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Having made this careless diagnosis, and given some direction as to the conduct, and prescribed for the tenesmic distress, I saw her again in the evening about seven o'clock. The pains, it was said, had been repeated every few minutes; and upon coming into the apartment, one would suppose the child was pressing upon the perineum violently, so loud was the sound of her respiratory effort in bearing down.

She had passed the moved by an enema.

scanty urine very often; the bowels had been I immediately examined, expecting to find the child's head under the arch, but was surprised to discover that it had not advanced at all since mid-day. The os uteri might be as much as an inch in diameter, and not more. While carrying the finger to the os uteri, it appeared to encounter a sort of cushion-like tumor occu pying chiefly the right half of the Excavation. On the left side of the Excavation there was nothing abnormal-the finger could be pressed to the left as far as the ischial plane. Upon discovering the tumor in question, my first impression was that it was a case of pelvic enterocele like that in Dr. Bicknell's patient; but farther exploration showed that it was not in the recto-vaginal peritoneal cul-de-sacwhich cleared up the diagnosis on that point. I asked again as to the urination which had been frequent, not free.

I introduced a catheter into the urethra-but when it had advanced about two inches it stopped, nor did any urine escape. I expected to carry the point of the catheter downward and backwards into the tumor, which I now presumed could be nothing else than a cystocele, consisting of the bladder of urine, which had been crushed under the womb, and obstructed so as to be unable to discharge the whole of its contents. Finding I could not cause the catheter to advance without using imprudent violence, I withdrew it. The patient lay on the back with the knees drawn up. Introducing three fingers of the right hand far into the pelvis, when the pain was off, I pressed the palps of the fingers upon the inferior surface of the mass, and lifted it upwards towards the plane of the superior strait. Just as I had raised it partially up, there came on a violent tenesmic effort-and the urine rushed from the orifice of the urethra in jets so violent as to surprise me. In the course of three or four such jets, the whole of the urine in the bladder was expelled; the tumor disappeared, and within forty minutes, the whole of the remaining dilatation of the cervix was completed and the child delivered.

As soon as the bladder was emptied, the singular, extraordinary tenesmic efforts returned no more-but the phenomena of expulsive action were thenceforth perfectly natural and customary.

The patient, when I came into her apartment, was in a state of extraordinary excitement, representing her sufferings as intolerable; her face was redly flushed and heated, and the heart rapid and tumult

uous.

This case seems to me worthy of record, first, as presenting an example of the bladder crushed beneath the uterus; second, as exhibiting the method of making diagnosis of such a case; third, as showing how it may be successfully treated; fourth, as proving that pains and distresses that contravene the co-ordinate action of the uterus in labor, being removed, the conformable play of its forces may be expected to take place; and, fifthly, as showing that where the bladder is crushed downwards below the womb in labor, it may be, for it was in this case, thrust to one side of the pelvis. In this instance, it was jammed to the right, and not at all to the left side of the excavation. In this very case, even the dilatation of the cervix was held in suspense until I relieved the bladder; whereupon the co-ordinate contractions of the womb being no longer contravened, they effected the remaining dilatation and delivery in forty minutes.

I refer the Student to p. 122 of my "Letters to the Class" for the history of a case of vaginal rectocele equally curious.

Management of the Cervix and Os Uteri.-The head has sunk low into the Excavation; the fontanel is in the proper position, neither too near to, nor too far from the symphysis, but it advances not at all; pain after pain passes with great suffering to the mother, and yet with no sensible advance of the head. What can occasion the retardation? The finger glides up behind the symphysis to the superior strait, and moves along the linea ileo-pectinea a considerable distance, showing conclusively that no disproportion exists between the head and the bony canal it is destined to traverse. All this uneasiness on the prac titioner's part will cease as soon as he discovers that the cervix uteri, which he had thought to be sufficiently dilated to offer no farther considerable opposition, has ceased for a time to yield, and during every pain, takes hold of the head so as to prevent the parietal protuber. ances from escaping into the vagina. The proper remedy here, also, is patience; a small venesection; a large draught of some warm relaxing fluid; the fortunate occurrence of nausea; a careful adjustment of the axis of the uterus, and of that of the pelvis; or perhaps a few very powerful exertions of the auxiliary muscles in bearing down, to which the woman can be exhorted. I have often, after allowing myself to get into a fret relative to the slow progress of affairs, found all my uneasiness dissipated by a more careful examination as above, thus

clearly ascertaining that no other than soft obstruction existed; whereas, from too careless an examination, I had erroneously believed that the os uteri had mounted up over the parietal protuberances of the foetal head, and that some unknown cause of retardation prevented the due

progress.

Effects of a Bad Sacrum.-The hollow of the sacrum is the essential cause of the obstetric properties of the excavation. Those properties will be present in perfection, where the sacrum is perfectly well formed and adjusted: but the sacrum may be either too little curved or too much so; and inasmuch as the rotation of the head requires for its regular and easy performance, a good curve in the sacrum, a very straight sacrum must offer impediments to that important act. Hence, a sacrum with too little curve will protract the period of delivery; and in fact, a case might arise, and such a one has arisen, where no rotation at all could take place, but the delivery, at last, occurs with. out this important act in the mechanism of labor-the vertex coming out under the tuber ischii: a case requiring the very extremest degree of flexion of the head. Let the Student consider a moment what process must be substituted for the rotation; the occipito-bregmatic diameter is but three and three-quarter inches, but the tubera ischii are four inches apart; hence, where the rotation fails, there must occur a greater dip, causing the occipital fontanel to take a position nearly in the centre of the pelvic canal, by which the relations of planes between the head and pelvis are adjusted, and the occipital bone enabled to pass out under the ischium, and the parietal protuberance under the pubal arch. Such a great degree of dip may be much promoted by the help of the fingers, as before stated, and by pushing the fundus uteri as far as possible to the left, which will take time. I have found it not very difficult when the head was of a medium size.

