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ON THE USE OF OPIUM IN UTERINE HÆMORRHAGES, AND PROTRACTED LABOURS.
10 readers of THE LANCET. The pad, which is about the had been for several years repeatedly enforced on their minds, size and shape of the point of a man’s thumb, is made to press of the great utility of opium in such cases, when a foreigner gently over the internal abdominal ring only, so as to allow had informed them of its safety and advantages. In this the muscular fibres of the ring to retain their natural figure. anticipation I was not disappointed, for since that period The spring of the truss is made to ascend from the pad several practitioners of - information and experience have obliquely towards the spine of the ilium; then to form a advocated in affirmativeterms the great utility of opium in curve round the skin covering the lumbar muscles above the haemorrhage. The last of these authorities that have’come crista ilii, and to terminate about half way between the um- within the range of my information is Dr. Griffin, who speaks bilicus and the spine of the ilium of the opposite side, upon the in the most confident manner regarding the propriety of anterior surface of the abdomen. The pressure of the truss giving large doses of opium in the most depressing cases from is confined to the pad and distal end ; but care is requisite in haemorrhage. Dr. Griffin does not express himself in the fitting these two extremities to the parts where the pressure unmeaning terms of most other writers on this subject, who must be made, otherwise the instrument will be of no use to inform their readers that they gave a full dose, a moderate the wearer. dose, or repeated small doses of opium, which is really no As the bones of every person have a something peculiar to useful information whatever; but he (Dr. Griffin) maintains them, I make it a rule, when required to provide a truss, to that five grains of opium should be given at once in cases of take the size and shape of the pelvis correctly, then to fit the great depression and danger, and even followed up with more, spring to the patient, and after adjusting it to the body, to ’ if required. harden the steel in oil and cover it with leather. Dr. Griffin has no mean authority, in favour of his mode of No wool or cotton should be used in covering the steel treatment in haemorrhage, in the Medico-Chirurgical Review. spring of a truss, for these substances generate heat and In the British and Foreign Medical Review for January, 1846, produce pain. Neither should the pad contain anything but is the following extract from Dr. Griffin’s work : " Of all the a piece of soft elastic cork, about half an inch in thickness, wonderful influences, however, exerted by opium, that by and covered with wash-leather ; and to prevent any galvanic which it sustains the power of life when sinking from hoemoraction from annoying the wearer, only one kind of metal rhage, and arrests the flow of blood, is the most extraordinary. should be used in the construction of the instrument. When, after severe uterine haemorrhage, the countenance is When the truss is in use, none of the actions of the abdothe eye hollow and glassy, the lips blanched, the skin minal muscles should be interrupted, for very little pressure cold, and the whole person corpse-like, when the pulse is of the pad is required to retain the intestine within the almost gone at the wrist, when the beat even of the heart is abdomen. In proof of this, I need only refer to the effect scarcely perceptible, and stimulants, even brandy and rectiproduced by the point - of a finger when pressing gently over fied spirits, are either vomited or uninfluential, there remains the internal abdominal ring. yet one remedy capable of restoring the patient to life, and When a truss fits a patient properly, it never shifts out of that is opium." its position, nor gives the least trouble to the wearer. The Again, Dr. Griffin states, " When the danger is imminent, five grains [of opium] may be given at the first dose, and two, following figure is a rude diagram of the truss :or three every hour or half hour afterwards, until the pulse, becomes distinct, the breathing easier, and the tossing or - flingi-ag about- the bed is allayed." The reviewer’s opinion of the above is thus expressed :This is a very valuable paper, and fraught with truths of the,
numerous
sunk,
E
greatest practical importance."
By referring to my cases of uterine haemorrhage, &c., pub-lished in 1839, it will be seen, that the quantity of laudanum that I found necessary to be given to save life, in cases of imminent danger, so well expressed by Dr. Griffin, and very 1846. Upper Fitzroy-street, Fitzroy-square, May, similarly expressed then by myself, is very nearly the same in .* We have seen this truss in use. It is an exceedingly dose as advised by Dr. Griffin; and yet what does the British simple, clever instrument, and may be worn with extreme and Foreign Medical Review say on reviewing my mode of, treatment- only a few years ago ? It said-" As to his treatease and the best possible effect.-ED. L. ment of haemorrhage, after the birth of the child, we need scarcely say, that we dissent strongly from it, and cannot help’ thinking that the number of relapses which he has described ON THE USE OF OPIUM IN UTERINE would not have taken place if the usual means of stopping AND PROTRACTED LABOURS. HÆMORRHAGES, haemorrhage had alone been resorted to." Now in any of the By JOHN CRAIG, M.D., Paisley. very few relapses that occurred in my cases, they were easily OBSTETRIC teachers and practitioners, of high standing, con- managed, and for the long period of more than twenty-five tinue to givepublicity to certain forms of protracted labours years every case recovered, which, by " the usual means of in which their proceedings are of a disastrous kind, being stopping haemorrhage," there is great reason to doubt, from hazardous, and occasionally fatal, both to the mother and the the result of such treatment, would, some of them, have been child. The published cases which show these unfortunate lost. However, I feel highly delighted to learn that the results are exactly, so far as they are described, similar to British and Foreign Medical Review now so strongly approves my detailed published cases, which terminated favourably, of a mode of treatment so very similar to that in my practice. both to the mother and the child, in a few hours, by a simple This review, then, as well as the British practitioner and the parturient woman lies under deep obligations to the late appropriate treatment. To assign a reason, then, for the continuance of a mode of foreigner who has convinced the former of the safety and procedure so abhorrent, both as regards protracted illness! effective certainty of the use of opium in the treatment of and fatal termination, precludes the possibility of even a con- haemorrhage. Now, as the practice in this particular department of jecture. No motive, however plausible, can justify a mode of treatment which protracts recovery and endangers life, when the obstetric art is, I trust, established, it has encouraged me other means have been clearly and repeatedly shown to be to request of the editor of THE LANCET to indulge me in my much more speedy and successful in their effects. No selfish further endeavours to place the remaining topic—protracted consideration should be allowed to harbour in the breast of labours-in the same favourable position, the nature and the obstetrician when by it the life of a fellow creature may treatment of which still lie, almost universally, under a cloud be sacrificed. Years, however, have rolled on since these im- of utter darkness. In the great proportion of labours, Nature,, provements were promulgated, yet up to 1845 the same crude- even in a considerably unsound state, will, after long agonizing ness of thought and inconsistency of treatment continue. efforts, accomplish her end; but when she is incapable of From these considerations, I felt induced to discontinue effecting her purpose, and requires the assistance of art, the further endeavours to persuade an obstinacy so incorrigible. daily published accounts show that those who ought to know .
