important to unload the primÆ viÆ effectually by an active dose of calomel or some other mercurial, before prescribing for the immediate symptoms of the complaint: beyond producing a little occasional nausea, five grains of calomel will act much more comfortably to the patient’s feelings than a smaller dose; there will be less griping and intestinal irritation, but the effect will be more complete and general; not only will the bowels be thoroughly evacuated, but the liver relieved of a large quantity of unhealthy acrid bile, the removal of which cannot but be highly advantageous. We may now proceed to the use of diaphoretics and opiates: of these, Dover’s powder stands foremost; and if given in doses of from ten to fifteen grains, accompanied with warm diluent drinks, rarely fails to induce sleep and a pretty active perspiration, which gives great relief. As the abdomen is usually more or less tender on pressure, it should be covered with a piece of soft flannel, or, still farther to ensure the full diaphoretic effect of the remedies, a warm bath may be had recourse to. Where calomel in the above dose has been premised, we seldom fail in procuring a free action of the skin, and, according to our own experience, with far greater relief to the system than where the perspiration has been induced merely by diaphoretics and external warmth.

If this condition of the uterus has been neglected, and the contractions are beginning to produce intense suffering; if the abdomen is rapidly becoming more tender to the touch, it should be covered with a hot poultice of linseed meal, made more stimulating by the addition of mustard flour, and this should be continued until the skin is considerably reddened. In the slighter cases of this affection, where the bowels have been opened, friction upon the abdomen frequently produces the happiest effects. We presume it is to these cases that Dr. Power alludes when he says, “in some, the improper action will be removed almost instantly, and, as it were, by a miracle; so that a case which has been protracted for the greater part of a week, under the most intense suffering, without the least progress, has been happily terminated in fifteen or twenty minutes from the first commencement of the friction.” (Power’s Midwifery, 1819.)

Where inflammation of the uterus takes place during labour, the case becomes one of the most serious character; for not only is the suffering, which is produced by every contraction, of the most intense description, but the presence of the child aggravates the state of inflammatory action, and excites the uterus to still more violent efforts, while the swollen and unyielding state of the os uteri, &c., precludes the chance of speedy delivery. Under such circumstances, we must trust almost entirely to the lancet in aiding this important object; for, until the circulation has received an effectual check by fainting, the dilatation of the parts cannot proceed, nor can any attempt be made to give artificial assistance. The abdomen should be covered with a hot linseed meal poultice, as above described, in the treatment of rheumatism of the uterus; warm decoction of poppies should be thrown up the vagina, or, if this cannot be procured at the moment, some thin gruel mixed with a little laudanum, or in which a few grains of Extr. Conii or Hyoscyami have been suspended; the bowels should be opened by a simple enema, after which a small opiate injection will be desirable, in order still farther to allay irritation.

Stricture of the uterus. We have already had occasion to allude more than once to that species of violent and continued contraction which we have denominated stricture of the uterus, but have chiefly considered it where it affects the os uteri; a somewhat similar condition of spastic rigidity is occasionally, though rarely, seen in other parts of this organ, and is capable of producing a most serious obstacle to delivery. The uniform and regular action of the uterus disappears; its contractions become partial, both in extent and effect, one part alone contracts whilst the rest of the uterus is relaxed; its shape thus becomes altered; for, by these partial contractions of its fibres, it may become elongated, shortened, flattened, &c.: the spasmodic action frequently varies its seat, and successively attacks different portions; thus, where it affects the body of the uterus, it becomes contracted almost like an hour-glass, having a transverse circular indentation, as if it had been tied with a cord. Where the contraction affects one side of the organ, it alters the shape of it materially; the fundus is pulled down equally, and the position of the child, as we have shown in the first species of dystocia, may be seriously affected. If the stricture has its seat in the os uteri, this becomes tightly contracted, hard, unyielding, and painful upon pressure: it does not dilate sufficiently, and the inferior segment of the uterus is generally pushed downwards, whilst the os uteri itself is drawn upwards. In cases of this kind, we find that although the uterus contracts, the child does not advance, but rather retracts, during a pain; the contractions are never general, but partial, and even where they are general, the fundus does not attain its due preponderance over the os uteri, so that the one contracts as much as the other does; in severe cases, also, the uterus continues in a state of spasmodic action during the intervals of the pains: this is frequently accompanied with a painful and harassing sensation of tension and stretching, very different to that produced by the action of regular pains upon the os uteri; and in the worst cases we occasionally observe a peculiar state of the brain, which manifests itself by attacks of insensibility, faintings, or even convulsions.

