l~eport~ of the .Dublin Obstetrical Society. 477"

surface of the organ~ near the upper, margin of the greater lobe, there was a softened circular enlargement, which he had not as yet opened, but would do so now in the presence of thr

[Upon being incised free!y_~fllis" ~swd~ing ~as ~ound to contain a quantity of softened, broken-up,.hepat[eistraemre~i~aix~4with blood. It was regarded as an instance of hepatic,aia~c~ple~r of,the obstructed portal circulation.J

The patient in tMs case was a .,man.of ~t~at i ~ l a e x a ~ ~h,%bits,--- January 7, 1865.

PROCEEDING8 OF TttE:DIJ-B, ~ OBST~]~ICAS~ S ( ) 0 ~ T Y . a

TW~NT~-SEV~ X_W~XL S~SSIO~:

DR. D ~ A ~ , President.

DR. CRO~Y~ exhibited a fetus with complete hernia of the brain, and other deformities. Dr. Foote was appointed to report Qn the anatomical structure of the specimen.--14th January, 1865.

.Report of Two Cases of.Protracted Labour, in which Delivery w~ Necessarily Effected by Craniotomy. BY J. C~o~-~, L.R.C.S.I., L.K.Q:C.P., Assist. Phys. to Dublin Lying-in Hospital.

I have selected the two lot}owing r in theL~ng=in Hospital within the same week; ~and as the ta-eatment pursued seemed totally ineffeetual~ at leust ~noue of them, I trust the society wil~ con- sider a brief description of some practical interest : ~

No. 1.--A. D., aged thirty-five, first pregnancy, admitted to hospital December 25, 1863, at 7, p.m. She stated her labour commenced at 10, p,m., on the 21st, when the waters came away. On ~dxamination, the os was found to be the size of a half-crown, membranes ruptm-ed, the head pressing firmly on the os~ which was thick and rigid, the vagina was also very hot and dry; fetal heart audible in left inguinal region. She was ordered warm bath and aperient medicine ; after the action of which she was treated by tartar emetic in nauseating doses, in combina- tion with opium; repetition of wirm baths and anodyne enemata were exhibited, the patient suffering much from want of sleep. This treatment apparently produced no effect until the evening of the 27th, when the os began to yield. -At 11: p.m., being dilated to about two-thirds of its

These Reports are supplied by Dr; Gee. H. Kidd~ Secretary%o the Society.

478 Be_ports of the Dublin Obstetrical Society.

diamcter~ on consultation with Dr. Denham~ it was decided to try craniotomy, as the fetal heart was inaudible for several hours~ and the patient beginning to show the usual symtoms of exhaustion~ being at that time 144 hours in labour. The operation was performed~ and the child, a large male, was with much difficulty extracted, the head being firmly ossified. Stimulants were freely given~ and the patient for some time went on favourably ; she suffered from retention of urine. On the third day she was attacked with symptoms of metro-peritoneal inflammation~ which ended fatally on seventh day.

No. 2 . --E. T , aged nineteen~ admitted to hospital December25 ~ had been in labour from the preceding day. On examination~ the os was found to be the size of a shilling~ thick, dry, and rigid~ the head present- ing, and membranes ruptured. Similar treatment was adopted~ and about forty hours after admission~ she being then fifty-four hours in labour, the os dilated fully. The patient remained six hours in the second stage~ the pains being weak and at long intervals; the fetal heart being faintly audible~ delivery by the forceps was determined on. There was great difficulty in passing a catheter; the forceps were applied without effect~ and craniotomy was resorted to. This patient went on well~ and was discharged the ninth day.

Having related the particulars of those two cases~ and their results--the first being fatal to both mother and child~ the second ending in the death of the child--I am induced to hope that the members of the society~ who have had experience of those very severe instances of protracted labour, may suggest any plan of treatment that has proved successful in their hands. Various methods of treatment~ such as the application of leeches and incisions through the rigid os~ have been recommended~ but I am not aware that they have found favour in this city. I think it right to add that bleeding from the arm was not tried in either case~ as the patients were too long in labour before admission to hospitaL--14th Jan.~ 1865.

DI~. D~ RlCCI read the following report on a work, On the Uses of Opium in Obstetric t~ractiee~ presented to the society by the author, ]Dr. Bribosia.

