Imagens das páginas
PDF
ePub

that we have manuals, and good ones too, upon almost every subject. But in the contemptuous sense in which the term was applied we cannot agree, for the manuals of the present day are in fact treatises of considerable length, retaining only the name of the former brief abstracts to which it was applied. Look, for instance, at the series published by Mr. Churchill; they ai-e certainly small in bulk, but that is the result of small, close print, and thin paper: any one of them, if printed in the old manner, would make a respectable octavo volume. But the most marked difference between them and their predecessors of the same name is, that they are the productions of the ablest men in the different departments of the profession. Almost every section has its volume, and their sale is the best proof of their popularity with the profession. Hitherto, midwifery has been the solitary exception, but at length this want is worthily supplied.

In Germany, more than one series of manuals, we believe, is in the course of publication. Dr. Spiegelberg's volume is one of a series publishing under the editorship of Dr. Schauenburg, and if the other volumes are of as high a character as the present, the students of Germany will have little cause of complaint.

As most of our readers are probably acquainted with Dr. Tyler Smith's former work 'On Parturition,' in which he so successfully applied Dr. Marshall Hall's discoveries to the elucidation of the physiological problem of pregnancy and parturition, they will no doubt be prepared to welcome another work from the same pen. Nor will this feeling be lessened by the practical character of his recent volume 'On Leucorrhcca.' He has shown that he possesses not only reasoning powers of a high order, but acute and accurate observation of facts.

It will be remembered that the course of lectures delivered by Dr. Tyler Smith appeared in print in the 'Lancet' for 1856, and so favourably were they received, that Mr. Churchill applied to the author to recast them for one of his manuals, in which popular form they are now presented to the profession.

We are inclined to begin our notice by finding a little fault, if Dr. Tyler Smith will excuse us. No doubt classification and division may be carried too far, but a certain amount is a great assistance to the student, and we cannot but think that the studied avoidance of such helps on the part of the author is a detect. To those who look closely, there is certainly an undercurrent of connexion, if we may so speak, between the different subjects, but superficially this does not appear. Of course we have the two great divisions of anatomy and physiology, and practical obstetrics. The execution of the first part is very good, perhaps clearer and more correct than in any of the ordinary w4orks on the subject. The second part is good also, but it is by no means superior, perhaps hardly equal, to some of the other manuals. In order to give the reader a bird's-eye view of the ground occupied, we shall quote the titles of the successive chapters. First, we have the subject of generation treated sufficiently fully, followed by a description of the organs of generation, ovulation, menstruation, conception, and the development of the ovum and its appendages, the signs of pregnancy, disorders of pregnancy, the causes and treatment of abortion, molar pregnancy, super-foetation, extra-uterine gestation, the nervimotor functions of the uterus, the foetus in utero, and the duration of pregnancy. We next come to the obstetrical portion of the volume, strictly so called, although no classification is made by the author beyond the separation into chapters. Here we find chapters on the pelvis, the anatomy of the foetal head, the mechanism of labour, the stages of labour, the management of natural labour, and of the puerperal state, face presentations, pelvic presentations, transverse presentations, funis presentations, placenta presentations, deformities of the pelvis, obstructed labour, difficult labour, tardy and precipitate labour, postpartum haemorrhage, rupture of the uterus, puerperal mania, puerperal convulsions, puerperal fever, phlegmasia dolens, and lastly, the various obstetrical operations, induction of premature labour, version, the forceps, embryotomy, the caesarian section, and a chapter on chloroform.

This enumeration will sufficiently prove the want of an adequate classification,

at the same time that it will enable the reader to estimate the wide range of subjects included in the work.

As tiie volume is merely an improved reprint of Dr. Tyler Smith's lectures, we do not think it necessary to enter upon an elaborate analysis of the volume, but shall content ourselves with culling an extract here and there which may appear to us interesting, original, or practically important.

On the subject of the "behaviour" of the uterine mucous membrane during menstruation, the author has carried still further the views of those who regard that membrane as excrementitious under certain circumstances. After describing accurately and carefully the phenomena of menstruation, the character and quantity of the discharge, and the condition of the ovaries and uterus, he observes:—

'' It appears to me in accordance with what I have observed on uteri examined during a menstrual period, the facts connected with membraneous dysmenorrhoea, and the detachment of the decidua in abortion and parturition, to suppose that the mucous membrane is in great part or entirely broken up, and its debris discharged during each menstruation. The blood is probably exuded during the breaking up of the mucous structure, and the duration of the menstrual period represents the time occupied in the periodical decadence and renewal of the mucous membrane of the body of the uterus. The new membrane becomes converted into decidua in the impregnated female." ..." According to the view I have stated, a new mucous membrane is formed as a part of the process of preparation for the reception of a foecundated ovum; not that the aptitude for the reception and implantation of the ovum belongs only to the newly-formed mucous membrane, though it is probably greater at this time than at others. The mucous membrane may become the seat of the change consequent upon impregnation just before a menstrual period, and in cases where menstruation is suspended. According to the view now stated, the mucous membrane of the uterus becomes excrementitious every month, and is discharged from the cavity of the uterus in a state of disintegration. The uterus appears to gain a new mucous membrane by a similar process to the reproduction of lost parts." (p. 62.)

