Imagens das páginas

nical pressure exerted by the blood on that organ, together with the counter-pressure of the distended brain on the medulla oblongata. In such cases bleeding should be performed with a view to its sedative action on the spinal marrow, and to avert the mechanical effects of vascular pressure from this organ. Alone, it will frequently be sufficient to subdue the disease particularly when the fits come on before the beginning of labour or after delivery. But the second important intention of bloodletting should never be lost sight of—namely, that of preserving the brain from injury during the convulsion. Besides the primary congestion, which may have been the cause of the attack by its counter-pressure on the medulla, the convulsive actions themselves, exerting great muscular pressure on the whole vascular system, and causing, as they do, great turgidity of the vessels of the head, are frequently dangerous sources of fatal cerebral congestion, or of serous or sanguineous effusion. As in the case of epileptics, women in puerperal convulsion frequently die of apoplexy, produced by the immense pressure exerted on the cerebral column of blood during the fits. It is, I believe, in great measure from the effects of bloodletting in warding off accident from the brain that bleeding is so general in this disease. The due recognition of the distinct operation of bloodletting on the cerebral and spinal systems is of the utmost consequence. In plethoric states of the circulation it is in this disease curative in its action on the spinal marrow, preventive in its action on the brain." (p. 505.)

One of the most important points in connexion with the management of convulsions is, whether- the labour is to be left to nature, or whether we are to interfere, and in what way. There is good sense in the following observations:—

"The general principle we may deduce is, that wherever artificial delivery can be effected with less irritation than would be produced by the continuance of the child in the parturient canal, and its expulsion by the natural process, it is advisable that it should be performed if the situation of the mother be perilous. It must be with reference to this principle—namely, to the irritation of any particular operation, and the irritation of labour itself—that turning, craniotomy, or the forceps must be decided upon." (p. 511.)

We confess to having a great objection to turn in such cases, and rarely will craniotomy be justifiable unless the child be dead. But here chloroform is invaluable, and deserving, we think, of a fuller notice than Dr. Tyler Smith has given it. It not only arrests the convulsion, but renders the application of the forceps safe and easy; and the delivery without pain, or a recurrence of the paroxysm.

In conclusion, we may congratulate the profession upon having the matured opinions of so able an accoucheur as Dr. Tyler Smith within reach, and the publisher upon having secured a valuable addition to his manuals. Of the style of the author we have enabled our readers to judge for themselves, and we do not think that their judgment will be adverse. The book is not perfect, of course, and we have taken the liberty of pointing out what we consider its chief defect— viz., that the practical part is rather a brief summary of the best current opinions, than a series of detailed instructions for the guidance of practitioners.

The illustrations, which are very numerous, are beautifully executed, and add much to the value of the book.

We are happy in being able to speak very highly of the second book at the head of the article. Dr. Spiegelberg deserves great credit for the care and pains he has taken. The volume has no pretence to originality; it is even more of a manual perhaps than Dr. Tyler Smith's, and its range is more limited, but so far as it goes, the execution is very respectable.

The first part consists of the anatomy of the pelvis and the parts of generation, with ample instructions for both external and internal investigation. Then follows the physiology and dietetics of pregnancy, labour, and childbed, with very minute details as to the changes effected in the organs involved; the development of the ovum, the diagnosis-of pregnancy, the duration of gestation, and the diagnosis of the life and death of the child. The sections are carefully written, and contain a large amount of information.

The author next speaks of labour, of the pains, including not merely the uterine contractions, but those of the vagina, as well as the action of the abdominal muscles; after which he describes the ordinary course of labour, the mechanism of parturition, and the management of labour, with a section on the use of chloroform. Then we have a carefully written section on the physiology and dietetics of childbed, both as regards mother and child.

The third division of the work concerns the pathology and treatment, first of pregnancy and then of delivery. Under the latter head we have sub-sections, where the pathological condition is referable, 1 to the pains, 2 to the pelvis, 3 to the soft parts, and 4 to the child, with the subsequent addition of complicated labour. This arrangement is excellent, and we very much prefer it to the absence of all such classification in Dr. Smith's manual.

The fourth division embraces all the obstetrical operations, and is both full and precise.

