Charles Delucena Meigs Alfred Velpeau.

A complete treatise on midwifery: or, the theory and practice of tokology ... online

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although the opening of the cervix is not considerable. Ritgen maintains, even,
that it is a means to be employed to hasten labor, when it delays too long mak-
ing its appearance, or when pregnancy appears to be prolonged beyond the natural
term. It is, in fact, certain that labor may in this manner be brought on, and
that it is a powerful preventive, and not a cause of uterine inertia. Facts col-
lected in the amphitheatre of Maygrier by Clement, and my own observations,
plead strongly in favor of the doctrine.

Eydramnios, carried to the extent to benumb and weaken the action of the
uterus, would therein find its most efficacious remedy. Whether it result from
inflammation of the membranes, as Mercier thinks; from disease of the foetus, as
Lee believes; from an alteration of the uterus, as in Ingleby's case; or from a
predisposition of the woman to hemorrhage, as Mr. Epps seems to admit, it is
still always true that it promotes singularly inertia of the uterus, and that, judg-
ing by the observations which have been related, by those of Mercier, Duclos, and
Moreau, it is an accident not to be neglected.

The same holds, too, where the position of the child is not fixed; where the
hips, shoulders, head, or any other part is found to present by turns at the centre
of the strait. In this case, we seize the moment when the head is well situated
to rupture the membranes, because, were this rupture left to nature, it might as
well take place while it is unfavorable as while the position is favorable. Where
the bag of waters does not retain the shape of a segment of a sphere, is very



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LABOR PROPER. 373

much elongated, or pyriform, its presence being no longer of any use as to the
progress of the dilatation, it should be broken without too much regard to the
degree of the dilatation. The same principles guide us in respect to the strength
of the pains. Their absence ought not always to deter us, for the rupture of the
membranes is often the best, and sometimes the only means of restoring them.

To effect this rupture there are a thousand different modes of proceeding : the
point of a bistoury, of a pair of small scissors, of a common sewing-needle or a
knitting-needle, of a pin, directed by the pulp of the forefinger, has often been
found sufficient, and perhaps been employed with advantage; for one must be very
unskillful or careless seriously to wound the mother or foetus with either of these
instruments. However, at the present day we proceed generally in a different
manner; the membranes are scratched through with the finger nail, while they
are tightly stretched. Following the example of Rhazes, of Smellie, and of
Levret, we should scratch with the nail the projecting part of the ovum whilst
it is most strongly on the stretch. Does M. Busch, who opposes this plan, be-
lieve that he runs less risk with the kind of curved scissors that he seems to pre-
fer, in imitation of Siebold, in such cases ? Others endeavor to burst them with
the end of the finger by suddenly pushing upon the tumor from its point towards
its base; and, if the first attempt does not succeed, we make a second, a third,
Ac., always during the height of the pain ; or again, and the method is a better
one, we firmly pinch a fold of the membrane, while in a state of relaxation, and
in such a way that the next contraction of the uterus, in essaying to form the bag
again, does not fail to rupture them.

After having thus pinched the membranes, Barbaut was careful to scratch
them against the thumb with the nail of the forefinger, to break them, and empty
them more quickly. Nevertheless, as has been known since the time of jEtius,
and as recently inculcated by Clement, it is owing to the rigidity and the thick-
ness, whether morbid or natural of the membranes, that the bag of waters remains
entire, and we are sometimes obliged to perforate it with a cutting instrument.

When the membranes have given way spontaneously very high up above the
cervix, and the tumor that had engaged in the vagina does not disappear, and
seems to interfere with the progress of the natural phenomena of the labor, we
ought most generally to perforate them as if nature had not yet effected it.
Lastly, when the membranous sac does not permit the liquor amnii to escape
until long after the dilatation of the orifice, it is generally found that the rest of
the labor proceeds with great celerity, and the woman should always, from the time
the rupture takes place, preserve a horizontal posture.

§ 4. FALSE WATERS.

Moreover, we must not at the onset of labor allow ourselves to be deceived by
what are called false waters. The flow of this foreign liquid, which takes place
more frequently during the period of pregnancy than at the moment of labor,
appears not to depend in fact on the premature* rupture of the summit of the
ovum. Peu, who takes strange ground against the matrons, because they admit
two kinds of waters, the first and the second, has failed, doubtless, to remark
that these women find their justification in the false waters pointed out by Levret
himself. Mauriceau says that some women yield three or four pints of this
fluid several months before labor, and, however doubted by Madame Lachapclle,
their existence is at present no longer disputed except by few persons.

