8
No.255. LONDON, SATURDAY, JULY 19. [1827-8. LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY, DELIVERED AT GUY’S HOSPITAL BY DR. BLUNDELL. LECTURE XXXI. WE resume, Gentlemen, the subject of the preceding lecture. When the placenta coheres to the uterus, in consequence of scirrhus, to ascertain this is not, in gene. ral, very difficult, for, although the womb be thoroughly contracted, and though the ac- couclieur pulls resolutely by the chord and body of the placenta, it is not found to de- aceod far into the vagina, and the hand bemg introduced into the uterus to inves. tigate the nature of the difficulty, the indu- ration and the firm adhesion may be felt. Now, when the placenta coheres to the uterine surface, there are different practices which may be adopted for its removal ; and, first, we may endeavour to break through the connexion by managing the placenta in the ordinary manner, excepting that we draw with a little more resolution than ordinary, care being taken to avail ourselves of those moments when the womb is in action, and the pains are felt. Again, if, as may be expected, the after birth cannot be abstracted in this manner, the chord breaking, and the body of the placenta tearing away, we may then en- deavour, by another method, to overcome the difficulty, namely, by passing the fin.. Ms between the placenta and the uterus, so as by peeling to detach the one from the t’her. Should the adhesion be firm; how- ever, we may also fail in this mode of detach- 1,,PT,t, aud it then becomes necessary to bve recourse to a third expedient. The hard being ic the uterus, the operator must cautiously tear away, piece by piece, that irsrt of the placenta which is not become surrhous, leaving each morsel, after detach- ent, in the uterine cavity; and proceeding to the separation of another, until all that part of the after-birth, which is not scir- rhous and adherent, has been separated from the rest. When the healthy portion of the placenta has thus been separated from that part which is diseased, we may bring away all the different portions at once from the uterus; and it is better to abstract in this manner simultaneously, than to remove each portion separately, as this method of operating demands the repeated introduction of the hand. The detached pieces of the placenta being thus with- drawn, the accoucheur introducing the hand afresh, carefully examines that part of the placenta which still remains adherent to the uterus, and brings it away, if this may be accomplished without violence ; but, should its safe removal be impracticable, lie then contents himself with the sepa- ration of any loose portions of placenta which may have been left in connexion with the scirrhous mass, and leaves the scirrhous part itself in the womb. It is, I conceive, very desirable that the scirrhous portion of the placenta, if left, should be thoroughly cleared of those loose portions which are not scirrhous and adherent, for they may be expected to lose the vital prin- ciple afterwards, and to putrify and give rise to offensive discharges in consequence. I here circulate a preparation which ex- hibits a portion of the placenta connected by scirrhous adhesion to the uterus ; in this case there was much putrid discharge ; and you may observe, that the practitioner had failed in clearing fiom the scirrhus the loose portions. But what is to be done, if the scirrhous part of the placenta, not to be detached, is left behind in the uterine cavity 1 Why, in such cases, I believe, the woman must be committed principally to her own resources, the practitioner palliating symp- toms as they may arise. The scirrhous portion of the placenta is said to have separated spontaneously, in some cases, after the practitioner had failed. More generally, however, if the patient re- cover, this diseased part wastes, sometimes, perhaps, wearing away under putrefaction, and, in other cases, wasting under a sort of absorption, similar to that which, after delivery, removes the secreting exerts-

LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

Embed Size (px)

Citation preview

Page 1: LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

No.255.

LONDON, SATURDAY, JULY 19. [1827-8.

LECTURES

ON THE

THEORY AND PRACTICE OF MIDWIFERY,

DELIVERED AT GUY’S HOSPITAL BY

DR. BLUNDELL.

LECTURE XXXI.

WE resume, Gentlemen, the subject ofthe preceding lecture. When the placentacoheres to the uterus, in consequence ofscirrhus, to ascertain this is not, in gene.ral, very difficult, for, although the womb bethoroughly contracted, and though the ac-couclieur pulls resolutely by the chord andbody of the placenta, it is not found to de-aceod far into the vagina, and the hand

bemg introduced into the uterus to inves.tigate the nature of the difficulty, the indu-ration and the firm adhesion may be felt.Now, when the placenta coheres to theuterine surface, there are different practiceswhich may be adopted for its removal ; and,first, we may endeavour to break throughthe connexion by managing the placenta inthe ordinary manner, excepting that we drawwith a little more resolution than ordinary,care being taken to avail ourselves of thosemoments when the womb is in action, and thepains are felt. Again, if, as may be expected,the after birth cannot be abstracted in thismanner, the chord breaking, and the body ofthe placenta tearing away, we may then en-deavour, by another method, to overcomethe difficulty, namely, by passing the fin..Ms between the placenta and the uterus,so as by peeling to detach the one from thet’her. Should the adhesion be firm; how-ever, we may also fail in this mode of detach-1,,PT,t, aud it then becomes necessary tobve recourse to a third expedient. Thehard being ic the uterus, the operator mustcautiously tear away, piece by piece, thatirsrt of the placenta which is not becomesurrhous, leaving each morsel, after detach-ent, in the uterine cavity; and proceedingto the separation of another, until all that

