Precipitate Labor Less Common than Lingering. - Undue rapidity of labor is certainly more uncommon than its converse, but still it is by no means of unfrequent occurrence. Most obstetric works contain a formidable catalogue of evils that may attend it, such as rupture of the cervix, or even of the uterus itself, from violence of the uterine action; laceration of the perineum from the presenting part being driven through before dilatation has occurred; fainting from the sudden emptying of the uterus; hemorrhage from the same cause. With regard to the child it is held that the pressure to which it is subjected, and sudden expulsion while the mother is in the erect position, may prove injurious. Without denying that these results may possibly occur now and again, in the majority of cases over-rapid labor is not attended with any evil effects.

[As an instance of rapid delivery, I report the following case: In September, 1848, a III-para of twenty-seven, in Philadelphia, was awakened in the night by a violent uterine pain, followed at once by a sensation of approaching delivery. Her husband, a noted accoucheur, was only up in time to receive the foetus, which came by the same pain that awakened his wife. A second foetus (both females) soon followed, and the whole labor, in all its stages, occupied but forty-five minutes. In two prior and two subsequent labors there was no marked haste in uterine action. The mother, who is living at seventy-two, has never been a strong woman.-ED.]

Precipitate labor may generally be traced to one of two conditions, or to a combination of both; excessive force and rapidity of the pains, or unusual laxity and want of resistance of the soft parts. The precise causes inducing these it is difficult to estimate. In some cases the former may depend on an undue amount of nervous excitability, and the latter on the constitutional state of the patient tending to relaxation of the tissues.

Whatever the cause, the extreme rapidity of labor is occasionally remarkable, and one strong pain may be sufficient to effect the expul

never was room to entertain a question about the use of instruments"; and even "when the discharge became of a green color, still the giving assistance was quite out of the question"! Can any reasonable man doubt that if the forceps had been employed hours and hours beforesay on Tuesday, when the pains fell off-the result would probably have been very different, and that the life of the child, destroyed by the enormously prolonged second stage, would have been saved? It must be remembered that early on Tuesday morning delivery was expected, so that the head must then have been low in the pelvis (vide Stockmar's Memoirs, vol. i, p. 63). It would be difficult to find a case which more forcibly illustrates the danger of delay in the second stage of labor. Then what follows? The uterus, exhausted by the lengthy efforts it should have been spared, fails to contract effectually; nor do we hear of any attempts to produce contraction by pressure. The relaxed orgau becomes full of clots, extending up to the umbilicus, and all the most characteristic symptoms of concealed post-partum hemorrhage develop themselves. She complained of being sick at stomach, and of noise in her ears, began to be talkative, and her pulse became frequent." Before long other symptoms came on, graphically described by Baron Stockmar, and which seem to point to the formation of a clot in the heart and pulmonary arteries--a most likely occurrence after such a history. "Baillie sent me word that he wished me to see the Princess. I hesitated, but at last went with him. She was suffering from spasms of the chest and difficulty of breathing, in great pain, and very restless, and threw herself continually from one side of the bed to the other, speaking now to Baillie, now to Croft. Baillie said to her, Here comes an old friend of yours.' She held out her left hand to me, hastily, and pressed mine warmly twice. I felt her pulse; it was going very fast-the beats now strong, now feeble, now intermittent."

Here was evidently something different from the exhaustion of hemorrhage; and no one who has witnessed a case of pulmonary obstruction can fail to recognize in this account an accurate delineation of its dreadful symptoms. Surely this lamentable story can only lead to the conclusion that the unhappy and gifted Princess fell a victim to the dread of that bugbear, "meddlesome midwifery," which has so long retarded the progress of obstetrics. I am, etc., W. S. PLAYFAIR.

CURZON STREET, MAYFAIR, W., November 29, 1872.

sion of the child with little or no preliminary warning. I have known a child to be expelled into the pan of a water-closet, the only previous indication of commencing labor being a slight griping pain, which led the mother to fancy that an action of the bowels was about to take place. More often there is what may be described as a storm of uterine contractions, one pain following the other with great intensity, until the foetus is expelled. The natural effect of this is to produce a great amount of alarm or nervous excitement, which of itself forms one of the worst results of this class of labor. It is under such circumstances that temporary mania occurs, produced by the intensity of the suffering, under which the patient may commit acts, her responsibility for which may fairly be open to question.