Their exact seat has not yet been determined. Do they depend, 1, on rupture
of a lymphatic vessel, or of an hydatid, as presumed by Koederer and Denman;
2, on a transudation of the amnios, as stated by Baudelocque and Ortlob; 3, on a
fissure, or fraying of the membranes, as many physicians have thought; 4, on
an accumulation of liquid between the chorion and amnios, as admitted by Osi-
ander, Madame Boivin, and others; 5, on a dropsy of the membrana decidua, as
some authors appear to have thought?— or, 6, are they but the result of a true



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374 OF LABOR.

accumulation of water, as Geil, in imitation of Nsegele, endeavors to show? It
would be difficult to say how far these different suppositions are well founded;
for, whatever Geil may say, we can imagine that the false waters may depend
occasionally on either cause. But I am induced to maintain, from my own ob-
servation, that they depend particularly on hydrometra and dropsy of the chorion,
when they cannot be explained by abrasion of the membranes.

§ 5. INERTIA OF THE UTERUS.

Another cause of protracted labor is the weakness, whether absolute or rela-
tive, of the uterine contractions. This is almost always the cause that is kept in
view by the authors of oxytocic remedies. Nevertheless, it is far from being the
most common one, and as the means proper to overcome it are most generally
hurtful in the other cases, it is easy to explain the discordance met with in the
works on the effects of substances employed to accelerate the process of parturition.

When the inaction of the womb is evident, and depends neither upon general
nor local fatigue, when it prevents the labor from proceeding, and the attention
and regimen which were spoken of at the commencement of this article have been
tried in vain, after having imitated Puzos, who recommends the head of the
child to be pushed up between the pains, to allow the waters to escape, and
especially when, instead of diminishing, it goes on increasing, hour after
hour — those substances that seem to exert a special action on the gestative
organ should be tried. It is in these cases that small injections of senna
are indicated; that stimulants in general have had some success; that biborate of
soda, extolled by the ancients, by Homberg amongst others, and brought as a
secret from Italy in the time of De la Motte, and re-introduced in our day by
Lobstein, L'Omer, and Hufeland, might be administered, remembering, even
then, that the accouchement often terminates whilst they are looking for, or
have gone for the remedy, as De la Motte, who prefers the hand to all the other
remedies, shows by a singular instance. Electro-puncture, twice successfully
used by Sarlandiere, may also be tried before having recourse to the forceps,
which Dupont de Lille has the courage to extol in such cases, after having tried
it on five women, of whom two died, and two suffered different accidents. The
same may be said of galvanism, recommended by Herders. But we know at
present two remedies which appear to deserve the preference above all others,
and of which I shall speak more in detail. I mean the ergot of rye, and abdo-
minal compression.

§ 6. ERGOT.

History. — The ergoted rye seems to have been used from time immemorial by
the old women, and by some country midwives, for the purpose of hastening deli-
very; it was mentioned in the Acta Nalur. Curios, for 1668, by Camerarius,and
the name of rye of the womb, of Rockenmiitter, and of Mutterkom, adopted by the
Germans, is a sufficient indication that the idea is not new. These traditions
of the vulgar at length attracted the attention of the profession, and M. Ths-
granges published his first researches upon the oxytocic properties of the ergoted
rye in the Gazette de Santi for 1777. Since that period, numerous observa-
tions have been collected and made public in the American, English, and
French journals, &c. &c. Stearns, Prescot, Chapman, Bordot, Goupil, Chevreul,
Gendrin, Bigeschi, and especially M. Villeneuve, have collected an infinite
number of facts that prove decisively that the ergot of rye is capable of restoring
the contractions of the womb during labor. Dittemer has already pointed out
its obstetrical properties. Parmentier says that the ladies Dupille de Cbaumont
made frequent use of it. It was also employed by a nurse, mentioned by Des-
granges; and Madame Vielmi, who learnt it of a midwife, long since dead,
employed it before it was thought of by us.