part of the after-birth, which is not scir-rhous and adherent, has been separatedfrom the rest. When the healthy portionof the placenta has thus been separatedfrom that part which is diseased, we maybring away all the different portions at oncefrom the uterus; and it is better to abstractin this manner simultaneously, than to

remove each portion separately, as thismethod of operating demands the repeatedintroduction of the hand. The detachedpieces of the placenta being thus with-drawn, the accoucheur introducing the handafresh, carefully examines that part of theplacenta which still remains adherent to

the uterus, and brings it away, if this

may be accomplished without violence ; but,should its safe removal be impracticable,lie then contents himself with the sepa-ration of any loose portions of placentawhich may have been left in connexionwith the scirrhous mass, and leaves thescirrhous part itself in the womb. It is, Iconceive, very desirable that the scirrhousportion of the placenta, if left, should bethoroughly cleared of those loose portionswhich are not scirrhous and adherent, for

they may be expected to lose the vital prin-ciple afterwards, and to putrify and giverise to offensive discharges in consequence.I here circulate a preparation which ex-hibits a portion of the placenta connectedby scirrhous adhesion to the uterus ; in thiscase there was much putrid discharge ; andyou may observe, that the practitioner hadfailed in clearing fiom the scirrhus theloose portions. But what is to be done, ifthe scirrhous part of the placenta, not to bedetached, is left behind in the uterine cavity 1Why, in such cases, I believe, the womanmust be committed principally to her ownresources, the practitioner palliating symp-toms as they may arise.The scirrhous portion of the placenta is

said to have separated spontaneously, insome cases, after the practitioner had failed.More generally, however, if the patient re-cover, this diseased part wastes, sometimes,perhaps, wearing away under putrefaction,and, in other cases, wasting under a sortof absorption, similar to that which, after

delivery, removes the secreting exerts-

Page 2: LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

482

cences which are formed upon the uterus when performing our operations, we mayof the ruminating animals. Observe this bruise, lacerate, or otherwise injure t’n

specimen. In all you do for these cases softer parts, by proceeding roughly: is

beware of violence. But, to proceed, the next place, we may persuade ourselvesAfter the expulsion of the foetus, the that the after-birth must be removed from

womb sometimes’ lies quiet for a few mi- the uterus, come what may, and, ic com-

nutes, and then again acts, the fundus and sequence of this persuasion, we may p’rbody contracting, while the mouth and neck sist in our attempts to remove it byxemain open. In consequence of this con- manual efforts, when it would be better htraction, the uterine surface separates from desist ; and, lastly, removing the placentathat of the placenta, and the after-birth, with difficulty, we may detach a portion bylying loose in the cavity of the uterus, is laceration, and, neglecting to examine theeasily expelled by a little further expulsory placenta very carefully after its abstraction,effort. Although, however, the uterus ge- we may leave this part unperceived in tLenerally operates in this way, it sometimes uterine cavity. In dismissing this impor:antremains inactive, more especially after labo- subject, I must not omit to observe, that Irious labours; and, in consequence of this have been called to one or two women,inaction, the placenta is neither separated dead before my arrival, and that, on inquiry,nor expelled, and this constitutes the next I have been informed, that the birth of thedifficulty of which I propose to treat. child had occurred two or three hours be-Cases of this kind, in which the placenta fore, and that a flooding, not very copies,is retained from the inertness of the had taken place afterwards, and that mode.uterus, may be recognised by the follow- rate force only had been used to abstracting indications :-the want of pains-the the placenta. On examining the body insoftness and large size of the womb, these cases, a day or two afterwards, I have6s felt through the abdominal coverings- detected, in the uterus, a lobe of placenta,and the failure of the descent of the chord not -u. coagnlum, about as large as a pul.when gently pulled. When properly ma- let’s egg, but no laceration-no obvious

naged, they generally terminate favourably, contusion-no intelligible cause of death.more especially if there be little-or no flood- Were these deaths the anomalous effects ofing ; but if the accoucheur lay hold of the moderate flooding, or of the retained por-chord without reflexion, and pull the pla- tion of the placenta?centa, an inversion of the womb, and per- Of Monsteos.-In practice we sometimes,haps a fatal flooding, may be the conse- though rarely, meet with foetuses that de-quence. In these cases, therefore,in which viate conspicuously from the ordinary make.the womb is inactive, it should be your first These fcetuses have been denominated mon-object to secure contraction of the uterus, sters, apparently because of our besottedbefore you take away the placenta; and for predecessors; some who have undertakenthis purpose you may wait for half an hour, the perilous task of forming human opi.or an hour, compressing the uterus, with nions, have been pleased to representthe hand placed above the symphysis pubis. such morbid structures as portending a