Little Treatment Possible.-Little can be done in treating undue rapidity of labor. We can, to some extent, modify the intensity of the pains by urging the patient to refrain from voluntary efforts, and to open the glottis by crying out, so that the chest may no longer be a fixed point for muscular action. Opiates have been advised to control uterine action, but it is needless to point out that, in most cases, there is no time for them to take effect. Chloroform will often be found most valuable, from the rapidity with which it can be exhibited; and its power of diminishing uterine action, which forms one of its chief drawbacks in ordinary practice, will here prove of much service.

CHAPTER X.

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE
SOFT PARTS.

Rigidity of the Cervix a Frequent Cause of Protracted Labor. -One of the most frequent causes of delay in the first stage of labor is rigidity of the cervix uteri, which may depend on a variety of conditions. It is often produced by premature escape of the liquor amnii, in consequence of which the fluid wedge, which is Nature's means of dilating the os, is destroyed, and the hard presenting part is consequently brought to bear directly upon the tissues of the cervix, which are thus unduly irritated, and thrown into a state of spasmodic contraction. At other times it may be due to constitutional peculiarities, among which there is none so common as a highly nervous and emotional temperament, which renders the patient peculiarly sensitive to her sufferings, and interferes with the harmonious action of the uterine fibres. The pains, in such cases, cause intense agony, are short and cramp-like in character, but have little or no effect in producing dilatation; the os often remaining for many hours without any appreciable alteration, its edges being thin and tightly stretched over the head.

Less often, and this is generally met with in stout, plethoric women, the edges of the os are thick and tough.

The effects of prolongation of labor from this cause will vary much under different circumstances. If the liquor amnii be prematurely evacuated, the presenting part presses directly upon the cervix, and the case is then practically the same as if the labor was in the second stage. Hence grave symptoms may soon develop themselves, and early interference may be imperatively demanded. If the membranes be unruptured, delay will be of comparatively little moment, and considerable time may elapse without serious detriment to either the mother or child.

The treatment will naturally vary much with the cause and the state of the patient. In the majority of cases, especially if the membranes be intact, patience and time are sufficient to overcome the obstacle; but it is often in the power of the accoucheur materially to aid dilatation by appropriate management. Sometimes Nature overcomes the obstruction by lacerating the opposing structures; and cases are on record in which even a complete ring of the cervix has been torn off and come away before the head.

Many remedies have been recommended for facilitating dilatation, some of which no doubt act beneficially. Among those most frequently resorted to was venesection, and with it was generally associated the administration of nauseating doses of tartar emetic. Both these acted by producing temporary depression, under which the resistance of the soft parts was lessened. They probably answer best in cases in which there was a rigid and tough cervix; and they might prove serviceable, even yet, in stout, plethoric women of robust frame. Practically they are now seldom, if ever, employed, and other and less debilitating remedies are preferred. The agent, par excellence, most serviceable is chloral, which is of special value in the more common cases in which rigidity is associated with spasmodic contraction of the muscular fibres of the cervix. Two or three doses of fifteen grains, repeated at intervals of twenty minutes, are often of almost magical efficacy, the pains becoming steady and regular, and the os gradually relaxing sufficiently to allow the passage of the head. Should the chloral be rejected by the stomach, it may be satisfactorily administered rectum. Chloroform acts much in the same way, but on the per whole less satisfactorily, its effects being often too great; while the peculiar value of chloral is its influence in promoting relaxation of the tissues, without interfering with the strength of the pains.

Various local means of treatment may be also advantageously used. One is the warm bath, which is much used in France. It is of unquestionable value where there is mere rigidity, and may be used either as an entire bath, or as a hip-bath, in which the patient sits from twenty minutes to half an hour. The objection is the fuss and excitement it causes, and, for this reason, it is an expedient seldom resorted to in this country. A similar effect is produced, and much more easily, by a douche of tepid water upon the cervix. This can be very easily administered, the pipe of a Higginson's syringe being guided up to the cervix by the index finger of the right hand, and a stream of water

projected against it for five or ten minutes. Smearing the os with extract of belladonna is advised by Continental authorities, but its effects are more than doubtful. Horton' advocates the injection into the tissue of the cervix of of a grain of atropine by means of a hypodermatic syringe, and speaks very favorably of the practice.