!
.
However, some months ago, in a paper of mine which appeared in THE LANCET, it is noticed that a foreigner had publicly intimated the advantages to be derived in uterine hæmorrhage from the use of opium, and that he had learned this practical fact from British practice. It is observed in the same paper, that there was considerable probability that British prac-
how to
titioners would now be convinced of the useful
shall
truth which
remove the causes of unnecessary lengthened suffering, and, consequently, to prevent danger and death, seem to be as little acquainted with the nature of the causes of delay as they are with the virtues of the means of relief. For the
truth there
of these statements, are
now
I
regret
to say,
that, in my view,
ample proofs in the late periodicals, and to advert.
these I
11 to the similar sider my conduct
The " two cases" appearing in the Medico-Chirurgical Reriew for January, 1846, headed " Two Cases of Labours protracted by Insuperable Rigidity of the Os Uteri; by John C. W. Lever, ILD.," shall be first noticed. The propriety of making unfavourable critical remarks upon cases from the perusal only of the review of the original document, may, perhaps, be justly questioned; however, it appears to me that the reviewer has faithfully given the principal points regarding the nature and treatment of the cases, and by his statement I shall closely abide, seeing that the original is not accessible by me at present. The first case is of a young woman with her first child. Labour commenced on the 10th of September, 1844, pains lingering till the morning of the 14th, when they became more severe; os uteri then not much larger than a shilling; its edges were hard and rigid. The patient was bled from the arm, and belladonna was applied to the mouth and neck of the womb. Dr. Lever saw the woman on the afternoon of the 14th, and recommended tartarized antimony until nausea was produced, and then a full dose of opium. No decided advantage was gained by the means used. At Dr. Lever’s visit next day, he found that a considerable portion of the cervix uteri, in a foetid state, had been expelled a short time previously. Child extracted by the aid of the perforator and crotchet. The woman died on the morning of the 25th. " Many cases," says Dr. Lever,"are on record similar to the one I have related, in which, during labour, the os uteri has been torn completely off." What is noted of this case shows it at once to have been, in the early part -of the labour, a case of very common occurrence; and as far as I have observed in such cases, when the usual means for the removal of the causes of delay are put in regular operation, the labour has terminated safelv in twelve or fourteen hours after the commencement of labour pains. This is really a notable case to be inquired into even by the philanthropist. One would think that from what is said regarding the nature and management of this case, it is intended only to encourage others to pursue the same course on such occurrences. We are told the woman was bled, but neither the quantity taken, nor the appearance of the blood on cooling, is made known. An os uteri dilated to the size of a shilling, and its edges hard and rigid, are conditions exceedingly common in labours of this description, and are very removable by the application of the means suited to the nature and causes of the rigidity. The pains on the 14th, when Dr. Lever first saw the woman, were more severe than they had been ; and yet, although the fourth day of the labour, tartarized antimony to nausea, and a full dose of opium, were all that Dr. Lever prescribed ; and he did not see the patient again in this deplorable state until next day, when he learned that a portion of the cervix uteri had been expelled. Such a fearful state of things shows, in the clearest manner, that there had been severe uterine expulsive action, which had produced at least such a degree of congestion in the strictured portion of the cervix uteri, as to induce gangrene and suppuration. It is true, Dr. Lever was not the principal actor in this i tragedy; yet although his colleague had nothing to prescribe ’, for the relief of a woman suffering four days in labour but a ’, bleeding, and the application of belladonna to the cervix ’, uteri, the prescription of tartar emetic and a full dose of opium, I, advised by Dr. Lever, is, in my view, and according to my I experience, in cases of so great obstinacy, as valueless as the
I have related." I should certainly conhighly censurable, in an endeavour to animadvert on the unfortunate issue of any case, under the superintendence of any practitioner, if he had shown an anxious desire for the welfare of his patient, and an acquaintance with the known forms and causes of obstructed labours, as well as with the proved means for their relief, according to their peculiar circumstances; but when publicity is given to cases which haveterminated in the most mournful and disastrous manner, and which, apparently, might have had a favourable issue, had the practitioner possessed an acquaintance with the causes of delay, and applied the known remedies for their removal, it is certainly a great duty to expose that lethargy or contempt, which, no doubt, is the cause of the incapacity which renders the result of so many one
manageable
cases so
appalling.
