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perineum, with the breech either in the hollow of the sacrum or at the brim of the pelvis, ready to descend into it, and, by a few farther uterine efforts, the remainder of the trunk, with the lower extremities, is expelled." (Douglas, op. cit. p. 28, 2nd ed.)

Farther experience has confirmed the correctness of Dr. Douglas' views (Med. Trans. of the Royal Coll. of Physicians, vol. vi. 1820 ;) and, indeed, the original case as related by Dr. Denman himself tends to prove that nothing like an "evolution" of the foetus takes place. "I found the arm much swelled, and pushed through the external parts in such a manner that the shoulder nearly reached the perineum. The woman struggled vehemently with her pains, and during their continuance I perceived the shoulder of the child to descend."

Some years afterwards, the late Dr. Gooch had the opportunity of observing a case of spontaneous expulsion with great accuracy, and came to the same conclusion as Dr. Douglas had done. "Resolved to know what became of the arm, if this (the spontaneous expulsion) should happen, and thus fit myself for a witness on this disputed point, I laid hold of it with a napkin and watched its movements: so far from going up into the uterus when a pain came on, it advanced, as well as the shoulder, still forwarder under the arch of the pubes, the side of the thorax pressing more on the perineum and appearing still more externally; it advanced so rapidly that in two pains, with a good deal of muscular exertion on the part of the patient, but apparently with less suffering than attends the birth of the head in a common first labour, did the side of the chest, of the abdomen, and of the breech, pass one after the other in an enormous sweep over the perineum till the nates and legs were completely expelled.” (Ibid.)

The celebrated Boer has, however, detailed a case where the arm had prolapsed into the vagina, the hand appearing externally; and on introducing his hand for the purpose of turning, he felt the hand distinctly receding, and the breech beginning to occupy the cavity of the pelvis. This is very different to a case of spontaneous expulsion: "The child lay completely across, with its abdomen towards the back of the mother; "* it had, in fact, not yet begun to press against the brim, or to assume any definite position, there having been as yet but little uterine contraction, and both rectum and bladder being considerably distended. When these were evacuated the pains increased: the breech, being nearest to the brim, descended, and the arm in consequence receded. Dr. Gooch considers it most probable that "it was only a breech presentation, the hand having accidentally slipt down into the vagina."

Although in cases of malposition where turning has become excessively difficult and dangerous, the spontaneous expulsion must be looked upon as a most fortunate process by which nature effects delivery, still, however, we must never venture to wait for it without making such attempts to turn the child as the state of the patient may justify. It is always more or less dangerous to the mother, and almost certainly fatal to the child. Indeed, it is our opinion, that the spontaneous expulsion can rarely, if ever, take place, except where the child has been already dead some time, or

Boer's Natürliche Geburtshülfe, b. iii. p. 64. A case of actual evolution has also been described by Mr. Barlow, p. 399.

where it is premature. "Nor can any event," says Dr. Douglas, "ever be calculated upon than that of a still-born infant. If the arm of the foetus should be almost entirely protruded with the shoulder pressing on the perineum, if a considerable portion of its thorax be in the hollow of the sacrum with the axilla low in the pelvis, if with this disposition the uterine efforts be still powerful, and if the thorax be forced sensibly lower, during the presence of each successive pain, the evolution may with great confidence be expected." (Op. cit. p. 42.)

On the other hand, if either from the rigidity, &c. of the child or of the passages, but little material advance is made in the manner abovementioned, if the soft parts are becoming swollen and inflamed, and the powers of the patient are beginning to flag, and exhaustion coming on, if turning has been attempted as far as could be done with safety, and still without success, we have no choice left but that of embryotomy; the chest and abdomen must be evacuated of their contents as already directed under the head of PERFORATION, and in this manner the child delivered. Malposition with deformed pelvis, or rigidity of the uterus. Where the pelvis is deformed, or the uterus (from the early escape of the liquor amnii) spasmodically contracted upon the child, and the os uteri in a state of rigidity, the difficulties and danger of the case are greatly multiplied: in the former complication the embryotomy must be carried much farther, in the latter we must have recourse to bleeding, opium, warm-bath, &c., as recommended under the head of TURNING.

The prolapsed arm is not to be put back or amputated. Where the arm has been some time prolapsed, and, from the pressure of the soft parts, much swollen, it fills up the vagina so completely that it would seem almost impossible to introduce the hand, unless we push up the arm first: experience, however, confirms the valuable rule of La Motte, viz. that we must slide our hand along the arm into the uterus; we shall rarely find, where the passages are in a proper state for undertaking the operation, that the prolapsed arm presents any serious obstruction to the passage of the hand. "An arm presenting," says Chapman, "and advanced as far as the armpit, is not to be returned, but the hand is to be introduced (which, as Deventer justly observes, is often found to penetrate with much more ease when the arm hangs down than when it is thrust back again) and the feet to be sought for, which, when found, the arm will prove no great hinderance in turning the child." (Chapman's Midwifery, p. 46, 2nd ed., 1735.)