However, MM. Desormeaux and Capuron do not appear to have much confi-



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LABOR PROPER. 375

dence in it, and Madame Lachapelle has published a long series of experiments,
'which tend to show that it enjoys no property of the kind, whether given in fine
or coarse powder, in infusion or in decoction, in extract or in syrup. It has been
much condemned. Capuron, who has unequivocally declared himself opposed to
it, denies that it has any advantage, and believes it perfectly useless. Jackson
has opposed the use of it with no less warmth in America, and in England Hall
is seen to throw it altogether aside. The fact is that it is strangely abused, and
that numerous successes attributed to it are simple coincidences. But that does
not prove anything against its efficacy. The paper of Chevreul, that of H.
Davies, those of Roux, of Mitchell, of Wiggers, of Roche; the thesis of Malartic,
who succeeded twenty-one times out of thirty- two trials ; that of Godquin, who
used it forty-two times with advantage ; and the numerous observations of Kim-
bell, leave no doubt upon this point. Voillot also relates three examples;
Campaignao and Merry each five; Toyl and Latham each one; P. Guersent
five; Blondin three; Morin and Painchaud three; Doumerc four; Malapert
three; Lefrancois three, in favor of its action on the uterus, which Schneider con-
firms by a hundred observations.

Granting that some of these facts may not be very conclusive, among them
two of Voillot's, two of Roux's and of Bardoulat's, it is very difficult to resist
such a mass of proof, inasmuch as we can yet add to them the several trials of
Bardoulat, Luroth, Threlfull, Blundell, Boards, Sewell, R. Smith, Bradfield, Lob-
stein, Bonfils, Holl, Brunati, Ryan, and the daily practice of a host of physicians.

In the last four years I have used it more than twenty times; M. Delanglar
and M. Verreux, Gorse, and a number of other practitioners, have* also used it at
my solicitation, and in every case its action has appeared to be evident, undenia-
ble. It forces the uterus to contract in a few minutes, in a quarter of an hour,
or, at most, in twenty minutes after it is exhibited. I have very recently had
another most convincing proof of its efficacy. To a young woman who had been
twenty-four hours in labor, I gave three doses in the space of forty minutes;
within five minutes after the first one, the pains, which had for several hours
been very feeble and slow, suddenly became strong and very frequent, but soon
relaxed again; the second dose brought them back in the same way. They
diminished a second time, and it was not until after the third dose that they
were maintained until the complete expulsion of the foetus, which soon took
place. It is thus that it almost always acts.

Doses and administration. — I prescribe it in the quantity of fifteen or twenty
grains in a spoonful, or half a wineglassful of sweetened water, and repeat the dose
two or three times, at intervals of fifteen or twenty minutes. Perhaps a larger
quantity may be safely given. Parmentier took half a drachm of it; Cordier
two drachms; MM. Lapre and Campernon a drachm, and a drachm and a half,
for several days together, without experiencing any sensible effects from it. Its
use might, therefore, be continued for a long time and in large doses, before any
well-grounded fear of inducing ergotism could be entertained.

Lalesque even relates the case of a woman who in twenty days took ten ounces
of the decoction, and that of another who used eight ounces in the course of a
month, without any ill effect. Lannyon says, also, that a considerable quantity
may be given without inconvenience, and Young maintains that in doses of less
than a drachm, good effects are rarely obtained. Upon this point, it must be
observed that it is difficult to decide. So many circumstances may alter the
action of ergot, that we rarely know whether the article employed possessed all
its properties.

It is to be hoped that the chemists will ere long separate the essentially active
principle of this substance. MM. Desgranges and Lapre have already observed
that four or five grains of the bark produce a greater effect than twelve or fifteen
of the entire grain. Comparative experiments made by MM. Betscher and



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376 OF LABOR.

Kluge tend to prove that that which is collected in the fields is far more active
than that gathered in the barn, and Blundell believes, with South, that its active
principle is an alkaloid. I doubt not but that in a short time a preparation will
be discovered of uniform strength. In the meanwhile, the fine powder of the
whole of the ergot appears to me to be preferable to the decoctions or the ex-
tracts, provided it be fresh and derived from grains that are entire and well
preserved. It may, indeed, be conceived how so many different opinions may
arise as to its strength and properties, when that which is employed has undergone
a change.