In Dr. Lever’s second case, we are informed that a woman became pregnant in March, 1844, and, when labour came on, the os uteri was found extremely rigid and undilateable. She was bled, purged, and nauseated with tartarized antimony, but all with little effect. Although the labour had continued for upwards of forty-eight hours, the uterine orifice merely admitted the tips of two fingers, and felt like ne hardened ring. It was then thought advisable to divide "the whip-cord margin of the os uteri towards the posterior part? of the sides of the pelvis, in the direction of either sacro-iliac synchondrosis. The incisions were made during the contractions of the uterus; the patient made no complaint; in fact,., they gave her no pain." In the course of three hours from this time the patient was delivered of a female child; eventually she recovered. In the remarks appended to this case, Dr. Lever very decidedly reprobates the practice of artificial dilatation." professes himself " a strong advocate for the
He
employment of incision." The very imperfect account given of this case, shows very clearly it should never have had publicity, atleast in this form; for, from the notice taken of it, it appears to be exactly one of the numerous cases of daily occurrence, which, by the
use of suitable means for the relaxation of strictured parts, and the removal of the other usual obstructions generally present in such cases, the expulsion of the child is effected in a few hours by the natural efforts of the mother. As the management of the present case, then, is much allied to the method pursued in the treatment of the preceding one, there is reason to think that the reviewer has done justice to the principal points, both as regards the nature and treatment-of the two cases; and if this be found to be the case, then those who are taught by Dr. Lever, and those who think with him, must follow the same kind of practice in the management of such labours. From all that I can gather, then, after a very careful perusal of what is related of the above cases, I feel an irresistible sympathising impulse in behalf of the parturient woman, which impels me to state, that by a careful consideration of the nature of such protracted labours, and by a knowledge of those therapeutic agents, with their appropriate application, as have been repeatedly enunciated, such labours will never continue to such an unnecessary length, or terminate in so deplorable a manner as has just been noticed. At least, from my experience, I cannot give credence to the necessity of such results, until a clear and distinct account is
given, both as regards
the nature of the case, and an accurate of the means used, and the manner in which they were used in every particular; but these requisites are always, in a great measure, kept out of sight. When such preceding. I again repeat, that in the treatment of labours of so attentions are thus paid to the lying-in woman, Dr. Lever, I resistance to the expulsion of the child, nothing short of the trust, will neither require to "reprobate artificial dilatation," careful and full application of the means of relief, as noticed ’, nor "advocate the employment of incision." in my cases, and so repeatedly alluded to in THE LANCET, can The other cases respecting which I beg a place in THE LANCET safely and speedily remove the obstructions to delivery. I, are in the number of that journal for Feb. 14th, 1846, Such treatment for the relief of such cases must as assuredly I p. 1T6, under the head, " Contributions to the Practice of be acted on, as opium must in future be freely given for the I Midwifery," by Dr. Hall Davis. The first case in this series preservation of life in uterine hæmorrhage. Nothing can goes to show what was several years ago suggested by memore clearly indicate that the practitioner has no idea of the namely, that when the presentation of the head of the child nature of the obstructing causes for the relief of which lie is is somewhat faulty, the best corrector of this mal-position is prescribing, than the indefinite manner in which he relates to establish natural expulsive pains, which seldom fail to his case; su let it never be forgotten, that whatever is the effect the desirable object in view. The second case-a nature and degree of the obstructions to delivery, the means breech presentation—is in my view anything but a wellsuited for relief must correspond. Unless the amount of the conducted one, either before or after Dr. Davis was called. be allowed to continue in power necessary to overcome the resistance offered by the That any woman should po&siblv obstructions to the expulsion of the child be well known to labour thirty or forty hours, under a midwife who had a right teachers of midwifery, the advice given by them in cases of to call to her assistance a physician who is appointed to the difficulty and danger, will in no way differ from the mazy charity in which she is employed, for the very purpose of notions of the nierst tyro. One should almost think that Dr. doing justice to pour women in labour, is an instance of that Lever exults, or, it may be, attempts to excuse himself, in the callous feeling which perhaps universally prevails in all such result of this case, when he says, " many cases are on record charities. It is stated that in this case the labour commenced
great
description
12 on the day before Dr. Davis was called, which half-past ten A.M. Now, had this woman been seen by a practitioner eight or ten hours after the commencement of labour who was acquainted with the common means used for the removal of obstructions in such cases, her delivery, from what is stated of the case, would in all probability havebeen effected naturally and safely in about fourteen or fifteen hours. Even when Dr. Davis was called, it does not appear that he used any means either to remove the obstructions or
that the above crude and irrational mode of procedure still
at three A.M.,