This memoir On the Uses of Opium in Obstetris Practice, including its employment in pregnancy, abortion, and delivery, forms the substance of the successful essay to which the prize of 600 francs was awarded by the Royal Academy of Medicine of Brussells, in 1863. I t is divided into four parts, each again being sub-divided into chapters and paragraphs~ and followed by an appendix and notes. I t commences with a short notice of opium and its chemical constituents, and the different varieties of it which are generally met in the market ; and the author here lays special stress on the fact that different samples of the same drug may

Reports of the Dublin Obstetrical Society. 479

contain very different quantities of morphia, varying from nine per cent., in Smyrna opium, to as little as two or three per cent. in Alexandrian opium~ and on the consequent uncertainty in estimating the real narcotic value of any opiate preparation, in the absence of any knowledge of the variety of the drug employed. Dr. Bribosia proposes that no opium should be employed by apothecaries except such as should bear the Government stamp, representing a certain standard per centage of morphia. I t then passes to the consideration of the physiological properties of opium~ and starts with the assertion that "opium exerts a special action on the nervous system~ which it tends to annihilate, not chemically, but vitally ;" that "opium alters the material composition of nervous tissue, and in large doses it alters it so far that it annihilates its functions altogether ;" also that it exerts a special power over the genital function~ increasing the menstrual discharge in women~ and also pro- ducing a sedative action on the gravld uterus. The author devotes several pages to the consideration of the physiological effects of opium both on the cerebro-spinal and on the sympathetic system, quoting largely from Miiller, C1. Bernard~ B.-S4quard, Waller, and Budge ; and at page 27 he enters on the more practical portion of his memoir, commencing with " T h e Uses of Opium during Pregnancy." Dr. Bribosia is of opinion that opium is so modified in its action by the existence of pregnancy, and that the toleration of it is so great in that condition~ that he actually proposes its administration in obscure and doubtful cases of pregnancy as an additional means of diagnosis, in which opinion he is followed by Van Huevel and Hyernaux of Brussells. He

J then passes to consider the different ailments to which pregnant women are liable, and which can be alleviated or cured by opium. And here he quotes largely from British medical literature, frequently mentioning the name of our distinguished President, together with those of Graves, Collins, Burns~ Denman, Gooch~ &c. Having c~nsldered the treatment of gastric derangements, in which he recommends opium in combination with alkalies, he passes on to spasm of the stomach and duodenum, and quoting from Burns, recommends laudanum and ether per orem~ together with saline injections per anum. He then altfides to the value of opium in constipation, and in the vomiting of pregnancy~ applying it endermi- cally in the latter case by sprinkling with morphia a spot over the pit of the stomach previously denuded of cuticle. Having reviewed the several gastric derangements in which opium can be made available, he enters on the consideration of the effects of opium on the circulatory system, commencing with uterine congestion. Having, at page 35~ described its symptoms, he says : - - " After a general bleeding, opium is the most valuable remedy we possess. True, that the plethoric condition is a counter-indication to the use of this narcotic by itself ; still, when once the tumultuous circulation will have been subdued by a bleeding, then

480 t~eports of the Dublin Obstetrical ~Societll.

the opium will prove of the greatest value~ . . . The dose must be large in order to produce immediate narcotic effects on the uterus, and thus render insensible the threatened organ; the intestines must first be emptied by a copious injection, followed immediately by a small one~ containing twenty drops of laudanum Sydenhami, to be repeated every half hour if nceessary~ foul" or five times in succession." Having exhausted this subject~ he passes to the consideration of hemoptysis s hematemesis~ hemorrhoids~ &% till~ at page 40,~ we come to Chapter III.~ which commences with the uses of opium in the treatment of hydrorhea~ and in the ptyalism of pregnancy~ where he specially makes honourable mention of our great Irish physician s Robert Gr~ves--one t o , h e m a

J .