This is ingenious, no doubt, but we think the facts hitherto observed are far from sufficient to establish it. Nor i9 it at present reconcileable with known facts, for if the exfoliation is an essential part of the regular monthly process, and necessary for the reception of the ovum, what proof have we that it occurs in those cases when conception takes place before a menstrual epoch, or how explain the occurrence of impregnation during the menstrual flow, as in the cases related by Raciborski? In truth, the condition and changes of the interior of the uterus during menstruation, gestation, and after parturition, require more careful and detailed observation.

The chapters on conception, and the development of the ovum and its appendages, are clearly and carefully written, but without any original observations. The different signs of pregnancy are detailed in a condensed and able manner. The description of the sounds of the foetal heart is somewhat imperfect: nothing is said of the peculiar rhythm which differs so much from the healthy adult heart, but which is occasionally simulated in typhus fever.

The variations in the actions of the kidneys are very well told, and the treatment of albuminuria very sound. A variety of the renal secretion is noticed by Dr. Tyler Smith, as he believes, for the first time, and we shall quote his own words:—

"I am not aware that the matter has been observed by obstetrical authors, but in some pregnant women, the urine, without being albuminous, contains habitually a large quantity of triple phosphates, is of a high specific gravity, and has an alkaline reaction during the greater part of pregnancy. The nervous and vascular erethism attendant upon, or produced by, the state of pregnancy, is followed by the same results as other and more marked causes of exhaustion. I have known this phosphatic diathesis to exist in cases in which fatty degeneration of the placenta has occurred in successive pregnancies." . . . . "The treatment in such cases should be that employed in the phosphatic diathesis occurring under other circumstances than pregnancy, namely, the mineral acids, opiates, rest, and a nutritious regimen. Such patients also require either during or after the completion of pregnancy, preparations of steel, as a marked degree of anemia is produced by the persistence of the disorder." (p. 121.)

When treating of retroversion of the impregnated uterus, under the head of disorders of pregnancy, Dr. Tyler Smith mentions M. Gariel's proposal to introduce his india rubber pessary, and then inflate it as a means of raising the fundus uteri, but he adds, that he is not aware of its having been tried. We had an opportunity of testing its value recently, and we are happy to say that it succeeded perfectly, and in a few minutes, without the least pain; but then it is only fair to state that .the patient was only about three months pregnant, the uterus by no means tightly filling the pelvis. The idea of thus replacing the uterus, however, is due to Dr. Halpin, of Cavan, who many years ago reported a case thus treated successfully to the Dublin Obstetrical Society.

The chapter on abortion and its treatment is very good as far as it goes, but scanty information is given upon one or two points which are most puzzling to beginners, and even sometimes to those of riper age. Suppose an abortion of two or three months, the foetus being expelled, but the shell of the ovum retained. We are to restrain haemorrhage of course, and to procure the expulsion of the retained portion by ergot, &c., if we can. But suppose we fail, and that we can neither expel nor extract it, what is to be done? Dr. Tyler Smith has not provided for such cases, and yet they are very common.

The cause of the ordinary position of the foetus in uterus, t. «., with its head downwards, whether it be the result of gravitation or instinctive and voluntary motions or reflex movements, is yet a subject of controversy. Probably no one of these theories affords an adequate explanation, aud this seems to be Dr. Tyler Smith's opinion. His own views are thus given :—