continues to prevail over the whole civilized world. Just after the above observations were finished, THE LANCET for March 28th, 1846, was handed to me, and in it I observed further contributions to midwifery, by Dr. Hall Davis. I shall only briefly notice the first case mentioned. The patient was aged forty-two, of stout habit and firm fibre, and in labour of her first child; she had enjoyed good health. Dr. Davis was sent for on Dec. 18th, 1845, at four P.M. to increase the expulsive efforts of the uterus, but at once True pains had first set in at 3 A.M. on the previous day, proceeded to bring down one of the legs, which he accom- (Wednesday.) At two P.M. of the same day, the orifice of the plished. To any one attempting to bring down the leg of a uterus had become fully obliterated. "The pains entirely left child similarly circumstanced as this one was, the difficulty her at one P.M., (Thursday,) three hours before my visit, but will be found to be very considerable. I once made an effort not suddenly, having latterly gradually lessened in force and to do this, but soon desisted from my mad attempt-used frequency. I found (says Dr. Davis) the expression of counmeans for the removal of the causes of delay, when the child tenance good, the face congested from the effects of previous was expelled in a short time afterwards by the natural efforts. efforts, skin moist and hot, pulse 100 and soft, no heat of The third case was a woman twenty-five years of age, of vagina, a puffy protuberance of scalp, the head impacted, the Under these circum. good health and conformation, and at her full period. bones felt slightly overlapping," &c. Dr. Davis was called to this case at six P.M., and labour pains stances, and after the evacuation of the bladder, delivery by had commenced at half past eleven of the previous even- the crotchet was effected. Had I been present when Dr. ing. The Doctor found the orifice of the uterus one-third Davis proposed destroying the child by the crotchet, my short of its full dilatation, parts cool, the pelvis of average question to him would have been, "For what reason will dimensions. At this distant period from the commencement you take the life of the poor hapless babe ? Your enuof labour, the doctor left his patient without a single prescrip- merated symptoms as regards the woman are all favourtion for her relief, only hoping everything would do well able ; and it is only the impacted condition of the child’s without constitutional treatment. It has been repeatedly head which seems to actuate you to deprive it of life 1" shown by me that no woman in labour, of the description The acknowledged congested state of the woman’s face under consideration, will continue many hours undelivered, showed clearly the nature of her case ; her "stout habit and unless from obstructing causes which are remediable, and the firm fibre,"subjected to long, unnecessary, severe pains, proremedies have also been clearly stated, as well as the mode of duced not only congestion and torpor of circulation in the using them. Yet we see that this poor woman was left with- face, but in every part of her body; and this condition of the out an attempt to relieve or shorten her woful, ineffectual, mother occasioned the same state in the child-namely, a suffering. At midnight, when Dr. Davis again called, he gorging with blood, and an increase of size of its whole body, found the pains frequent and strong, the head still at the and especially its head, forming the principal cause of imbrim of the pelvis, pulse firm and full. He again left the paction. A labour like the present, left without suitable patient, but now he advised bleeding under certain circum- treatment, is the principal cause of impaction, and a fertile stances. At six A.M. he was again summoned, the patient had source of excuse for destroying infantine life. The extraction been bled to sixteen ounces; the head was now immovable in of a sufficient quantity of blood in this case would, at the the pelvic brim. The doctor called again at one P.M., when same instant, have lessened the congested state and bulk of considerable protrusion of the scalp had taken place, still, he the child, as well as the congested and swollen parts of the says, the bony part of the head had not descended lower than mother, which, along with the other usual and necessary at his previous visit. Eighteen ounces or more blood were! means, would have given more room for the passage of the taken. child, while the very common rigidity of the perinasum met Up to this stage of the proceedings, bleeding was the onlywith in such cases would have been relaxed, so as to have allowed the child to pass alive by the natural efforts of the means of relief used, and yet the reader is not put in possessionL of those distinctive symptoms necessary to be known in ordermother. to enable him to judge even of the propriety or impropriety of Paisley, May, 1846. the course pursued. However, it is quite certain, that in some protracted cases of a somewhat similar description, ON LIGATURE OF VEINS. bleeding is not the remedy required; and in other labours, By WALTER YATES, Esq., Surgeon, Nottingham. although bleeding is absolutely necessary, yet it will prove I HAD occasion a little while ago to ligature a vein-the quite inadequate of itself to remove the obstructions to the advancement of the child. It is stated, that about half-past particulars of the case are these: two P.M., on account of peculiar symptoms, the labour was Ann C-, aged thirty-three, a very stout person, was terminated by the operation of craniotomy. Such a revolting coming carelessly down stairs with a chamber-pot in her termination to a case apparently so simple and remediable in hand, and happening to tread on her dress, she fell all her its early stages, ought truly to thrill the sensible parts of man,I length to the bottom; the chamber utensil was broken into a and rouse his mental energies to arrest a procedure so lethargic very many fragments, from some of which she sustained a severe injury of the arm. She immediately got up, and found and apparently so uncalled for. The remaining cases are of so similar a description, are so her dress to be almost completely besprinkled with blood; a similarly treated, and consequently their oneness of result stream of the same fluid was also flowing down her arm. with the preceding ones, render it unnecessary to occupy time Assistance happening most luckily to be at hand, her arm She was bound tightly up with six or seven handkerchiefs. and space in repeating what has already been said. It is stated that one of the children was large, and that the considers the loss of blood