Artificial Dilatation.-Artificial dilatation of the cervix by the finger has often been recommended, and has been the subject of much discussion, especially in the Edinburgh school, where it was formerly commonly employed. It is capable of being very useful, but it may also do much injury when roughly and injudiciously used. The class of cases in which it is most serviceable are those in which the liquor amnii has been long evacuated, and in which the head, covered by the tightly stretched cervix, has descended low into the pelvic cavity. Under these circumstances, if the finger be passed gently within the os during a pain, and its margin pressed upward and over the head, as it were, while the contraction lasts, the progress of the case may be materially facilitated. This manœuvre is somewhat similar to that which has been already spoken of, when the anterior lip of the cervix is caught between the head and the pubic bone, and, if properly. performed, I believe it to be quite safe, and often of great value. It is not, however, well adapted for those cases in which the membranes are still intact, or in which the os remains undilated when the head is still high in the pelvis. When there is much delay under these conditions, and interference of some kind seems called for, the dilatation may be much assisted by the use of caoutchouc dilators, described in the chapter on the induction of premature labor, which imitate Nature's method of opening up the os, and also act as a direct stimulant to uterine contraction. But it should be remembered that it is precisely in such cases that delay is least prejudicial. If, however, the os be excessively long in opening, its dilatation may be safely and efficiently promoted by passing within it, and distending with water, one of the smallest-sized bags; and, after this has been in position from ten to twenty minutes, it may be removed, and a larger one substituted.

Rigidity depending upon Organic Causes.-Every now and again we meet with cases in which the obstacle depends upon organic changes in the cervix, the most common of which are cicatricial hardening from former lacerations; hypertrophic elongation of the cervix from disease antecedent to pregnancy; or even agglutination and closure of the os uteri. Cicatrices are generally the result of lacerations during former labors. They implicate a portion only of the cervix, which they render hard, rigid, and undilatable, while the remainder has its natural softness. They can readily be made out by the examining finger. A somewhat similar, but much more formidable, obstruction is occasionally met with in cases of old-standing hypertrophic elongation of the cervix, which is generally associated with prolapse. In most cases of this kind the cervix becomes softened during pregnancy, so that dilatation occurs without any unusual difficulty. But this does not always happen. A good example is related by Mr.

1 Amer. Journ. of Obstet., 1878, vol. xi. p. 482.

Roper, in the seventh volume of the Obstetrical Transactions (p. 233), in which such a cervix formed an almost insuperable obstacle to the passage of the child.

Carcinoma of the cervix uteri, which produces extensive thickening and induration of its tissues, and even advanced malignant disease of the uterus, is no bar to conception. The relations of malignant disease to pregnancy and parturition have recently been well studied by Dr. Herman. He concludes that cancer renders the patient inapt to conceive, but that when pregnancy does occur there is a tendency to the intra-uterine death and premature expulsion of the foetus, and the growth of the cancer is accelerated. When delivery is accomplished naturally there is generally expansion of the cervix by fissuring of its tissue, but the harder forms of cancer may form an insuperable obstacle to delivery.

Agglutination of the margins of the os uteri is occasionally met with, and must, of course, have occurred after conception. It is generally the result of some inflammatory affection of the cervix during the early months of gestation; and I have known it recur in the same woman in two successive pregnancies. Usually it is not associated with any hardness or rigidity, but the entire cervix is stretched over the presenting part, and forms a smooth covering, in which the os may only exist as a small dimple, and may be very difficult to detect at all. Occlusion of the os uteri from inflammatory change sometimes so alters the cervix that no sign of the original opening can be discovered; and in two such instances the Cæsarean operation has been performed in the United States, by which the women were saved.❜

Their Treatment.-Any of these mechanical causes of rigidity may at first be treated in the same way as the more simple cases; and with patience, the use of chloral and chloroform, and of the fluid dilators, sufficient expansion to permit the passage of the head will often take place. But if these methods produce no effect, and symptoms of constitutional irritation are beginning to develop themselves, other and more radical means of overcoming the obstruction may be required.

Under such circumstances incision of the cervix may be not only justifiable but essential, and it frequently answers extremely well. On the Continent it is resorted to much more frequently and earlier than in this country, and with the most beneficial results. The operation offers no difficulties. The simplest way of performing it is to guard the greater portion of the blade of a straight blunt-pointed bistoury by wrapping lint or adhesive plaster around it, leaving about half an inch of cutting edge toward its point. This is guided to the cervix, on the under surface of the index finger, and three or four notches are cut in the circumference of the os to about the depth of a quarter of an inch. Very generally, especially when the obstruction is only due to old cicatrices, the pains will now speedily effect complete expansion, which may be very advantageously aided by applying the hydrostatic dilators. When the obstruction is due to carcinomatous infiltration or inflammatory thickening, the case is much more complicated, and will pain

1 Obst. Trans, for 1878, vol. xx. p. 191.

2 Harris's note to second American edition.