Balardini and Roux gave it in wine. Maygrier prescribes eight grains in
water, every quarter of an hour. It appears that Girard tried to inject it into
the veins of a cow.

Its value. — If there be some who doubt its efficacy, a far greater number
fear the energy of ergot. Some look upon it as a dangerous abortive agent
Oslere, for instance, says that it produces abortion not only in women, but in
brutes. Thomson rejects it for the same reason, as does Duchateau, who em-
ployed it only to hasten the delivery of the placenta, or to arrest hemorrhage.
In confirmation of its influence on the uterine system, Maurice cites the obser-
vation that the hens of Sologne lay but little in consequence of its effects on the
oviduct. The same might be said of the ergot of maize, which, according to
Roulin, causes the hens to produce eggs without shell. Although its abortive
effects are not so far absolutely demonstrated, it would be, nevertheless, prudent
to avoid using it in the case of pregnant women except during labor. The ad-
ministration cf ten ounces in twenty days to a woman in whom pregnancy was
uninterrupted, proves nothing, because the decoction, and not the powder, was
taken, and because in this case it was not known whether the ergot was



Other practitioners have thought that it might injure the woman, distress the
digestive organs, and induce gangrenous ergotism. An instance of this last
accident has even been published by Robert de Langres ; bnt it is easy to see
that in this case gangrene had nothing to do with the use of the rye. The re-
searches of Courhaut, and of Neale, and what daily takes place in Sologne, show
that its power of producing mortification is engendered only by its too prolonged
use or by an excessive dose. Some women, in fact, vomit it or bear it badly;
but there follows no ill effect.

It has been feared that it would render labor difficult ; but Ingleby says that
a practitioner of his acquaintance, who has tried it more than two hundred
times, has seen nothing to sustain snch an idea. On the other hand, we shall
see that ergot is an excellent means to hasten the expulsion of the placenta.

Its opponents have especially accused it of injuring the child. Girardin says
that it is a popular belief in America. Merriman, who has not a very exalted
idea of it, adopts this opinion. So thinks Burns; and Ingleby remarks that
still-born foetuses are very common in the United States since the frequent em-
ployment of spurred rye. Moreau, who has tried it but once in twenty years,
cites five instances of children born dead, when it was made use of in the prac-
tice of some other physicians. Evrat and Deneux recommend also on this ac-
count that it be used with the greatest caution.

My own observation leads me to partake partly of this view. Out of forty
cases in which it was given either by myself or some one of my colleagues, I
have seen seven children born dead. It is true that, in the case where I was
called in by MM. Leseble, Cisset, and Malgaigne, death may readily be attributed
to the length of the labor; but in some others, in two particularly, I have
found difficulty in not ascribing it to the ergot It is an accident which has
been accounted for in different ways.

Mr. Charles Hall pretends that ergot does not act directly upon the womb;



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LABOR PROPER, 377

that its deleterious qualities in the first place alter the natural qualities of the
blood of the mother, then that of the child; and that, if the uterus contracts,
it is only to withdraw the foetus from the poisonous action of the medicine. It
is an explanation which appears to me to be completely void of foundation.
Women generally present none of the phenomena of intoxication during the
effects of the rye, and the circulation of the foetus suffers in a different manner.
Hosack and Houston believe, on the contrary, that the child runs risks on ac-
count of the difficulty that the blood has in passing from the womb to the
ovum. This opinion, though defended by some distinguished accoucheurs of
Paris, is destitute of foundation, inasmuch as there is no direct utero-placental
circulation.

If the foetus perishes at that time, it is because under the. influence of the
ergot, not only the organic action, as might be thought, but the whole con-
tractile power, of the uterus is brought into play. The efforts of this organ, re-
peated at very short intervals, having no complete intermission as in natural
labor, act in such a manner that the child is soon so compressed that the circu-
lation of the placenta, the movements of the heart, the course of the fluids in the
cord and even in the viscera, undergo obstructions that may become dangerous.

