been of sufficient strength to dilate the os uteri, it will generally come away of itself. One objection to the wire crotchet is, that it tears the membranes, and lets out the liquor amnii, and perhaps the embryo.* This is by all means to be avoided; the larger the body which is to be expelled, the more powerfully and effectually does the uterus contract upon it: hence, therefore, if the membranes of a three or four months' ovum be imprudently pierced with a view of hastening the expulsion, the liquor amnii and embryo escape, but the secundines remain, and require protracted efforts of the uterus to expel them, during which time the sufferings of the patient are prolonged, and the hæmorrhage kept up; whereas, if the ovum had remained whole, it would have been expelled more easily and quickly. On the other hand, where the foetus has already attained a considerable size (fifth month,) the plan recommended by Puzos of rupturing the membranes is very desirable; by this means the size of the uterus is reduced by the escape of liquor amnii, and thus the hæmorrhage checked; and the foetus remaining in the uterus is of sufficient weight and bulk to excite contractions to expel itself and the membranes.

The treatment after abortion varies considérably in many cases it will be merely necessary for the patient to remain in bed for a few days afterwards; but where she has been much reduced, a mild course of tonics will be necessary, in order to prevent that disposition to leucorrhoea and menstrual derangement which is so common a result: this, where it is possible, should be combined with removal into the country, or to the seaside, or, what is still better, to a watering-place, where there are mineral springs of a chalybeate character. For the treatment of anæmia we must refer our readers to the chapter on HÆMORRHAGE.

small size. (See accompanying figure, which represents the instrument onethird the natural size.)

This instrument is highly useful in cases in which the flooding continues after the ovum has been broken and its contents expelled. A portion of the involucrum sometimes insinuates itself into the neck of the uterus, and prevents the degree of contraction necessary to interrupt farther bleeding. This accident most frequently attends the earlier abortions. As hæmorrhage is maintained by the cause just named, it suggests the propriety of never breaking the ovum; especially before the fourth month. When the flooding is maintained by this cause, it will not cease but upon the event of its removal. This condition of the placenta and neck of the uterus is easily ascertained by an examination; it will readily be felt to be embraced by the neck of the uterus; and though a portion may protrude a little distance below the os tincæ, it cannot be extracted by the fingers; for the os uteri or cavity of the uterus will not be sufficiently large to permit the fingers to pass into it, that this mass may be removed; the crotchet should then be substituted; the mode of using it is as follows:-The fore-finger of the right hand is placed within or at the edge of the os tiuca; with the left we conduct the hooked extremity along his finger, until it is within the uterus; it is gently carried up to the fundus, and then slowly drawn downwards, which makes its curved point fix in the placenta; when thus engaged, it is gradually withdrawn and the placenta with it.

Dr. Dewees says, that in every case in which he has used this crotchet, the discharge instantly ceased. See Art. "ABORTION," by Dr. Dewees, in American Cyclopedia of Pract. Med. and Surg. Dr. Dewees "from some late experience is induced to believe" that "in cases in which we cannot command the removal of the placenta by the fingers-that is, when this mass continues to occupy the uterine cavity, or but very little protruded through the os tincæ," the administration of ergot will often supersede the necessity of the crotchet. Treatise on the Diseases of Females. Sixth Edition, p. 351.-ED.

Dr. Dewees recommends the crotchet only where the flooding continues after the ovum has been broken. See preceding note. ED.]

PART III.

EUTOCIA, OR NATURAL PARTURITION.

CHAPTER I.

STAGES OF LABOUR.

PREPARATORY STAGE.-PRECURSORY SYMPTOMS.-FIRST CONTRACTIONS.-ACTION OF THE PAINS.-AUSCULTATION DURING THE PAINS.-EFFECT OF THE PAINS UPON THE PULSE.-SYMPTOMS TO BE OBSERVED DURING AND BETWEEN THE PAINS.CHARACTER OF A TRUE PAIN.-FORMATION OF THE BAG OF LIQUOR AMNII.-RIGOR AT THE END OF THE FIRST STAGE.-SHOW.-DURATION OF THE FIRST STAGE. -DESCRIPTION OF THE SECOND STAGE.-STRAINING PAINS.-DILATATION OF THE PERINEUM.-EXPULSION OF THE CHILD.-THIRD STAGE. EXPULSION OF THE PLACENTA.-TWINS.

PARTURITION may be divided into two great orders, Eutocia and Dystocia, the one signifying natural labour, which follows a favourable course both for the mother and her child; the other signifying faulty or irregular labour, the course of which is unfavourable.

