Part 24 (1/2)
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, a.s.sisted, _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 a.s.sumes a totally different character; from being in a nearly pa.s.sive state, it a.s.sumes 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 a.s.sisting 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 ca.n.a.l, 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 pa.s.sions or affections of the mind; from hereditary temperament, const.i.tution, 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 haematoma; cicatrices from former ulcerations or rupture, or by any other circ.u.mstances 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 pa.s.sions 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 haemorrhage 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 v.a.g.i.n.a. 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 pa.s.ses into a state of action. The intestinal ca.n.a.l 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 a.s.sume 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 s.h.i.+vering, 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 v.a.g.i.n.a is hotter than natural; the secretion of mucus is sparing; and both os uteri and v.a.g.i.n.a 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 antic.i.p.ations as to the result, but from causes of a much slighter character, which are nevertheless well worthy the attention of the pract.i.tioner: 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 pa.s.sages 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 quant.i.ty 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 cus.h.i.+ony, and the v.a.g.i.n.a also warm and s.p.a.cious; 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 haemorrhoids, 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 pa.s.s 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 pa.s.s 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 circ.u.mstances: 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 pa.s.sages 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 v.a.g.i.n.a 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 primiparae 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, haemorrhage, retained placenta, or hour-gla.s.s 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 refres.h.i.+ng 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 a.s.sist 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 r.e.c.t.u.m of any faecal matter which may be lodging there, but a.s.sist 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 pract.i.tioners 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 a.s.sisting labour. We have combined these two medicines with the best effects, and generally give them in the following manner:--[Symbol: Recipe] Secalis Cornuti [Symbol: scruple] i--ij; Sodae Subborat. gr x; Aq. Cinnamomi [Symbol: ounce] 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.