Part 18 (1/2)
Among his objections, Baudelocque states, that ”the neck of the uterus at seven months has seldom begun to open; it is still very thick and firm.
The pains, or the contractions of that viscus, cannot then be procured but by a mechanical irritation pretty strong and long continued; but those pains, being contrary to the intentions of nature, often cease the instant we leave off exciting them in that manner. If we break the membranes before the orifice of the uterus be sufficiently open for the pa.s.sage of the child, and the action of that viscus strong enough to expel it, the pains will go off in the same manner for a time, and the labour afterwards will be very long and fatiguing; the child deprived of the waters which protected it from the action of the uterus, being then immediately pressed upon by that organ, will be a victim to its action before things be favourably disposed for its exit, and the fruit of so much labour and anxiety will be lost. Premature delivery obtained in this manner is always so unfavourable to the child, that I think it ought never to be permitted except in those cases of violent haemorrhage which leave no chance for the woman's life without delivery; the nature of the accident also disposes the parts properly for it.” (_Baudelocque_, transl. by Heath, -- 1986, 1987.) All this plainly shows that Baudelocque did not rightly understand the real objects and nature of artificial premature labour, to which, in fact, his objections do not apply, but to the _accouchement force_ of the French pract.i.tioners, where, on account of the sudden accession of dangerous symptoms, such as haemorrhage, convulsions, &c. &c., the os uteri was rapidly and violently dilated by the hand, which was then pa.s.sed into the uterus, the feet seized, and the child forcibly delivered, an operation which is now rarely performed in Germany and never in this country.
The celebrated Carl Wenzel, of Frankfort, was the first in Germany who declared himself in favour of the operation. Kraus and Weidemann followed, the former two having performed it with complete success. The favourable results also in the hands of English pract.i.tioners and its increasing reputation quickly silenced the virulent abuse which was levelled at it by Stein, jun., and some other German authorities; the celebrated Elias von Siebold, of Berlin, who had first opposed it, candidly confessed his error and became one of its earliest supporters. Increasing experience showed that it could scarcely be looked upon as a dangerous operation for the mother, and that in by far the majority of instances it was also successful as regarded the child. Professor Kilian, in his work on operative midwifery, has collected the results of no less than 161 cases of artificial premature labour. (_Operative Geburtshulfe_, erster band, p.
298.) Of these, 72 occurred in England, 79 in Germany, 7 in Italy, and 3 in Holland: of these cases, 115 children were born alive and 46 dead; of the 115 living children, 73 continued alive and healthy; 8 of the mothers died after the operation, but of these, 5 were evidently from diseases which had nothing to do with the operation.
The most unfavourable circ.u.mstances under which the operation can be undertaken are, where the child presents with the arm or shoulder: here it will require turning, which, in many cases, owing to the faulty form and inclination of the pelvis, cannot be effected without considerable difficulty, and greatly diminis.h.i.+ng the chances of the child being born alive. With this exception we cannot see why it should not be as favourable as labour at the full term of pregnancy; it is far less dangerous than other species of premature labour, for the haemorrhages, which are so apt to attend them, are never known to occur here.
This mode of delivery has not only been proposed in cases of contracted pelvis: ”There is another situation,” says Dr. Denman, ”in which I have proposed and tried with success the method of bringing on premature labour. Some women who readily conceive, proceed regularly in their pregnancy till they approach the full period, when, without any apparently adequate cause, they have been repeatedly seized with rigour and the child has instantly died, though it may not have been expelled for some weeks afterwards. In two cases of this kind, I have proposed to bring on premature labour, when I was certain the child was living, and have succeeded in preserving the children without hazard to the mothers.”
(_Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 180.)
_Period for performing the operation._ Although under the head of PREMATURE EXPULSION we have stated that a foetus is capable of maintaining its existence if born after the twenty-eighth week of pregnancy, we must not be supposed to recommend the artificial induction of premature labour at so early a period as this. ”Experience has shown that it was not necessary to induce labour at so early a period as was first imagined, on account of the very great difference which even one or two weeks are found to make in the hardness of the foetal skull. Thus, for instance, in cases where the antero-posterior diameter was only three inches, six weeks before the full term of utero-gestation were found sufficient, and where it was three inches and a half, fourteen days made sufficient difference.”
(Naegele, _MS. Lectures_.) Still, however, as it is so difficult to be quite sure of the data upon which we have made our reckoning, it will be safer to fix the operation a week or two earlier; and if we lose a little time by failing in our first endeavours to induce uterine action, it will be of so much the less consequence: hence, therefore, as a general rule, the most eligible time will be between the thirty-fourth and thirty-sixth week; and if the deformity be very considerable, we may commence operations as early as the thirty-second week or two months before the full term, short of which it will seldom either be justifiable or necessary. On the other hand, where the state of the cervix and the history of her pregnancy combine to make our reckoning nearly a matter of certainty, the later we can safely delay the operation the better, for by so doing the process resembles more a natural labour, and the chances in favour of the child are much increased.