We may define eutocia to be the safe expulsion of the mature fœtus and its secundines by the natural powers destined for that purpose. No function exhibits such infinite varieties, within the limits of health and safety to the mother and her offspring, as that of parturition; no two labours, even in the same individual, are exactly alike; still, however, the great objects of the process will be the same, viz. 1st, the preparation of the passages and the fœtus for its expulsion; 2dly, the expulsion of the fœtus; and 3dly, the expulsion of the placenta and membranes.

That we may form a clearer and more comprehensive view of this process, labour has usually been divided into stages or periods, marked by the changes just now alluded to: hence it is generally said to consist of three stages; the first, or preparatory stage, commencing with the first perceptible contractions of the uterus, and terminating in the full dilatation of the os uteri; the second, or stage of expulsion, terminating with the birth of the child; and the third, consisting of the expulsion of the placenta.

Preparatory stage.-Precursory symptoms. For some time before the commencement of actual labour, a variety of changes are taking place which must be looked upon as the precursors of this process: during the

last weeks of pregnancy, nature appears, as it were, to be preparing for the great change which is at hand, and to be making such arrangements as shall enable it to be completed with the least possible danger both for the mother and her child.

One of the earliest warnings which we have of approaching labour is an alteration in the form of the abdominal tumour; the cervix uteri has by this time (especially in primiparæ) entirely disappeared; the presenting part of the child has therefore descended to the lowest part of the uterus; the fundus has sunk lower and more forwards; and from the diaphragm being enabled to act with greater freedom, the respiration is performed with more ease and comfort to the patient; she therefore feels more capable of moving about, and is in better health and spirits than for some time previously. Upon examination per vaginam, the head will be found deep in the cavity of the pelvis, covered by the lower and anterior segment of the uterus; the os uteri is still closed, and situated in the upper part of the hollow of the sacrum, forming merely a small circular depression. In women who have already had children, a portion of the cervix uteri is still remaining; it is thick and bulky; and, in some cases, where the uterus has been greatly distended in several successive pregnancies, it is nearly as long as in the unimpregnated state; the os tincæ or os uteri externum is open, its edge irregular from former labours; the upper extremity of the canal of the cervix is contracted, and forms the os uteri internum; it has been closed during the greater part of pregnancy, but usually is now sufficiently open to admit the finger; the os uteri is neither so high up nor so far backwards in the pelvis as in primiparæ, and is reached with greater ease; whereas, the head of the child, instead of being felt in the cavity of the pelvis, generally remains at the brim until labour is more advanced.

First contractions. The first contractions of the uterus (in a state of health) are so slight as scarcely to be noticed by the patient; they create a sensation of equable pressure and general tightness round the abdomen, and during the contraction the uterus feels somewhat firmer, but they are neither attended with pain, nor do they appear at first to have any effect upon the os uteri: these precursory contractions generally come on a day or two before actual labour commences, and sometimes are felt at intervals for one or two weeks. Where the uterus has been exposed to any source of irritation, and especially where there is a disposition to rheumatic affection of this organ, they may produce much suffering, and give rise to one form of what are called false pains, hereafter to be described. The first contractions, says M. Leroux (Sur les Pertes de Sang, § 41,) are feeble, and communicate no sensation to the patient; in order to discover them we must hold our hand upon the abdomen, and if we feel the globe of the uterus raise itself and become hard, this is a true contraction. These contractions gradually increase until they excite pain: but pain is not essential to a contraction; it depends on the distention and compression of the nerves produced by the resistance of the body upon which the uterus acts, and increases in severity in proportion to the degree of resistance and contraction.

In proportion as the lower part of the uterus descends into the cavity of the pelvis, so does it exert a degree of pressure on the neighbouring

parts; the capacity of the bladder and rectum is diminished; and being therefore unable to contain the usual quantity of urine and fæces, and being probably rendered more irritable by the pressure above-mentioned, the patient experiences frequent calls to pass water and evacuate the bowels, which is sometimes effected with considerable difficulty: in some instances she is obliged to lean forward, or support the abdomen, in order to take the weight of the child off the neck of the bladder before she can empty it; the same cause occasionally requires the use of the catheter, and sometimes renders the introduction of it a matter of considerable difficulty.

As these various changes make their appearance, the patient becomes restless and anxious; she cannot remain long in the same posture; the slight precursory contractions which have been just described, are becoming stronger, and begin to produce a sensation of pain; the os uteri (in primipara) opens somewhat, its edge at first is exceedingly thin, and feels almost membranous; by degrees, however, it swells, grows thick and cushiony, and is now more dilatable.

Action of the pains. The os uteri does not dilate merely by the mechanical stretching which the pressure of the membranes and presenting part exert upon it; it dilates in consequence of its circular fibres being no longer able to maintain that state of contraction which they had preserved during pregnancy; they are overpowered by the longitudinal fibres of the uterus, which, by their contractions, pull open the os uteri equally in every direction.