statue.should long ago have been erected in this city~ if ever~emus and knowledge deserved one. Passing Chapter IV., which ~ devoted to the consideration of opium in the treatment of affections of the respiratory orgaas~ we come to the treatment of puerperal mania~ where we find our author again quoting Gra~es and our distinguished ]President~ We then find hlm quoting Corrigan and Donoyan as h~vmg xecommended opium in large quantities ~in rheum~tism~; "and ,as this is so often, though so mysteriously, connected with ,ehorea~ Dr, Bribosia advises its employment freely in the .last mentioned disease. Passing then to eclampsia~ some- times called the epilepsy of pregnant women~ he says that opinions are divided as to the advantages of opium in the treatment of "this disease, In England~ Burns is of opinion that it should be tried if the convulsions do not yield after bleedlng ; while in Germany~ Seanzoni~ of Wurzburgh, looks on it as a sheet anchor in this affection. His own opinion is that its administration' must be greatly influenced by the condition of the patient: if you have to deal with a strong plethoric woman~ bleed largely ; if~ on the contrary, with a feeble~ nervous~ anemic creature~ then give opium; in a medium ease use both bleeding and opium. Dr. Bribosia believes that eelampsia often arises from alhumimtria~ and consequent uremic ,poisoning.. ~He,, reeommeads extremely large doses of .opium in the tr.eatn~e~t ~f: i t - ~ much as one grain .of solid opium every ten minutes~ till.as much as ,~ ten an4 even twenty grains of opium shall have been.administered (see~. 61) ; ,and he asserts that although it will calm the spasmodic, act~ion of the uterus~ it will not much retard the progress of the labour. Our author strongly recommends the use of opium in spasms of the lrterus~ as well as in rigidity of the neck and os ; and for the treatment of pruritus vulvm--always a troublesome affection~ and when very severe becoming a serious complications leading even to abortion~he records an instane6 in which a woman miscarried eight successive times in consequence of pruritus. Passing to the subject of miscarriage, he says : ~ " I f there be one remedy~ the effect of which is truly effieacious~nay, wonderful~ in the treatment of this misadventure~ it is d~cidedly opium. 0pium~ together with bleeding, are the most

Reports of the Dublin Obstetrical Society. 4 8 1

powerful means we possess in the treatment of miscarriage." He recom- mends opium~ not only to arre~st~ threatened miscarriage and premature. labour, but he advises it to be. employed: ~ even as a prophylactic in all- cases of pregnancy which have been preceded b y miscarriage. In the, uterine hemorrhage of pregnancy he reeommends~ opium :in large doses (see p. 89)~ and in the management of threatened abortion he considers opium the most valuable remedy we possess ; but he cautions the opracti- tioner to make sure that the fetus is alive~ because if dead no means should be adopted to ,retard delivery. He prefers to administer; iV per anumt in small enemata~ containing half drachm doses of taudanum i repeated every hour, until the uterus shall have ceased to contract; it will be necessary, however, to watch the patient carefully, and i f the pains should be very severe~ and if there should be great rigidity o f the os, he advises bleeding from the arm~ and the:admlnistration of ~opinm per orem. Coming now tO the consideration of labour at full time, ~he s a y s : - - " After parturition~ if there- should b e a n y difficulty in removing 4he placenta, owing to spasmodic contraction of the uterus~ opium will again be found of the greatest value." Dr. Bribosia, however, differs from Burns (whom he loves to quote) on the subject of the value o f opium as a local stimulant to the uterus in cases Of weak labour ; he says-that it is a mistake to look upon it as a stimulant~--that it is, on the contrary, a perfect calmative, and that when its administration ~ends to help weak and tedious labour~ it does so by suspending uterine acti6n f e r n tlm% and thus allowing the woman to recruit her strength by rest and sleep. Then comes the consideration of all the various conditions o f the womb inj~vhich opium will be found of u s e ~ " rigidity of the neck and the os~"' afiomalous contractions~ clonic and tonic spasms~ or uterine tetanus, as~ho. Cal]s it, false pains, lumbar pains~ &c, followed by thedetails of m~ny~ cases~ in all of which opium was administered w~h advantage till we arrive at 1)art IV., which treats " O f the Uses of Opium During a~d After Del ivery ." He commences now with hemorrhage, which he divides~ into primary and secondary, according as it arises during the first hour after delivery, or later ; having enumerated the several causes o f it~ he begins by considering the treatment of hemorrhage caused by ~inertia o f the uterus~ and asks the question--" Is opium advisable in this form of ~ hemorrhage ? Almost all the French obstetricians recommend it~ while in England its value is commended beyond measure ;" but, notwithstand- ing this general recognition of its value, Dr. Bribosia is decidedly o f opinion that opium is not the remedy that ought to be administered i n uterine hemorrhage from real inertia, except in such exceptional cases a s might present inertia of one portion of the womb associated with spas- modic contraction of some other portion of it; but in simple uncomplicated inertia of the uterus our aim should be (he says) to encourage that organ to contract as speedily as possible--and as opinm~ according to his views.

