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. To the Editors of the Medical and Physical Journal.
Romarks on the Practice in Cases of Twins. GENTLEMEN, I HAVE read the case of twins communicated by your Corrego pondent, Mr. Jones, (page 311) with much interest, and think it valuable, inasmuch as it proves, that under some circumstances the second of twin children may be safely left in the womb for an unusual length of time after the birth of the first. But I cannot admit, that this case at all supports the doctrine of superfetation; nor can I agree with him in the opinion which he wishes to draw from it, “ that it would be more prudent, if no unfavourable symptoms occur, to leave the expulsion of the second child to nature, rather than to interfere according to the present practice.”
Considered simply as a matter of prudence, I conceive, that it is generally right, not to allow the second child to be retained (unless under such unavoidable circumstances as your correspondent mentions) for many hours after the birth of the first. If it were to become an established maxim, that the accoucheur was not to interfere, when the second child is retained in the uterus, unless unfavourable symptoms should arise, 'it is to be apprehended, that his interference would sometimes be de. layed, till it would be impossible to interfere with effect, should any alarming symptoms come on.
I know a gentleman in the practice of Midwifery, who among his first patients met with a case of twins. The first child having been born about an hour, he began to think that it would be necessary to accelerate the birth of the second child by art: but being unwilling to trust to his own judgment, he requested the advice of a senior practitioner. The senior gave a very decided opinion, that no assistance was necessary, and that time should be allowed for nature to expel the child. Hour after hour passed away, in waiting for the spontaneous action of the uterus, with much iinpatience on the part of the patient and her friends, and much anxiety on the part of the young practitioner, till the opportunity of delivering by art was gone by. On the third or fourth day after the birth of the first child, a violent hæ. morrhage from the uterus took place, which could by no means be restrained, and the poor woman very soon expired, after haxing excluded the second child in a lifeless state. This case alone sufficiently proves the danger of leaving the management of twin cases entirely to nature, and this is not the only one attended with fatal consequences from similar delay, which I am acquainted with.
There is much analogy between the cases of the second of twin children retained in the uterus, and the retention of the placenta ; in either case it may be sometimes safe, but it may not be always prudent, to trust to nature. The late Dr. Wilkam Hunter, at one period of his practice, always left the placenta to be expelled by the efforts of the uterus, and he taught his pupils, that it was a diabolical operation to introduce the hand into the uterus for the purpose of separating the placenta. His authority had great weight with other practitioners of midwifery, and it became customary to leave the placenta, not only many. hours, but even many days, till at length it was expelled naturally. For some time no unfavourable case occurred; all the women in whom the placenta was left to nature did well, and the Doctor was thought to have introduced a great improvement of the art of midwifery. At last however the scene changed, several women died, some with the placenta still adhering to the uterus, and others only lived to expel the placenta in a state of the most dreadful putrefaction: so that Dr. Hunter was compelled to abandon kis doctrine, and to admit the necessity of the interference of art in the management of the retained placenta. Since this period, the treatment of these cases has been conducted upon more rational principles, and perhaps admits now of very little improvement.
I have no hesitation in saying, that in the management of twin cases, we ought to be guided by similar principles. It is well to know that our interference may not always be necessary, but our judgment will probably determine us not to let slip a favourable opportunity of relieving our patient from her apprehensions, and preserving her from the chance of danger, by finishing the delivery while we have it in our power.
OBSTETRICUS. April 8, 1811.
To the Editors of the Medical and Physical Journal.
Case of Embryulcia.
As the recording of cases has not been much attended to since the time of Smellie's publication, the history of particular occurrences in the art of midwifery, comparatively with those in the other branches of medical science being few in number, and as it is indisputable that the publication of select cases tends to add to our stock of knowledge, I have transmitted to you the following instance of the operation of embryulcia ; and I request, if
you approve of it, to see it inserted in your extensively circulated Journal.