in this short time to have been not sacro-pubic diameter of the pelvic brim" did not exceed three less than two quarts. (?) She feels faint, is very pale, and and a half inches. Dr. Burns, in his Dlidwifery," seventh dreadfully alarmed lest she shall lose her arm. Having at edition, page 431, states that it is the opinion of high authority, hand everything necessary for the purpose of effectually and with which he agrees, that if the dimensions of the pelvis securing any vessel or vessels that might be wounded, I removed the handkerchiefs, immediately upon which a terrific were certainly under three inches, a living child could not be born; yet, in the next page, he refers to a case by Baude- gush of blood followed, which I was unable to arrest by the locque, when a living child, by the use of the forceps, was firmest pressure of a bandage, being obliged to have recourse delivered, when the pelvis, in its conjugate diameter, did not to the tourniquet. Having thus temporarily prevented the Now were the obstructing haemorrhage, I then searched the wound-which was deep, measure more than three inches. and was directed horizontally across the front of the elbowcauses to delivery removed early with a pelvis of the dimensions of three aud a half inches, it is my belief, that, by the joint, the incision being about three inches in length. I action of the uterus alone, a living child would be born. discovered a large vessel, which I at first took to be the Although I have selected the foregoing cases as exhibiting humeral artery, but which afterwards turned out to be the the practice pursued by two eminent metropolitan obstetri- common basilic vein. The incision proceeding as it did cians, and although their practice, according to my experience, through three-fourths of its calibre only, allowed the vessel is fraught with the evils of severe, unnecessary, protracted to gape very considerably, hence the tremendous escape of suffering, great danger, both to the mother and the child, and blood. Without further loss of time I then passed a tenanot unfrequently, as we have seen in various instances, with culum through the vein, above the place where it was injured, the lamentable loss of life; yet from all the research which and a second one through it below the same place, and directly I have made for several years up to the present time, it seems divided the remaining portion of the tube, disconnecting very
was
at
!
_________________
numerous
sunk,
E
greatest practical importance."
By referring to my cases of uterine haemorrhage, &c., pub-lished in 1839, it will be seen, that the quantity of laudanum that I found necessary to be given to save life, in cases of imminent danger, so well expressed by Dr. Griffin, and very 1846. Upper Fitzroy-street, Fitzroy-square, May, similarly expressed then by myself, is very nearly the same in .* We have seen this truss in use. It is an exceedingly dose as advised by Dr. Griffin; and yet what does the British simple, clever instrument, and may be worn with extreme and Foreign Medical Review say on reviewing my mode of, treatment- only a few years ago ? It said-" As to his treatease and the best possible effect.-ED. L. ment of haemorrhage, after the birth of the child, we need scarcely say, that we dissent strongly from it, and cannot help’ thinking that the number of relapses which he has described ON THE USE OF OPIUM IN UTERINE would not have taken place if the usual means of stopping AND PROTRACTED LABOURS. HÆMORRHAGES, haemorrhage had alone been resorted to." Now in any of the By JOHN CRAIG, M.D., Paisley. very few relapses that occurred in my cases, they were easily OBSTETRIC teachers and practitioners, of high standing, con- managed, and for the long period of more than twenty-five tinue to givepublicity to certain forms of protracted labours years every case recovered, which, by " the usual means of in which their proceedings are of a disastrous kind, being stopping haemorrhage," there is great reason to doubt, from hazardous, and occasionally fatal, both to the mother and the the result of such treatment, would, some of them, have been child. The published cases which show these unfortunate lost. However, I feel highly delighted to learn that the results are exactly, so far as they are described, similar to British and Foreign Medical Review now so strongly approves my detailed published cases, which terminated favourably, of a mode of treatment so very similar to that in my practice. both to the mother and the child, in a few hours, by a simple This review, then, as well as the British practitioner and the parturient woman lies under deep obligations to the late appropriate treatment. To assign a reason, then, for the continuance of a mode of foreigner who has convinced the former of the safety and procedure so abhorrent, both as regards protracted illness! effective certainty of the use of opium in the treatment of and fatal termination, precludes the possibility of even a con- haemorrhage. Now, as the practice in this particular department of jecture. No motive, however plausible, can justify a mode of treatment which protracts recovery and endangers life, when the obstetric art is, I trust, established, it has encouraged me other means have been clearly and repeatedly shown to be to request of the editor of THE LANCET to indulge me in my much more speedy and successful in their effects. No selfish further endeavours to place the remaining topic—protracted consideration should be allowed to harbour in the breast of labours-in the same favourable position, the nature and the obstetrician when by it the life of a fellow creature may treatment of which still lie, almost universally, under a cloud be sacrificed. Years, however, have rolled on since these im- of utter darkness. In the great proportion of labours, Nature,, provements were promulgated, yet up to 1845 the same crude- even in a considerably unsound state, will, after long agonizing ness of thought and inconsistency of treatment continue. efforts, accomplish her end; but when she is incapable of From these considerations, I felt induced to discontinue effecting her purpose, and requires the assistance of art, the further endeavours to persuade an obstinacy so incorrigible. daily published accounts show that those who ought to know .
!
.