"The

The vagina also swells and grows more cushiony, and this is followed by a copious secretion of colourless and nearly inodorous mucus. more albuminous it is the better, and it is always a good sign when lumps of albuminous matter come away from time to time; the thicker, softer, and more cushiony the os uteri is, the more mucus does it secrete." (Wigand, Geburt des Menschen, vol. ii. p. 292.) The thin hard os uteri does not dilate, its fibres are all in close contact, and like a well-twisted cord will not yield; whereas, when they are separated from each other by the swelling of the os uteri, they easily yield to the dilating force which is applied to them. Besides serving the purpose of lubricating the passage, the secretion of mucus is of great importance as a topical depletion, for, by thus unloading the congested vessels, they diminish the vascularity and heat of the part, and render it more capable of dilatation. "If, on the other hand, the entrance of the vagina is small, the neighbouring parts cool, dry, inelastic, and as if tightly stretched over the bones; if the finger, in spite of being well oiled and carefully introduced, produces pain upon the gentlest attempt to examine, we may expect a tedious and difficult labour." (Op. cit. p. 190.)

The patient is now no longer able to conceal her pains when they come on. If she be in the act of conversing, she stops short, and remains silent until the severity of the pain is over; if she be walking about her room, she is obliged to stand still for the time, and rest against or hold by something until the pain has gone off. The true labour pains are situated in the back and loins; they come on at regular intervals, rise gradually up to a certain pitch of intensity, and abate as gradually: it is a dull, heavy, deep sort of pain, producing occasionally a low moan from the patient: not sharp or twinging, which would elicit a very different expression of suffering from her.

Auscultation during the pains. "If we direct our attention to the changes of tone which the uterine pulsations present during auscultation, we shall find them generally stronger, more distinct and varied in tone during labour; and this is especially the case just before a pain comes on. Even if the patient wished to conceal her pains, this phenomenon, and more especially the rapidity of the beats, would enable us to ascertain the truth. The moment a pain begins, and even before the patient herself is aware of it, we hear a sudden short rushing sound, which appears to proceed from the liquor amnii, and to be partly produced by the movement of the child, which seems to anticipate the coming on of the contraction: nearly at the same moment all the tones of the uterine pulsations become stronger; other tones, which have not been heard before, and which are of a piping resonant character, now become audible, and seem to vibrate through the stethoscope, like the sound of a string which has been struck and drawn tighter while in the act of vibrating. The whole tone of the uterine circulation rises in point of pitch. Shortly after this, viz. as the pain becomes stronger and more general, the uterine sound seems as it were to become more and more distant, until at length it becomes very dull, or altogether inaudible. But as soon as the pain has reached its height, and gradually declines, the sound is again heard as full as at the beginning of the pain, and resumes its former tone, which in the intervals between the pains is as it was during pregnancy, except somewhat louder. This is the course of things if the pain be a true one, and attain its full intensity: where the pains are false or irregular, it is very different; the uterine sound either remains unaltered, or increases only for an instant, or its seeming increase of distance, as above mentioned, is not observed." (Die Geburtshilfliche Exploration, von Dr. A. T. Hohl, erster theil, s. 105.) Effect of the pains upon the pulse. It is curious to observe the effect which a regular pain has upon the rapidity of the mother's pulse; as the former comes on and goes off, so does the other increase or diminish. "The increasing rapidity of the pulse announces the commencement of the pain; it rises and attains its summum with it; and as the pain subsides so does the pulse gradually resume the rate which it had during the intervals; a similar ebb and flow may be heard in the uterine souffle. The more regular the pain is, and the more distinctly it rises to its full extent, the more marked, regular, and distinct, is this change in it. We may also invert the order of things, and say, the more distinctly the rapidity of the pulse comes on and announces the pain, the more regularly it rises and attains a certain height, which it maintains, and then gradually subsides; in like proportion will the pain be more perfect, attain its full extent more completely, and act more efficaciously upon the regular progress of the labour. Where, however, the rapidity of the beats subsides before it had scarcely begun to increase, the pain is too weak; or where the rapidity rises by sudden starts, the pain is a hurried one; and in either case its effect will be imperfect.' (Hohl, op. cit. vol. i. p. 108.) In order that we may ascertain these changes correctly, we ought to note the rapidity of the pulse during each successive quarter of a minute as directed by M. Hohl; thus, in a pain which lasts two minutes, the increase and diminution in the rapidity of the pulse may be as follows, 18, 18, 20, 22; 24, 24, 22, 18. As labour advances it increases, so that