A System of Midwifery Part 26

ENCYSTED PLACENTA.

_Situation in the uterus.--Adherent placenta.--Prognosis and treatment.--Placenta left in the uterus.--Absorption of retained placenta._

By the term _encysted_ placenta, we mean that state of irregular uterine action after the expulsion of the child, where the lower portion of the uterus, particularly the os uteri internum, is closely contracted, while the fundus contains the placenta enclosed in a species of _cyst_ or cavity formed by itself and the body of the uterus.

Upon examination externally, we find the fundus pretty firmly contracted, but probably somewhat higher up the abdomen than usual; the v.a.g.i.n.a and os uteri externum, or os tincae, are usually found dilated, the pa.s.sage gradually tapering like a funnel to the os uteri internum, or upper end of the ca.n.a.l of the cervix.

_Situation in the uterus._ This state has been very generally considered to arise from a spasmodic contraction in the circular fibres of the body of the uterus, by which it was as if tightly girded by a cord at its middle, and, from the form it was supposed to take, was called _hour-gla.s.s contraction of the uterus_.

From the observations of later years there is much reason to suppose that the true hour-gla.s.s contraction, as now described, is of very rare occurrence, even if it does take place at all; and that, in by far the majority of cases, the stricture is either produced by the upper part of the cervix, as we have already mentioned, or resides in the os uteri externum or inferior portion of the cervix.

Baudelocque was the first who pointed out the neck of the uterus as the real seat of the stricture in these cases: "that circle (says he) of the uterus which is round the child's neck, according to the general laws of its contraction, must narrow itself much quicker after delivery than the other circles which compose that viscus, because it is already narrower, and its forced dilatation at the instant of the expulsion of the child's trunk is only momentary, and because it has naturally more tendency to close than the other circles have, since it is that which const.i.tutes the neck of the uterus in its natural state." (Baudelocque, _Heath's Trans._ vol. ii. -- 969.)

Dr. Douglas, of Dublin, also investigated this subject, and came to a similar conclusion: he considered that encysted or incarcerated placenta from hour-gla.s.s contraction, resulted either from morbid adhesion of the placenta, or from inactivity of the uterus, and does not occur as a primary affection; his observations lead to the conclusion that the stricture in hour-gla.s.s contraction "does not form from the middle circ.u.mference of the uterus; it is formed by the lowest verge of its thickly muscular substance, at the line of demarcation of its body and cervix." "Thus, then, it would appear that the upper chamber comprises in its formation the entire of the body of the fundus; whilst the lower chamber engages only the cervix uteri and the v.a.g.i.n.a." (_Medical Transactions of the Col. of Phys._ vol. vi. p. 393.)

The late W. J. Schmitt of Vienna considered that the stricture was produced by the os tincae, or os uteri externum.

From our own experience we would say that the seat of the stricture varies considerably in different cases; that in the simplest form it is nothing more than a contracted state of the os uteri externum; that in others it is formed by the upper portion of the cervix uteri, or os uteri internum; but in other instances it appears to be formed by the inferior segment of the uterus itself. The contraction in this part of the uterus, which, according to the observations of Professor Michaelis, comes on when the os uteri is fully developed, and, by closely surrounding the head, is one chief means by which prolapsus of the cord is prevented, may easily produce a state of stricture after the birth of the child, and thus retain the placenta; it may, however, be questioned whether this portion of the uterus, when fully dilated by pregnancy, and which then forms its inferior segment, would not become the os uteri internum when the uterus is empty and contracted.

Hour-gla.s.s contraction of the uterus is liable to occur where the action of the uterus has been much deranged or exhausted, either by the unusual rapidity or excessive protraction of the labour. In all cases where the child has been rapidly expelled before the uterus has had time to contract regularly and uniformly, the disposition in the os uteri to contract, as pointed out by Baudelocque, will manifest itself. This state may also be induced by great previous distention, as from twins, or too much liquor amnii; by irritation, as by improperly pulling at the cord, by having used too much force in artificially delivering the child, by the introduction of the hand or instruments too cold, &c. The most frequent cause, however, is over anxiety to remove the placenta; the cord is frequently pulled at, and at length the os uteri is excited to contract; in this case we generally find the stricture at the os tincae, which yields without much difficulty, either by gentle friction with the hand over the fundus, and cautiously pulling the placenta in the axis of the superior aperture, or by introducing the hand and bringing it away.