However, some months ago, in a paper of mine which appeared in THE LANCET, it is noticed that a foreigner had publicly intimated the advantages to be derived in uterine hæmorrhage from the use of opium, and that he had learned this practical fact from British practice. It is observed in the same paper, that there was considerable probability that British prac-
how to
titioners would now be convinced of the useful
shall
truth which
remove the causes of unnecessary lengthened suffering, and, consequently, to prevent danger and death, seem to be as little acquainted with the nature of the causes of delay as they are with the virtues of the means of relief. For the
truth there
of these statements, are
now
I
regret
to say,
that, in my view,
ample proofs in the late periodicals, and to advert.
these I
11 to the similar sider my conduct
The " two cases" appearing in the Medico-Chirurgical Reriew for January, 1846, headed " Two Cases of Labours protracted by Insuperable Rigidity of the Os Uteri; by John C. W. Lever, ILD.," shall be first noticed. The propriety of making unfavourable critical remarks upon cases from the perusal only of the review of the original document, may, perhaps, be justly questioned; however, it appears to me that the reviewer has faithfully given the principal points regarding the nature and treatment of the cases, and by his statement I shall closely abide, seeing that the original is not accessible by me at present. The first case is of a young woman with her first child. Labour commenced on the 10th of September, 1844, pains lingering till the morning of the 14th, when they became more severe; os uteri then not much larger than a shilling; its edges were hard and rigid. The patient was bled from the arm, and belladonna was applied to the mouth and neck of the womb. Dr. Lever saw the woman on the afternoon of the 14th, and recommended tartarized antimony until nausea was produced, and then a full dose of opium. No decided advantage was gained by the means used. At Dr. Lever’s visit next day, he found that a considerable portion of the cervix uteri, in a foetid state, had been expelled a short time previously. Child extracted by the aid of the perforator and crotchet. The woman died on the morning of the 25th. " Many cases," says Dr. Lever,"are on record similar to the one I have related, in which, during labour, the os uteri has been torn completely off." What is noted of this case shows it at once to have been, in the early part -of the labour, a case of very common occurrence; and as far as I have observed in such cases, when the usual means for the removal of the causes of delay are put in regular operation, the labour has terminated safelv in twelve or fourteen hours after the commencement of labour pains. This is really a notable case to be inquired into even by the philanthropist. One would think that from what is said regarding the nature and management of this case, it is intended only to encourage others to pursue the same course on such occurrences. We are told the woman was bled, but neither the quantity taken, nor the appearance of the blood on cooling, is made known. An os uteri dilated to the size of a shilling, and its edges hard and rigid, are conditions exceedingly common in labours of this description, and are very removable by the application of the means suited to the nature and causes of the rigidity. The pains on the 14th, when Dr. Lever first saw the woman, were more severe than they had been ; and yet, although the fourth day of the labour, tartarized antimony to nausea, and a full dose of opium, were all that Dr. Lever prescribed ; and he did not see the patient again in this deplorable state until next day, when he learned that a portion of the cervix uteri had been expelled. Such a fearful state of things shows, in the clearest manner, that there had been severe uterine expulsive action, which had produced at least such a degree of congestion in the strictured portion of the cervix uteri, as to induce gangrene and suppuration. It is true, Dr. Lever was not the principal actor in this i tragedy; yet although his colleague had nothing to prescribe ’, for the relief of a woman suffering four days in labour but a ’, bleeding, and the application of belladonna to the cervix ’, uteri, the prescription of tartar emetic and a full dose of opium, I, advised by Dr. Lever, is, in my view, and according to my I experience, in cases of so great obstinacy, as valueless as the
I have related." I should certainly conhighly censurable, in an endeavour to animadvert on the unfortunate issue of any case, under the superintendence of any practitioner, if he had shown an anxious desire for the welfare of his patient, and an acquaintance with the known forms and causes of obstructed labours, as well as with the proved means for their relief, according to their peculiar circumstances; but when publicity is given to cases which haveterminated in the most mournful and disastrous manner, and which, apparently, might have had a favourable issue, had the practitioner possessed an acquaintance with the causes of delay, and applied the known remedies for their removal, it is certainly a great duty to expose that lethargy or contempt, which, no doubt, is the cause of the incapacity which renders the result of so many one
manageable
cases so
appalling.