When the womb is contracted it will feel something mysterious and alarming—credofirm and hard, and something larger than quod impossibile est-and this too has beenthe head of a full-grown fcetus; and, when believed. A great fish has a large swallow,these indications are observed, you may but superstition-grave, argumentative, in-proceed immediately to the abstraction of solent, arrogant, silly superstition, has a

the placenta, which may be removed with- swallow still larger; it enjoys a sort ofbut further difficulty. If the womb be in- omnipotence this way ; nothmg is too bigdisposed to contract, although you have for it, nothing too small. Alas! poor humanwaited for half an hour or an hour, you may reason. According to the mood of the mind,then endeavour to stimulate it by some of we may weep or laugh at thee.the deobstruents formerly recommended, but The celebrated French naturalist, Buffon,these should not be needlessly tried. Be- has divided these monsters into four dwer-ware of flooding—beware of inversion-be- ent classes, those, I mean, in which theware of tearing the placenta, and leaving a parts are deficient; those in which they arepart of it unobserved in the uterine cavity- redundant ; those monsters in which thebeware of the needless insertion of the parts are mis-shapen ; and those in which,hand into the uterine cavity. It may some- although they are naturally formed m othertimes be necessary to peel the placenta from points, certain parts are misplaced; and uthe uterus by interposing the fingers, but these four classes, if you please, a fifth maythis operation it is always desirable to be added, comprising those monsters whichavoid. are of a mixed character ; cases, for exani.

Three errors we aie liable to incur in ple, in which some parts are redundant andmanaging cases of retained placenta in all others wanting, in the same individual.their different varieties. In the first place, Of the deficient monsters, some fine sfe’

Page 3: LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

483

. cimens are on the table before you, and of a Ilindoo’s doll-house or goddery-(the al-all these, the most important is that in which lusion in this latitude is not profane)-athere is a want of the bones of the cranium, brahma, for example, deprived, as was his(basis excepted,) and where, together with fortune, of one of his three heuds : two faces,the deficiency of bone, there is also a defi- you may observe, it has, and they look in.ciency of the cerebrum and cerebellum, different directions. This monster we some-wholly or in a great measure. This monster times meet in the moral world. The vota-it is which is called brainless. In the cir- r-ies of Janus did not all of them perish incla of my own obstetric acquaintances, it the ruins of his temple. Here, too, ishas repeatedly occurred, and it is not, there- another specimen of rarer, though not veryfo-e, very uncommon ; and it becomes infrequent occurrence, in which you havethe more desirable that you should pay a two bodies, with one head in common tolittle attention to it. It may not be amiss both. There is, too, a deficiency in thisto remark here, when speaking of this monster as to the brains. Pretensions tomonster, that not infrequently it is born beauty, it certainly cannot make ; and yet,alice, and that it lives for a few hours after on viewing this monster, those who arebirth. When living, it admits of some cu- familiar with the elegant and fancifulfablesnous observations; and should you ever of classical mythology, may, perhaps, be-meet with a case of this kind. in the course think themselves of the mystic tale of Sal-of practice, pray insert your finger into the macis and Hermaphroditus.mouth to try whether it will suck, in order The third specimen, a very valuable ob-to know whether the sensorial powers, stetric curiosity, consists of two fœtuses ofwhich relate to these actions, are above or full size, so finely formed, that any onebelow; whether they are in the spiual mar- might be proud to own the paternity ; theserev.’, the medulla oblongata, or the brain. fotuses, however, though so beautifullyA specimen I here show you of greater modelled, are united by the thorax and

decree of deficiency. You will find the abdomen. In fœtuses like these, the ab-whole thorax, together with the head and dominal cavity is, I suspect, generally com-s!raulders, are wanting, the child consisting mon to both, so that if you were to en-merely of the parts below, the abdomen deavour to separate them by the knife, theforming a sort of cyst. Monsters of this abdomen would be laid open. Fond as Ikind are by no means so frequent as the am of abdominal surgery, of this I do notformer. approve. This specimen of monstrosity be-The third monster, you will notice, is comes particularly valuable, because it came

deticir nt in its lower parts, the legs being away from a woman who had borne a largewaating, so as to give it an appearance as if family previously, occasioning merely a

all amputation had been performed ; in rea- small laceration of the perineum, the chil-lrtc, however, this is the product of disease. dren descending under the foot presenta-Should a fcetus like this, deficient in the tion, and the head of the one being depo-lower extremities, be lying across the pel- sited on the neck of the other, during theMs, presenting by the arm, hip, or back, no transit through the pelvis. The one fœtus,small diliiculty would arise in an attempt to as you may perceive, is placed a little belowturn it, and, probably, we should be ob- the level of the other, and the head seem9liged to resign the operation altogether. still inclined to repose upon the neck of itsYou will see, too, that the hands are companion.not to be found. Into the causes ofmonsters, as the subjectThe fourth monster which I exhibit is, is rather physiological than obstetric, I for-

tike the preceding, destitute of the lower bear at present to inquire ; suffice it to ob-extremities; and, in place of them, there is serve, that monsters sometimes, if nota conical cyst of skin, containing cellular always, are of very early formation, pro-substances, and a piece of bone, this piece duced within a few months, or perhaps, incfbone being, apparently, the vestige of some instances, within a few weeks afterthose houes which belong to the lower ex- the commencement of gestation. Here is atremities. specimen consisting of twins, united by the