u XXXIX, NO. 787 N S. ~ I

482 R ~ a of the Dublin Obstetrical Societal.

possess quite ~ e contrary power~ it shonld never be prescribed. Still, OpiU~ is greatly used in En~la~nd; and Burns~who is so great an authority in all obstetric matters ( I quote the words of Dr. Bribosia), looks upon it as the most p~w~ffu! agent we possess for the treatment of these cases. Feeling him~lf so 4ia .m.~tr~cally app,oscd_~ not only to Burns~ but also to his countrymr he en~ea~ours to seek out and determine the reasena w'h:mh have ~cleei.de4 Burns to place so great a faith in the administration of opium in such .cases, and after quoting from him a couple af pages, al~ length he concludes ,that ~ .is eviden~ that the British obstetrician recog- nises two causes inn. th'.m form of Test parfum hemorrlmge--"the relax)~tion' of the ~tcrino fihres~" _an4 a~lso " a .certain spasmodic condition'of the,

/ blood vessels,.," bot~h which cause~ tend to the ,production of ;~angestion o~ ~he us and he thc re~or, o places reliance on ,opium ~in ,such cases,

. / % because he recngniz~ th~ v~ue of ~h~t drug m sub,mug spasm. Dr . Bri:bosia, h0wever~ do, ca ~ot bdievr in this spasm at all; and being. r ~h~t ~the h~l~orrhagr is engirely due to relaxation of the uterine muscular file.e, c o a d ~ the us~ of apium~ ~a~d,rel~s entirely on ergot. In those~ o.piniana the ~aa~b~o~-~o)!s~ders ~ a t he, is hacked ~up by the, wri~ings of, our !~te x esp0c~e4 P r e ~ i d ~ Dr.~Beat~y, from ~hieh he quotes at length. Dr. Bribosiais ,not, however, so averse to the use of opium i~n the !~ter st,agOs of l~ost p~tu~a h~morrhage~ when ~t may be necessary tO allay nervous e~ci~emon~ and proc,u~ sleep, and he illustrates it by numerous well-dotaila~ cases, We now come to secand~ary hemorrhage, the deflation of w,h'~h he ad, ops from Dr. i~'Clintock; and, having disposed of it, he eaters on ~1~: consideration of pneroeral ma~ia coming on some time after delivery., In this form of puerperal mania he is of opinion, that our principal ~eh'a~r should be placed in opium, and he quot~, in support of i~, from t_he w~ritings of our friend, Dr. Athi~l. F~om this he passes t9 review ~he uses of opium in complicated labour ; a~d fin.ally, at page .1~8, .ha enters the subject of rupture of ~he uterus, a~ a(~r O~.~ha ~O~,_~t~.~o_rt~-alm~st.atways. fatal; and when not so r co~ng specially, if not ahvays, to~ tl~ .free adminiss of opium in l~Xqi~ doses. Speaking o~ the v~u~ ~f ~hi~ drug in "~hese "cases, our r t~-~4'~l~, a~e~r ~ t~is pro~-tiee agrees completely with the t~r pe~u~ag0n of bhe intestines by opium--a discovery due tc~ ~,~ay~a:0fbI~u.b!i~ .azadl~he ,pra~ieo pf~v~hieh has been adopted in every co~,~n_~y,~and~ ~e~r established rule. We th~a find him extolling the ~as~s ~f ~p~m:~in,~aqal and instrumental deli~ery~ commencing with the Cesa~aa ~ect~oa ~ ea~ite ; and as the mortality in this operation of four oat of five is ~laa, according to Keyser, principally to traumatic peritouig~ and a~ opin.~a has helen proved of such signal value in perfora- tion of the in~es~ines~ he conqludes that i,t will be found of,equal value in ~his opera~iqn. Phlegm, ~asia 4olens no~ forms the subject of She author's argument, and again we find him largely quoting f~om Graves, who