In no case is it necessary to separate the arm at the shoulder, "for I have found it," says Dr. Denman, "a great inconvenience, there being much difficulty in distinguishing between the lacerated skin of the child, and the parts appertaining to the mother." (Essay on Preternat. Labours, p. 32.)

Dr. Meigs, of Philadelphia, has added another powerful argument against this practice, viz.: that cases have occurred where the arm had been cut off and where the child was nevertheless born alive.

As to how far it is possible or advisable so to alter the position of the child as to make it present with the nates or head, this has already been considered in the chapter upon TURNING.

The presentation of the arm with the head is of very rare occurrence,

so much so that some have doubted if it really existed: two cases of this kind have come under our own notice, in both of which the child was born in this position, although with some difficulty.

"Independent of the awkwardness of position which the head may assume, from the circumstance of the hand or arm descending with it into the pelvis, there will be so much increase in the bulk of the part as to render its passage slow and difficult; yet if the case be not interrupted by mismanagement, it will terminate favourably, for this complication of presentation seldom happens but in a wide pelvis." (Merriman's Synopsis, p. 48, last ed.)

It is by no means uncommon to feel the hand lying upon the side of the head or on the cheek; but this produces no impediment to the labour, for as the head descends through the brim of the pelvis, the hand usually slips up: in the other case we have felt the arm bent over the head, and pressing the ear on the opposite side.

Presentation of the hand and feet. We sometimes also meet with cases where the hand presents with one or two feet; but these complications merely exist at the commencement of labour, where the uterus has been greatly distended with liquor amnii, and where its contractions have not yet begun to press the child into the brim. Cases of this nature sooner or later are sure to terminate in presentations of the nates or shoulder, unless the process of labour has been interfered with.

Presentation of the head and feet. Presentations of the head and one or both feet have also been described: these, however, have only occurred during the operation of turning, when the feet have been brought down into the pelvis before the head had left it, and, therefore, must be considered as having been made by unskilfulness on the part of the practitioner. Where this is the case it may be necessary to premise blood-letting, &c., on account of the inflamed condition of the parts from the previous unsuccessful attempts to turn: after this, a fillet should be passed round the feet in order to secure them, and then the head may be safely pushed out of the pelvis.

Rupture of the uterus. Of the injurious results arising from protracted or neglected cases of arm or shoulder presentation none can compare in point of danger with those where the uterus has given way or burst. This state may also be produced by deformity of the pelvis, tumours, and other causes of obstruction to the passage of the child, by which the uterus is excited to unusually violent efforts in order to overcome the impediment during which the laceration is effected. It may also arise from injuries to the uterine tissue without undue exertions, as from exostosis of the pelvis, sharp projecting edges of the promontory or brim, and also from organic disease: thus," when the rent speedily follows the accession of labour, before the pains have become severe, or the uterus has scarcely begun to dilate, its structures will probably be found diseased." (Facts and Cases in Obstetric Medicine, by I. T. Ingleby, p. 176.)

Usual seat of the laceration. The part of the uterus in which laceration is most frequently observed to occur, is near to, or at the junction of the uterus with the vagina: this happens rather more frequently behind than before, but the difference in this respect is very trifling. Thus in 36 cases which were collected by Mr. Roberton of Manchester, "In 1

the cervix was separated from the vagina except by a thread: in 11 the laceration was posterior, in 8 it was anterior, in 5 lateral, in 3 anteriorlateral, and in 3 posterior-lateral." (Edin. Med. and Surg. Journal, vol. xlii. 1834, p. 60.) In 34 cases which occurred at the Dublin Lyingin Hospital," in 13 the injury was at the posterior part; in 12 anteriorly; in 2 laterally; in 1 the mouth of the womb was torn, and in 6 the particular seat of the laceration was not described." (A Practical Treatise on Midwifery, &c., by Robert Collins, M. D., 1835, p. 244.)

The nature and extent of the laceration varies a good deal: in the worst cases the uterus is torn completely through, and the child escapes either partly or wholly into the abdominal cavity; whereas, in many, the peritoneum has not given way, the laceration being confined entirely to the tissue of the uterus itself. Thus, in 9 of the 34 cases recorded by Dr. Collins, "the peritoneal coat of the uterus was uninjured, although the muscular substance of the cervix was extensively ruptured." In other instances the peritoneum has been cracked or torn in numerous places without any injury to the subjacent tissue.