_Adherent placenta._ When the placenta is still attached either wholly or in part, there are generally some preternatural adhesions to the uterus, which, by keeping its upper portion distended, give rise to partial contractions below. This condition of the placenta is observed to attend nearly every severe case of hour-gla.s.s contraction; in some instances its whole surface appears as if grown to the uterus, forming an adhesion so close and intimate as to be overcome with the greatest difficulty: we have met with cases where the placenta tore up into shreds which still adhered to the uterus as strongly as before; in others, however, the adhesions are of smaller extent, varying from the size of a s.h.i.+lling to that of a crown piece, sometimes there being only one, sometimes two or three in the same placenta.

The nature of these adhesions is but little understood; it is generally considered that they have been produced by some inflammatory process taking place between the uterus and placenta; and certainly the firm feel and lighter colour of the part which has been adherent might, perhaps, justify such a conclusion. Cases have occurred where the inflammatory action has extended in the contrary direction (outwards,) producing mischief in the neighbouring parts, viz. abscess and injury of the pelvic periosteum with subsequent pelvic exostosis. (_Neue Zeitschrift fur Geburtskunde_, band v. heft 1.) We may also observe, that these adhesions of the placenta usually occur several times in the same individual.

_Prognosis and treatment._ The danger in these cases depends chiefly on the presence or absence of haemorrhage; in the latter case, we may wait safely, and give the uterus the opportunity of contracting upon the placenta, so as ultimately to dilate the stricture and expel it. In most instances, where the os tincae is the seat of the contraction, and the placenta (as is usually the case here) already detached, a little patience, aided by gentle friction of the fundus, and carefully abstaining from all irritation of the os uteri, will be sufficient to attain this object; the os uteri will gradually relax and the placenta slowly exude into the v.a.g.i.n.a. Where, from the feel of the fundus, the uterus appears still unable to exert such a degree of contraction as shall overpower the os uteri, we may follow the plan of Dr. Dewees, in his section "On the enclosed and partially protruded Placenta," and rouse its activity by some doses of ergot: "should this not succeed within an hour, the uterus must be gently entered, by slowly dilating the os uteri, and the placenta removed." One finger after the other must be pa.s.sed through the os uteri, until it has yielded sufficiently: if the placenta be quite detached, two fingers will generally be sufficient for this purpose, by which means it may be gradually brought down into the palm of the hand, and then removed.

Where more or less of it is morbidly adherent, which may be presumed when it continues for some time at the upper part of the uterus without any disposition to descend, we must carefully introduce the whole hand, and endeavour to find the edge of the placenta at which we should begin the process of separation. Where, however, the edge is very thin, and the attachment firm, it is not easy to effect this without risk of injuring the structure of the uterus itself with the nails, nor can we always distinguish the thin and closely adherent edge of the placenta from the uterus itself: in these cases it will be safer to plunge the fingers into the central and thicker portions of the ma.s.s, and gradually separate it towards the circ.u.mference. Wherever this close adhesion prevails over a considerable extent, it becomes nearly impossible to prevent portions being left adhering to the uterus; thus it not unfrequently happens, where a placenta under these circ.u.mstances has been artificially removed, that there are one or more large irregular cavities on its uterine surface, from a portion of its ma.s.s having been torn from it, and left adhering.

Cases have occurred to us,[134] where the whole central portion has thus remained, the amniotic surface of the placenta having come away entire with the larger umbilical vessels attached to it, and merely a narrow margin of parenchyma at its edge; in others, the whole ma.s.s has broken up, the cord, the larger branches of the umbilical vessels, and the membranes have come away, but the greater part of the placenta has remained closely adhering to the uterus. In such a case it becomes a question, whether it be safe to persist in our efforts to remove the remains of the placenta, or whether it will not be better to leave the case to nature: experience shows that the latter plan is the safer, and that a pract.i.tioner is not justified in running the risk of severely injuring the uterus by repeated and violent efforts to effect his object.

_Placenta left in the uterus._ Where a portion of placenta has been thus left in the uterus, the case may terminate in one of three ways: either it may be expelled in the course of from twelve to twenty-four hours, without any perceptible marks of putrefaction, and with but little or no disturbance to the system; or where, after a longer interval, the discharges have become very offensive, and the placenta has been expelled in a putrid state, with serious disturbance of the health; or lastly, where the lochia has been sparing but natural, and where no trace whatever of the placenta has appeared.