The process of natural labour is, generally speaking, uniform ; but at the same time, we well know, is always attended with pain, and oftentimes with danger. After the operation of embryulcia has been performed, in many cases of very difficult parturition, labour is also frequently retarded, and not without considerable danger to the patient, by reason of the extreme deformity of the pelvis, or disproportion of its cavity to the volume of the cranium, or the wrong position of its base; from which latter circunistance it cannot readily be extracted in the long diameter of the superior aperture of the pelvis, by the blunt hook or crotchet after this operation. Perplexing as these cases are thus rendered, this operation is still preferable to the cæsarean section, where the child is not sacrificed for the preservation of the mother, but where the mother is, in fact, devoted to the child : or even to that of the section of the symphisis pubis, where both mother, and child are involved in the same impending danger. · Mary Osborne, the wife of a butcher, No. 6, Phoenix-street, near the Seven Dials, about twenty-four years of age, in her second pregnancy, was admitted as a lying-in patient at the St. Mary-le-bone General Dispensary, in November last; the child of which she was delivered in the former case was born dead, though large, without the use of instruments, and she had passed a tolerable good share of health since that period to the time of her delivery in the present case. She was taken in labour on Tuesday morning the 19th of February, with the usual symptoms accompanying its accession, and was attended by one of the midwives belonging to the charity, during the course of that day; the child still remaining very high up, and finding it impossible to deliver her, she sent for me on Wednesday morning folJowing at nine. Being unable to attend by reason of the indisposition of part of my family, and having been up many preceding nights, I requested my superintending pupil, Mr. Andrews, a gentleman of very promising abilities, to attend for me.' He remained with her the whole of that day and night, without any prospect of success. On the morning' tollowing, the 21st, he returned much about the same hour, and requested me to accompany him with instruments, observing, it was impossible the delivery could be otherwise accomplished, as the cranium was very large, and resting on the superior aperture of the pelvis, in the short diameter. Accordingly I went, and passing my examination, I made the following deductions on the state of the case : that as the cranium was very large, and completely ossified at the sutures and fontanelles, and resting as it did with the occiput on the base of the sacrum and face over the pubis ; a
considerable considerable angle being formed at the base, not admitting more than two fingers, or about two inches distance from sacrum to pubis ; an adventitious'tumour also lining nearly one half of the vagina, which as it happened did not impede either the progress, or any of my future operations in the completion of the labour, I considered it of little importance, but from the above circumstance, and the poor woman having been for some time in very strong convulsions, which still continuing, I determined on the propriety of the operation in the first instance, rather than submit her to the long sufferance of a tedious and difficult case, to the risk of life. I formed my aperture at that part of the cranium, near the posterior fontanelle, on the left parietal bone, which I penetrated with considerable difficulty beyond the knobs of the instrument, on the opening of which I was obliged to get assistance, the consolidation of the bones being so great. I formed another aperturę near the pubis with the same difficulty, and after several hours labour, and the contents evacuated, I extracted about four pieces of parietal and frontal bones, but could not fix the crotchet in the great foramen, or, in short, in any part, to get it in the proper direction of the long diameter of the pelvis. Ultimately, about three o'clock in the afternoon, I got three singers of my right hand introduced laterally between pubis and sacrum, and through the integuments of the cranium up to its base, the middle one of which I passed into the foråinen magnum occipitalis, and the other two along the clenoid processes of the ethinoid bone, and giving it a turn, succeeded in placing it in the right direction. Having yet a difficulty to overcome in getting the base of the cranium edge ways, and not be ing able to fix the crotchet on the internal part, I obtained possession of a portion of the integuments, and fixing the integy.. ments on the external part of the occipital bone, passed it through the superior aperture, and after much exertion through the external orifice. I had nearly the same trouble in getting the shoulders through in the right direction, they were so very large. So far the labour was completed. Had the labour continued much longer, I must inevitably have lost my patient. The placenta was brought away easily in the usual manner, in about half an hour. A few days afterwards she was seized with peritoneal inflammation, which soon subsided by proper treatment, and is now perfectly recovered from the parturient state.
To the Editors of the Medical and Physical Journal.
About eight years ago I inoculated with the same lancet, at the same time, two children belonging to Mr. T of Blackburn, Lancashire, with vaccine fluid taken from a subject on the seventh day after vaccination; the disease was communicated in both instances, and went through its usual course regularly and satisfactorily, leaving two distinct scars in both the arms of each child, which are visible at the present time.
After an interval of seven years from the time of vaccination, the above-mentioned children were exposed to the contagion arising from a person labouring under the confluent Small-pox, and soon after, the subject of this case was attacked with fever and sickness, and at the usual time after seizure, an eruption appeared all over the body, which unquestionably terminated in the Small-pox. The pustules were pretty numerous and distinct, and gradually filled with matter, which dried away in eight or ten days from the time of their appearance, leaving bluish marks on the cuticle. During the progress of the eruption, the child, at my request, was visited by Mr. Coultate, a practitioner in the town, who fully concurred with me in opinion respecting the identity of the disease. • It is far from my intention, by relating this case of small-pox subsequent to vaccination, to invalidate the latter disease, for it is the only instance of failure which I have witnessed; nevertheless, it may not be altogether improper to remark, that the advocates for cow-pox appear to me to have carried their prejudices against inoculation too far, as is evident from the perusal of the works of most authors who have written on vaccination that they have drawn their conclusions in favour of the utility of cow-pox over small-pox inoculation with too much precipitation, almost leaving small-pox inoculation out of the question. Reflecting on this circumstance, I am led to believe that if the faculty had encouraged both modes of inoculation agreeably to the inclination of the parents, a much greater number of children