There is a fifth specimen here, in which thorax and abdomen, in the same manner asboth the lower limbs coalesce, so as to form in the preparation I last exhibited to you ;but one compound member, and the foot is and I know, from its dimensions and propor-placed in the retroverted position, the heel tions, that its age could not exceed twolying forward and the toes behind. This is months.a mixed monstrosity, consisting of a defi- Monstrosity is not confined to the humanciency of parts and a misplacement. subject; animals are liable to monstrosity,Un the opposite end of the table are ar- and none, perhaps, more so than pigs.

:wa;ed monsters of the redundant kind ; Blumenbach thinks that the domesticatedand I begin by showing you one which re- are more obnoxious to this disease than thesembles some of the august inhabitants of wild varieties.. Here is a specimen of a

Page 4: LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

484

monstrous kitten, which, in correspondencewith the human monster already mentioned,consists of one head and two bodies in con-nexion.

I was indebted to Mr. Dent for an en-graving, from which I took this pencil draw-ing, of a Hindoo monster of very rare oc-currence. The child, as I was informed,was of healthy make enough in other parti-culars, but it was possessed of two heads,united vertex to vertex, with a deficiency ofbone at the place of contact; vessels pass-ing from the one to the other, and the su-perior evidently nourished and supported,as to its vitality, by the inferior head ; aneck of rude form surmounted and termi-nated the second head. Of this monster itis very remarkable, that it lived for someyears after birth, and was exhibited in theIndies. I was told, too, but I have notbeen able to ascertain this with perfectauthenticity, that when the child laughed orcried, particularly if the mind was greatlyagitated, both countenances were affectedat once. What a precious subject for pole-mical psychology. In an age of folios, ahundred weight of controversy might bewritten upon it-one hundred weight of

controversy ! and why not ; no harm needensue : at the end of the debate, each partymight continue to hug his own opinion, asIxion did the cloud. After all, however, ina metaphysical or moral point of view, per-haps there are few monsters more interest-ing than this.Of the misshapen monsters, and those in

which the parts are misplaced, I make e nofurther remark, because, in a view to prac-tice, they are not of much importance ; thetwo classes principally interesting, are thoseof which I have shown you specimens, con-sisting of the deficient and the redundant ;and of their management I now proceed totreat.

Now, if it should so happen that you haveunder your care a case in which the partsare deficient, provided you adhere to someof those wholesome rules which have been

prescribed in the course of these Lectures,you will probably experience but little dif-ficulty in the delivery. Even if you knowthat there is a deficiency-a monstrosity, itdoes not follow that you are, in a meddle-some manner, to interfere. A meddlesome

midwifery is bad ; give a fair trial to thenatural efforts, and the child being smaller,instead of larger, in consequence of thisdefect of parts, it will come the more easilyaway.In cases of redundancy, moreover, the

child may be very strangely formed, and

yt, after all, it may come away from theuterus with very little assistance from theaccoucheur. It sometimes happens, thatthe pelvis of the patient is very large, and

still more frequently ’it happens, whtr*foetuses are of monstrous formation, tLKthey come away in the sixth or seventhmonth ; and in this way, tlierefore, their

multiplicity of members is compensated bytheir small size, and the conformability oftheir soft texture. Were I called to a casein which I knew there was a redundant mon.

strosity, and where there were two fttusesformed, I should, in the general, give a fairtrial to the natural efforts, say for four-and-twenty hours, unless some dangerous symp.tom obviously demanded delivery, and ifdangerous symptoms occurred, or if the pa.tient liad been in strong pains for four-and.twenty hours, the monster not descending,I should then have recourse to the lever, theforceps, or. perforator ; either the one orother instruments, according to the circum-stances of the case.The surgeon who had under his manage.

ment the case I have shown you, in whichthe two foetuses, of full size, are in all reospects well formed, with the exception oftheir thoracic and abdominal junction, per-ceiving something monstrous in the con.

struction of the foetus, deemed it necessaryto do something to facilitate the labour; tothis end, therefore, he took a pair of scis-sors, and tried to cut away the lower partof one-of them, a very rough expedient, inwhich he was unsuccessful; he then wait-ed, and the consequence was, that the de-livery which he could not accomplish, wascompleted spontaneously by the naturalefforts of the uterus ; the foctus coming awaywith only a small rent of the perineum, sothat in those cases you are not rashly to de.spair and give up all expectation of a naturaldelivery. As in every other case, so here, ameddlesome midwifery is bad; give, there-fore, a fair trial to the natural efforts, and ifdangerous symptoms supervene, or if thelabour make little or no advance under a fullaction of the uterus for twenty-four hoursafter the discharge of the waters, you maythen properly enough have recourse to yourinstruments, to be used in the way I have

already explained at large.

