PART VII

SPECIAL PATHOLOGY OF PARTURITION

LABOUR is said to be healthy when the mechanism of the expulsion of the ovum is subject to no disturbance. This has already been shown to depend upon the normal condition of the expelling forces, on the one hand, and upon the obstacles they meet with, on the other. Now, as the latter consist of the relations of the child to be expelled to the passages through which it has to pass, deviations from the normal mechanism may be caused by

1. Anomalies of the expelling forces.

2. Contraction of the maternal passages.

3. Anomalies (in shape or position) of the foetus which obstruct its passage through the normal parturient canal.

We shall now consider, in their order, all these causes of the abnormal mechanism of labour.

CHAPTER I

ANOMALIES OF THE EXPELLING FORCES

As the resistance which the expelling forces meet with varies greatly, so also does the intensity which they must reach to terminate labour vary equally greatly.

In one case so moderate a force suffices to expel the child that the woman scarcely heeds it, and is completely taken by surprise by the commencing labour. In another case the greatest efforts of the contracting muscular fibres of the uterus and the assistance of the auxiliary forces are necessary to overcome the obstacles to delivery. It is evident that in the first case, although the pains are unusually feeble, we are not entitled to speak of pathological weakness of the expelling forces, since they accomplish the expulsion of the child; and in the other case it is equally evident, although the pains have

reached an extraordinary degree of intensity-so great, perhaps, as to awaken the fear of a rupture of the uterus-that there is no reason to call it an anomaly of the expelling forces. Here the anomaly lies in the abnormal obstruction; the too great increase of the expelling forces is only a consequence of that, and in general a very salu tary one, without which labour could not have been terminated naturally. It would tend to the worst practical consequences if such pains were considered pathological, and therapeutic measures accordingly taken against them. The test by which alone we can estimate the pains is the effect they produce, and thus even the most powerful pains may still be too feeble for a given case.

Therefore no general measure can be given of too strong or too feeble pains. We have seen very feeble pains suffice in one case, and the strongest possible even insufficient in another to terminate labour. We can only speak of relatively too strong and relatively too feeble pains.

Let us add that, in general, the strength of the pains accurately increases with the amount of the obstacles, and when this relation between the expelling force and the obstacle is disturbed, the obstacle is, in the great majority of instances, the primary active agent, and the anomaly of the expelling forces is the secondary, the consequence.

These considerations will serve to justify the course we adopt in regard to the anomalies of the expelling forces. As they are rarely of primary origin, we shall here speak of them shortly, and shall treat of them in connection with the abnormal obstacles as cansed and produced by them.

Too feeble pains are very frequent at the commencement of the first stage, so that the first part of labour passes on very slowly, and there may even be a complete cessation of the pains for some time. At this period the weakness of the pains has no practical significance. Since with such feeble pains the woman is able to walk about and attend to her lighter duties, as long as there is no urgent indication to hasten on the labour, all that is required is the necessary patience of the attendant and the woman. But if she and her relatives become very uneasy on account of the retardation of stronger pains, or if a longer delay also is to be feared from a medical point of view, which exceptionally occurs through premature rupture of the membranes, labour may be made to advance by the application of the douche, or by the introduction of an elastic catheter.

In the further progress of the first stage and during the stage of expulsion, primary defective pains are rarely seen.

Sometimes, but by no means always, this occurs in consequence of a general debility, or after exhausting diseases. More frequently it depends upon congenitally feeble development of the uterine muscular fibres.

The condition of the latter is, above all, of the greatest importance. Their contractility may have been diminished by too great distension of the uterus during pregnancy, as by twins and by hydramnios, and, without doubt, also by endometritis, metritis, and their consequences. A very frequent cause of debility of the uterine muscles, and one practically of very great interest, is frequent and rapidly succeeding labours,

especially when they have been very difficult. In the latter case there is almost always an anomaly of the pelvis, which, in conjunction with the defective pains, acts very unfavorably. Here, as well as in the cases above mentioned, treatment directed to the strengthening of the pains cannot do much, and artificial means must replace them as soon as it appears possible and necessary. Only when the weakness of the expelling force is due to an enormous distension of the uterus do we possess, in suitable cases, a very effective remedy for increasing the uterine action in the artificial rupture of the membranes.

When the shape and size of the uterus are altered by neighbouring tumours its action is very easily disturbed. Independently of new growths in the abdomen, the accumulation of fæcal masses in the rectum, or of the urine in the bladder, deserves to be noticed in this respect. The latter is quite a common cause of feeble pains, and, after emptying the bladder by means of the catheter, the pains almost always become stronger.