Although the head does not advance in spite of the strongest pains, yet, upon examination, we find no want of proportion between it and the pelvis; if the intervals of uterine action be of sufficient duration to allow it, we shall feel the head quite moveable in the pelvis, or, at any rate, with plenty of room for the finger to pass round it, and yet when a pain comes on, the head remains fixed, or if it does descend somewhat, it returns again to its former situation as soon as the pain is over. This state of things is usually seen where the body of the uterus is the seat of the stricture, and is contracted transversely upon that of the child, which it tightly encircles, and renders all farther advance impossible.

This state of spasmodic action is produced by whatever tends to irritate the uterus and excite it to irregular action; thus, premature rupture of the membranes, especially when it has been suddenly drained of a large quantity of liquor amnii; the irritation arising from acrid matter in the intestines, or from their being loaded with accumulations of fÆces; improper examination, and more especially, attempts to dilate the os uteri by the fingers or hand; endeavouring to strain and bear down during the early part of labour, and when the patient is not involuntarily compelled to do so; attempting to apply the forceps when the os uteri is not fully dilated, or whilst the instrument is very cold: malposition of the child, especially after rupture of the membranes; and lastly, anxiety, fear, and other affections of the mind. The circulation is generally in an irritable state, the patient is of a delicate excitable habit, and is apt to be nervous and hysterical.

The treatment in these cases will be precisely on the same general rules as we have above described; the bowels must be relieved by a laxative or by an enema; if necessary, the circulation must be reduced to the proper standard by bleeding, and the irregular uterine action controlled by opiates. Besides these means, the warm bath is of the utmost service, and seldom fails to produce a favourable change. Where the action of the uterus is impeded, or otherwise rendered faulty by organic disease, lesions of its structure, &c., we shall in all probability be compelled to use artificial assistance.

II. Where the action of the abdominal and other muscles is at fault. Where the faulty character of the labour arises from a faulty state of the partly voluntary, partly involuntary, action of the abdominal muscles which is destined to aid the uterus in expelling the child, this may equally be a result of general debility from previous disease, exhaustion from the long duration of the labour, from the abuse of spirituous liquors, &c. It may also arise from various causes which tend to impede the respiration; such as excessive corpulence, great deformity of the spine, bronchocele, spasmodic asthma, rheumatism of the diaphragm, ascites, hydrothorax, phthisis, pneumonia, aneurism of the aorta, dilatation of the heart, &c.

Where the size is such as renders the patient very unwieldy, or the spine is much deformed, we must place her in that position in which she can exert herself with greatest effect, and at the same time experience the least possible obstruction to her breathing: with deformed people, this is of great importance; she should be propped up with pillows, &c. into whatever posture she can lie with most comfort, and the practitioner must manage to deliver her in this position. Patients suffering from pluerisy or pneumonia are unable to bear the continued strong inflation of the lungs which is necessary during the second stage: under these circumstances, the pain and inflammation are greatly aggravated; venesection must be used with great promptness, but it does not always bring relief or remove the danger; for the disease is kept up by the presence of labour, which, therefore, in all probability, will require to be terminated by art. In some cases, however, as we have already mentioned, especially where the disease is of an acute character, the uterus appears to take upon itself the whole exertion of the labour, so that the child is born apparently without any effort on the part of the mother.

Faulty state of the expelling powers after the birth of the child. The last stage of labour, which comprehends the expulsion of the placenta, may also be retarded by a faulty state of the expelling powers. This not only arises from the causes which we have already mentioned, but from those connected with the labour itself; as from premature and immoderate straining during the pains, misuse of medicines given to increase the pains; also, where the uterus has been exhausted by the length and severity of the labour, or where it has been thrown into a state of inertia by the sudden evacuation of its contents, especially when previously much distended. This condition is frequently induced by not supporting the child sufficiently when the shoulders are about to pass through the os externum; the main bulk of the child is therefore suddenly expelled, and the uterus is at once thrown into irregular action by the sudden shock of so great a change, or falls into a state of inertia. The separation and expulsion of the placenta may be also retarded where the labour has required the forceps, turning, or perforation, especially the latter, on account of considerable pelvic deformity; the more so if there has been considerable delay in giving assistance. Irregular and partial action of the uterine fibres, after the expulsion of the child, may easily render the last stage of labour dangerous; for, under such circumstances, the portion of the uterus to which the placenta is attached may be in a state of firm contraction in one part, while the other is quite relaxed, so that incomplete separation of the placenta will be the result, and hÆmorrhage follow: hence we cannot be too cautious in avoiding every cause which may at all influence the regular action of the uterus during the last stage of labour, which is far more dangerous than the two others put together.

