146

ATTITUDE AND POSITIONS OF THE FETUS IN UTERO.

2

nomena as almost beyond the reach of explanation. "I feel wholly unable," observes Dr. Lee,1 "to explain the cause of preternatural presentation occurring repeatedly in the same individuals, as described by Dr. Denman and other systematic authors." "It is," he elsewhere observes, "very difficult, or impossible, to explain why the head of the child does not invariably present in labor, or assign a cause for the same woman having preternatural presentations in several successive labors, the head of the child being rarely, if ever, in them the presenting part."

The doctrine of the causation of the positions and presentations of the fœtus, which I have attempted to develope in the present memoir, affords a simple key to this obstetric enigma.

Some of the causes producing malpresentation, in the way described, are occasional or accidental only; and are not liable to recur in other pregnancies in the same mother. Hence, under the action of these causes, a malpresentation of the foetus will occur in one or two labors only in the same patient, and not in all. To this set of instances belong the presence of twins; death or disease, and malformation of the fœtus; prematurity in the labor; mechanical, accidental displacement of the fœtus; and changes in the configuration and form of the uterus from spasms in its parietes, from the cervical or other anormal implantation of the placenta, and perhaps from other conditions which I have not taken time to trace out in the preceding observations, as focal accumulation in the colon, compression of the abdomen, and other such causes as may produce unequal pressure on the external surface of the uterus, and thus change the shape of its internal cavity-causes, some of which are capable of being prevented and treated, and their effects on the presentation of the child thus averted. But other causes of malpresentation of the foetus are not occasional and accidental, but permanent and constant. They are not limited to one pregnancy, but present in all. They are anatomical conditions, either existing throughout the whole life of the mother, or recurring with each successive labor. For example, the lower part of the ovoid cavity of the uterus may be altered from the normal configuration and shape in each successive pregnancy, by deformity of the brim of the maternal pelvisthe deformed brim preventing its full development, forcing it always to assume a peculiar type and form, and this type being one which obliges the foetus to assume some special or preternatural position, in order to adapt and accommodate itself to the existing special and preternatural form of the uterine cavity. I have already cited from Dr. Ramsbotham, Renard, &c., cases of deformity of the brim of the pelvis, leading in this way to a succession of preternaClinical Midwifery, p. 117. 2 Lectures on Midwifery, p. 327.

tural presentations of the child in the same mother. Again, if the uterus itself is misshapen and malformed, a similar result follows. In each successive pregnancy there is the same constant deviation from the normal ovoid form of the uterine cavity, and as a consequence, the same deviation from the normal adaptive position of the fœtus. In the instances which I have quoted above from Walther and Lecluyse, of the recurrence of the same malpresentation in several successive pregnancies in the same mother, the cause of these malpresentations was an irregularity in the configuration of the uterus. The same organ-as the mouth, nose, hand, &c. &c.is liable, when irregular in form, to present the same irregularity in several members of the same family. The same no doubt holds good in regard to the uterus also. Dr. Keiller has informed me of an instance of preternatural presentation recurring in different pregnancies in twin sisters. It appears to me that this curious fact will find its solution in some peculiarity in the form of the uterus repeated in the two sisters.

If the preceding remarks had not already extended far beyond the limits intended, I would have proceeded to show that the positions of the head, &c., of the child, in relation to the circumference and different diameters of the maternal pelvis, are, like the presentations, regulated in their ultimate analyses by the reflex or excito-motory actions of the foetus. It is only by reference to the reflex excitations and motions of the foetus, that we can explain, for example, the rarity of the positions of the head, &c., in the direct diameter of the brim, their frequency in the oblique, and especially in the right oblique diameter-and the greater relative proportion of occipitoanterior than of occipito-posterior positions of the cranium.

ON THE EXCITATION OF FETAL MOVEMENTS BY COLD.1

Ir is very generally believed by accoucheurs that the sudden application of a cold hand, or other similar body, to the cutaneous surface of the abdomen of a woman advanced in utero-gestation, is capable of exciting movements on the part of the foetus; and such application has been often recommended as one of the simplest and best means of ascertaining, in doubtful cases of pregnancy, both the existence and the vitality of the child.'

'See Edinburgh Monthly Journal of Medical Science, July, 1850, p. 90.

See, for example, Montgomery's Exposition of the Signs of Pregnancy, p. 89; Dr. Gooch on Diseases of Women, p. 203; Dr. A. Hamilton's Letters to Dr. Osborne, p. 147; Dr. J. Hamilton's Practical Observations, p. 151, &c. &c.

But as there is no direct organic communication between the abdominal walls of the mother and the body of the fœtus, or between the nervous system of the mother and that of the child in utero, the power of exciting muscular movements in the latter by a sudden impression of cold upon any part of the abdominal maternal skin seems, physiologically considered, an impossibility. And clinical observation and direct experiment seem to me to prove the whole idea to be fallacious.

If the hand, whether cold or hot, is so much pressed inwards, as it inadvertently often is, so as either to indent, or alter the shape of the uterine walls, or to push and irritate the body of the fœtus, then fœtal movements will be liable to follow.