Our limits will not permit us to enter upon a detailed analysis of this work, but we shall notice one or two points.

Dr. Spiegelberg is an advocate for the use of chloroform, and we think that he has met the usual objections in a fair and satisfactory manner. He lays down the following conditions for its administration: 1, that an inhaler is not necessary, provided the handkerchief or towel be held at a short distance from the face, so as to admit the free mixture of atmospheric air; 2, the chloroform must be pure; 3, the inhalation should commence at the beginning of the second stage; 4, and should be continued only during a pain; 5, in normal labour, an extreme degree of anaesthesia need not be produced; 6, we should commence with a moderate dose; 7, the patient need not be confined to one position, and special attention should be paid to the evacuation of the bladder; 8, chloroform should neither be given after a full meal, nor after long fasting; 9, the greatest quiet is to be observed, especially at the commencement of inhalation; 10, the patient is not to be awoke.

As our object is not so much to exhibit the style of the author, .as to show the manner in which he treats his subject, we will turn to the section on narrow pelvis, and to that on the operation by the forceps, for this purpose.

The former commences by the distinctions between general narrowing, or that arising from special deformity of bones or joints. Thus we have the equally undersized pelvis, which may take the female, the juvenile or the male form, the funnel shape, the diminished conjugate diameter of the brim, synostosis of the sacrum and innominata, Naegele's oblique distortion, and synostosis of both sides, as described by Robert. Next, we have carefully described the varieties of deformity caused by rickets, osteomalacia, exostosis, and fractures, with admirable illustrations; then those resulting from hip disease, acute and chronic, and from changes in the vertebral column. After a full account of the distortions, the author enters upon the consideration of their diagnosis, and their influence upon pregnancy and child-birth; and lastly, the treatment, according to the amount of narrowing, divided into four degrees.

Thus it is evident that in brief space we have a complete review of the whole subject, and we do not see a single point of importance omitted. The descriptions are short and to the point, and the practice recommended is in accordance with the best authorities.

Now let us take the forceps operation. The author begins with a description of the long and short forceps, with plates of Levret's, Smellie's, and Naegele's instruments; and proceeds to consider their action, whether mechanical or dynamical. Then follow the conditions requisite for the operation, and the circumstances which indicate its necessity, and the prognosis.

There is sound sense in the rules laid down as to the time of the operation, so as to enable us to save both mother and child if possible; at all events, to injure neither.

After enumerating the preparations necessary, such as emptying the rectum and bladder, placing the patient in the proper position, ,fcc., ,fcc., and recommending the use of chloroform, Dr. Spiegelberg lays down twelve general rules for the ope

I ration, as to the position of the forceps, the mode of introduction, the mode of closing and holding the instrument, and the line of extraction and amount of duration of the force employed.

From the way these two subjects are handled, the reader may form an idea of the book itself. They were not selected as being better than the rest, but were taken haphazard. Each subject has been thoroughly investigated, and though we may not agree with all the author's conclusions, we have always been gratified by the care he has bestowed and the amount of information he has brought forward.

The third volume prefixed to this article, is a record of cases of difficult labour, preceded by some general remarks on the subject and followed by a statistical report of 7302 cases delivered under Dr. Hall Davis's superintendence. Details of 144 cases, presenting some difficulty or peculiarity worthy of notice, are given with great care, and will form a valuable body of reference to the practitioner. The preliminary observations are sound as far as they go, but in one respect they too much resemble the operative part of Dr. Tyler Smith's book—they are too general, too short and cursory, so that they do not meet the practical difficulties which beset the accoucheur. A chapter might be profitably written on difficult parturition as affecting the accoucheur. The most prominent subjects of the book are the cases requiring the forceps or craniotomy, and to some remarks upon them we shall confine ourselves. We could have wished that Dr. Davis had marked out more distinctly the limits of the two operations, especially as we see from the journals that a controversy on the subject of craniotomy has taken place between an anonymous writer in the Dublin (Literary) Review, and Dr. Churchill in the Dublin Quarterly Journal. When we find craniotomy absolutely proscribed, except in the case of dead children, and the caesarian section proposed as its ordinary substitute, it becomes quite necessary to define, with as much accuracy as possible, the limits of the former operation, not with reference so much to hysterotomy as the alternative, as to the employment of the forceps.

