author's assertion, that the placental murmur is never heard at the fundus, nor is the placenta ever situated there.* Such being the case, then, in the second place it was to be supposed, that the uterine contractions would constringe the vessels, interrupt the function of the placenta, (and consequently destroy the life of the child,) and most probably detach it altogether, and that too "very early in the process of parturition."+ No such effects, however, were produced; the labour proceeded naturally, the infant was born alive, and no hæmorrhage at any period took place. But supposing that the uterus could contract in the way described, (namely, by the anterior wall shrinking within itself, and making the upper part of the posterior wall, first become the fundus, and afterwards amalgamate itself with the anterior paries,) without producing the ill effects anticipated, still another objection, founded upon the foregoing case, may be urged against this theory. If the uterine contractions were thus effected, it should necessarily have happened, that the bruit, which was faintly heard across the fundus about an inch below its highest point, should gradually have mounted upwards; and as labour proceeded, and that portion of the posterior wall, to which the placenta was attached, at last assumed an anterior position, it should have become louder and louder, until it developed itself in full intensity under the instrument placed in the centre of the uterine tumour below the fundus. And the situation of this distinct murmur should from that period have descended, according as the capacity of the uterus diminished, until at length it almost arrived at the pubis. This appears a fair deduction from the author's observations. such being the facts, I most explicitly declare, that no change whatever was observable in the position of the placental souffle, nor was there any alteration in its relative intensity in the regions of the uterus. * Page 460. But instead of + Page 455. Again, if such a revolving movement took place, as the membranes remained uninjured, until the foetal head had been impelled deeply into the pelvis, I suspect the orifice, through which the child passed, should have shown, that at the time of their rupture, the placenta was situated on the anterior wall. But on the contrary, the membranes at the anterior edge of the placental mass were rather longer than at the posterior edge, and the pouch formed for the fundus was somewhat anterior to that organ; thus pointing out its situation to have been, all through labour, the same as stethoscopic examination already proved it to be. From the foregoing cases I think it is obvious, that to avoid the early separation of the placenta, and its attendant consequences, it is not necessary, that that substance should adhere to the back part of the uterus, or even to any region, in which contractions do not take place, save for the purpose of detaching its own connexion. But furthermore, I maintain, that no such contraction, as that for which Mr. Carmichael contends, could by any possibility be effected by such structures as, anatomy shows us, alone exist in the genital organs. The only resemblance in the body to such a rotatory movement, is the pulley-like contraction of certain muscles, such as the digastric, the obliquus superior oculi, the circumflexus palati, &c. In all these, there are necessarily present, at least one strong attachment to a bony structure, which during the action of the muscle acts as a fixed point, and a collar in which the muscle plays, and which serves to retain it in its proper place. Where then are we to find such an arrangement in connexion with the generative organs? The vagina, to which the uterus is attached below, during parturition, dilates and becomes more relaxed in its tissues, and could not act the part of such a firm bond of union; nor could any of the ligaments by which the womb is supported, but not fixed in its natural situation. Even the round ligaments which have been supposed, erroneously, I think, to perform the office of tendons to certain of the uterine fibres, do not take a direction, that would enable them to be of any service in the newly proposed action. On the contrary, the uterine contraction must, by bringing their points of attachment nearer to each other, prevent them from giving any fixity to the organ. Where then are we to seek the point around which the fundus turns, and without which, such a partial contraction of the uterus must, instead of producing a revolving movement in that part, draw it directly downwards, and cause the convex fundus to assume a flattened form. The author attempts to supply this deficiency, by assigning to the foetal body the office of a fulcrum.* I am not prepared to deny that such perhaps might be the case, if the remainder of his theory were correct; but I would inquire, what fulcrum can there be, where the uterus, having expelled the child, again "relaxes completely," as in the case which that author brings forward, as the fifth instance where he found the placenta on the posterior wall? What prevents us in such a case, when causing contraction by external pressure or the application of cold, from feeling the fundus grow flat under our hand? How is the rounded prominent appearance of the fundus maintained?† Such are the considerations which, to my mind, throw a doubt upon the validity of the theory proposed by Mr. Carmichael. The subject of the contraction of the uterus, and the mode in which the placenta maintains its adhesions undisturbed, and its function unextinguished, during the uterine efforts, are certainly involved in great obscurity, and the explanation offered by that gentleman (obviously the result of deep thought and extensive research on this curious subject) carries with it such apparent truth, that it deservedly excited great attention in the profession. But I trust I have demonstrated the incorrectness of his premises, and the fallaciousness of his conclusions, with * Page 473. † Page 475. respect to these points. If I have succeeded in doing so, I need scarcely allude to his theory of the development of the uterus. If the assumed mode of contraction be not the true one, there is no necessity for imagining its growth to be confined almost entirely to the anterior wall. The old doctrine, indeed, that all the parts of the womb enlarge, holding the same relative position to each other, but being allowed a certain latitude in the degree and period of their expansion, affords, I think, a much more ready solution of well known facts connected with gestation. It accords with the different forms the uterus assumes at the several stages of pregnancy; its being first pyriform, then oval in consequence of the increase of its transverse diameter at its central and lower part, and becoming at last globular, when the cervix has also dilated. It explains too the phenomena observable in placental presentations, in which the hæmorrhage, consequent on expansion of the uterine parietes, occurring where the placenta has not the power of accommodating itself to the change, in general takes place almost entirely in the three last months. But while thus employing myself in the useful, but by no means agreeable office of testing the views of another, I own, I have myself no theory to bring forward, no new speculation to offer. It is still to me a mystery, how the functions of the placenta continue uninterrupted during labour, and by what means that organ is enabled to remain adherent, until the proper time at which it should be thrown off. The only opinion apparently at all probable is, that during the expulsive process the contractions are confined to the external layers, and only partially affect the central substance of the uterus, in which its vessels are imbedded, producing thereby not an absolute arrest of the circulation, but for the most part changing the souffle into a pulsation, as may be observed during the continuance of the pains, and that it is only after the child is expelled, the internal surface feels what Hunter calls the stimulus of necessity, which causes it to corrugate itself, and so cast off the substance at tached to it. But for various reasons even this explanation is exceptionable, and I still think, in the words of Mr. Carmichael, that "the nature of the contractions of the womb is not well understood, and that something yet remains to be known generally on the subject." ART. X.-Researches in Operative Midwifery. No. 2. Version or Turning. By FLEETWOOD CHURCHILL, M.D., Physician to the Western Lying-in Hospital and Dispensary, and Lecturer on Midwifery, &c. at the Richmond School of Medicine. Neque temerè neque timidè. THE term version or turning is applied by midwifery teachers, generally, to that manual operation by which one presentation is substituted for another, less favourable; and in a more limited sense, to the rectification of certain malpositions. For the furthering of one or other of these purposes, it has been known to the profession for a considerable period, but the full benefit of the operation and the class of cases in which it is useful is of much later discovery. A slight sketch of the history of the operation may perhaps be not uninteresting. Among the ancients, we find Hippocrates referring to bringing down the head. Celsusa advises us to seize the feet when the head is not within our reach, but this is only to be done when the child is dead. Ætius and Paulus Æginetus are the first ancient writers who recommend this manoeuvre to be attempted with a living child. Rhodion, Franco, and Ambrose Parès mention the operation as a usual one, but without much detail. Guillemeau, however, who was a pupil of Ambrose Pare's and who may have been indebted to him for his knowledge on * Lib. 7, cap. 29. b Des divers Accouch. fautt. 25, 27. Livre 24, ch. 33, p. 700. Dated 1573. |