In Dr. Lever’s second case, we are informed that a woman became pregnant in March, 1844, and, when labour came on, the os uteri was found extremely rigid and undilateable. She was bled, purged, and nauseated with tartarized antimony, but all with little effect. Although the labour had continued for upwards of forty-eight hours, the uterine orifice merely admitted the tips of two fingers, and felt like ne hardened ring. It was then thought advisable to divide "the whip-cord margin of the os uteri towards the posterior part? of the sides of the pelvis, in the direction of either sacro-iliac synchondrosis. The incisions were made during the contractions of the uterus; the patient made no complaint; in fact,., they gave her no pain." In the course of three hours from this time the patient was delivered of a female child; eventually she recovered. In the remarks appended to this case, Dr. Lever very decidedly reprobates the practice of artificial dilatation." professes himself " a strong advocate for the
He
employment of incision." The very imperfect account given of this case, shows very clearly it should never have had publicity, atleast in this form; for, from the notice taken of it, it appears to be exactly one of the numerous cases of daily occurrence, which, by the
use of suitable means for the relaxation of strictured parts, and the removal of the other usual obstructions generally present in such cases, the expulsion of the child is effected in a few hours by the natural efforts of the mother. As the management of the present case, then, is much allied to the method pursued in the treatment of the preceding one, there is reason to think that the reviewer has done justice to the principal points, both as regards the nature and treatment-of the two cases; and if this be found to be the case, then those who are taught by Dr. Lever, and those who think with him, must follow the same kind of practice in the management of such labours. From all that I can gather, then, after a very careful perusal of what is related of the above cases, I feel an irresistible sympathising impulse in behalf of the parturient woman, which impels me to state, that by a careful consideration of the nature of such protracted labours, and by a knowledge of those therapeutic agents, with their appropriate application, as have been repeatedly enunciated, such labours will never continue to such an unnecessary length, or terminate in so deplorable a manner as has just been noticed. At least, from my experience, I cannot give credence to the necessity of such results, until a clear and distinct account is
given, both as regards
the nature of the case, and an accurate of the means used, and the manner in which they were used in every particular; but these requisites are always, in a great measure, kept out of sight. When such preceding. I again repeat, that in the treatment of labours of so attentions are thus paid to the lying-in woman, Dr. Lever, I resistance to the expulsion of the child, nothing short of the trust, will neither require to "reprobate artificial dilatation," careful and full application of the means of relief, as noticed ’, nor "advocate the employment of incision." in my cases, and so repeatedly alluded to in THE LANCET, can The other cases respecting which I beg a place in THE LANCET safely and speedily remove the obstructions to delivery. I, are in the number of that journal for Feb. 14th, 1846, Such treatment for the relief of such cases must as assuredly I p. 1T6, under the head, " Contributions to the Practice of be acted on, as opium must in future be freely given for the I Midwifery," by Dr. Hall Davis. The first case in this series preservation of life in uterine hæmorrhage. Nothing can goes to show what was several years ago suggested by memore clearly indicate that the practitioner has no idea of the namely, that when the presentation of the head of the child nature of the obstructing causes for the relief of which lie is is somewhat faulty, the best corrector of this mal-position is prescribing, than the indefinite manner in which he relates to establish natural expulsive pains, which seldom fail to his case; su let it never be forgotten, that whatever is the effect the desirable object in view. The second case-a nature and degree of the obstructions to delivery, the means breech presentation—is in my view anything but a wellsuited for relief must correspond. Unless the amount of the conducted one, either before or after Dr. Davis was called. be allowed to continue in power necessary to overcome the resistance offered by the That any woman should po&siblv obstructions to the expulsion of the child be well known to labour thirty or forty hours, under a midwife who had a right teachers of midwifery, the advice given by them in cases of to call to her assistance a physician who is appointed to the difficulty and danger, will in no way differ from the mazy charity in which she is employed, for the very purpose of notions of the nierst tyro. One should almost think that Dr. doing justice to pour women in labour, is an instance of that Lever exults, or, it may be, attempts to excuse himself, in the callous feeling which perhaps universally prevails in all such result of this case, when he says, " many cases are on record charities. It is stated that in this case the labour commenced
great
description
12 on the day before Dr. Davis was called, which half-past ten A.M. Now, had this woman been seen by a practitioner eight or ten hours after the commencement of labour who was acquainted with the common means used for the removal of obstructions in such cases, her delivery, from what is stated of the case, would in all probability havebeen effected naturally and safely in about fourteen or fifteen hours. Even when Dr. Davis was called, it does not appear that he used any means either to remove the obstructions or
that the above crude and irrational mode of procedure still
at three A.M.,
continues to prevail over the whole civilized world. Just after the above observations were finished, THE LANCET for March 28th, 1846, was handed to me, and in it I observed further contributions to midwifery, by Dr. Hall Davis. I shall only briefly notice the first case mentioned. The patient was aged forty-two, of stout habit and firm fibre, and in labour of her first child; she had enjoyed good health. Dr. Davis was sent for on Dec. 18th, 1845, at four P.M. to increase the expulsive efforts of the uterus, but at once True pains had first set in at 3 A.M. on the previous day, proceeded to bring down one of the legs, which he accom- (Wednesday.) At two P.M. of the same day, the orifice of the plished. To any one attempting to bring down the leg of a uterus had become fully obliterated. "The pains entirely left child similarly circumstanced as this one was, the difficulty her at one P.M., (Thursday,) three hours before my visit, but will be found to be very considerable. I once made an effort not suddenly, having latterly gradually lessened in force and to do this, but soon desisted from my mad attempt-used frequency. I found (says Dr. Davis) the expression of counmeans for the removal of the causes of delay, when the child tenance good, the face congested from the effects of previous was expelled in a short time afterwards by the natural efforts. efforts, skin moist and hot, pulse 100 and soft, no heat of The third case was a woman twenty-five years of age, of vagina, a puffy protuberance of scalp, the head impacted, the Under these circum. good health and conformation, and at her full