APPLIED OBSTETRICS Introduction. - Parturition difficulties natur ally occupy a prominent place. It is well known that many valuable breeding animals are annually sacrificed for want of a little knowledge and initiative in correcting wrong presentations and positions of the foetus, or deviations of its extremities. For example, a fore leg flexed or turned back at the knee is easily straightened, as a rule, in the early stages of labour; at a later stage the deviation may be difficult or impossible to set right without serious injury to dam or offspring. Neverthe less our aim is not to provide a compendium of first-aid treatment or to set forth anything new, but to indicate in plain language the measures required to bring about successful parturition, and, with a view to prevention, to discuss the causes of the various accidents and diseases connected with birth. Broadly speak ing, obstetrics is the study of the dangers and diseases occurring in the process of reproduction, commencing with the period before conception, and ending with the diseases of the very young animal. But a restricted, or less comprehen sive, meaning is often attached to the word. Thus obstetrics commonly means the study of parturition difficulties and how to overcome them, including the accidents and diseases incidental to or following the act, but especially those connected with difficult labour. The principal obstetrical operations also claim con sideration. We use the term"Applied Ob stetrics"in this sense. Difficult birth, or dystocia, occurs whenever assistance is required to effect delivery. It may depend either upon the mother or the foetus, but the latter is gener ally at fault in the lower animals. Hence in dealing with difficult birth we shall confine our remarks to foetal dystocia.
Applied obstetrics is considered under the following heads: 1. Parturition difficulties.
2. Inversion of the uterus, vagina, and bladder.
3. Retention of the afterbirth.
5. Postpartum haemorrhage and rupture of uterus.
1. Parturition Difficulties in the Larger Animals (Mare and Cow). It is generally admitted that dystocia is more frequent in the cow than mare, notwithstanding the fact that in most districts more cows are bred than mares.
The incidence of dystocia is increased by domesti cation and an intensive system of management. Thus the chief sufferers are dairy cows which are tied up most of the year, while pedigreed and other cows which enjoy plenty of freedom, and other species which lead a natural life in the open, are less often affected. The influence of confinement is well seen in pampered brood mares and in pet dogs, especially toys. Under a rational system of management these animals suffer to a much less extent from difficult labour. Among all the domesticated animals dystocia is of most importance in the mare, both in regard to the recovery of the mother and the life of the foal. The reasons for this are both maternal and fcetal—maternal, because the mare's labour pains are always violent, birth is rapid, and the mare is most susceptible to infection; foetal, because the long limbs and neck of the foal, especially in thoroughbreds, are more difficult to adjust, and therefore more liable to injure the dam. Again, dystocia in the mare generally means a dead foetus; whereas the calf is born alive, in spite of the fact that delivery may take several hours. This dissimilarity in the foal and calf is largely accounted for by the differences in the placental attachment (see"Retention of the Afterbirth"). The membranes in the mare rapidly separate from the uterus; and the foal, deprived of the oxygen circulating in the mother's blood, soon becomes suffocated. Furthermore, the foetal circulation is seriously interfered with by the mare's powerful expulsive efforts, which bring pressure to bear on the umbilical cord.
In any animal, birth must be quickly effected as soon as the cord is compressed or ruptured, if the life of the offspring is to be saved. The violent straining of the mare also hinders the passage of the hand between the foetus and the uterine wall, and renders manipulation much more difficult. These facts being fully known and widely recognized, we arrive at the simple conclusion that the greater and more prolonged the straining the worse the dystocia becomes and the more the difficulties of the operator are increased. Given the same malpresentation, or deviation of limb or head, the mare, all force and violence, will soon render delivery of the intact fcetus impossible, or force it out in a wrong position, and endanger her own life; whereas the cow, more patient and tractable, will stand a delay of six hours with impunity. Notwith standing these serious impediments to successful parturition, the mare has the advantage over the cow in three respects: (1) the long, narrow head of the foal occupies less room, and is thus more easily delivered; (2) the standing position generally assumed by the mare proves of assistance to the operator; (3) it is but seldom that mares require help during labour, although, when it is needed, it must be given quickly. Experience teaches many useful and much needed lessons, but none more important than the danger of delay in securing skilled assist ance. For not merely is a simple deviation of an extremity (turning back of the head or a limb) greatly aggravated, but the lives of fcetus and dam are jeopardized, while, in the event of recovery, the latter may prove to he sterile (see"Prevention and Treatment of Sterility"). Again, a dead fcetus in an improper position is less easily extracted for the reason that con tractions of the uterus fail to set up spontaneous movements in a dead doubled-up fcetus. These movements in the live animal tend to extend and straighten the limbs and head. Delay also increases the chances of infection by leading to the exhaustion of the mother. The owner, therefore, no less than the expert, is directly concerned in relieving the mare of the foal at the earliest possible moment. He should send for the veterinary surgeon at once in every case of difficult labour in the mare. This advice need not deter him from rendering first aid, as far as circumstances permit, on the lines indicated hereafter.
