The practice of dilating the os uteri first, as recommended by Brüninghausen, Kluge, and others, has, as far as we know, never been attempted in this country, and resembles much too closely the accouchement forcé of the French authors ever to be permitted.
The simplicity of the operation of tapping the membranes has rather led practitioners to overlook a still greater improvement, viz. the inducing uterine action first: this was proposed by Dr. Hamilton to be effected by passing up a catheter, and separating the membranes from the uterus to a considerable distance above the os uteri. The operation certainly succeeds in some cases; but our own experience goes to prove, that in the majority it is not sufficient by itself to provoke uterine contraction, and in order to ensure success we must combine with it other means.
The plan of treatment which we have found most certain is first to clear out the bowels by a full dose of calomel and colocynth, then to give the patient a warm bath, in which she may remain twenty or more minutes, after which the abdomen should be well rubbed with stimulating liniment as she lies in bed, and the secale cornutum given in doses of a scruple of the powder in cold water, repeated every half hour for five or six times. Contractions of the uterus rarely fail to follow, and although they generally require the secale to be renewed after a few hours, they will be found to have effected several very important changes preparatory to actual labour;—the abdomen has sunk, the fundus is lower, the cervix is shorter or has disappeared, and not unfrequently we feel the head has already passed the brim and is now in the cavity of the pelvis; the vagina and os uteri are lubricated with a copious secretion of remarkably pure and albuminous mucus; and in these cases especially, we frequently meet with those little lumps of inspissated mucus which were formerly called the ovula Nabothi. All these precursory changes are so many preparations of nature for a natural labour, and contribute not a little to the successful termination of the case, advantages which cannot be enjoyed where the membranes have been previously ruptured. If, however, we do not succeed in producing more than a slight dilatation of the os uteri, if the repeated exhibition of the ergot only produce vomiting, or constant pains which have no other effect beyond preventing rest and inducing exhaustion, the separation of the membranes from the uterus, as proposed by Dr. Hamilton, will now have the best effects: even if this fail and we are compelled to puncture the membranes, it will now be performed under so much more favourable circumstances, from labour having already commenced to a certain extent.
A warm bath and the other usual means for recovering the child should be in readiness. In most cases the secretion of milk follows as after labour at the full term, which is a great advantage; for the thin watery secretion of this early period is much better adapted to the weak digestive organs of the premature child. It is frequently a matter of some difficulty under these circumstances to make a child take the breast at first, and this is the chief reason why their digestive organs so soon become deranged. “In case no milk be present, a good substitute may be made by beating up fresh eggs and milk, boiling them over a gentle fire and straining off the thin fluid.” (Reisinger, die künstliche Frühgeburt.)
One great encouragement in cases requiring this operation is the fact that in every successive pregnancy the uterus is more easily excited to premature action; and in some cases where it has been induced several times, it has at length, as it were, got so completely into the habit of retaining its contents only up to a certain period, that labour has come on spontaneously exactly at the time at which in the former pregnancies it had been artificially induced.[103] We have already alluded to this circumstance in the chapter on Premature Expulsion of the Fœtus.[104]
CHAPTER V.
PERFORATION.
Variety of perforators.—Indications.—Mode of operating.—Extraction.—Crotchet.—Embryulcia.