For this reason I have been led not to give rye in the commencement of
labor, notwithstanding the assurance of Mitchell, and not before I am almost
certain that one or two hours' efforts at the furthest will be sufficient to terminate
the accouchement In addition, I think I have observed that its action is often
very feeble, null and void when the child is dead. The eight trials that I have
made of it in abortion, without having so far given me perfectly conclusive re-
sults, permit me, nevertheless, to recommend it in these cases as an excellent
means. I have seen, too, that, if it does not act at the end of twenty or thirty
minutes, we can scarcely depend on its effects. In that I agree with Mr. Young,
and believe with Dewees that the contractions brought about by it are distin-
guished by their permanency from ordinary uterine contractions. They are, as
Moreau says, true pathological contractions. 4 fc a ^ events, I should not fear
more than Emery does to give it to women in their first labor, when the conditions
above indicated exist. In forbidding it at that time, Moreau and Villeneuve are
justified only on account of the resistance presented by the soft parts to a first
child, and inasmuch as it might be given too soon.

In order that the ergot of rye may be given with some chance of success,
and without any danger, it is necessary, 1st, that there should be no manifest
tendency to hemorrhage from excess of irritation ; 2d, that it be possible for the
delivery to take place through the natural passages ; 3d, that the child be in a
good position ; 4th, that the cervix be soft and dilatable ; 5th, that the general
irritability be not too great; 6th, that the digestive organs be in a good state;
and 7th, that the weakness of the uterine action shall depend upon the want of
irritability of that organ. M. Legras advises that it be given, also, for the pur-
pose of steadying the head at the superior strait previously to applying the for-
ceps.* Its utility in tokology is, as far as I am concerned, a settled point, as

• Many children perish in this country from the improper use of ergot The power of
the article ought not to admit of further doubt: it excites generally, within thirty minutes
after its exhibition, a contraction of the womb which does not wholly cease until the child
is born ; or, in case of any insurmountable resistance, until the strength of the uterus is ex-
hausted. The ergotic pain is a single pain ; hence, if the parts are not in a state to admit
of the proper dilatation, the ergot destroys the child by causing a contraction or spasmodic
effort of the womb, which presses the placeuta so firmly and so long against the foetus, that
the utero-placental intercourse is as effectually destroyed as it would be were the after-birth
detached. The child which is killed by ergot dies, therefore, by asphyxia from the com-
pression of its placenta. Where the os uteri is well dilated and yielding, and the vagina
and vulva in a similar conditiou, no danger can ensue upon the use of this powerful and
valuable article. — M.



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878 OP LABOR.

clear as that of quinine in intermittent fever. The reasonings of Jackson, of
Capuron, and of Lascauve will not affect it. The only point is to prevent the
abuse of it by trying to regulate its use.

§7. ABDOMINAL COMPRESSION.

One expedient which might be tried before the spurred rye, and which is par-
ticularly adapted to fat, lymphatic women, in whom the belly is soft, or muscular
action but little developed, is the application of a bandage over the abdomen— a
belly-band. This plan, the discovery of which has been disputed by Messrs.
Allen and Waller, seems to be derived from the Kalmoucks. Martins says, in fact,
of these people, that during labor they knead and compress the belly of the
woman with girths or straps. Ingleby for his part says that it is a useful pre-
caution in the case of extreme suppleness of the abdomen. I have employed
it myself, since 1826, for a case of very strongly-marked anterior obliquity, to
correct the efforts of the womb, and again to put a stop to some symptoms of
false labor, in a woman who had completed but seven months of pregnancy.
Rognetta says that he found advantage from it in a case in which labor had
stopped several hours. It is proper to remark that it is not an excitant, but only
a support given to the womb, and that the abdominal bandage acts here like the
belt worn by runners, by furnishing & point d'appui for the abdominal muscles,
as well as for the uterine contractions. Besides, as no ill effect can result, I do
not see why we should deprive ourselves of such an aid when labor is progress-
ing slowly, or when the abdomen is sufficiently prominent or sufficiently deve-
loped to need support. A napkin, well spread out from the pelvis to the um-
bilicus, and firmly secured towards the loins, with another napkin underneath,
form the entire apparatus, which each one can apply after his own fashion. •

SECT. II.— OF DYSTOCIA,* (OR DIFFICULT LABOR, PRETERNATURAL
LABOR, LABORIOUS LABOR, MECHANICAL LABOR, MANUAL LA-



Online LibraryCharles Delucena Meigs Alfred VelpeauA complete treatise on midwifery: or, the theory and practice of tokology ... → online text (page 58 of 102)