It is also a well-known fact that mental emotions influence the strength of the uterine action, and this is worthy of the attention of the practitioner. In such cases opium is the most effective remedy for increasing the pains.

It rarely happens that the pains are unable to dilate the os and to push the head through the normal pelvis without there being a known cause for this bad effect of the uterine action. If in such cases the bag of waters be still intact, though the ovum be not over-distended, artificial rupture of the membranes is the best means to advance labour. Even where only the small quantity of liquor amnii in front of the head has drained off the os is seen rapidly to dilate and the head to descend. If there are objections to the artificial rupture of the membranes the introduction of an elastic catheter will have a very precise effect. After rupture of the membranes the defective uterine action may be increased by gentle friction of the fundus uteri. The action of internal remedies is always very uncertain, and the most efficacious of them, ergot of rye, produces a general, uniform tension of the uterus, rather than regular and powerful pains. After delivery this acts very beneficially upon the closure of the maternal vessels of the placenta, but it has very slight if any influence whatever upon the progress of the child.

Too strong pains are not injurious when the labour is properly managed. When the resistance is very slight and the pains very strong, the os is very rapidly dilated, and the head is somewhat impetuously pushed through the genital fissure-Partus præcipitatus. If no support is given to the perinæum, especially when the woman is in an unsuitable position, considerable injury may be inflicted upon it. There is no necessity for moderating the powerful pains. They are either required to overcome a mechanical obstacle, or, in its absence, the child is rapidly born, and the strong pains produce a good contraction of the uterus.

The case is somewhat different with painful uterine action. This term is also a strictly relative one. There are women who, even during uninterrupted convulsive uterine action, do not complain of pain, whilst others, even at the commencement of labour, make a great outery at the slightest contraction of the uterus.

So much, however, is certain, that the suffering produced by the uterine action may reach such a degree of intensity as to become unbearable, and may lead to momentary mental disturbance. Since we possess means to remove the pain with certainty and without danger, it would be cruel on our part not to use them in cases of great suffering.

The general tonic contraction of the uterus-tetanus uteri-is always due to extraneous causes, which, as a rule, are very evident and close at hand. This disease is never primary.

Convulsive contractions of some part of the uterus, the so-called strictures, which are rather frequent during the third stage of delivery, are very rare indeed before the child is completely expelled. They are chiefly due to repeated and less careful examinations of the external os. The previously flaccid os feels very tense and firm in the intervals between the pains, and slightly contracts during a pain. This is easily and safely removed by two or three not very superficial incisions into the os. Convulsive strictures of the internal os, happily very rare, may be a serious and important impediment to delivery. Warm baths and narcotics, as well as abstaining from continual trials at delivery, may here prove very beneficial.

The accessory force of the pains, the abdominal pressure, which acts upon the progress and expulsion of the child, may, at the commencement of labour, be regulated by the will, but towards the termination of labour it sets in involuntarily. It is seldom subject to any anomalies. In the rare cases, where it is completely absent or almost so, labour, nevertheless, proceeds under otherwise normal conditions quite undisturbed.

CHAPTER II

ANOMALIES OF THE MATERNAL PASSAGES

I. OF THE SOFT PARTURIENT CANAL

A.-Malformations of the Genital Canal

THE one-horned uterus, with or without an atrophied accessory cornu, has not been observed to disturb the process of labour. In the different forms of double uterus, labour, although frequently quite normal, has more often been prolonged than in the single uterus. The anomalous labour, independently of the mechanical impediment, which several times the septum of the vagina offered, appeared to be due chiefly to the oblique position of the impregnated half of the uterus, which exerted an unfavorable influence upon the pains and upon the position of the child, which was frequently a shoulder presentation. Several times also the uterus has been ruptured. The action of the one-horned or double uterus does not seem to be defective when the organ is in its normal position. If only one half of a double uterus contains a fœtus, the os of the other half sometimes remains entirely closed during labour, at other times it also dilates. If both halves are impregnated each may expel its fœtus independently of the other, and there may be a long interval between the expulsions. Even in simultaneous labour the contractions of the halves are quite independent, so that one may contract whilst the other dilates. In the third stage the double uterus easily produces abundant flooding, and, on account of its unequal contractions, this may be particularly dangerous when the placenta is inserted into the septum.

B.-Occlusion and Narrowing

1. Of the Uterus.-As complete atresia of the os prevents conception, it follows that an occlusion of the os observed in labour must have taken place during pregnancy.

Very frequently there is a superficial and easily separable agglutination of the external os. It is due to an inflammatory process of the lips of the os from a previous blenorrhoea. During labour the