« ForrigeFortsæt »
less equivocal. The stethoscope would appear to be the most reliable when by its means a distinct fetal cardiac sound is heard at opposite or distant parts of the gravid uterus. It was, however, considered but of little importance to have discovered the existence of twins before labour, ivasmuch as the treatment up to the birth of the first child was precisely the same as though it were a simple case. But when the first child was born pressure was immediately made by the hand over the fundus uteri, and everything was done to accelerate the birth of the second. Hence, after a short interval, the membranes were punctured, and the fundus uteri gently rubbed. By this means uterine action was for the most part quickly restored, and the second child was speedily expelled. If, however, inertia of the uterus supervened, ergot was exhibited, and if this failed, either the forceps were applied if the head were below, or turning resorted to if above the pelvic brim.
B. Prolapsus of the Cord.—These cases were treated with reference to the following varieties: first, when it was found presenting previous to the rupture of the membranes; second, when it was found prolapsed in the first stage; third, when the prolapse was discovered at the commencement of the second stage; and fourth, when it was discovered during the progress of that stage.
In the first case the patient was maintained in the horizontal position until the os uteri was sufficiently dilated to admit of the operation of turning previously to the rupture of the membranes. In the second, version was also the remedy, and this was resorted to much earlier in the case of pluriparous females than primiparous females. In the third, if the head had not descended into the pelvis version was also attempted, but if it had, labour was either accelerated by the application of the forceps, or an attempt was made to raise the cord above the sphere of pressure. In the fourth, the same practice was pursued, and it was either attempted to elevate the cord above the head, or to accelerate delivery by the forceps. In short, it is observed that two rules mainly regulated the management of these cases. The first was the delivery by version in tbe early stage, and the application of the forceps in the later; unless, indeed, the funis was pulseless, in which case the labour was left, as much as was consistent with the mother's safety, to nature.
C. Hemorrhage. We need scarcely premise that this is treated of under the two forms of accidental and unavoidable hæmorrhage. The causes of the former were generally difficult to discover, but when discoverable were found to consist of falls, blows, over exertion, strong mental emotion, or some indiscretion. When cases came under treatment, before the os uteri had commenced to dilate, the horizontal position was enjoined, and a cool apartment, cold applications, cold acidulated drinks, and acetate of lead and opium were prescribed.
The diagnosis between this and the unavoidable form of hæmorrhage was mainly determined by the constant oozing of blood during the intervals of the pains and its cessation upon their accession, and by the absence of the placenta from the neighbourhood of the os uteri, the cervix uteri in these cases conveying to the finger a peculiar feeling of elasticity, which contrasted strongly with the soft and doughy feel which was experienced when the placenta was attached to a greater or less extent of its surface.
As to the treatment of these cases, the plan was to rupture the membranes as soon as possible, and if the os uteri were not sufficiently dilated to admit of this operation, ergot was given. Generally on the discharge of the liquor amnii the hæmorrhage ceased, and the pains set in with great vigour and frequency, otherwise ergot was again giren, and if the bleeding continued after the head had entered the pelvis, either the forceps or the perforator were resorted to, according as the child was believed to be living or dead. In one case only was the tampon introduced for the purpose of hastening the dilatation of the os uteri so as to admit of the rupture of the membranes.
Unavoidable hæmorrhage is subdivided into two varieties, according to the greater or lesser extent of the placental attachment over the os and cervix; the one being called complete, the other partial placenta prævia--the former of course being infinitely the more dangerous variety.
The diagnosis of these cases was always easy-the occurrence of hæmorrhage during the period of the pains rather than during their cessation-the sensation given to the examining finger by the spongy placenta as distinguished from the elasticity of the amniotic Auid, and the inability to distinguish the foetal presentation in cases of placenta prævia, afforded adequate data for diagnosis.