RaTorts o~ ~h~ D, Ubli~ ~Obs~etCivat ~oeiet~, ~83-

recommends full,doses ,~ ~pium~in its 4reat~he:a%~ and he ends by sayi~g--- "the instructions ~h~h ~e have :here l~ceived :from the celebrated Irish professor ar~ of the gr~ates~ ~alue~. We ~br ~hat the .rules which he lays down, relative to ~the !treatment r post ,~a~tux~ a~eideitcsv w~iil bd the means of directing our steps towards' a happier and more successful system of treatment. His directions to sustain Vhe ~viml force by analepties, opium, and quinine, and not to abstract hlood., e~c~p*.l~c~l/.y~ and even then with the greatest reserve, ought to b% according to him,, the basis, of ,treatment, and we fully concur with him'?' At ,puge t89 ~we find him engaged with the subject of puerperal peritonitis, which he recognises as one of the most fatal of diseases, and, one which, nogwi~h- standing al~ {ha'~ has been written about it, and all ~he d~ssertations and: long dlscus~ons he!d aboUt it' a~ th e :Academy ot~ ~edlc~ne, sfi'l~ remains surrounded by unexplained que~ti6ns and di~i~i'd~il~es. Then follow several cases e.xtracted i~incipal]y. ~i~om '~f.~ l~i'~li~tb61~s ~ t i n g s , ~ ~n which the principal fea~ffre Was the treatment by opium and w:ine ; and again, on this occasion, Dr. Bri'bos{a takes the opportuh{ty of paying a high compliment tO the Dublin Obstetric School, as ~n the following quotation : - -" We owe very much to British obstetricians, from whose theory and practice we have received many valuab!e suggestions ; and the ideas of l~urph% i{ardy, ]YJ[~Clin~bcl/, Church~ll, i~[ontgoniery, Beatty, Denman, &c, are be'com~'mg every day more known ,arid accep~dd , an5 we have seen even Trousseau himself finally ad0pr them.!' ,,.

We have now concluded (says Dr. Bribosia) oar ,stud, s on ~he xatue, of opium in, obstetric practice, and When ~e lo(~k ripen .the ~r p0~er of this drug, We eann6t feet ~urpi-iged that ~h6ahei~t's sl~6~ild halve regarded it as a "g iR Of the gods.'~--ldth Janum'y, i8~5. ~= �9 :

~tatistics of Lfing-i~ t:[o~ital of M oseou~The I~V. PRO~SS~. HiUGHTOI~ commtmicuCed the foliowf~g: ~a~isties, whic]i h~e h~d 61)~ainefl from the MS. record's of the Lying-in Hospital during a recent visig ~iO !VIoscow : -

From .1832 to 1860, inclusive :--Total deliveries~

Natural,, Irregtfiar (hand),

Do. (ingtrumental)~ Twins, Trins, Stilt-born, .

Disposed of as follows,:-- To Foundling Hospital (Boys),

Do; do. (Girls), Taken home -by mothers,

.. 38,317

. t,329 �9 739

; 846 11

45,162

3,450 , . . . . 4 ~ , 0 s 8 "

21,944 ~ �9 20,'525 ~ 8 ~ '

42,555 2 1 2

484 ~efiorts of the :Dublin Obstetrical Society.

T h e mor ta l i t y of the ch i ld ren in the F o u n d l i n g Hospi ta l , du r ing the pa s t th ree years, a f te r b i r th , was 42 pe r cent. Of those t h a t live, the males a re t r a ined up for the Russ i an a r m y and the gir ls a re ins t ruc ted in var ious indus t r i a l oceupa t ions . - -14 th January; 1865.

DR. H. KE~NEDr read a paper on ttydrocephalus; w h i c h wil l a p p e a r in the J o u r n a l for A u g u s t . - - 1 l t h February, 1865.

On the Action of Ergot of Rye upon the Fetus. B y DR. M~CLn~TOCK.

T h a t the admin i s t r a t ion of e rgot of rye, in the second s tage of l abour ,

is v e r y ap t to be followed b y in ju r ious or f a t a l consequences t0/ti~e fetus, i f i t s b i r t h be delayed m u c h beyond an hou r and a half , i$~a proposi t ion t h a t wil t scarcely be called in quest ion here ; and I bel ieve there is h a r d l y a n y accoucheur Of eminence or exper ience a t the p re sen t day who is no t of the same opinion w i t h r e g a r d to this medicine. I n d e e d so notor ious is

th i s effect of ergot, w h e n good, and g iven in ful l doses, t h a t i t has been

proposed to call i t ~the p ulvis ad metre% ~s a f i i t ing subs t i tu t e for i t s n a m e of pulvis ad partum, a

Soon a f te r the in t roduc t ion of ergot in to obstetr ic p rac t i ce i ts modus operandi in thus affect ing the chi ld became a subjec t of close i nqu i ry I t s in ju r ious ac t ion upon the fe tus was mani fes t ly a g rea t b a r to its.