Natural Presentations and Labour.Occasion ally the various domesticated animals require aid in parturition, even in natural presentations, when the labour pains are weak and the work of expulsion does not proceed; yet undue or improper interference is to be deprecated. In such cases the attendant should not hesitate to make an internal examination, provided he exercises every care, pares and files his finger nails, washes and disinfects his hands and arms, and makes use of a lubricant such as fresh lard or butter, olive oil, vaseline, or even soap, if nothing else can be obtained. The hind parts of the animal should also be washed and disinfected, while the box or stall should be clean, dry, and well bedded with fresh straw. The hand should be introduced during an interval in the straining with the fingers extended in the form of a cone, care being taken not to press against the dam. These precautions are necessary in order to prevent infection and its results (see"Metritis"and"Retention of Afterbirth"); and no harm can ensue if they are properly observed. The manual examination will ascertain whether the fcetus is coming naturally and the"os"(neck of womb) fully dilated. If so, it is advisable to wait a while, especially in heifers, meantime making the animal as comfortable as possible. A good deal depends upon the water bladder, which, by mechanically opening up the passage, prepares a way for the foetus. The bladder consists of the foetal membranes distended with fluid, and makes its appearance at the vulva during the throes at an early stage of labour. Being transparent, the nose and fore feet of the fcetus are sometimes seen through it. Soon the water bladder ruptures spontaneously (it should never be interfered with in ordinary births), and the"natural waters"are expelled. Sufficient fluid, however, remains in the uterus to be pressed out at each pain. In addition to its function as a dilator, the fluid acts as a natural lubricant in facilitating birth, besides preserving equable pressure on the fcetus and preventing the womb contracting too tightly upon it. But these valuable effects disappear when labour has been prolonged and the reserve fluid expended, so that the maternal parts become dry and contracted. The time of rupture varies, but it should be noted in every parturi tion. With the mare rupture may be delayed until the foal is born imprisoned in the intact membranes. In this way several foals are annually lost owing to no one being at hand to set them free. The young animal generally presents longitudinally in an upright position, with the fore limbs, head and neck extended in a straight line, and the nose resting upon the pasterns or fetlocks. This arrangement enables it to occupy the least possible space in order that it may pass through the fixed bony inlet of the maternal pelvis. Occasionally the fcetus presents posteriorly with hind legs in the passage. This occurs more often in twins, one of which may come head first, the other tail first. In both presentations it should be remembered that there is little room to spare; any departure from the normal, either in the position of the foetal body or in the arrange ment of its limbs, readily causes dystocia. It is clear that unless the young animal is coming longitudinally in line with the pelvis and passage of the dam, and with its head and limbs ex tended in a straight line, it is bound to stick at the pelvic inlet. This happens every day when the fcetus is upside down, or when a limb or the head is turned back in the uterus, the fcetal diameters being thereby increased and exceeding those of the mother. The latter, represented by the bony pelvis, are unchange able, hence the size of the fcetus must be de creased by straightening the extremities, alter ing the position, or by amputating one or more limbs.
The word Presentation, it should be explained, is used to designate that portion of the foetus which first enters the pelvic inlet or passage of the dam; thus the term"Anterior Presenta tion"means that the fore parts are coming first, that is, they are presented and can be felt at the entrance to the pelvis, or in the vagina. Sometimes they are outside the vulva. Birth takes place almost as readily in the posterior as in the anterior presentation; but in the former the young animal is more often born dead, or in a moribund condition. This is due to com pression of the umbilical cord, or extensive separation of the placental membranes, before the fcetus is able to breathe. The third pre sentation, the transverse, is rare, decidedly abnormal, and mostly confined to the mare. Here the foal lies across the pelvic entrance, mostly on its side.