In a case of this kind, we do not feel the uterus contracting into the firm globular mass above the symphysis pubis, as might have been expected; but if inertia uteri be present, it remains soft and large, the peculiar pains of the last stage which indicate the speedy separation and expulsion of the placenta do not make their appearance, or only in a very insufficient degree. If it be contracting irregularly and only in part, we shall feel this distinctly, from the unequal shape and hardness of the uterus, which in some cases will have almost a lobulated feel; in others, it presents a considerable depression either upon the fundus or anterior wall.

HÆmorrhage. The danger here, chiefly depends upon the occurrence of hÆmorrhage: if the placenta be still attached by its whole surface to the uterus, no hÆmorrhage can ensue; but if the contractions have been of sufficient power to detach more or less of it from the uterus, large trunks, which have hitherto conveyed maternal blood into the placental cells, are torn through, and a profuse discharge must be the result. The degree of the hÆmorrhage will in most instances furnish us with a tolerable estimate of the extent to which the separation has taken place; but it is far from easy to ascertain correctly the quantity of blood which has been lost, and we must rather try to ascertain what are the effects produced upon the system of the patient. The pulse becomes smaller and quicker, the column of blood is evidently diminished, and the heart for a time drives on its contents more rapidly; but as the loss increases, so does it become enfeebled, and although beating with a very frequent stroke, it now becomes so weak as to be scarcely or no longer capable at the wrist of producing such a resistance to the finger as will give the sensation of a pulse; the necessary consequence of this is, that the patient at first complains of great weakness, the face becomes pale, the lips white, the breathing anxious; this is followed by a sense of great prostration, the perspiration breaks out upon the face and forehead, tinnitus aurium, confusion of ideas, and sense of darkness before the eyes succeed; the load at the prÆcordia, and the oppression of breathing, become more insupportable; she tosses her arms about, and in some instances has a sensation that the room is going round with her, or that she is sinking through the bed; in other cases, the breathing becomes gradually more feeble, until it is almost imperceptible; she every now and then takes a deep sobbing grasp, which seems to rouse her to consciousness for a moment, and then she relapses into a state verging upon insensibility; the pulse is probably now no longer perceptible at the wrist, the face is undergoing a rapid change, the features are contracting, and there is a general expression of death-like collapse which shows too truly the urgency of the danger. The alterations which are taking place in the state of the brain and nervous system, vary in different individuals: in some, there is strabismus; in others, temporary mania, or at least, delirium; and in more unfavourable cases, even convulsions; these last are especially formidable, as they not only show that the system has been severely affected by the loss of blood, but are apt, from their violence, to extinguish the little spark of life which is left, or, in other words, to be followed by sudden death.

These are some of the many symptoms indicating a sudden and extensive loss of blood; others also occur, depending on the external or internal character of the hÆmorrhage. The want of contraction and general flaccidity of the uterus, as felt through the abdominal parietes, have been already noticed; if the blood be prevented escaping by the contracted state of the os uteri, by coagula, or the detached placenta, it begins to collect in the cavity of the uterus, which therefore swells as the accumulation continues to increase, so that it may even equal the size which it had before labour, containing many quarts of blood, and the patient may be in the most imminent danger of dying from hÆmorrhage, perhaps, without any blood having issued externally: this is the internal uterine hÆmorrhage, a form which is justly looked upon as peculiarly to be dreaded, from the insidious character of its attack. In most cases, the uterus fills to a certain extent only, and then, as if excited to contraction by the distention of its parietes, or any slight concussion, produced by coughing, &c. it expels a large quantity of coagula and half coagulated blood, and returning to its former state of atony, again begins to swell from fresh accumulation of blood in its cavity.

Treatment. So long as the inertia or atony of the uterus continues without any symptoms either of external or internal hÆmorrhage, we are not justified in interfering directly, either for the purpose of exciting the uterus, or still less of removing the placenta. This condition chiefly occurs where the uterus has been previously much distended, or suddenly emptied of its contents, where it has been exhausted by long and difficult parturition, and also, as Leroux has observed, “in women of a phlegmatic temperament and lax fibre, who, during pregnancy, have suffered much ill-health, by which the tone of the solids has been weakened; who have very large pelves, and a soft dilatable os uteri.” (Sur les Pertes de Sang, 1776.)