"In the early development of the embryo the limbs are deficient in muscular power, and do not assume any definite form. The nervous system has hardly commenced its control over the, as yet, feeble muscles. The quantity of liquor amnii is very large in proportion to the size of the uterus, and the uterus is circular rather than ovoid in shape. We have to consider these elements as slowly altering from day to day in an almost inappreciable manner, during the middle and later months of pregnancy, and while the foetus is gradually taking up its ultimate position. The limbs of the foetus enlarge, becoming subject to the vis nervosa, under the influence of tone; the arms and legs, particularly the latter, become contracted so as to form the foetal ovoid. During this time, the relative quantity of the liquor amnii diminishes, so that at the full time the liquor amnii scarcely does more than fill up the interstices left between the foetus and the uterus. Synchronously with these events, the uterus itself, by the development of the cervix, changes from the circular to the pyriform or ovoid shape. With this change of shape the uterus acquires more power of muscular contraction, and becomes the subject of reflex and peristaltic actions. The contractions of the uterus necessarily exert a moulding or adaptive influence upon the foetus, poised lightly as it is in the liquor amnii, and moved within the limits of its prison by the slightest impetus. These causes are aided by the reflex movements of the foetus itself. Under irritation, the limbs of the foetus strike out, but only to return it more closely to the ovoid shape, and to accommodate it as accurately and easily as possible to the uterine cavity. All these influences, combined with the effects of gravitation and of the inclined planes upon which the foetus rests in the upright and recumbent positions of the mother, arrange and preserve the foetus in the normal position with the head at the os uteri. No single power, however, gives its attitude or position to the foetus, and it is difficult, amidst such a number of adaptations, all contributing to the same end, to single out the most important. If we give the predominance to any single one of them, I think the spinal principle of Tone must be considered as the most influential, and it is to the absence of this, more than of any quality, that we must attribute the irregular presentations of dead children. (p. 217.)

Passing on to the consideration of labour, we find that Dr. Tyler Smith divides it practically into a preliminary and supplemental stage, and three principal ones— dilatation, propulsion, and expulsion. There is no great harm m making more stages than usual, provided the limits are steadily borne in mind; at the same time, we contend that there is a practical advantage in marking the distinction between what has been generally called the first and second stage, or the interval before and after the passage of the head through the os uteri. The entire history of prolonged labour turns upon the question of the stage in which the delay occurs, and if we add the question of relative proportion between the pelvis and that which has to be transmitted through it, we shall include all the problems of uncomplicated midwifery. A prolonged first stage involves no danger to the child, and none to the mother, except so far as loss of sleep may produce exhaustion, and is a bad preparation for a possibly long second stage. Whereas the second stage very slightly prolonged beyond its normal duration will give rise to constitutional symptoms, and if much prolonged, will involve both mother and child in imminent peril. We strongly recommend the study of the chapters on the management of natural labour and the puerperal state to the junior members of the profession.

When describing the mechanism of face presentations, Dr. Tyler Smith states that the emergence of the head from the pelvis with the chin on the perineum, as described by Smellie and Hamilton, is impossible without assistance; and in this we are satisfied that he is right. He also very properly objects to the different modes of management which have been laid down, and truly states that the treatment is very simple:

"We may assist the chin in making its rotation forwards and downwards by introducing the finger into the child's mouth, making traction upon the lower jaw, and bringing it under the arch of the pubis. Meigs lays it down as a great rule of practice in face cases, that the ohin should be brought towards the pubis as the face emerges from the pelvis. This is an analogous procedure to that of bringing the occiput down in vertex cases, either directly, by the fingers applied to the back of the head, or indirectly, by pressure exerted upon the forehead. The principle is the same in both cases—viz., to favour the birth of that part which tends to be born first. Should the head fail to rotate in the pelvis, the forceps will generally be necessary or the head must be dislodged, and the child delivered by turning." (p. 335.)

The directions for delivery in breech or footling cases are clear and concise, based upon a due appreciation of the source of danger to the child. Pressure upon the funis is to be watched and guarded against if possible, but as it is important to allow the body of the child to be expelled slowly for the more perfect dilatation of the passages, we are unwilling to afford assistance if it can be avoided; but after the arms are expelled and the head is in the cavity of the pelvis, we must interfere, or the child will be lost.

"The necessity of interference being clear, there is no great difficulty in rendering it. A finger or two of the left hand should be introduced into the child's mouth, or laid one on each superior maxilla, and the face drawn steadily down towards the fourchette of the perineum: at the same time, the occiput should be pushed up by a finger or two of the right hand, introduced behind the pubis. This manoeuvre will bring the shortest diameter of the foetal head into relation with the antero-posterior diameter of the outlet of the pelvis. The head will emerge now with the aid of gentle traction towards the knees of the mother, and the birth is complete. Whether the position of the foetus is a dorso-anterior one or an abdomino-anterior, the management varies hardly at all. The occiput rotates forwards from its posterior position just as in third and fourth vertex cases; and nature will generally adapt the head to the pelvis much better than the accoucheur. No force should be used in the extraction of the head. Above all, traction should never be exerted upon the shoulders, as very slight extension of the neck is sufficient to destroy the child." (p. 350.)