_Operation._ The original mode of artificially inducing premature labour was merely by puncturing the membranes and allowing the liquor amnii to escape; the more gradually this is done the better, for by this means the uterus is not entirely drained of its fluid contents, and is, therefore, prevented contracting immediately upon the child; the value of this precaution was pointed out by the late Dr. Hugh Ley, and also by Wenzel. A considerable interval may elapse between puncturing the membranes and the first contractions of the uterus, generally varying from forty to eighty hours: it should be performed while the patient is in the horizontal posture, in order to prevent the escape of too much liquor amnii. A moderately curved male catheter, open at its point and carrying a strong stilet sharpened at the end, is the best and simplest instrument for the purpose: on pa.s.sing it up to the membranes, the stilet should be protruded, but to a short extent, to avoid injuring the child; and as soon as the liquor amnii runs from the other end, the instrument should be withdrawn, and the patient desired to remain quiet. A dose of opium has been usually given after the operation by the English pract.i.tioners, but its utility appears rather questionable: a brisk purge of calomel and jalap, some hours previously, is much more important; uterine action comes on much more regularly and effectively, and there will be much less chance of those rigours occurring which some pract.i.tioners, although erroneously, have supposed, were connected with the death of the child.
The practice of dilating the os uteri first, as recommended by Bruninghausen, Kluge, and others, has, as far as we know, never been attempted in this country, and resembles much too closely the _accouchement force_ of the French authors ever to be permitted.
The simplicity of the operation of tapping the membranes has rather led pract.i.tioners to overlook a still greater improvement, viz. the inducing uterine action first: this was proposed by Dr. Hamilton to be effected by pa.s.sing up a catheter, and separating the membranes from the uterus to a considerable distance above the os uteri. The operation certainly succeeds in some cases; but our own experience goes to prove, that in the majority it is not sufficient by itself to provoke uterine contraction, and in order to ensure success we must combine with it other means.
The plan of treatment which we have found most certain is first to clear out the bowels by a full dose of calomel and colocynth, then to give the patient a warm bath, in which she may remain twenty or more minutes, after which the abdomen should be well rubbed with stimulating liniment as she lies in bed, and the secale cornutum given in doses of a scruple of the powder in cold water, repeated every half hour for five or six times.
Contractions of the uterus rarely fail to follow, and although they generally require the secale to be renewed after a few hours, they will be found to have effected several very important changes preparatory to actual labour;--the abdomen has sunk, the fundus is lower, the cervix is shorter or has disappeared, and not unfrequently we feel the head has already pa.s.sed the brim and is now in the cavity of the pelvis; the v.a.g.i.n.a and os uteri are lubricated with a copious secretion of remarkably pure and alb.u.minous mucus; and in these cases especially, we frequently meet with those little lumps of insp.i.s.sated mucus which were formerly called the _ovula Nabothi_. All these precursory changes are so many preparations of nature for a natural labour, and contribute not a little to the successful termination of the case, advantages which cannot be enjoyed where the membranes have been previously ruptured. If, however, we do not succeed in producing more than a slight dilatation of the os uteri, if the repeated exhibition of the ergot only produce vomiting, or constant pains which have no other effect beyond preventing rest and inducing exhaustion, the separation of the membranes from the uterus, as proposed by Dr.
Hamilton, will now have the best effects: even if this fail and we are compelled to puncture the membranes, it will now be performed under so much more favourable circ.u.mstances, from labour having already commenced to a certain extent.
A warm bath and the other usual means for recovering the child should be in readiness. In most cases the secretion of milk follows as after labour at the full term, which is a great advantage; for the thin watery secretion of this early period is much better adapted to the weak digestive organs of the premature child. It is frequently a matter of some difficulty under these circ.u.mstances to make a child take the breast at first, and this is the chief reason why their digestive organs so soon become deranged. ”In case no milk be present, a good subst.i.tute may be made by beating up fresh eggs and milk, boiling them over a gentle fire and straining off the thin fluid.” (Reisinger, _die kunstliche Fruhgeburt_.)
One great encouragement in cases requiring this operation is the fact that in every successive pregnancy the uterus is more easily excited to premature action; and in some cases where it has been induced several times, it has at length, as it were, got so completely into the habit of retaining its contents only up to a certain period, that labour has come on spontaneously exactly at the time at which in the former pregnancies it had been artificially induced.[103] We have already alluded to this circ.u.mstance in the chapter on PREMATURE EXPULSION OF THE FOETUS.[104]
CHAPTER V.
PERFORATION.
_Variety of perforators.--Indications.--Mode of operating.-- Extraction.--Crotchet.--Embryulcia._
The perforation is that operation ”where we make an opening into the cranial cavity, and, by allowing the brain to escape, thus diminish the bulk of the head.” (_Obstetric Memoranda._)
Perforation is one of the most ancient operations in midwifery, for in former times it was the only means of artificially delivering the child when the head presented: hence we find that from the age of Hippocrates down to the last century, midwifery instruments almost entirely consisted of knives or lancets for piercing the foetal head, and blunt or sharp hooks for extracting or dismembering the child.
Thus Hippocrates, Celsus, and Albucasis, and others, have described a variety of such instruments and given full directions for their use.
_Variety of perforators._ No instrument has been so greatly modified or has appeared under such different forms as the perforator; but it is not our object to enter into any detailed account of its history, for it would not, like that of the forceps, lead to any useful information; we shall, therefore, content ourselves with mentioning those few which have been in general use during the last century. They are chiefly of the scissor kind; the two most commonly known are the perforators of Dr. Smellie and M.
Levret: the former are merely strong long-handled scissors, the backs of the blade being neither exactly sharp nor blunt,[105] and furnished each with a projecting shoulder or rest to prevent them from entering too far.
Levret's perforator, which is extensively used in this country under the name of Dr. Denman's perforator, and which was originally invented by Bing, of Copenhagen, is also formed like scissors, but has its cutting edges outside; the blades are also furnished with rests or shoulders like the Smellie perforator.
[Ill.u.s.tration: Naegele's perforator.]