In the first mode of termination it may be presumed that the attachment of the placenta has yielded either to the continued contraction of the uterus, or from a slight degree of incipient putrefaction, by which its union with the uterus was weakened; in the second case, from contact with the external air, and being constantly kept at a considerable temperature by the heat of the surrounding parts, the lacerated placenta rapidly putrefies, putrid matter is carried into the system, producing all the effects of a deadly poison, and the patient is placed in a state of the greatest danger; the pulse becomes quick and small, the tongue red and dry, accompanied with great depression of the vital powers, the uterus frequently swells, grows hard, and excessively painful, followed by general peritonitis; it is not, however, the inflammation which necessarily destroys the patient, but the prostrating effects upon the nervous system, produced by the introduction of an animal poison into the circulation.

_Absorption of retained placenta._ Where the placenta has not been much lacerated, or at any rate where every portion has been removed which could be separated without violence, where also the uterus has contracted firmly and closely, the part which is retained does _not_ pa.s.s into putrefaction, little or no inconvenience is experienced by the patient; the lochia, as we before observed, is sparing but natural, and ceases after the usual time, but not a trace of the placenta comes away. This fact has been repeatedly noticed, especially in later years; but the attention of medical men was first called to the subject by Professor Naegele, of Heidelberg, in 1828. In 1802, and again in 1811, cases of premature expulsion of the foetus occurred to him where the membranes and placenta did not come away, and where no trace whatever of them appeared afterwards. In 1828[135] his a.s.sistance was required in a case of unusually firm adhesion of the placenta, and where, from this as well as other circ.u.mstances, the extraction was so difficult that he was compelled to leave considerably more than one-third in the uterus. (_Med. Gaz._ Jan.

10, 1829.) About the same time, a most interesting case was published by Professor Salomon, of Leyden, where the _whole_ placenta of a child only three weeks short of the full time was retained by the firm contraction of the uterus, and, according to Dr. Salomon's view of it, removed by the process of absorption. About the end of the third week, the uterus, which had hitherto been larger than is natural under ordinary circ.u.mstances after labour, and more globular, now diminished considerably, and began to a.s.sume the usual form as in the unimpregnated state. Besides the cases already alluded to, which we have described in our Midwifery Hospital Reports, we may again refer to one which was mentioned by Dr. Young, formerly professor of Midwifery at Edinburgh: "I could get my hand to the placenta, but no farther, the uterus having formed a kind of pouch for it, so that I at last was obliged to trust to nature; _what was very remarkable, the placenta never came away_, yet the woman recovered."

Cases have also occurred where the placenta, after having been retained many days in the uterus, has been expelled quite fresh, the edges worn or rather dissolved away by the process of absorption; thus Dr. Denman mentions one where the whole placenta was retained till the fifteenth day after labour, and was then expelled with little signs of putrefaction except upon the membranes, the whole surface which had adhered exhibiting fresh marks of separation. Cases of abortion have occasionally been observed where the embryo has escaped, but the secundines have never come away, although the discharges, &c., have been watched with the greatest attention; after a time the menses have returned, the patient has again become pregnant, and has pa.s.sed through her labour at the full term without any thing unusual occurring.

The subject has recently been considered very fully, and much interesting knowledge added, by Dr. Villeneuve, of Ma.r.s.eilles. Besides putting the fact beyond all doubt, he shows that cases of total adhesion are rarely if ever fatal; and that, where cases have terminated fatally, the placenta has only partially adhered, and the patient has been either destroyed by haemorrhage, or by the effects arising from the absorption of putrid matter, or from injury of the uterus in attempting to remove the placenta.

He considers that a placenta which is not fixed to the uterus by organic and intimate adhesions cannot be absorbed, though it may perhaps be retained for several days without danger, if there is contraction of the uterus. (_Gazette Medicale de Paris_, July 8, 1840.) It may, however, be doubted whether this last observation be correct, as it is a well-established fact that cows which had been supposed with calf, and in which the symptoms of pregnancy had again subsided, have afterwards been killed and nothing but the bones of the calf found in the uterus, the soft parts having been removed by absorption. The same fact has been observed also in sheep and other animals; and knowing how abundantly the human uterus is supplied with absorbents, coupled with what has been already stated, there can be little or no doubt but that the placenta in these cases had been acted upon by a similar process. Although we strongly deprecate repeated attempts to remove the adherent portions of placenta, especially where we have brought away a considerable quant.i.ty of its foetal part, still we would warn our readers against leaving any loose ragged pieces in the uterus, for these rapidly pa.s.s into putrefaction, and produce the alarming symptoms above-mentioned. The safety of our patient mainly depends on the firm contraction of the uterus preventing the access of air, and on our constantly removing, by means of injections, any putrid discharge which may have collected. The sparing quant.i.ty of lochia which has generally been observed, especially where the _whole_ surface of the placenta has adhered, can easily be accounted for, the greater portion of the vessels which ordinarily furnish this discharge being closed up by the adherent ma.s.s: from the same reason we can explain why cases of total attachment of the placenta are rarely or never attended with haemorrhage.