Convulsions.

Convulsions from pregnancy or deliveryare by no means common ; yet this case weoccasionally meet, and great danger attendsit. ’When a patient becomes the subjectoiconvulsions, she may be seized without pe-monitory symptoms ; these, however, some-times occur, and more especially in the cor;-vulsions of pregnancy. Tremors of the whdtmuscular system, and shudderings, crampypains felt in the region of the stomach,cerebl al afflux of blood, flushing of the face,throbbing of the carotid arteries, severe andsplitting pains of the head, stammering,

Page 5: LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

485

perhaps, and failure of utterance, consti- panies every pain, so that if the painstute some of the leading prognostics. Some- thicken, the convulsions multiply ; and

times the patient becomes deaf, and more hence, in these cases, if, during the fit, youf:e,;uently her sight is affected, dazzled, lay your hand on the muscles of the abdo-perhaps, with light, or blinded. When the men, you find them very hard; if your! superrenes, the woman becomes entirely place the finger in the os uteri, you per-insensible, and, together with this insensi- ceive its dilatation, and the advance of thebility, she has a violent commotion of the vo- faetus. Be at the bed side, therefore, in

lunzarv muscles - and the arms and legs are these convulsive cases, and watch ; for as theagitated, and the features flicker, and the eyes paroxysms return, the labour may advance,are distorted, and the tongue is involuntarily and the foetus may suddenly emerge.pushed forth from the mouth, and perhaps Again, we sometimes meet with patientsihere is a spasm of the levators of the jaw, prone to cerebral afflux; and, in those per-which closes the teeth, and wounds it. A sons, convulsions are occurring in the mid-cc.r well secured between the teeth may dle and earlier months sometimes, but stillsometimes prevent this. Respiration is af- more frequently in the end of pregnancy.iected sometimes, and the patient may When convulsions attack a patient in thebreathe with a sort of hissing noise, as has progress of gestation, she may have a singlebeenvrellobservedby Denman, so thatin the fit only, or several, the intervals being usual-next chamber you may hear her breathing; ly irregular and somewhat long, hot of a fewfoaming is by no means uncommon ; and this minutes only, but of hours perhaps, or days.foam being not infrequently mixed with When first the attack occurs, on making ex-blood, gives to the patient, in the eye of amination, it may be that you do not find afriends, an alarming and even terrific ap- single symptom of labour, the feetus is unap-pearance. When these attacks have con. proachable, the uterus is shut, and there istinued for a few minutes in different cases, a perfect freedom from uterine pains. Soonera longer or shorter period, we find the pa- or later, however, if the fit continue, par-tient recovering more or less completely, t-urition of itself commences, without theIn most attacks of convulsions, where the interference of the accoucheur ; and theattack is not severe, the spasms ceasing, the womb opening, and the membranes pro-patient seems very well, awaking up as if truding, and the liquor flowing, a suddenfrom a slumber. When asketd how she feels, emersion of the foetus occurs ; and thisshe replies, perhaps-Well ! nor is she may happen, not only where the patientaware of the attack to which she has been has pain,.and may give an account of hersubjected. It is not always, however, that feelings; but in those cases also, in whichthe recovery is complete. Sometimes the the disease is associated with apoplexy, sopatient lies apoplectic, or in a state analo- that, during the whole time the woman isgous; or she is deaf or blind, or incapable either comatose or convulsed, and henceoi speaking, or both ; or the limbs are it sometimes happens, (and let this be re-benumbed ; in fine, it seems as if the sen- membered,) that under convulsions deliveryMritm has received some permanent in. may take place unknown to the attendants,jury, the corresponding parts of the body the child perhaps being, of consequence,suffering in consequence. suffocated in the bed. In these cases, there-