With muciparous women, the timely extraction of the head is easy enough, and Dr. Tyler Smith's rules may be safely followed, but with a first case we are pretty sure that a rigid observance of them would entail the loss of the child. The truth is, that in such cases a certain amount of traction force must be used, but it is our duty to take care not to exceed what the child can safely bear; and that force must be exerted upon the shoulders, simply because there is no other part on which it can be effectively exerted. If the body of the child be carried very much forward, not towards the knees, but between the thighs, the face will generally sweep over the perineum in time, and without requiring an injurious amount of traction.

Dr. Tyler Smith differs from Dr. Barnes as to the cause of placenta praevia. Ilia opinion is that it is caused by the impregnation of the ovule, or attends the

"Arrest of the impregnated ovule after it has descended through the Fallopian tube and

uterus, so as to reach the upper part of the cervix uteri, this being the last point at which the ovule retains its capability of impregnation and attachment to the uterine surface . . . There is no more difficulty in supposing that, instead of being arrested or impregnated in the tube or in the fundus, it may in some cases pass on to the lower part of the cavity of the uterus, the point at which it joins the cervical cavity, in which case we have placenta praevia." (p. 376.)

This does not appear to us very explanatory; it is at most another way of expressing the same fact.

We are rather surprised at the omission of the stethoscope as a means of diagnosis in these cases. In several cases we have been able to decide between accidental and unavoidable haemorrhage by its aid alone.

We quite agree with the author in the use and value of the ping, and in the opinion he expresses of the usefulness of astringents. Puncturing the membranes we think objectionable unless good pains be present, or the haemorrhage have ceased, as emptying the uterus would not control the flooding, but might divert it, and render the case one of internal haemorrhage. Dr. Tyler Smith observes—

"In my opinion, turning is the great operation in placenta praevia, when the child is living and viable-—that which, if performed at the proper time, affords the greatest chances of safety both to the mother and child. But there are circumstances in which turning is the best practice, when the safety of the mother alone is concerned, the child being already dead. The conditions favourable to turning are, a dilated or dilatable condition of the os uteri, the retention of the liquor amnii, or a moderately relaxed uterus, a pelvis of average capacity, the absence of dangerous exhaustion, or a temporary cessation of the haemorrhage. If the placenta be attached to one side of the uterus the hand should be introduced on the side opposite to the placental site; or if it extends over the whole os, the hand should be passed in the direction in which the attachment is least considerable, or where the separation has already taken place. The advantages of turning are, that without materially increasing the danger of the patient, and in a very short space of time, the feet and body of the child may be brought down so as to act as a tolerably efficient plug to the os and cervix uteri. During the early part of the operation the hand and arm of the accoucheur form a tampon. Turning is generally easy in placenta praevia at the full term, as compared with other cases in which it is required, because the contractions of the uterus are commonly less powerful than usual. The flooding itself tends to produce dilatation (qu. relaxation) of the os uteri, and to weaken uterine action. It is, therefore, a less severe operation to the mother than in many other cases in which it is called for. This is particularly the case in multiparous women. As regards the state of the uterus, primiparous women, as in other cases requiring turning, offer greater difficulties than women who have borne children. When the operation of turning is performed early in placenta praevia, the proportion of mothers saved is large, and a considerable number of children are bom alive. Turning should always be performed in placenta praevia, when it is considered advisable, the instant the operation is rendered practicable by the condition of the os and cervix uteri. In cases where the os uteri has been dilated for many hours sufficiently to admit of turning, and blood or strength has been lost in the interim, we should blame not the operation, but the delay, for a great proportion of the fatality to the mother and child." (p. 382.)

It does not appear that Dr. Tyler Smith is convinced of the advantages of completely detaching and extracting the placenta according to Dr. Simpson's plan, nor of detaching the lower portion, as proposed by Dr. Barnes.

The chapter on convulsions is very complete. Under the heads of centric and excentric causes the author enumerates all the physical excitants of the disease; and he adds, under the former head, a valuable paragraph upon the psychical causes. Moreover, the subject of albuminuria, and its connexion with convulsions, receives special and careful consideration, the author availing himself of Dr. Braun's valuable treatise.

As regards bloodletting, we quite agree with the following remarks of the author:—

"The action of bloodletting on the spinal marrow is greatly modified by the condition of the circulation. In fulness of the vascular system, it is a powerful sedative of spinal action. Hence venesection is a great remedy in the simpler form of puerperal convulsion, where the disease chiefly depends on stimulation of the spinal marrow by excess of blood, or the mecha

« AnteriorContinuar »