From the greater degree of resistance to the passage of the child, in cases of first labour, we might naturally suppose that rupture of the uterus would be more frequently seen among primiparæ: this, however, is not the case, for of 29 cases mentioned by Mr. Roberton, only one of them was a primipara; a larger (and as an average probably more correct) proportion, viz., 7 in 34, has been given by Dr. Collins: of the multiparæ, 5 were in their sixth pregnancy, 2 in their tenth, and 2 also in their eleventh pregnancy.

Experience also shows that in a large proportion of these cases, the duration of the labour has been very far from being longer than usual; indeed, in a considerable majority, the mischief has taken place very few hours after the commencement of active labour. Thus, the average duration of it in the 36 cases recorded by Mr. Roberton, was 15 hours: in 24 of those by Dr. Collins, it was 17 hours: but if we take merely the majority of them, we shall have a much smaller average: thus, in 20 of Mr. Roberton's cases it was 9 hours, and in 15 of Dr. Collins' it was only 6 hours.

Causes. A large proportion of the cases where the uterus gives way during labour, are connected with more or less deformity of the pelvis, and where, from previous severe and difficult labours, its structure has been injured, and rendered incapable of bearing that degree of tension, which even the ordinary exertions of the uterine fibres would require. In many others, the impediment produced by the contracted pelvis, or malposition of the child, has roused the uterus to those violent efforts which have produced the laceration. Organic diseases of the uterus, or cicatrizations of the soft passages from extensive injuries in former labours, either render its powers of resistance defective, or, by increasing the resistance, excite it to unusual violence. "The operation of turning is not unfrequently a cause of laceration of the vagina or mouth of the uterus, particularly where it is performed previous to the soft parts being sufficiently dilated to admit the easy passage of the hand, or where great haste is employed. The same consequences may ensue from rash or violent attempts to remove a retained placenta. I have also known the

mouth of the womb to be torn by the imprudent use of the forceps when not sufficiently dilated." (Dr. Collins, op. cit. p. 242.) "The sex of the infant, it would appear, may also have some share in occasioning this very distressing occurrence." (Practical Remarks on Lacerations of the Uterus and Vagina, by Thomas M'Keever, M. D., p. 4.) Thus, of 20 cases reported by Dr. M'Keever, 15 were delivered of boys and 5 of girls; of the 34 cases described by Dr. Collins, "23 of the children were males. This is satisfactorily accounted for by the greater size of the male head, as proved by accurate measurement made by Dr. Joseph Clarke." Another circumstance which influences to a certain extent the frequency of rupture of the uterus is the rank of the patient: in private practice, especially among the better classes of society, it is an extremely rare occurrence; but in the lower grades of life several causes concur to render it more frequent. They are "much more exposed to falls, bruises, and other accidental injuries during pregnancy, in consequence of which the uterus may be either ruptured at the time they have sustained the violence, or may be so weakened in structure at some particular point, as readily to give way during its efforts to accomplish delivery. Lastly, they are more liable to fall into the hands of ignorant, inexperienced midwives, who, not unfrequently, with a view of expediting the process of delivery, rupture the membranes at an early period of the labour; in consequence of which, the firm, unyielding head of the child is prematurely brought in contact with the passages, exciting, by its pressure, swelling, inflammation, and an interrupted state of the circulation in the uterus and adjacent parts. In such a case should there unfortunately exist any disproportion between the parts of the mother and the head of the infant, or should proper measures not be employed to obviate distressing symptoms, and the labour pains continue to recur with extreme violence, there is great risk of the uterus giving way, the laceration being of course most likely to occur at that part where the greatest pressure has been sustained." (M'Keever, op. cit. p. 3.)

The premonitory symptoms of rupture of the uterus are not always sufficient to warn us of the impending danger, for in many cases nothing unusual has occurred until the actual injury has been produced, and it has then been inferred by the alarming change observed in the patient's appearance. In many cases, especially where the muscular substance only of the uterus was torn, the pains have continued with a sufficient degree of power to expel the child; in others, the mischief has been attended with so little suffering at the moment, and for the time with so little constitutional derangement, as to excite no suspicion, either on the part of the patient, or her attendant. "Farther, as on some occasions, the uterus has been known to give way during the very pain which effected the delivery of the child, instances of which may be found in the works of Crantz and Guillimeau." (Ibid. p. 15.)

Symptoms. "When a rupture of the uterus has really happened, it is generally marked by symptoms which are decisive; but it being a case which occurs so very rarely, they do not immediately create suspicions. When labour has continued violent a considerable time, if a pain expressive of peculiar agony is followed by a discharge of blood, and an immediate cessation of the throes, there is reason to apprehend this mischief.

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