In practice, I find it useful to divide con- fore, you should give directions that thevulsive cases into three kinds or varieties, patient be strictly watched, and that, onaccording as they occur after parturition, the first appearance of blood or pains, ob-duringlabour, or in the progress of gestation, stetric assistance may be summoned.Two cases I have now seen, in which the A lady, in the end of her pregnancy, wasattack of convulsions supervened after de. seized with convulsions, her attendant waslivery, one of the patients doing perfectly sent for, and decided that there were nowell notwithstanding. Of these cases, one indications of labour, and that a stay waswas shown to me by my friend Mr. Gait- unnecessary. Quitting the house, then, thes.ell, and large bleedings completely cured midwife returned on the morrow, it wasLer, The second was shown to me by early in the morning, when the patient wasMr. Masterman; large bleedings were re- found dead; the child, too, the birth ofMrted to here, but the patient never re- which no one seems to have suspected, laycovered, and, in a few hours, died. In- lifeless beneath the clothes. In managingspection was refused. I suspect that these human affairs, the men have done so many:acks of convulsion, after expulsion of the foolish things, that they have no claim’ tu·, are more dangerous than those attacks whatever to treat with severity the errors ofcocurring during the time of delivery. the women ; allow me, however, to remark,In labonous labours, or in preternatural or that, in this instance, the error, a great one,

natural parturition, convulsions still more was committed by a female practitioner.frequently occur ; and, in these cases, a Felix quem faciunt aliena pericula cautum.j.a:oac-au of convulsions sometimes accom- Remember the story. It is worth a para.

Page 6: LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

486

ble, or an apologue, for it conveys a useful dexterity. Venesection of the jugular is petruth. culiarly advantageous, because, in thi:.!m..

Convulsions being a very alarming dis- of operating, you take away the blood fromease, a variety of remedies have been the head. More frequently, however; pa.recommended, every one being laudably tients are bled from the arm ; and as cilr

anxious to interpose some relief, in cases of purpose is to relieve the vascular systemso much danger. To avoid confusion, how- generally, as well as the head, for that isever, I am accustomed to divide these reme- the principal object, those bleedings fromdies into two classes ; the first comprising the arm may do very well. After brachialthose which constitute our principal reli- venesection, you ought to bind the arm

ance; the second, those which, though not with more than ordinary care, because, ifto be forgotten, may be regarded as of small you apply the bandage with inattention, aimportance. In an affection like this, which large quantity of blood may issue from therequires promptitude and decision, it is of wound, in consequence of a displacement ofthe greatest importance to keep your minds the bandage during any subsequent strug-fixed on the leading and principal remedies, gles. Bleedings from the arm are morecareful not to lose yourselves in the ad- likely to occur, than bleedings from theministration of those remedies, which can neck. Repeatedly those bleedines Lace.have but small effect upon the disease. It taken place, in consequence of detachmentsis now, I believe, well agreed between of the dressings; and, I believe, it was thethose who have seen much of this formida- observance of the benefit .derived fromble malady, that a main remedy is the ab- these large accidental bleedings, that firitstraction of blood from the vascular system, led practitioners, within the last few years,as largely as the patient may safely bear. to resort to copious venesections. Re.So long as the line of prudence is not ex- member further that, in order to have theceeded, the more largely you bleed, the full benefit of your bleedings, you mustbetter ; not that these copious venesections adopt them early. Hours-nay, minutes,are- wholly unattended with danger, but are not without their importance here. Inthat the convulsions themselves are so cases of this kind, blood may be effused onformidable and urgent, and the power over the brain ; and I know that water is foundinanition is, in the present state of our sometimes both on its surface, and in its

knowledge, deemed to be so great, that the ventricles. Now, when these effusions lia-erisk may be reasonably incurred, in order occurred, there is little to be expected fromto give the patient this chance of recovery. the bleeding, but so long as the fluids areTwenty, thirty, forty, fifty, sixty, or seventy contained in the vessels, venesection, ifounces of blood, have sometimes been taken large and early, will be powerfully effectual.away from a woman of ordinary stature and Does arteriotomy possess peculiar adtan-moderate plethora, in the course of six or tages in convulsions ?twelve hours. I once myself abstracted In convulsions, again, there is a secondfrom a patient seventy ounces of blood, remedy which I wish you to look upon as

in the course of two or three hours, and she of very great importance, viz. the thoroughdid not ultimately suffer from inanition; I evacuation of the alimentary tube—thewas with a medical friend at the time ; I stomach, I mean, and bowels. In sometried the smaller bleedings, but they were cases, indeed, the patients lying comatoseineffectual; this patient recovered. Be do not easily swallow; but, in most in-steadfast in these cases, but not rash. We stances, if you watch the proper moment,little know how many under disease, perish deglutition may be accomplished. Senna

by large bleedings. The lance has killed and salts, a smart dose of calomel, the crotaEits thousands, and the lancet....... oil, &c., may be thought of in these cases.Timely transfusion may, perhaps, hereafter Senna and salts will answer perfectly well,diminish the number of these victims. where the patient can swallow; calomel

In these cases, I repeat it, be steadfast ; and the croton oil may have the preferene,but not rash. Watch your patient dili- provided you want to give a dose that litsgently. If the smaller abstraction-if, for in a very small compass. Powerful purginginstance, a bleeding of twenty or thirty may be produced, by rubbing over tLeounces be sufficient, let this content you ; tongue, the cork of the croton oil botle.but if you find the convulsions continue, Should gastric aperients fail, after a trie! efand the afflux of blood remains, with due three or four hours, injections into t’e

prudence your bleedings must be repeated. rectum may be tried with great propriety;There are different ways in which this and these remedies are more especially

blood may be abstracted, two modes being useful, when they are superadded to purp.the most convenient ; the venesection of tives, taken by the mouth, some few hm.-athe arm, I mean, and that of the external before. Two or three scruples of the com-jugular vein; the latter being an operation pound extract of colocynth, half a p’::which all ought to be able to perform with of water, and as much soap as wiil blead