The word Position is less easily defined. It expresses the relation of a certain portion of the foetus to the pelvic inlet of the mother. For purposes of description, it is convenient to choose a fixed point on the fcetal body—the withers for the anterior longitudinal presenta tion, the loins or lumbar region for the posterior presentation, and the head or cephalic region for the transverse presentation. An example will show what is meant. Suppose the fcetus is upright, and the fore parts are in the passage, as in Fig. 328. Clearly, the dorsum (withers) of the fcetus is opposed to the sacrum (spine) of the dam. The term dorso-sacral, therefore, indi cates the position. Similarly the term lumbo sacral indicates that the lumbar region (loins) of the fcetus is opposed to the sacrum of the mother (Fig. 334). Here it is obvious that the young animal is coming the wrong way, hind legs first; but the position is again upright, because the spines of mother and offspring correspond. It will be noticed that the first part of the compound word refers to the fcetus, the second to the dam; the whole indicating very briefly, not only the position of the fcetus in relation to the mother, but also the presentation or part which first enters the pelvis.
Abnormal or Unnatural Presentations.No work is more exacting, requiring more sound judgment and resource, than the handling of dystocia in the larger animals. No two cases are quite alike, and the obstetrician must possess plenty of patience and common sense, as well as the skill acquired by long practice. Further more, he must be prepared to adapt himself to circumstances as they arise. Yet in fairly simple cases—and most dystocians are simple at the outset—the stock-owner or his"handy man"can render useful service if he will but keep cool,"make haste slowly,"and observe certain elementary rules and precautions. One common mistake is to assume that the foetus must be extracted within a given time, and at all costs. Another is to rope the first parts encountered and to pull on them without dis covering whether the feet are neighbours, or whether they belong to the same animal. Not infrequently we have found men pulling on a fore and a hind foot belonging to the same or different foetuses. Yet they wonder why they are unable to extract the foal or calf ! Still another fault is the failure of the novice to push back one limb (after attaching a cord to it) in order to get up another, which is folded back and, possibly, beyond reach. It should be distinctly understood, as the chief axiom in difficult labour, that there is no room at all in the maternal passage in which to bring round the head or a limb; nor can the young animal be rotated or turned in this situation. Attempts to do so only result in serious injury to, and sometimes the death of, the dam. But there is plenty of room back in the womb, and the farther the fcetus is pushed back the easier the operation becomes. It follows that re pulsion, or pushing back the fcetus, is the most important obstetrical manoeuvre, and the one most frequently practised. In addition to repulsion the following measures and precautions require to be observed in very many cases of difficult birth: I. Secure the parts presented with suitable ropes or cords (not necessarily for immediate traction). Slip nooses, for example, are applied to the fore fetlocks and the lower jaw. Keep the cords always tense to prevent slipping. Never be afraid to lose sight of a foot, but remember which it is, and mark the cord attached to it.
2. Identify the limbs (fore and hind), the presentation, and the position. In order to distinguish a fore from a hind limb lying far back in the vagina or uterus, remember (a) knees and hocks bend in opposite directions, the knees being broad from side to side, the hocks from front to rear; (b) the fore fetlocks and knees bend in the same way, the hind fet locks and hocks in opposite ways; (c) the fore foot is slightly larger and the shank or cannon bone shorter, although this may prove of little assistance in the process of identification.
3. In the anterior presentation, soles of fore feet are downwards; in the posterior, soles of hind feet are upwards. If they point in the opposite direction, fcetus is on its back.
these away. Use the hands as much as possible; they are the best and safest instruments.
5. Secure the dam, alter her position, as required, e.g. standing, recumbent, or lying on either side. Use bull-dogs for cow, if necessary, twitch or rope hobbles (seldom required) for mare. Where much force is applied, prevent dragging the mother by attaching a rope to horns, raising hind parts, passing a cart rope, sacking, or breeching, or even the joined hands of two assistants round the hind quarters. The mare's fore foot may be picked up when the hand is first introduced into the womb.
6. From time to time inject large quantities of lubricative fluids into the dry, contracted, often swollen vagina and uterus, e.g. linseed tea, cresol solutions per cent (disinfectant as well as lubricant), rape or linseed oil. First check the straining, elevate hind quarters, and disinfect hands, tube, and external parts of animal. Repel fcetus a little, if required, and introduce a long rubber tube far into the uterus, attach a good pump, and inject several pints of fluid at blood heat, or as much as the womb will hold. Remember it is useless merely to syringe out the vagina. Not only does the fluid act as a lubricant, but it distends the uterus, stimulates its contractile power, and affords room for the easy and safe delivery of the fcetus.