In the partial variety of unavoidable hæmorrhage much the same practice was pursued as įn cases of accidental hæmorrhage. The membranes were early punctured, and the case was permitted to proceed as naturally as possible; but when the os uteri was undilated the tampon was applied with the best results. In the complete variety of unavoidable hæmorrhage the tampon was at once introduced and retained until the os uteri was sufficiently dilated to admit of the introduction of the hand and the operation of turning. Subsequently we learn that the tampon usually employed was a sponge wrung out of warm water and smeared over with an unguent.
D. Convulsions are divided into apoplectic and hysterical, the latter, it is stated, being extremely rare. The treatment of the former is considered with reference to their prevention as well as cure, and when patients were found labonring under anasarca, albuminuria, headache, or dizziness, before labour, the practice was to purge them freely and repeatedly with hydragogue cathartics; maintain a horizontal position in a cool ward, and allow none but the mildest and lightest nutriment.
With reference to the relations of albuminuria to convulsions, it was found that in nearly all the cases that came under treatment anasarca and albuminous urine were present to a greater or less degree, yet that convulsions did occur, and even in the most violent form, when neither anasarca or albuminuria could be discovered.
The carative treatment consisted in free bleeding, and purging as soon as the convulsion ceased, and during its continuance preventing the patient, as much as possible, from injuring herself or biting her tongue. Enemata of turpentine or castor oil and assafætida were found useful, and if the convulsions returned, shaving the head, cold lotions, and tartar emetic, with opium, were prescribed. Chloroform was seldom given, and consequently no inference could be drawn as to its efficacy. If the head were within reach the forceps were applied, but whenever the severity of the case was great perforation was unhesitatingly resorted to. Of the 63 so treated 13 died, or about 1 in every 5.
E. Rupture. Including under this head cases in which the breach of continuity was confined either to the uterus, to the vagina, or both, 17 occurred, of whom 1 only recovered. In these the symptoms of impending rupture laid down in books were not always observed, and in one the event occurred without any premonitory symptom whatever. Vomiting during the second stage of labour was always considered a suspicious symptom, especially when this had been severe or prolonged, and whenever pain, fixed and increased upon pressure, was referred to the pubes during the expulsive stage, that stage having been severe and protracted, the indication was to deliver as soon as possible by the means best suited to the particular case. The symptoms of the actual occurrence of rupture were more constantly those which are usually observed, but the collapse varied much in degree, and the sensation of something having given way was not always observed. The treatment, after due attention had been given to the state of prostration and to the delivery, was directed to the subsequent peritoneal inflammation certain to take place, and mercury and opium were chiefly employed, the latter very freely.
F. Inversion of the Uterus.—This accident occurred but once during the seven years. It occurred in a primiparous patient, nineteen years of age, after an easy labour of six hours' duration. The gentleman in attendance, after having tied and separated the funis, had maintained the contraction of the uterus with the hand above the fundus for a quarter of an hour, when, finding a tendency to draining, he increased his pressure, but not more than was usual. Whilst doing so the uterus was felt suddenly to yield and recede from his grasp, and he immediately saw it expelled from the vagina an inverted mass, with the placenta still attached. The organ was immediately replaced, the placenta having been previously detached, and the patient made an excellent recovery.
G. Premature Labour. The chapter devoted to this subject is chiefly of a statistical nature, but contains a few practical observations upon the treatment of abortion, from which we learn that when a patient entered the hospital with hæmorrhage in the early months, two indications were kept in view—first, to endeavour to preserve the ovum, and secondly, finding this impossible, to effect its complete discharge as soon as practicable
. The first indication was fulfilled by rest, a cooling regimen, acidulated drinks, acetate of lead with
opium, and the other means generally employed for restraining hæmorrhage; the second, by the introduction of the sponge tampon, as already described, and the administration of ergot in ten-grain doses every two hours.
We find no reference to the use of sponge tents in the treatment of abortion, and the patients would appear to have all done well without them.