Lastly, should any symptoms of fever or abdominal inflammation supervene, they must be treated according to the rules which we have given under these heads.[136]

CHAPTER IX.

PRECIPITATE LABOUR.

_Violent uterine action.--Causes.--Deficient resistance.--Effects of precipitate labour.--Rupture of the cord.--Treatment.--Connexion of precipitate labour with mania._

The second division of Dystocia comprises those species of labour where it becomes dangerous for the mother or child, without obstruction to its progress. Of these we shall first consider precipitate or too rapid labour, not only because it is liable to be followed by a great variety of injurious results, but also because it has received little or no notice by the obstetric authors of this country.

Precipitate labour depends on one of two conditions; either the expelling powers exceed their ordinary degree of activity, or the resistance to the pa.s.sage of the child is less than usual. "Every normal labour has a certain course, which is neither too slow nor too quick. The pa.s.sages are thus dilated gradually and without excessive suffering; the uterus is felt alternately hard and soft; and the pains have certain and regular intervals, which become very gradually shorter, during which both mother and child are enabled to recover themselves." (Wigand, _Geburt des Menschen_, vol. i. p. 68.)

_Violent uterine action._ In the present case the pains are extremely violent from the very commencement of the labour; they produce great suffering; each pain lasts a considerable time, and the intervals between them are very short. During their presence, the patient is irresistibly compelled to bear down and strain with all her force; the whole body partakes of the general excitement: the patient is more restless and less manageable than usual, her manner is altered and becomes strange; the head is hot, the face flushed, and the pulse quick and full.

In some cases the intervals between the pains are scarcely perceptible, for one pain has scarcely left off before the next has already commenced; or the uterus falls into a state of continued violent contraction, which does not cease until the child is driven into the world. The abdomen is very hard during the pain, the whole body stiff and rigid; the patient expresses her sufferings very loudly, or actually raves with pain. From the constant and irresistible effort to strain, it seems as if she has scarcely time to get her breath, for she continues to hold it so long that respiration might be almost supposed to have stopped altogether. "As long as consciousness remains, the impulse to lay hold of any object within reach and pull by it is extraordinarily strong, until at length, in the midst of a violent scream, or grinding of the teeth, covered with sweat and with simultaneous evacuation of the r.e.c.t.u.m and bladder, she is suddenly delivered." (Wigand, _op. cit._ vol. i. p. 71.)

_Causes._ This storm of uncontrollable uterine action "appears to depend upon an unusually powerful influence of the nervous system upon the contractile fibres of the uterus or upon a morbid degree of irritability."

(_Ibid._) In some cases it appears as an individual peculiarity, every successive labour of the patient being remarkable for its violence and rapidity. Precipitate labours of this kind are frequently observed to be hereditary, and like an opposite and equally faulty condition of the expelling powers, viz. slow and lingering uterine action, are sometimes peculiar to certain families, the mother and the sisters of the patient having had all their labours peculiarly rapid and violent.

The character of the catamenial periods before pregnancy is frequently observed to bear a considerable relation to that of the labours in the same individual; thus, if she has always suffered much pain and other symptoms of uterine excitement just before or during these times, so much so as even to require slight medical treatment to allay the periodical suffering, the uterus almost invariably manifests a similar degree of energy and irritability during labour. On the other hand, where the menstrual periods produce so little suffering or derangement that, but for the appearance of the discharge itself, the patient has scarcely any means of determining their recurrence, the uterus betrays a similar want of activity when labour comes on, which may therefore, _caeteris paribus_, be expected to be slow and lingering.

Mental affections, which we have already shown to be capable of r.e.t.a.r.ding labour, occasionally have the opposite effect, and rouse the uterus to violent action. It is well known that the dread of the forceps, which the pract.i.tioner has declared would be required, has frequently been followed by so much activity of the uterus as to render its application unnecessary.