7. Check the straining as follows: (a) raise hind parts with turfs, straw, litter, etc. In byres and cow-sheds the channel may be filled up with battens, soil, or turfs over which plenty of straw is laid. The raised position also assists repulsion. (b) Give a sedative, such as one to two ounces of chloral hydrate, or one to two of laudanum, to cow or mare (see"Inversion of Uterus"). With the mare chloroform is particularly useful in bad presentations (Figs. 332, 333, 337, 338, and 339). (c) Pinch cow's back behind withers, or, better still, tie a soft rope loosely round chest and tighten up with a stick, but not sufficient to make her lie down. (d) Opening the wind pipe may be practised in extreme cases to pre vent the animal taking a deep breath and bearing down with all her strength.
8. Make sure the extremities—head and feet —belong to the same fcetus (see twins).
9. Lubricate and disinfect hands and arms, as described. If decomposition of the fcetus has set in, the operator must protect himself by thorough and repeated disinfection.
10. There should be plenty of floor space behind the animal for assistants pulling on the ropes.
11. Empty bladder and rectum, if necessary.
12. For assistants, traction and removal of extremities see"Obstetrical Operations and Manipulations." 13. Be careful to pull on the ropes during the pains, and to stop during the intervals. The direction should be upwards, straight backwards, and lastly downwards as birth proceeds.
With the exception of Nos. 328 and 334, which portray normal birth, the figures represent the principal malpresentations and malpositions assumed by the foal at parturition. They apply equally to the calf and to other animals.
FIG. 328. Anterior Presentation: Dorso-sacral Position. Nose of foal rests on or near fetlocks; head, neck, and fore limbs fully extended. This is the most natural arrangement, and the one generally assumed in normal births. Soles of fore feet are directed downwards. Assum ing that the dam is healthy, no impediment to easy delivery exists.
Variation. Jamming of Stifles or Hips at Pelvic Inlet. Parturition proceeds naturally until the head, fore limbs and shoulders are born, when further advance becomes impossible. This dystocia seldom occurs in animals other than the cow, in which it is not infrequent. The calf is usually large, and both its hips pass together into the pelvic entrance, and become firmly wedged. Sometimes the obstruction appears to be due to the stifles being partly flexed and catching on the pelvic brim. The elbows may be caught in a similar manner (Fig. 330, variation 3). The accident is more likely to occur if traction is exerted in an upward or straight backward instead of a downward direction during the later stages of labour. Delay in summoning skilled aid, as well as excessive and mis directed traction, causes fcetus to jam so tightly that it cannot be moved backwards or forwards; the maternal parts also become dry and contracted, and the hand cannot be introduced into uterus. In ordinary circumstances, repel calf a little, lift stifles by pulling downwards on the fore parts, and, more important still, pull obliquely on one rope at a time, in order that one stifle or hip may enter the pelvis before the other. If the calf is pulled downwards towards the hocks immediately birth is arrested, nothing more may be required. Failure of these measures calls for alteration in the position of cow; turn over, or place on back if recumbent, or sling up by hind legs. Inject fluids into womb whenever possible. As a last resource, and without undue delay, amputate a fore limb, remove the internal organs of fcetus, and divide its pelvis with a long sharp chisel.
FIG. 329. Anterior Presentation: Position. Foal on back, its withers or"dorsum"corresponding to pubis of mother. Hence the term dorao-pubic. The heavy head tends to drop below the pelvis towards bottom of womb. In the figure, however, the head is somewhat advanced in the passage. The soles of fore feet are directed upwards. Occasionally the mare manages to foal herself, but the cow seldom calves without assistance. Delivery. In the absence of head, make sure you have knees, not hocks, to deal with. Cord feet and lower jaw if available; push back foetus with arm or crutch, and attempt rotation by turning the young animal on its long axis so as to bring the withers uppermost. Do this by placing hand under withers, and pressing from left to right or right to left, while an assistant crosses the fore legs and twists in the same direction. If the legs are sufficiently advanced outside the vulva, strap a board between them, and so gain more leverage. With roomy animals, especi ally mares, when the maternal parts are well relaxed, endeavour to pull the foal or calf away as it lies; but straighten head as much as possible, pull upwards towards tail to give more room for passage of head, and avoid too much force. If rotation fails in the cow, cast, turn on back, inject fluids, and deliver calf in an upright position. Remove a fore limb, if necessary, but this is seldom required.
Variation. Foetus upside down, head turned back on side (Fig. 332). This is a bad presentation in both mare and cow. Amputate fore limbs at once at the shoulder. Even then it is difficult to bring the head forward after placing a hook in the orbit. As in Fig. 329, the head and body of foetus gravitate towards lowest part of uterus. The body is also curved, and it takes up much more room than in the upright position. When confronted with this com plication in the cow, we prefer to cast the animal and place her on her back. Amputation of one fore limb may then suffice to get the head.