a The evidence which might be accumulated on this point is overwhelming. On the ethel" hand~ Dr. Denham, in a paper published in a back number of this Journal, has expressed doubts as to the injurious effects of ergot on the fetus ; but a rigid examina- tion of the cases therein detailed will show that they are not directly at variance with the principles above lald down. In like manner a close analysis of the 173 c a s e s

reported by Dr. R. U. West to the London Obstetrleal Society, clearly demonstrates that very few.. of them can be taken as data for deciding the particular question before us ; whilst the number which can strictly be said to bear evidence on the opposite side is extremely small--not more than about 12 cases. For although there are 28 of his eases in which the interval between giving ergot and delivery was two hours or upwards, still in 16 of them either the ergot produced no marked increase of pains, or only one dose was administered, or the liquor amnli was not evacuated when itwas given ; and, under any of these circmnstaaces, hurtful effects to the child are not to be expected.

In 95 (more than the half) of his cases the child was born w~ithln one hour from the giving of e r g a ~ i ~ 44 instances it was born within thirty-six minutes. In the great majority oflnstances the os was not fully dilated at the ?~ime of exhibiting the ergot, and in 38 instances it was onlythe size of a shilling or half-a-crown ; and in 17 cases the membranes were ~till entire when the ergot was administered. In none of the cases was the fetal heart examined. ~rom this brief summary it will be apparent that in deciding the questlon--how far ergot can affect the fetus ?--Dr. West's long list of cases, though valuable and interesting in many respects, carries very little weight. In one way they afford corroboration of the views expressed in my present com- munication, by showing that, where ergot is not given in a full dose, nor in the second stage of labour after the discharge of the waters, nor with the effect of exciting per- sistent uterine contraction--then, under any of these circumstances, there is little or no risk of injury to the child.

ReTort8 of tlie Dublin Obstetrical Society. 485

employment~ a grdat check upon its :usefulness~ and hence accoucheurs were most desirous to discover how this baneful effect was brought about~ in the hope of ~eing able to obviate or correct it. Two opinions have been advanced to account for the destructive action of the medicine on the child. According to one of these the ergot acts in a physiological way~ that is to say~ it enters the circulation of the mother , and is conveyed, through the medium of the blood~ to the fetus. Now this is one explana- tion ; and amongst its supporters we find the names o'f two of the highest authorities on the subject of ergot of ryemviz., Dr. Beatty and Dr. Hardy ; and it is not~ I assure you, without considerable appreheh~ion and reluctance tha t ' I would yenture to dissent from any opinion:of ihdirs upon an obstetric subject i much less upon one which they have s O closely and so successfully investigated. But

Amicus Plato, ami~us Socrates,. magis arnica veritas.

On the supposition that the poisonous property resided in some l~articular element or component part of the ergot~ various attempts have been made to isolate the different constituents of the medicine~ with the hope of obtaining the true parturifacient principle distinct and separate from the poisonous one. But all such at tempts have been unsuccessful, and for a very sufficienr reason I think. NIany years ago I assisted in making a s.eries of experiments with different-preparations of ergot, but the results did not at all answer our expectations.

The other opinion, as to the modus operandi of ergot upon the fetus, is toj this effect--that the child is destroyed in consequence solely of the vi()lent or continuous labour pains which the ergot excites . . . .

Up to the present moment it is an unsettled quew which o f thes~ two explanations is the correct one. Authors a nd practitioners ure stitI dlvide~ upon it, though I am bound to say that the greater portion o f ~ e profession seem inclined to adopt the second theory as the correct one.

I t is not my intention to weary you with any examination of the facts and arguments which have been brought forward in support of each of these theories by their respective advocates--I merely wish to~]ay before you~ in a very general way, the results of m y own experience and reflec~ tion on the point~ and to state my reasons for believing that the second~ or t~ mechanical theory,, as it has been. designated~ embodies the true explanation of the mode by which ergot acts on the fetus. This is not by any means an unimportant or speculative inquiry ; on the contrary, it is one of the deepest interest to the obstetrician, and~ like all questions relating to the action of remedies, has an intimate bearing upon practice.

At the outset of my professional life I adopted the opinion that ergot exerts a direct and specific influence on the fetus. More enlarged obser- vation led me to doubt, and subsequently to relinquish, this idea--as~ throughout a pretty wide field of experience~ I did not meet with any

486 t~epar~s of the Du'blin Obstetrical Society,

evidence that could, in a direct; positive mannel,, ]~en4 it support. I have never met with a ease where the child manifested, after its birth, .symptoms of what might be c~!led "ergotic poisoning ;" and the cases I have seen where depression of the heart~ or even the death of the child took place after ergot, and in the absence of its usual effects on the uterine contractions, were so very rare as to be quite exceptional, and could be equally well explained by the weakened state of the child (from the previous length of the labour) at the time of giving the ergot----under which circumstances any further delay was of course fraught/ivith imminent hazard to its existence. ! fully admit that if th~ ~cases of this kind amounted to any considerable number, they mighv ~aen justify an inference, Which cannot~ with any show of reason~ he deduced from a very few solitary instances.