On the other hand, if the sacrum be too much curved, its apex will jut forwards towards the pubis, so as to form a sort of shelf, on which the head lies; the expulsive forces being vainly expended in impelling the head down upon this shelf or ledge. The gradual compression of the cranium, however, at length moulds it into the requisite form, and allows it to slide off the ledge, and the delivery takes place. It is to be understood, that the highly aggravated degrees of this vicious. conformation involve the necessity of direct interference with some one of the various instruments employed in obstetric operations.

Influence of a Badly Shaped Pubis.-When the pubal arch is not low, but retains the character of early life, or of the male pelvis,

great retardation takes place, because the act of extension of the head cannot occur in due time. Such a narrow arched pubis compels the head to continue its descent much longer than one where the arch is broad and low. It has as bad an effect as, and indeed it is equivalent to, a long symphysis pubis; for in the ordinary conformation, as soon as the occipital bone can come to apply itself to the arch, the vertex begins to rise, extension of the head takes place, and the perineum requires no inordinate degree of protrusion.

But imagine a pubic symphysis of two and a half inches, instead of one of an inch and a half, and it is plain that the perineum must go much farther down before the head can escape under such an arch.

CASE. A patient with a very narrow arch had been under my care in two of her labors, in which, the natural pains being insufficient, I was compelled to reinforce them by the ergotic stimulation. By violent efforts of the womb and abdominal muscles, she gave birth in both cases to living children. I need not, in self-defence, say that I waited as long as I deemed it prudent, but my confidence in her strength was in vain in each instance. In 1841, I delivered her for the third time; but was obliged to use the forceps.

The Perineum.-The resistance of the perineum and vulva is, in many women, so great, as seriously to retard the delivery. I have waited six hours by the bedside, after the vertex has begun to jut out between the labia, the patient all the while suffering severe labor pains, that vainly tended to expel the head. There is nothing to be done but wait patiently after having placed the woman's constitution in its proper attitude by means of venesection; by every psychiatric resource of exhortation, assurance, encouragement, and honest promise of relief; by the least fatiguing posture of the body; by the application of mucilaginous fomentations to the genital region; by the exhibition of relaxing drinks; by emollient enemata, anodynes, and the warm bath. I consider that we have no right to apply a force, additional to one strong enough, that nature furnishes, and which it is evident must be effective if left to itself. Under such perverse re

sistance of the soft parts, time is required to enable them to acquire a yielding temper. To force the head through them by the ergot or the forceps, would be to incur the hazard of shocking lacerations of the external organs of generation, or even of the womb itself, which it is rashness, in the highest degree, to stimulate and lash into fury where the uterine contractions are already very powerful, and where they

would soon effect the delivery, were it not that the external parts are unprepared to admit of it. The true principle of practice here is, to diminish the resistance, not to increase the power, already excessive, and therein dangerous. Let me be fully understood as referring, in the above remarks, only to cases where the energies of the uterus, though great and manifest, are yet unequal to the task of overcoming the resistance rapidly, and where they evidently will overcome it in a reasonable time. In other circumstances, as where the resistance is powerful and the pains poor and weak, let the just proportion be established, by means of the ergot, a glass of wine, or the forceps, between the power and the resistance it is destined to vanquish.

CASE. Three years ago I attended a young woman in labor with her first child. The process was most painful and tedious. The bead was fully six hours pressing upon the perineum and external parts, under violent uterine contractions. The child was at length born, but was dead. As this was a result which I very much feared, I was extremely desirous of applying the forceps. Would it have been justifiable to use them in a case where the contractions were so strong as to lead me to apprehend that the perineum would give way under every natural pain? I thought not. It is perhaps impossible to find expressions fitted justly to set forth the tormenting doubts and anxieties of the accoucheur in cases like this; cases where he feels that he has power to terminate the sufferings of his patient, but dares not violate the injunctions of his conscience, which tells him he may not yet intervene.

When the head begins to emerge it does so by pushing away before it the perineum, which continues to cover the cranium like a tight cap. It should be remembered that the direction of the forces is parallel to the axis of the superior strait; but it is equally true that at this stage, the direction of the movement is not in the same line; the head is repelled by the curved line of the sacrum; it is driven against the sacrum, but, coincidently with Carus's curve, glides off from its curved surface towards the outlet; from which, if unrestrained by the perineum, it would escape without much extension. It has happened that the head has passed directly through the perineum, perforating it as if a six pound ball had passed through, without injuring the commissure of the vulva or the sphincter muscle of the anus; and there is always supposed to exist some danger of its tearing the anterior edge of the perineum, at least when that point is unsupported. Hence, the general care of writers to direct that the perineum be supported.

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