The practical question which presses upon every one extensively engaged in midwifery is, "What are the limits, on either side, of the operation with the forceps and of craniotomy?" In other words, on what grounds are we to determine that either operation is unnecessary on the one hand and useless on the other? Between these two extremes lies the ground which such operation will occupy, and to which each must be limited.

Let us consider the forceps first. The delay may be the result of dynamical or mechanical onuses, or a combination of both. There may be ample space in the pelvis, and no ascertainable physical impediment, and yet the pains, strong at first, become gradually less effective, though to the full as painful. Or the mechanical impediment may be extremely slight, so slight, indeed, that nothing but experience could satisfy us that assistance could be necessary. We have more than once seen labour rendered powerless by the child's nose pressing against the symphysis pubis, the forehead being anterior, and where there was otherwise ample space and good pains; and yet this very slight obstacle protracted the labour until assistance with forceps was necessary. Again, there may be good forcible pains, but the pelvic space may be diminished by some unusual condition of the soft parts, or by the sutures of the child's head being ossified, or by an actual disproportion between the head and the pelvis. Now in each of these cases the important question is, how far we are to trust to the natural powers, and by what are we to be decided in having recourse to art? Is it to be a question of time, symptoms, or measurement? Let us hear what Dr. Davis says: before operating—

"We should feel satisfied that there is risk to either the mother or child from a longer protracted pressure. But on no account must we withhold our assistance till that extremity of prostration of the vital powers has supervened in which little or no hope remains that art can avail us in rescuing either life. The danger of injury lies in the pressure exerted in labour being violent and long continued on the same tracts of tissue, the head immovably fixed in one position, so as to interrupt the free circulation in the parts pinched, so to speak, between it and the pelvic walls. The head may sometimes remain stationary in the pelvis after full dilatation of the uterine orifice for a longer period than even twelve hours, and no evil result follow. But for this to occur there must be ample space, with the soft parts moist and relaxed, and little or no labour action present. In due time, often after a refreshing sleep, which it may be judicious to promote by artificial means, nature resumes and completes her work with safety. It is usually admitted that so long as the head advances pari passu with the pains of parturition, so long there can be no necessity for interference, even though the above stated limit of time may have been much exceeded. As a general principle this is undoubtedly a fact, but fatal exceptions to its universal truth have occurred." (p. 24.)


"There must be room in the pelvis for the safe introduction of the forceps at the two opposite points of the circumference of the head. If the child is known to be at or near the full term, and appears to be of the average size, there should, in my opinion, be at the brim of the pelvis in the conjugate diameter, and at the outlet in its transverse diameter, a clear space of three inches and a quarter, to afford us any hope of success in a forceps operation. A labour in which the head is so completely locked and wedged in the pelvis that an ear cannot be reached, and when the examining finger cannot be passed between the head and the pelvic wall at any point, is obviously one in which we could not have recourse to the forceps." (p. 23.)

Lastly, Dr. Davis observes,

"As an aid to our decision in favour of interference, I may refer to a sign which I have for several years past found useful as an intimation of approaching^ danger from protracted pressure in obstructed labour, namely, an olive-coloured or brownish slimy discharge, a depraved secretion from the mucous membrane, the result of long-continued irritation. The child may often be saved after the occurrence of this discharge, which differs in character from that of meconium."

Thus we find that Dr. Davis takes into consideration time, space, and certain symptoms or results of delay. We cannot agree with him that the whole danger consists in the long-continued pressure. Even when this is in no degree excessive, the febrile symptoms of powerless labour may arise, and the patient die, if not delivered in time. Neither is the olive-coloured discharge a trustworthy guide; when it does arise from irritation of the mucous membrane, subjected to long pressure, it is very significant; but how often sdoes a similar discharge occur at all periods of labour where there has been no undue pressure? We saw a case lately in which the liquor amnii resembled green peasoup, and the entire labour was completed in two hours.

In making up our minds, then, we must take into consideration first, the character of the pains. If they have been strong and propelling, and are now getting less forcible, producing less impression on the head, and if by degrees instead of forcing the patient to bear down, they occasion an outcry like first-stage pains, we may fear that, irrespective of any obstacle, they alone may not be sufficient to complete the labour.