We must therefore give the uterus time to recover from the great and sudden change which it has undergone, to collect its strength, to remodel and arrange its forces, until it is at length able, not only to resume its efforts, but to contract to that extent which shall both ensure the expulsion of the placenta and the safety of the patient. Whilst this state of inertia lasts, the patient should be kept as quiet as possible; she should be placed in a comfortable posture, take a little cool drink from time to time (as cold tea, toast and water, &c.,) in order to refresh her;[131] or, if she has been much exhausted by her labour, a glass of wine may be given with good effect. If, however, hÆmorrhage appears, this shows that a separation of the placenta from the uterus must have taken place: our great object should now be to excite contraction of the uterus, for by this means alone can we stop the discharge.

In ordinary cases, a little circular friction with the tips of the fingers over the fundus will generally be sufficient. If the uterus begins to swell, we may grasp it with a sudden but moderate degree of force; or we may give the fundus every now and then a smart jog with our hand. Whilst these measures are pursuing, a dose of secale cornutum (see Dystocia, p. 330,) will be of great service; for even if it does not act soon enough to aid the expulsion of the placenta, it contributes greatly to ensure the contraction of the uterus afterwards. If the hÆmorrhage nevertheless continues profuse, it will be necessary to introduce the hand into the uterus and remove the half-separated placenta: its contractions are too feeble for that purpose of itself, and the presence of the hand in its cavity, and the artificial separation of the placenta, act as a stimulus, and rouse it to greater activity. The opinion that we only increase the danger by thus increasing the bleeding surface does not hold good, when, from the profuseness of the hÆmorrhage, it has become evident that the greater part of the placenta is already separated from the uterus; on the other hand, where there is but a slight discharge, the case is very different, and would not justify our having recourse to so strong a measure.

If the contraction which has been excited by the artificial removal of the placenta be but temporary, we must proceed to the use of other means for the purpose of rousing the activity of the uterus. The sudden application of cold is a most valuable means; it acts here solely by the shock which it produces at the moment, and not by lowering the circulation and favouring coagulation. Thus we find that a cold wet napkin suddenly flapped upon the abdomen has an immediate effect upon the uterus; but it ought not to remain on long, and the skin should be dried with a warm towel, in order that a fresh application of the cold may produce the greater effect. A series of such shocks may be produced by using another wet napkin to the vulva, and a third to the sacrum and loins; an assistant should remove them in the order in which they have been applied, and dry the skin, for a repetition of the remedy, if necessary.

A still more powerful mode of producing a sudden shock, and thus rousing the uterus to activity, is by a douche of cold water upon the abdomen. This may easily be effected by a teapot or kettle held at some height above, and slowly emptied upon the lower part of the abdomen; the uterus will seldom refuse to obey such a stimulus as this, however great may be the inertia into which it has fallen. The inefficiency of a prolonged application of cold to the abdomen, however severe, and the efficiency of the contrary practice, is admirably expressed by Dr. Gooch, in his description of a dangerous case of hÆmorrhage:—“Finding the ice so inefficient, I swept it off, and taking an ewer of cold water, I let its contents fall from a height of several feet upon the belly: the effect was instantaneous; the uterus, which, the moment before, had been so soft and indistinct as not to be felt within the abdomen, became small and hard; the bleeding stopped, and the faintness ceased—a striking proof of the important principle that cold applied with a shock is a more powerful means of producing contraction of the uterus than a greater degree of cold without the shock.” (An Account of some of the more important Diseases belonging to women, by Robert Gooch, M. D.)

Another mode of applying cold to induce uterine contraction, and little, if at all, inferior to that above-mentioned, is the injection of cold water into the uterus itself: this can only be effectually employed after the removal of the placenta and membranes, and frequently proves of the greatest assistance, being capable of rousing the uterus when many other means have failed. If, from the sultriness of the weather, water cannot be procured of sufficient coldness, or if the case be very urgent, vinegar and water in equal parts may be used; but the injections of spirit and water, which some have recommended, can scarcely be considered as a safe proceeding.

These various means frequently require to be repeated several times before the contraction of the uterus becomes permanent, nor must we be discouraged by finding the uterus becoming soft again in a minute or two after ceasing to use them; for we may feel assured, with few exceptions, that if we can only keep the uterus, by this means, in a state of tolerable contraction for half an hour, it will ultimately become permanent, and remain so of itself.[132]

It is, in these cases, where pressure is of so much importance, not for the purpose of producing uterine contraction, as of maintaining it when once excited. By pressure applied at this moment, we may frequently keep the enfeebled uterus in a state of contraction, which, but for this support, would have yielded to the general force of the circulation, and have again expanded. For the same reason, whenever the uterus begins to swell again from internal hÆmorrhage, and by the renewal of the above remedies, it becomes hard, but does not diminish in size: this shows that the contraction has not been powerful enough to expel the blood, which, in all probability, has already begun to coagulate in its cavity: where this is the case, the hand, or at least two fingers, should be passed, to dislodge the clots, and assist in their expulsion; after which, a cloth folded into a thick compress should be placed over the fundus, and firmly bandaged upon the abdomen by a broad towel.