On the other hand, the common voice of experience proclaims that the danger to the child is in proportion to the intensity and uninterruptedness of She pains; and that where these are only imperfectly developed by the ergot, or are~ dist~etly intermittent~ hours may elapse with impunity to the fetus~

We may lo,ok upon it~/tl~en', as: sU~ciently ~tablished. that the influence of ergo~ on the fetus, after the discharge of the waters, and dilatation o~ the mouth of the womb, bears a due proportion to the intensity of the uterine contractions~ But something further, some evidence of a synthetic kind, is wanting to prove that the pains and the state of the fetus stand in the relation of cause and effect. I t may therefore be asked~do we~ over see effects like to those of ergot produced in the ferns by uterine contractions of spontaneous origin ? To this very proper and pointed qucstiQ~ my own experience enables me to gi~e an affirmative reply.

I~ has,been d~mbted, by som~ writers whether powerful and continuous eont~actiQns~ of th~ uterus~ such at leant as ergot is capable of exciting, e.~,~r o~,eur n~t~_r~!!y~ On:ae~'~at= oeea~ionsi hawe.~errit has fMlen to my

"~!ot t~ witn~ss~the.m, a.n~ he* doubt: ma~y ~around" me have dolm the same. ~hia~kiar d a~e~i~e_'a~ot~ ha~ ber ~o~unaptly i termed ~ tetanie," from ~h:~ ~v~qj~lac~ ~5,pexsistence o~f th~contmct~ns.. 1;Ie~e~ then~ is a case in which the p~i~s Bos~ss the peculiar characters belonging to those which ergot excites; and in these cases of tetanie uterine action experience shows that, quite irrespectively of the length of the labour, the infant is very apt to be dead be~rn,:ualesa art interfere to extract it, or to moderate the violence ef the ~texin~ co~ttraetions. For another reason~ namely, the

�9 imminent risk of rupture of the uterus, we are generally obliged to give prompt assistance of some kind to the patient ; but in any case the danger to the child~is very great under these circumstances, and when still-born it has presented that livid congested appearance so often observed where ergot of rye has been given, Between the two classes of cases, those

, R ~ s g,tlu ~UbtiU O~ste~'eai ,S'~ie~. ~8~

of e rg~ic and thos~ of ~etanlc ~ ' i ~ a c t i o n , tl~ere is the closest resem, blance, quoad their destructive effects on the child. But this i , not all, We, may ear, r y the eompariso~ further, a nd weiahalt:fi~ that' the effects on the fetal pulse, attributed' t~ ergo:t~ are~lik~w~e, pro~hiee&~a the case of tetanic uterine action. I have been eaeeful t04n~estig~te~kispo~ut; and in all, the cases where~ I had ~ opportunity' ef~ ~x~miui,n~, the~" fet~l~ heart was found notably diministie4 in stre~gth~ an4, f r e ~ y , ,ah~ ~t time~ irregular. These phenommm are identi~alr you~ observe~with.$h6s~hie]~ ergotie coutraetions ~ ordinarity produce. In both eludes ~ of;,'ca$e~, the depressio~ and irregularity of the. heart's, sound~ ~ere: m~)s~ m ~ k e d immediately on the cessation of a paim l n d ~ d I ha-~ fo~nd:it~t~ h~l~ good as a general r~le~ that the.immediate' effect o~ strong uter~r traeticn~ afVer ~he~ escape,,of th~ w~ters~ i~ to d e ~ s ~ th~ p u ~ 0f th~ fe tus~ tha t is~ to render ~h~ hea~'~a gou~d~ s~b~r and ~ feebler ~ and tl~is fact in itself supplies us~ I thii~k~, with $ l~ey "tO e~plAino th~ mode of action of- ergot upon. the ch'~d~