Page 7: LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

487

the whole, may be thrown into the rectum is a very rough one, but ought not to beevery half hour or hour, till it acts. Fur- lost sight of ; it is a sort of homely shower-there where patients are seized with fits of bath. In one or other of these modes, then,convulsion, and you have bled them, if there by sprinkling, by icing, or by pouring wateru amthing wrong with the stomach, you on the bust, the head is to be refrigerated ;Mv give an emetic. The sulphate of xirac is resolutely beat down the action of the cere-rather a rough remedy, but its promptitude bral vessels, and you may thus diminish therecommends it; and these are cases in quantity of blood in the head.which no time should be lost. Ipecacuanha But here you will ask, is there no otheris a medicine that may, in most instances, remedy to which we can have resort ?-h glffn safely enough ; and a drachm of Bleeding, purging, and refrigeration, is thisdie powder being mixed with two ounces of all?—Is it not further proper, in all cases,water, and shaken, one quarter of this mix- to deliver the patient ? No, it is not ; andture may be administered every twenty or it is, I believe, an ascertained fact, that

thirty minutes, till it acts. Here then is a more women die, when they are officiouslysecond remedy fitting in convulsions, a delivered by force, as it is called, than whenthorough evacuation of the alimentary tube, they are committed to their own resources.more especially proper in those cases which That delivery is a powerful remedy in con-tend to the chronic form. vulsions, there can be no doubt-after theWhen patients are affected with convul- fœtus is expelled, the convulsions usually

sions, you will generally, if not always, find cease-but this remedy requires much dis-symptoms of a cerebral afflux of the blood ; cretion.the carotid arteries are thumping, the scalp The rules with respect to delivery lieis hot, the face is larger, and the features principally here-a meddlesome midwiferyare suffused and bloated. Hence the im- is bad-this is the first article of the obste-

pcrtmee of another capital remedy in con- tric creed; if, then, you can relieve yourvulsione, I mean the complete refrigeration patient by bleeding, purging, and refrigera-of the head. A chordee is promptly re- tion, it is not fitting that you should havelieved by plunging into water ; the arteries recourse to artificial delivery; exceptionsare quieted, and the parts collapse ; in there may be, but this is the general rule.like manner, if the patient labour under In considering, therefore, what convulsivecerebral turgescence, produced by an in- cases are fitted for delivery, we may, in thecreased action of the carotids, apply cold very outset, reject all such cases as admitwater, and the action may sink. There of relief by the other means.are different modes in which the head may Again. When convulsions occur, the con-be refrigerated, and, provided you accom- dition of the ovum, with respect to delivery,.plish the object thoroughly, I am careless may vary, for sometimes the head of the’how you proceed. In ordinary cases, on foetus may lie so low, and the parts may beurgency, you may, if you please, with the so lax, that. without difficulty, it may be re-hearth brush and cold water, very plenti- moved by the forceps. In other cases, again,fully besprinkle the head and neck of the the child may be altogether above the brim,patient. If the case be more obstinate, it and yet the mouth of the womb being capa-may be necessary to remove the hair; but cious, and the parts being lax, and the uterineas this is looked on by young ladies as a fibres continuing in good measure at rest,very agreeable ornament, it ought not, I it may be neither dangerous nor difficult tothink, to be wantonly sacrificed. Should deliver by turning. Nor must it be forgot-tlns refrigeration fail, you may apply ice, ten, that in those cases in which the con-which, in this metropolis, may be commo- vulsions occur in the latter or middle months,diausly bought by the pound at the fish-- at the commencement of the disease es-

mongers or pastry cooks. Expel the air pecially, the womb may be firmly shut. Now,from a bullock’s bladder, and half fill it with these considerations premised,let us supposethe ice ; it may then be applied to the that you have one of those undesirable cases,head in the manner of a cap. You may also in which delivery is indicated, inasmuch asrefrigerate the head very much, by pouring your other remedies-your bleedings, yourcold water upon it, and this, -in some very purgings, your refrigerations, have beenbad cases, has been done with very great tried without effect. What remains to beadvantage. You draw the patient’s bust done ? Why, if without bruising, tearing,beyond the bed side, and placing a tub, or or otherwise injuring the genitals, you cantservoir, beneath the head and shoulders, abstract the ovum, do so, if you pleasewith a proper vessel, you pour water on the but if you find the case is such that yethead till the features shrink, and the scalp cannot deliver without risk of injury, therf thoroughly refrigerated. I know of one leave the system to its own resources, foor two cases in which two or three pailfuls in my mind it is far better (and I shoul(of water were poured over the head with wish this principle to be acted upon in madvantage. The practice, like the disease, own family); I say, it is far better that the

Page 8: LECTURES ON THE THEORY AND PRACTICE OF MIDWIFERY,

488

woman should die convulsed in the handsof nature, than that she should perish bythe cruel ’and savage operation of rough andunskilful midwifery.