Where every means has failed to induce a sufficient or permanent degree of contraction, we believe that the only certain means which remains, is putting the child to its mother’s breast. Under no circumstances do we see the sympathy between the uterus and the breast so beautifully displayed as here, and we may most truly affirm that we have never known it fail where the mother was sufficiently conscious to know that it was her own child. To a by-stander, ignorant of what was taking place, the sudden gush of blood mixed with coagula, which follows the application of the child, would be nothing less than a sign of renewed danger, while, in fact, it is a proof that the uterus is beginning to contract and expel its contents.

If the pulse has been seriously reduced by the loss of blood which the patient has sustained, a glass of wine, or a spoonful or two of brandy, will be of great service in rousing the vital powers; and this must be repeated or increased, according to the urgency of the circumstances; a little weak beef-tea, given from time to time, frequently appears to rouse the system, even more than the brandy, and is more refreshing to the patient; it can also be taken in larger quantities, for when the exhaustion is very great, stimuli appear to excite vomiting, which is by all means to be avoided. Where, however, it occurs spontaneously, it need not be looked upon in so formidable a light: thus Dr. Denman observes, “when patients have suffered much from loss of blood, a vomiting is often brought on, and sometimes under circumstances of such extreme debility that I have shrunk with apprehension lest they should have been destroyed by a return or increase of the hÆmorrhage, which I concluded was inevitable, after so violent an effort: but there is no reason for this apprehension; for, though vomiting may be considered as a proof of the injury which the constitution has suffered by the hÆmorrhage, yet the action of vomiting contributes to its suppression, perhaps by some revulsion, and certainly by exciting a more vigorous action of the remaining powers of the constitution, as is proved by the amendment of the pulse, and of all other appearances immediately after the vomiting.”

When a slight trickling of blood continues, although the uterus is tolerably hard and contracted, it will be desirable to make an examination, for we shall frequently find a long slender coagulum hanging through the os uteri into the vagina, upon the removal of which, the discharge will cease.

The application of the child to the breast is not less valuable for preventing any return of the hÆmorrhage than for stopping it in the first instance: we are never perfectly secure against hÆmorrhage coming on during the first few hours after delivery, even where every thing has turned out as favourably as possible: the exhaustion from the length or severity of the labour, the warmth of the bed, and in some cases, it would even seem, the relaxing effects of deep sleep, are all liable to be followed by inertia uteri and hÆmorrhage. In no way can we ensure our patient so completely against this kind of danger as by putting the child to the breast; the uterine contraction which it excites is not only powerful, but permanent; nor do we consider that a practitioner is justified in leaving a patient in whom the uterus has shown a disposition to inertia without having ensured her safety by this simple but effectual safeguard.

There is a form of hÆmorrhage after the birth of the child, which seems to depend upon an over-distended state of the circulation, and where its activity appears too great for the contractile power of the uterus; so that, in spite of the uterus being tolerably firm and hard, a profuse hÆmorrhage is almost sure to follow the separation of the placenta. This condition has been described by the late Dr. Gooch, and still more recently by Professor Michaelis, of Kiel; to the former, especially, we are indebted, not only for having first pointed out this important fact, but for having placed it before us in the simplest and clearest light. “I had now witnessed,” says Dr. Gooch, “two labours in the same person, in which, though the uterus contracted in the ordinary degree, profuse hÆmorrhage had nevertheless occurred: let me be understood—after the birth of the child, I laid my hand on the abdomen, and felt the uterus within, of that size and hardness, which is generally unattended by, and precludes hÆmorrhage; in both instances, the labour had been attended by an excessively full and rapid circulation. I could easily understand that a contraction of the uterus, which would preclude hÆmorrhage in the ordinary state of circulation, might be insufficient to prevent it, during this violent action of the blood-vessels; and the inference I drew was, that, in this case, the hÆmorrhage depended not on a want of contraction of the uterus, but on a want of tranquillity of the circulation; and that if ever she became pregnant again, a mode of treatment which would cause her to fall in labour with a cool skin and a quiet pulse, would be the best means of preventing a recurrence of the accident.” This will be effected by an occasional venesection during the last weeks of pregnancy, by the use of saline laxatives; and if there be still much disposition to heat the surface, and excitement of circulation, by doses of nitre three times a day, and by strict antiphlogistic regimen.