If, on the contrary, the hand, however cold, be applied so as merely to touch the skin, and not make pressure upon it and the uterus beneath, the impression of cold thus produced will never, I believe, be found to excite fœtal movements.

Such at least is the result of numerous clinical observations which I have tried to make upon the subject. In some direct experiments in regard to it, I touched the surface of the abdomen with metallic bodies, both larger and colder than the human hand, without exciting any movements in the fœtus. In a number of instances, with Dr. Weir, I applied large pieces of smooth ice to the surface of the abdomen, without in any one instance finding fœtal movements to follow. And yet, in these same cases, comparatively slight pressure with the hand upon the abdominal parietes and uterus, excited foetal movements, whenever in any way the foetus was irritated or displaced by that pressure.

VITAL CONTRACTIONS IN THE UMBILICAL ARTERIES AND VEINS.1

(From Edinburgh Monthly Journal of Medical Science, May, 1851, p. 494.)

It is well known that, up to a late period, some physiologists doubted entirely whether the larger arteries of the human body could be made to contract at individual points by stimulants applied to those points. Few or no satisfactory experiments have yet been published, showing that the veins possess the property of contracting locally under local stimuli. But in the umbilical cord, the medical practitioner may have daily an opportunity of repeating the following observations and experiments, which prove both of these important physiological facts, viz., the local contraction both

1 Extracted from Proceedings of Edinburgh Obstetric Society, March 26, 1851.

of the tubes of arteries, and of the tubes of veins, under local stimuli applied to them.

First. After the child is born, the cord, whether tied or not, is generally seen to become contracted at different points, in consequence of the local contraction at those points of the vessels included within it. In fact, its vessels are thrown, by the irritation of the external atmosphere, and in consequence of their partially empty condition, into tubes consisting of a series of dilatations and contractions, like the peristaltic contractions of the intestine; but with this difference, that the contractions of the vessels are permanent.

Secondly. By pinching a portion of the cord, immediately after the birth of the child, between the nails of the thumb and finger, contractions of the vessels of the cord will be seen to occur at the point irritated. And if this mechanical irritation is confined to individual vessels, as to one of the arteries or to the vein, the effect is equally marked.

Thirdly. If the sheath of the cord be slit up by a pair of scissors or knife, with any of its vessels or arteries exposed, the same experiment may be repeated upon the exposed individual vessels with similar effect, viz., that the mechanical pinching of them will be followed in the course of a short time, by gradual but very marked contraction in the irritated part.

Fourthly. Similar local contractions of these vessels occur, under the local application to them of irritating chemical substances, or of electricity.

Fifthly. These contractions do not instantly follow the application of the stimulant, but a short time intervenes before the effect is seen, and the contraction is permanent.

Sixthly. When the experiment is made upon the human umbilical cord, or upon that of the lower animals, when the circulation is still going on in the vessels of the cord, the irritated vessel will sometimes almost entirely close its tube under such local irritation.

Seventhly. These simple experiments, illustrative of the contractility and irritability of the coats of the veins and arteries, are the more remarkable as seen in the umbilical veins and arteries, in consequence of anatomists not being able to detect any nerves in the umbilical cord; although probably elementary nervous tissue may exist in some form in it. For if it did not exist, then we should

have irritability in these vessels existing without nervous influence. The investigation of the existence of nerve in any form in the umbilical cord and its vessels, thus becomes an interesting microscopical study, in reference to the physiological question of the dependence or independence of the contractility of vessels on the presence of nerves.

PERITONITIS IN THE FETUS IN UTERO.

(From Edinburgh Medical and Surgical Journal, October, 1838, p. 390.)

In the recent progress of pathology it has been amply proved that the fœtus in utero is liable to a considerable variety of morbid states. Of its diseases, some, we have reason to believe, are altogether of a functional nature; but in regard to this class of foetal affections we as yet possess comparatively little information, because, excluded as the foetus is, during its abode in utero, from any of our present means of observation, it is only when its morbid derangements produce symptoms of a very aggravated character, that we are enabled to recognize their existence during the continuance of intra-uterine life. Indeed for nearly all the limited knowledge which we as yet possess of the diseased conditions of the foetal system, we are indebted principally if not entirely to pathological anatomy; and consequently the diseases of that system with which we are chiefly acquainted, are either such as are organic in their nature or that lead to an organic result.

Of all the various morbid actions which are liable to occur in the foetus, inflammation, with the different pathological changes which it produces, seems to be one of the most important, both as regards the frequency of its occurrence, and the nature of the effects to which it gives rise. In the present communication, it is my intention to bring forward a series of cases to prove, that one species of inflammatory action, namely, peritonitis, forms a common variety of fœtal disease, and probably constitutes one of the more frequent causes of death of the fœtus during the latter months of pregnancy.

It may be necessary, however, to premise, that the investigation by pathological anatomy, of the presence and effects of inflammatory action, and indeed of all other morbid changes in the foetus, is beset with unusual difficulties. When the foetus labors under any morbid state which happens to prove fatal during its abode in utero, there generally elapses an interval of from five to twenty days before the uterine contractions, necessary for its expulsion, supervene. During this period a number of changes are liable to occur, which are cal