MIDWIFERY, AND THE DISEASES OF WOMEN AND CHILDREN. 85.-ON IMPROVED METHODS OF INDUCING AND By Dr. ROBERT BARNES, Lecturer on Midwifery at St. Thomas' [The results of the modes of inducing premature labour usually followed have not appeared to Dr. Barnes to be very satisfactory. There is for instance no certainty about the time at which labour commences, and when it comes the child is liable to be expelled somewhat suddenly in the absence of the medical man. Moreover, owing to the frequent excess of liquor amnii when the child comes to present, it is liable to assume an unfavourable position, or the cord falls through. Hence it follows that it is desirable to keep a control over the whole course of the labour.] Assuming that it is both desirable and possible to control and to regulate the entire course of labour prematurely induced, I will describe the method after which the proceeding should be conducted. It is convenient to divide the act of artificial labour into two stages. The first stage is provocative and preparatory; this includes some amount of dilatation of the cervix uteri, and implies a certain amount of uterine action, and lubrication of the cervix and vagina. The second stage is the accelerative or concluding stage; it consists in the expulsion or extraction of the foetus and placenta. The ordinary modes of conducting an induced labour almost ignore the last stage, or the means of accelerating delivery. 6. 1. The provocative and preparatory stage.-The means of preparing the uterus for the task prematurely thrown upon it are numerous. I will not discuss their relative merits in detail, as I have done this in a memoir on The Induction of Premature Labour," in the Obstetrical Transactions, 1862; but I think it important to repeat an emphatic warning against one of them. I mean, the plan of injecting water or other fluid into the uterus. This was introduced by Schweighänser and Cohen ; and is sometimes described as Kiwisch's plan. But Kiwisch's plan is simply to inject water into the vagina, playing the stream against the os uteri, not into the cavity of the uterus. Now Kiwisch's plan is generally harmless, but it is certainly often useless. On the other hand, Cohen's intra-uterine injection, although far more certain in its action, is fraught with extreme danger. Both in this country and abroad several cases of severe shock and of sudden death have been caused by it. Of course no advantage, or convenience, however great, can counterbalance such a danger. The plan, therefore ought to be rigorously discarded. There are means that are perfectly safe and effective. It is important to recognise, in limine, the essential difference between provoked premature labour and labour at term. In the premature case, labour finds the uterus in an imperfect state of development. This condition involves imperfection in the contractile power of the body of the uterus, and greater resistance in the cervix. These things must be taken into account. They call for artificial aid. The uterus is called upon suddenly, and before its time, to do that for which it is not prepared. It is but reasonable to anticipate that help will often be useful. And help can be given to facilitate the dilatation of the cervix, and to supplement the contractile energy, if this cannot be aroused. The course I adopt is as follows: Having determined as closely as possible the period of gestation, I fix the day for the operation. On the evening of that day, the patient being in bed, I pass a No. 8 or 9 elastic bougie into the uterus, as far as it will easily slip in; it will generally go in to the extent of four to six inches. The end projecting beyond the os is then twisted up into the vagina; this keeps the bougie in situ. The patient keeps her bed for the night, so as not to disturb the bougie. Next morning, it will almost always be found that some degree of preparatory action has been effected. The cervix will be softer, and perhaps admit the finger; the vagina will be well lubricated with mucus; and some uterine contraction or pains will be present. If this should merge into active labour, the bougie may be withdrawn ; otherwise it may be left or replaced. Towards the afternoon, the cervix will be more yielding and expanded. The further course must then be determined by the special indications of the case. If the pelvis be normal, and the labour have been induced on account of constitutional disease, it is generally better not to resort to any active accelerative measures, but to let the labour take its own course. When the cervix will admit of two or three fingers, if active pains are not present, it will, however, be desirable to tap the membranes by making a sinall scratch with a stilet or a quill. The drawing-off of a little liquor amnii, allowing the uterus to collapse, commonly stimulates it to increased activity, and in a few hours the child may be expelled. It is, of course, necessary to watch, lest the position of the child should become unfavourable, or the cord become prolapsed; circumstances, I repeat very likely to occur in premature labour. If the labour have been provoked on account of pelvic distortion, greater assistance will be required. The first difficulty to overcome is the resistance of the cervix uteri. The great agent in dilating this structure is the direct pressure upon and within it of the foetus and membranes distended by liquor amnii. But when the brim is contracted, this pressure can rarely be exerted effectually. Hence the tediousness and the danger attending the laissez-faire or expectant treatment. The child may perish from long compression; the mother may be exhausted by protracted pain and shock. To avoid these dangers, it is now necessary to dilate the cervix by means that imitate as nearly as possible the natural agency. Introduce the caoutchouc waterdilator into the cervix, taking care that the narrow middle part of the bag be gripped in the ring of the cervix; then distending it gently and slowly with tipid water, the finger on the cervix takes note of its effect. In half-an-hour or an hour, the middle sized bag will commonly have increased the dilatation so that the cervix will admit three or four fingers. This is the time to rupture the membranes. If the uterus act with sufficient power, and the pelvic contraction be not so great as to impede the passage of the child's head, watch, and let nature do her work. But if the head is delayed at the brim, the physician must intervene. He has two alternatives. He may first try the forceps. If the distortion is moderate, the conjugate diameter measuring say 3.50", the head may come through. But if it do not come easily, and especially if the conjugate