In those cases, again, where delivery isnot to be accomplished without the risk ofcontusions and lacerations, you should still

keep a close eye on the case, making fre.quent examinations, say every half hour orhour; for, as in floodings so in convulsions,sudden and extensive changes occur in thecondition of the parts ; and though in themorning you may not be able to deliver thepatient, yet in the evening you may find thedelivery easy ; nay, in half an hour only, insome cases, a great change may occur, and,when circumstances conduce, the deliveryshould be with promptitude accomplished.

Here, then, are some general principles,which, combined with the observations Ihave made in preceding lectures, may keepyou near the right line of practice in thesedistressing cases. Let it be your first prin-ciple not to deliver artificially, providedyou find the convulsions may be subdued byother means, unless, indeed, in those ano-malous cases in which the ovum may beabstracted without the least difficulty.—Again : in those cases in which bleedingsand purgings and refrigerations fail, andwhere delivery is to be looked upon as theonly remaining effectual remedy, let it stillbe yourprinciple to have recourse to delivery

’’

in those cases only in which the abstractionof the fœtus may be easily and safely accom-plished, since death from convulsions is pre.ferable to death by the hand of the accou-cheur. Lastly, if delivery is desirable in

consequence of the failure of other remedies,should the state of the parts forbid it, youwill act wisely in making repeated, thoughcautious, examinations, (since sudden andfavourable changes may occur,) completingthe delivery by artificial means, if necessary,as soon as circumstances conduce. I con-clude this topic by remarking, that I shouldbe sorry to undervalue the efficacy of de-livery in these cases ; but moderation is

profitable to all things, and I cannot bearto hear of delivery by force. Arte non vi.In a scientific midwifery, force has no place.,Some practitioners seem to be too fond ofthe turf.

"THE FISH" TIIAT SWALLOWED JONAH.

AT a meeting of the Wernerian NaturalHistory Society, held on the 22d of Marchlast, the REVEREND Dr. Scott of Costor.phine, read a paper "on the great fish thatswallowed up Jonali, and, after three daysand nights, cast him out on dry land;" show-ing that it could not be a wliale, as gere-rally supposed, but was probably a "SQUA-LUS CARCHARIAS, or WntTE SHARK,"—Jamison’s Philo5ophical Journal.

FOREIGN DEPARTMENT.

TENMINA RION OF THE U3fBILICAL S’Fa’ .,

THE RIGHT AURICLE, AXD A SINGLE

UL-VIBILICAL ARTERY ARISING FROM 1’:1

ABDOMINAL AORTA IN A NEW-BOBY

INFANT.

BY PROFESSOR MENDE.

THE child, in whom these remarkabledeviations from the natural state were OJ.served, died shortly after birth, without an yapparent cause. There was nothing M.usual on the exterior of the body ; but, oaiuj ecting the vessels, it was found that theumbilical vem did not divide into twobranches to traverse the liver, but was can.tinued as a single trunk along the convexsurface of the right lobe of this organ, with.out being attached to it, as far as the rightauricle of the heart, when it opened itself alittle above, and in front of the terminationof the inferior vena cava. The base of theheart was inclined a little more than naturalto the right side, and towards the sternum.There was only one umbilical artery whicharose from the abdominal aorta at its bifur.cation ; it passed on the left side of thebladder, and continued its course to theumbilicus.

Professor Mende draws from this case

some physiological conclusions, relative tothe uses which the liver serves in the fœtus.He considers that this organ doesnotrecmeall the blood which comes from the placenta;the comparison which has been institutedbetween the human fmtus and amphibiousanimals, especially the seal, being incor.

rect ; and. that the blood coming from theplacenta is not modified by the liver,anddoes not serve for the secretion of bile, thegall-bladder being, in the case descnbedabove, full, and the fcatus well-nourished.

DISEASE OF THE HEART, WITH A RAREANOMALY OF THE VASCULAR SYSTEM.

By PROFESSOR FRANCKE, Dresden.The disease of the heart, of which the sub.ject of the following case died, was Men.rism, with hypertrophy of the left ventricle.There was, at the same time, hydrops peri-cardii, as well as traces of chronic inflam-mation of the liver, induration of the

spleen, and, among other changes, a re-

markable one in the situation of the ascend.

ing vena, cava and its relation to the aorta, towhich there is only one similar example re-corded, and that in Morgagni. (De Sedi-bus et causis Morb. Lib.iv.epist.66. art. 32The aorta was in its natural situation, b4t