Where the patient is stout, robust, and plethoric, or of a nervous hysterical habit, this state of unruly uterine action is frequently attended with great cerebral excitement; during the pains she raves wildly, and for some time becomes quite unmanageable, or in other cases this state pa.s.ses into actual convulsions.

In febrile diseases, especially of the eruptive kind, the labour is usually of this character; the exertions of the uterus in such cases, especially in scarlet fever, are sometimes quite extraordinary, so that the child seems to be born without any effort on the part of the mother.

This is of great importance in inflammation of the lungs, &c. where the patient would be unable to inflate the lungs to that extent which is necessary for any violent efforts.

_Deficient resistance._ Where the rapidity of the labour arises from want of that degree of resistance to the expelling powers which is natural, it may depend on circ.u.mstances connected with the mother or the child; thus, it may arise from too large a pelvis; the head, covered by the inferior portion of the uterus, is forced down deeper into the pelvis than usual, especially if, as is not unfrequently the case, this state be accompanied with violent and powerful pains; the head may thus be actually forced through the os externum before it has pa.s.sed the os uteri: cases have been recorded where nearly the whole uterus, has been thus protruded. In an "extraordinary case," as Deventer justly terms it, "the head of the child had pa.s.sed the os externum as far as the shoulders, and only the summit of it was visible, three-quarters at least of the head being still enclosed in the uterus, although the head and neck had already pa.s.sed." (_Novum Lumen_, part. ii. chap. 3.)

In other cases the sudden expulsion of the child appears to depend merely upon the great dilatability of the soft parts, and may occur quite independently of any disease. We recollect a case of this sort where the patient, a healthy woman, had only two pains--the first awoke her out of a sound sleep and ruptured the membranes, the next drove the child with great violence into the bed. Where the patient is weakened by previous disease, and the soft parts are very relaxed and flaccid, they produce no resistance to the advance of the head: this condition is very unfavourable, "as it implies a greater state of relaxation, or want of tone, than is compatible with the welfare of the patient: hence it is seldom found to take place except when the unfortunate subject is sinking under the last stage of debility, as in phthisis," &c. (Power's _Midwifery_, p. 138.)

The want of due resistance to the expelling powers may depend upon the size and hardness of the head; it is either smaller than usual, from the child being premature, or, if of the full size, the cranial bones are imperfectly ossified, the sutures are wide, the fontanelles large, and the whole head very yielding and soft; or it may depend on some congenital defect, in which the brain and cranial coverings are more or less imperfect.

In the ordinary cases of precipitate labour the case depends generally on a complication of violent pains, wide pelvis, and small child.

_Effects of precipitate labour._ Besides the mischief which may result from the rapid expulsion of the child causing prolapsus uteri, laceration of the v.a.g.i.n.a, perineum, and haemorrhage from inertia coming on in consequence of the uterus being so suddenly emptied, dangerous syncope, or even asphyxia, may follow from the shock which the nervous system has sustained, or in consequence of the sudden removal of that degree of pressure which the gravid uterus had exerted upon the abdominal circulation during pregnancy. Where the patient has been very unruly, and has exerted herself with great violence, "emphysema of the face and neck (says Dr. Reid) may suddenly occur during labour, and cause great alarm to a young pract.i.tioner, as it alters and disfigures the countenance in an extraordinary manner. Great straining or screaming may produce it, and it probably depends on some partial rupture of the lining membrane of the larynx. I have seen two or three cases of this description, and one which occurred to a great extent in the case of an out-patient of the General Lying-in Hospital, in whom this tumefaction spread to the shoulders and chest." (_Manual of Pract. Midwifery_, by James Reid, M. D. p. 231.)

The _child_ also may suffer from a precipitate labour, where the pains are excessively violent and run into each other, so that the whole labour is effected during one continued storm of uterine action. If the membranes have given way at an early period, so that the body of the child is exposed to the immediate pressure of the pains, the abdominal circulation suffers, and the child is destroyed in the same way as by pressure on the cord itself; or it may be suddenly dashed upon the floor before the mother has had time to reach her bed, or even put herself in a rec.u.mbent posture upon the floor: in this way it may receive a severe injury upon the head, or the cord may be lacerated, and the child die from haemorrhage before a.s.sistance can arrive: such accidents, however, are not so dangerous to the child as have been supposed, a fact which has been proved by medico-legal investigations. The direction of the pelvic outlet and v.a.g.i.n.a is such as to expel the child obliquely downwards and forwards when the mother is in the upright posture, so that the force of the blow is in a great measure broken by this circ.u.mstance; the head also, as well as the other parts of the body, are soft and yielding, and nearly preclude the chances of injury taking place; the violence of the fall is generally diminished in some measure by the patient being almost always compelled to drop upon her knees at the moment of great suffering, whilst the child is pa.s.sing; her clothes also surround it more or less, and thus s.h.i.+eld it from any severe injury.