is reduced to 300" or below, turning is the true accelerative means. If I may trust my experience, I should, without besitation, say the prospect of a child being born alive under the conditions postulated is much better than under any other mode of delivery, and even better than is the prospect under turning in ordinary circumstances at the full period of gestation. The explanation is as follows: the child's head is not only smaller, but it is more easily moulded; it is caught at the smaller or bi-temporal diameter, between the projecting promontory and the symphysis pubis; the jutting promontory leaves abundant room on either side in the sacro-iliac region of the brim for the cord to lie protected from pressure; and if care be taken that the cervix uteri be adequately expanded, the head comes through so quickly that the danger of asphyxia is not great. The mode of turning demands consideration. The object being to secure a quick delivery, the soft passages must be well prepared. We might turn by the bi-polar method without passing more than two fingers through os uteri. But I have found that, although it is always well to avail ourselves more or less of the bi-polar principle to facilitate turn ing, it is desirable in this case to pass the greater part of the hand through the cervix to grasp the further knee. The reason is this: the cervix that will admit the hand will in all probability admit the ready transit of the child. We thus secure adequate dilatation. It This When the turning is completed, extraction must follow. should be performed gently, drawing upon the one leg until the breach has passed the outlet; the extraction of the trunk should be slow, and a loop of cord should be drawn down to take off tension. When the arms are liberated, the neck of the child is in danger of being constringed in the circle of the cervix. is the moment for acceleration. The two legs are held at the ankles by the left hand, whilst the right hand fingers are crutched over the back of the neck. The head is sure to enter the contracted brim in the transverse diameter; it then has to describe the circle round the point of the jutting promontory which I have described (‘Lectures on Obstetric Operations,' Med. Times and Gazette, 1868) as "the curve of the false promontory.” Traction must, therefore, at first, be carefully exerted in the direction of this curve or orbit; that is, well backwards, so as to bring the head round and under the promontory. When it has cleared the strait and is in the pelvis, the occiput commonly comes forforward, and traction is changed to the direction of Carus' curve, to carry the head through the outlet. Unless rigorous attention be paid to the above rule for bringing the head through the brim, so much time may be lost as to imperil the success of the operation. Turning, as a mode of delivery in contracted pelvis, is not, I believe, yet established as an orthodox proceeding. Certainly to be successful it requires precision in diagnosis and skill in execution. But these are requisite conditions in all surgical operations. I have now, with tolerably mature experience of the operation in all its applications, no hesitation in expressing my opinion that turning in contracted pelvis, where labour is induced prematurely, is an operation of the highest value as a means of extricating the mother from peril, and of saving the child. It has this great advantage: it enables us to postpone the induction of labour for two or three weeks or more, so as to reach a stage of greater development of the child. If, for example, we preclude ourselves from turinng, and the pelvic contraction leave only 3.00" or less of conjugate diameter, we must bring on labour at the end of seven months, or spontaneous delivery may be defeated, and with this the child is lost: whereas, if we contemplate turning, the gestation may be allowed to go on till the end of eight months; for a living child may easily be drawn through a conjugate of 3:00". A further advantage obtained by this postponement consists in the greater probability of hav ing to deal with a viable child. If we calculate too closely, say from the first week after the last menstruation, and fix the induction of labour 220 days from that time, we may find that the child has really not attained a stage of development corresponding to our calculation. One design of the proceeding is thus frustrated by error of estimation. But if, on the other hand, we feel confidence in putting off the labour until the 250th day, we cover this range of liability to error, and secure a child that is at any rate viable.-St. George's Hospital Reports, Vol. 3, 1868, p. 111. 86.-ON STRICTURE OF THE INTERNAL OS AS A CAUSE OF MISCARRIAGE. By Dr. WILLIAM MARSHALL, Mortlake, Surrey. Mrs. D., aged 30, a delicate woman, five months advanced in pregnancy, was taken with labour pains about six o'clock one evening. I saw her at 8.30. The pains were strong and forcing, very similar in character to those which immediately precede the expulsion of the head in a primipari. I was told that when pregnant last she had miscarried at the fifth month, and that the pains then, for three hours, had been very severe-much worse than she had ever had them in any confinement, and similar to what they were now. On examination, I found the os uteri dilated to the size of half-a-crown, and very soft. On passing my finger further up in order to feel the fœtus, I found the canal of the cervix becoming decidedly narrower, when suddenly she cried out that I was cutting her, and jerked herself away. On a second attempt the same thing was repeated; but on a third, being prepared for her moving, I ascertained that a tight resisting constriction existed at the internal os, which would not admit the tip of the finger. As soon as I touched the constricted part, she complained of a severe cutting pain; and on attempting to pass the finger through it, she became hysterical, and on my persisting, perfectly maniacal. On withdrawing my finger she immediately became rational, and complained of the agonizing pain I had caused her. As she was quite positive that in her previous miscarriage she had suffered for three hours as much as she was doing now, I waited for a couple of hours. During this time the pains were very strong, and the suffering greater than I had ever seen in any confinement. In order to make a thorough examination, I put her under chloroform. The external os was very soft, and dilated; but at the internal os there existed a constriction which still readily allowed the finger to pass through, and which seemed now quite dilatable. The breech was presenting, and I had no doubt that when a pain came it would be |