H. Retained Placenta. According to established practice, this is treated of under three heads having reference to the cause of the retention--viz., simple inertia, irregular contraction, or morbid adhesion. For the first, the practice was, if possible. to make the uterus expel its contents before introducing the hand for the purpose of removing them; to effect this, cold applications, pressure, and frietions over the fundus were resorted to, and these failing, the hand was introduced. When the placenta was retained from irregular nterine contraction, whatever the character or variety of the contraction, such cases were all treated by the introduction of the hand. As regards morbid adhe sion, artificial detachment was in all cases practised, and great care was taken to detach the placenta as completely as possible; but it this were found impracticable without the exercise of undue force, as much was removed as had readily yielded, and the remainder was left behind.
We have thus passed over in rapid review some of the more practical portions of the work, and have endeavoured to give in a condensed form the leading rules of practice which are at present observed in the Dublin Lying-in Hospital. Regarding it as one of the great centres of obstetric learning in this country, we have, in deference to this consideration, ventured upon little more than an analytical notice of the volume, and if in the analysis we have submitted to the reader he is enabled to discern but little that is original or novel in the practice, we would venture to observe that an important inference is deducible from the factą viz., that it is not from such institutions that the many innovations and reputed improvements upon established practiee wbich are to be found in the current literature of the day for the most part date their origin. He who has the responsible management of a lying-in hospital in which nearly 2000 women are annually delivered, can have little time or taste for engaging in abstract or speculative disquisitions, and must see the operations of nature conducted upon too large a scale to seek to control them by unnecessary artificialities. We accordingly do not find in the work any proposal for the conversion of natural into preternatural labour's—10 proposition for the abolition of craniotomy from obstetric practice, no rules of treatment founded merely upon speculative considerations. Hence, indeed, the great value of such works as the present: they reflect, as it were, a faithful image of the realities, dangers, and responsibilities of obstetric practice, as distinguished from its idealities—they show how these difficulties are capable of being met, how far successfully, how far otherwise, and they offer equally encouragement and consolation to all who are engaged in this arduous calling-encouragement, by showing how often the greatest difficulties may be successfully overcome, and consolation under failure, by showing how often the best directed efforts may prove abortive and unavailing.
We have ventured in the introductory observations of this article to point out what appears to us to be two great drawbacks to the practical value of this work, the one being a too great deference to artificial classifications, the other a redundancy of statistical calculations in reference to facts of little practical import. The former deprives many of the subjects treated of of their full value and interest, the latter sorely perplexes and confounds the reader who seeks to elicit from its pages the point and spirit of the work. We trust that the future historian of the practice of the Dublin Lying-in Hospital will guard against both these tendencies, and that he will bear in mind the excellent admonition of the late Dr. Gooch to those who are engaged in the study of midwifery-advice which appears to us to be s applicable to authors as to students:-“Watch cases attentively, and take notes of their important particulars, and not lengthy notes containing a diffuse description of unimportant trifles, which from the time that they occupy, will soon cease to be written, and if written, are sure never to be read; but a short description of the leading circumstances, with an equally short mention of the reflections which they suggest.
The Works of John Hunter, F.R.S. ; with Notes. Edited by JAMES
F. PALMER. Four Vols. 8vo. Illustrated by a Volume of Plates
in Quarto.--London, 1835. The late re-interment of the remains of John Hunter has naturally recalled his memory to the public mind, and more especially and more vividly to the mind of that profession which he did so much to enlighten and to elevate. The publication of a collected edition of his works, now more than twenty years since, accompanied with introductory essays and explanatory notes, by men eminently qualified for the task, might well have been supposed to have made his labours thoroughly familiar to the profession, and to have rendered superfluous any further attempt to exhibit the greatness and the peculiarity of his genius, to vindicate his opinions from misrepresentation, or to point out the benefits which he has conferred on various departments of medical science and practice. According to our observation, however, these effects have been slow in following. In a general way, the name of Hunter is invested with all imaginable honour ; but his views are still very imperfectly understood ; several important results of his inquiries are frequently ascribed to others; he is praised for discoveries that he did not make, and censured for tenets that he never held ; and, on the whole, if the broad question were proposed,“ What did John Hunter achieve for scieuce, to entitle him to the lofty posi