_Rupture of the cord._ The cord is liable to be torn in these cases, showing that a considerable jerk had been applied to it, but neither the child nor its mother have suffered from it. Ten or twelve cases of ruptured cord have come to our own immediate knowledge, and in none of them were any unfavourable effects produced. It can scarcely be imagined possible that so much force could be applied to the cord, at the moment when the uterus is so suddenly evacuated, without inversion or prolapsus being the almost unavoidable result, the more so when we recollect that the cord at the moment of birth requires considerable force to break it.

This circ.u.mstance may be partly attributed to the firmness with which the uterus contracts at the moment that the child is expelled, but chiefly to the fact that the axis of the brim is nearly at right angles with that of the outlet, more especially if the fundus, as is usually the case, is inclined somewhat forwards; the cord pa.s.ses round the posterior part of the symphysis pubis as upon a pulley, so that a considerable portion of the force which is applied to it, is spent here before reaching the fundus uteri. It is however remarkable, that the umbilicus of the child should receive no injury from a jerk which breaks the cord, when, if we try afterwards to break the remaining pieces of the cord, we find that it will resist very powerful efforts: this fact, and the circ.u.mstance that the cord usually ruptures at about two or three inches from the umbilicus, as in some animals, seems to imply that this part is weaker than elsewhere, as if intended by nature to give way with a moderate degree of force.

Wigand considers that patients are particularly disposed to have quick labours, who are of a scrofulous, rheumatic, or arthritic diathesis; that such patients are very liable to have adhesion of the placenta after the birth of the child, with hour-gla.s.s contraction: the observation, however, has not been confirmed by the experience of others, and certainly not by the cases which have come under our own notice.

_Treatment._ Where, from the smallness of the child or unusual size of the pelvis, the pains are forcing the lower portion of the uterus down to, or through, the os externum, it will be necessary to support it carefully, until the os uteri is sufficiently dilated to let the head pa.s.s. A case of this kind occurred to Professor Naegele, of Heidelberg, where, during the patient's former labour, the pains had been so violent, and the uterus had been detruded to such an extent, that actually the lower half of it appeared between the l.a.b.i.a: to prevent a similar accident occurring this time, (as the pains were beginning to show the same disposition to violent action as before,) he applied a broad T bandage very firmly upon her, coming over the os externum, so as to prevent the uterus being prolapsed beyond the l.a.b.i.a; he cut a hole in it corresponding to the v.a.g.i.n.a, and the child was born through this with perfect safety to the mother.

Where we have sufficient warning, opium in effective doses will probably a.s.sist in lulling the irritability of the uterus: if the bowels have been previously well opened, an opiate enema will be desirable; if not, a large emollient enema should be premised.

The patient should be made to lie upon her side, and not only strictly forbidden to resist to her very utmost, the urgent impulse which she feels to strain and bear down, but must carefully avoid even holding by or pus.h.i.+ng against any fixed body with her hands or feet. Still farther, to quiet the turbulence of the abdominal muscles, a broad bandage should be fastened firmly round the abdomen; it not only gives the patient a comfortable feeling of support, but tends greatly to calm the spasmodic irritability of these muscles. These precautions will be of so much more service if they can be used early, as in cases where we have been already warned by the character of her previous labours: we can thus avoid the premature rupture of the membranes, which is a thing by all means to be avoided; the uterus acts with increased power where its bulk has been diminished by the escape of the liquor amnii, and at the same time becomes still more irritable and unruly from contracting immediately upon the child; and not only is there imminent danger of its giving way in some part, but the child is almost inevitably destroyed by the violence of the pressure to which it is exposed.

In cases where the vehemence of the expelling powers appears to be quite beyond our control, Wigand has recommended a copious bleeding to complete syncope as the only means; in which suggestion, he has been followed by Froreip: neither of these authors, however, appear to have had any experience of this mode of treatment, and knowing how much more active the uterus becomes after a smart bleeding in ordinary cases, and how powerfully the state of syncope promotes the dilatability of the soft parts, we should hesitate exceedingly to employ so doubtful a remedy.