period. bones felt slightly overlapping," &c. Dr. Davis was called to this case at six P.M., and labour pains stances, and after the evacuation of the bladder, delivery by had commenced at half past eleven of the previous even- the crotchet was effected. Had I been present when Dr. ing. The Doctor found the orifice of the uterus one-third Davis proposed destroying the child by the crotchet, my short of its full dilatation, parts cool, the pelvis of average question to him would have been, "For what reason will dimensions. At this distant period from the commencement you take the life of the poor hapless babe ? Your enuof labour, the doctor left his patient without a single prescrip- merated symptoms as regards the woman are all favourtion for her relief, only hoping everything would do well able ; and it is only the impacted condition of the child’s without constitutional treatment. It has been repeatedly head which seems to actuate you to deprive it of life 1" shown by me that no woman in labour, of the description The acknowledged congested state of the woman’s face under consideration, will continue many hours undelivered, showed clearly the nature of her case ; her "stout habit and unless from obstructing causes which are remediable, and the firm fibre,"subjected to long, unnecessary, severe pains, proremedies have also been clearly stated, as well as the mode of duced not only congestion and torpor of circulation in the using them. Yet we see that this poor woman was left with- face, but in every part of her body; and this condition of the out an attempt to relieve or shorten her woful, ineffectual, mother occasioned the same state in the child-namely, a suffering. At midnight, when Dr. Davis again called, he gorging with blood, and an increase of size of its whole body, found the pains frequent and strong, the head still at the and especially its head, forming the principal cause of imbrim of the pelvis, pulse firm and full. He again left the paction. A labour like the present, left without suitable patient, but now he advised bleeding under certain circum- treatment, is the principal cause of impaction, and a fertile stances. At six A.M. he was again summoned, the patient had source of excuse for destroying infantine life. The extraction been bled to sixteen ounces; the head was now immovable in of a sufficient quantity of blood in this case would, at the the pelvic brim. The doctor called again at one P.M., when same instant, have lessened the congested state and bulk of considerable protrusion of the scalp had taken place, still, he the child, as well as the congested and swollen parts of the says, the bony part of the head had not descended lower than mother, which, along with the other usual and necessary at his previous visit. Eighteen ounces or more blood were! means, would have given more room for the passage of the taken. child, while the very common rigidity of the perinasum met Up to this stage of the proceedings, bleeding was the onlywith in such cases would have been relaxed, so as to have allowed the child to pass alive by the natural efforts of the means of relief used, and yet the reader is not put in possessionL of those distinctive symptoms necessary to be known in ordermother. to enable him to judge even of the propriety or impropriety of Paisley, May, 1846. the course pursued. However, it is quite certain, that in some protracted cases of a somewhat similar description, ON LIGATURE OF VEINS. bleeding is not the remedy required; and in other labours, By WALTER YATES, Esq., Surgeon, Nottingham. although bleeding is absolutely necessary, yet it will prove I HAD occasion a little while ago to ligature a vein-the quite inadequate of itself to remove the obstructions to the advancement of the child. It is stated, that about half-past particulars of the case are these: two P.M., on account of peculiar symptoms, the labour was Ann C-, aged thirty-three, a very stout person, was terminated by the operation of craniotomy. Such a revolting coming carelessly down stairs with a chamber-pot in her termination to a case apparently so simple and remediable in hand, and happening to tread on her dress, she fell all her its early stages, ought truly to thrill the sensible parts of man,I length to the bottom; the chamber utensil was broken into a and rouse his mental energies to arrest a procedure so lethargic very many fragments, from some of which she sustained a severe injury of the arm. She immediately got up, and found and apparently so uncalled for. The remaining cases are of so similar a description, are so her dress to be almost completely besprinkled with blood; a similarly treated, and consequently their oneness of result stream of the same fluid was also flowing down her arm. with the preceding ones, render it unnecessary to occupy time Assistance happening most luckily to be at hand, her arm She was bound tightly up with six or seven handkerchiefs. and space in repeating what has already been said. It is stated that one of the children was large, and that the considers the loss of blood in this short time to have been not sacro-pubic diameter of the pelvic brim" did not exceed three less than two quarts. (?) She feels faint, is very pale, and and a half inches. Dr. Burns, in his Dlidwifery," seventh dreadfully alarmed lest she shall lose her arm. Having at edition, page 431, states that it is the opinion of high authority, hand everything necessary for the purpose of effectually and with which he agrees, that if the dimensions of the pelvis securing any vessel or vessels that might be wounded, I removed the handkerchiefs, immediately upon which a terrific were certainly under three inches, a living child could not be born; yet, in the next page, he refers to a case by Baude- gush of blood followed, which I was unable to arrest by the locque, when a living child, by the use of the forceps, was firmest pressure of a bandage, being obliged to have recourse delivered, when the pelvis, in its conjugate diameter, did not to the tourniquet. Having thus temporarily prevented the Now were the obstructing haemorrhage, I then searched the wound-which was deep, measure more than three inches. and was directed horizontally across the front of the elbowcauses to delivery removed early with a pelvis of the dimensions of three aud a half inches, it is my belief, that, by the joint, the incision being about three inches in length. I action of the uterus alone, a living child would be born. discovered a large vessel, which I at first took to be the Although I have selected the foregoing cases as exhibiting humeral artery, but which afterwards turned out to be the the practice pursued by two eminent metropolitan obstetri- common basilic vein. The incision proceeding as it did cians, and although their practice, according to my experience, through three-fourths of its calibre only, allowed the vessel is fraught with the evils of severe, unnecessary, protracted to gape very considerably, hence the tremendous escape of suffering, great danger, both to the mother and the child, and blood. Without further loss of time I then passed a tenanot unfrequently, as we have seen in various instances, with culum through the vein, above the place where it was injured, the lamentable loss of life; yet from all the research which and a second one through it below the same place, and directly I have made for several years up to the present time, it seems divided the remaining portion of the tube, disconnecting very
was
at
!
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