Permit me now to recapitula*o : - ~ t , W~ h a ~ seen that~ asia ,general rule, the danger m the child , after g~h~g ergot, is'exactly in proportion to the energy of the uterine cuntractionsi 2:. i~ i~ no' less' true that where but little uterine action is: excited by th~ e~V~, it ~ does not seem~ to exexclse a noxions infl~lence.on~th~ fe~s~ 3~ The e~de~c~ thut ~vget is acting injuriou~l$ o~: the ~ ehilcl ~" d~rive~ f ~ ~he: cardia~'s~u~dsr which become refldce~' i~ strength and,, f r ~ u e n e y . 4~ T~hwimmedia~eeffec~. of uterine contraction upon, the fetal l~uls~ i~ to produee~" ~ t~n~pb~gry diminution os its foree~ and rapidivy, 5./~nd~ lastly~ i~t]~e ~ e ~ I

'have seen where ~oten~ a~d continuous uterine: a c t i ~ t ~ lflacg~ f~n~ nattuc~b causes~ the fetal pulse underwe~-the'same changes a~ ~f~er~r,g~t~ and the. ehildxen were born inca highly r s~te~, dead~or pax~ialiy asphyxiated, unless, d~l~vere~ soon: after~ ~h~, aegeS~on Of th~s~ tetanie cantract~o~s o f the-uteru~ _ ,

Of course it r ~ for future, observer~:toeorroborate ov ~va~date the facts I ha:v~ adduce<L But~, assuming that my observations a~6 correct an, d well grounded~ I think ir will be hard to, avoid~ the ~o~c'lusion that the action of ergo~ of rye on the f~tas, i~ due seIely r~ the uterine contractions excited by tl~is ~ medicine.'

Let me here digress far a moment, I have had or to spea]e of certain changes in the characters of the fatal h~art'g sougds, and t~ rem~,k that in one class of cases (iho~e of ergotir or tetanic uterine ~etio~, slob- nest, weakness~ and i~regut~r~ity are theprecursors of th~ child',s,de~th~; whilst in other' cases~ on the contrary (chiefly tho~e of difl~etil~ l~l~au~)~ extreme frequency and weakness of the cardiac sounds are found to l~reeed~ the fatal event. No doubt the mode or cause of death might account for these differences. The subject~ however~ is one every way worthy of being closely investigated~ and I recommend it to some of my junior

488 Reports ~of the Dublin Obstetrical Society.

brethren around me who have opportunities for prosecuting such ~ an inquiry.

A very interesting question, originating out of what has been already stated, now presents itself to us~ and it is th is - - -How do the uterine contractions operate upon the fetus ?

There are three ways, I believe~ in which, the vital condition of the fetus may be affected by the pains : -- ls t . The umbilical cord may be subjected to direct pressure from the contracting nterus~ and if this pressure be so great as to completely stop the circulation through the funis, the death of the fetus certainly and very speedily ensues. 2rid. The compression which the brain and medulla oblongata undergo~ ~vhere the head is wedged or impacted in the pelvis, has been deem~ed'sufficient to endanger or to destroy the life of the child. I t is yery remarkable how great a change of configuration the head may bear consistently with the preservation of the fetus. But here the change is slowly and gradually effected, whereas in the cases under consideration--namely, those of strong and continuous uterine action, the change must, i f it take place at all~ be effected quickly and under "high pressure." I t is ~aly when there is resistance from the hard structures that pressure on the head can be really dangerous to the child~ and therefore I believe that pressure on the head is very rarely a cause of fetal death. I f what I have just stated be true, it furnishes us with an instance of the occasional antagonism of maternal and fetal interests. I t is desirable fo~ the mother that the pressure of the head on the soft linings of the pelvis should be as transient as possible, but for the child it is desirable that the compres- sion of the head by the pelvis should be slowly and gradually made. Lastly~ persistent uterine contraction may affect the child by causing imperfect oxidation of its blood in the embryonic villi of the placenta.

There are the strongest anatomical and physiological reasons for supposing that the current of blood through the maternal cells of the placenta is checked dmSng uterine contraction, so that the change in the fetal vessels from venous to arterial blood is then arrested or imperfectly performed~ just as the a~ration of blood in the pulmonary vessels of a breathing animal, or in the branchial vessels of a fish~ is stopped when the needful supply of air or of water is withheld.

We can, then~ have no difficulty in understanding why pains of a violent kind~ recurring at very short intervals, or succeeding one another without intermission~ must operate prejudicially on the fetus~nor why the chfld~ when born under these circumstances, so commonly presents a congested livid appearance~ and is so apt to be expelled in an asphyxiated eondition.--llth February, 1865.