2. The Symptoms.—If at any period of the second stage we find the pulse higher than usual, and remaining so between the pains, the skin becoming hot, the mouth and tongue dry, with other symptoms of powerless labour, we may rely upon it that we rim great risk by delay, as we generally find also, when these symptoms arise, that the pains dimmish, in power at least.

3. Time.—We quite agree with Dr. Davis, that it is impossible to fix a precise time for interference, inasmuch as unfavourable symptoms will arise in one patient in five or six hours, and not for twelve or eighteen in another. Of course, in speaking of time, we refer to the second stage only, or after the os uteri is fully dilated, or the head has passed through it. To us the question of time seems rather subordinate to the other conditions generally; but it is very important in calculating on the results of continued pressure, and also upon the life of the child. It is hard to say exactly after what period the child is in peril; but we know that it becomes so, and this will be an element for our calculation, especially in forceps cases.

4. Space.—We must not forget that, under certain dynamical conditions, a very little obstacle will, so to speak, paralyse uterine action, and ultimately render the labour a "powerless" one; so that we must estimate its importance not per se, but by its effect upon the progress of the child's head in its descent, allowing sufficient time. If strong pains, continued for a sufficient time, do Lot overcome the obstruction, and force through the child's head, unfavourable symptoms will result, and it is our duty to anticipate these. On the other hand, though we cannot easily measure the number of inches in the conjugate or transverse diameters, we can arrive practically at sufficiently correct conclusions by comparing the child's head with the pelvis, and observing the 'dip' or protrusion during each pain. If the finger cannot pass between the head and the pelvis at any part, we quite agree with Dr. Davis that the case is not one for the forceps apparently. But it may pass to a certain extent without reaching the ear; and we confess we should be very unwilling to destroy a child in such a case without trying to introduce the forceps. The kind of instrument preferred by Dr. Davis is not easy to introduce, except laterally; whereas one blade of the singlecurved forceps, when properly made, may be passed under the arch of the pubis, where there is generally the most room, and afterwards changed into the oblique position without difficulty or danger, if the operator be only gentle and dexterous; the other blade will pass easily posteriorly. We have ourselves repeatedly succeeded in introducing the blades, and extracting a living child, in cases where at first it seemed impossible. Of course, great care and judgment will be necessary both in the introduction and in the amount and continuance of the force employed in extracting; still, when the alternative is the destruction of life, no means Bhould be left untried to guard against so fearful an operation.

These, then, are the points for our consideration in every difficult or protracted case, and upon them our decision must be founded as to the necessity of the operation, and the time best suited for our interference. There is a singular amount of tact acquired by practice, which is beyond price to the accoucheur and the patient. Those who have seen many cases of this kind will very often be able to predicate that interference will ultimately be necessary long before any urgent symptoms seem, to an ordinary mind, likely to require it. Now if by any accurate means we can arrive at this conclusion, it is evident that many hours of suffering may be spared, and the safety of both mother and child made more secure.

We have said that we do not agree with Dr. Davis in his preference of the forceps with the double curve, but we think the rules he has laid down for their application intelligible and correct. He has hardly dwelt enough upon the local care and attention which the nurse should be directed to observe during convalescence.

Now let us say a few words upon craniotomy. No doubt it is a most painful operation, when the child is alive, to any man of feeling, and certainly if it be wantonly and unnecessarily employed, it is nothing short of murder; however, Dr. Davis is quite correct in observing that, "in performing this destructive operation on the child, we are not necessarily sacrificing its life, for it is consolatory to know that in most cases, ere we are compelled to resort to it, the child has already ceased to live." It is generally admitted that when assistance is necessary to deliver, if the child be dead, craniotomy is preferable to the forceps.

But, though few, there are still some cases in which the child is alive, and in which we are called upon to act. Are we to act as soon as the necessity is established, or wait until the child die, notwithstanding the increased risk to the mother? Unhesitatingly, we should choose the former, if the case be one where craniotomy affords the only chance. What, then, will be sufficient ground for

« AnteriorContinuar »