FIG. 330. Anterior Presentation: Carpal Flexion.Both fore limbs bent back at knee; head in passage; knees in contact with the pelvic brim. The cannon or shank bones are parallel to, and just below, the forearms, while the shoulders are bulged out and unable to pass through the pelvis (compare shoulders in Fig. 328). The diameters of the foetal chest are further increased by the feet and fet locks, in addition to the shoulders and arm. The cow's narrow pelvis gives more trouble than the mare's. Flexion at the knee, one or both, is perhaps the commonest form of dystocia in the cow. Delivery. Feel the head and knees; the foal's fore feet are generally beyond reach. If head is outside vulva, amputate immediately at first joint, dis secting back skin, tying it over the bone, and leaving end of cord outside. It is often very difficult to push back the foal's head, and impossible in the case of the calf. More commonly, head is in passage; here cord lower jaw and raise hind quarters of dam with bunches of straw to lessen pressure and straining, and to obtain the assistance of gravity. Guide crutch (repeller) with hand in vagina, fix it against brisket, and push foal well back. An assistant should exercise constant pressure on the crutch. Before or during repulsion, coil up looped end of cord in hand, pass it through bend of knee, draw it outside vulva, insert free end of cord through loop, and slip the running noose thus formed up, and tightly round the limb. Continue the repulsion while pulling on cord round knee, thus drawing knee upwards and forwards, and permitting a cord to be placed round pastern. The next step is to straighten the limb. With foal far back in uterus, press knee outwards towards flank of dam and bring foot round inwards, while an assistant pulls on cord attached to foot. In executing this manoeuvre, take care to double foot back into hollow of pastern, protect foot with hand, and bring it round quickly as it impinges on the pelvic brim. Also wait for an interval in the labour pains, or foot may be forced through uterus of Uterus"). Bring round other limb in the same way after again repelling foetus. Gentle traction will now accomplish delivery.
Variations. (1) One fore leg presented, other limb and head back. See"Deviation of Head,"Fig. 332.
(2) One fore leg doubled back at knee, the other extended alongside head and sometimes outside the passage. The case is simpler than Fig. 330, although the bent knee may press against pelvis and obstruct delivery. Proceed to get up the retained limb as before. If foal is alive and difficult to repel, with flexed knee near vulva, extract foetus in the false position, provided there is room and moisture (lubrication, natural or artificial). To accom plish this, cord the presented limb and head, and also forearm of retained limb; pull the latter cord upwards, pressing cannon bone close against forearm, thus pre venting the retained foot being driven through vagina.
(3) Head and two fore limbs presented, elbows flexed. At first sight the presentation seems natural, but traction fails to effect further progress. Note that the nose is too far forward in relation to the feet, sometimes beyond them, due to incomplete extension or straightening of the fore limbs. The hand detects points of elbows below the pelvic entrance, and pressed hard against it. The elbows are caught on the pelvic brim, and the shoulders are also too prominent. Delivery is simple, once the obstruction is located. Cord extremities (head and fore feet); repel foetus a little; introduce hand, palm upwards, under elbow and lift it over the bony ledge; simultaneously, assistants pull the limb in an upward direction. Handle other limb in the same fashion.
(4) Fcetus sticking at the shoulders. As before, parturi tion appears normal up to a certain point, when progress ceases. On examination, the elbows are clear, but the shoulders are wedged at pelvic inlet. Repel, and advance one shoulder at a time by pulling alternately and obliquely on the limbs.
one Fore Limb.Retained limb is bent backwards under body of foal, and proves an insuperable obstacle to normal birth. The shoulder-blade is forced back on side of chest and bulged out. Head is farther advanced than in Fig. 330, sometimes outside vulva, with one fore limb alongside it. If the hand can be introduced into the vagina on the side of the missing limb, it meets the shoulder at the pelvic inlet. At the outset, the case may be one of simple carpal flexion; but, owing to the powerful straining efforts advancing the fcetus, the bent knee is pressed against the pelvic brim, and the whole limb is gradually forced back into the uterus. The partial retention thus becomes complete. Delivery. As usual, cord the parts presented, that is, the head and fore foot; then repel fcetus towards roof of uterus. Repulsion acts in two ways—not only does it give room to manipulate the missing limb, but it causes the shoulder to slip forward on the chest wall. This brings the forearm within reach, and enables a cord to be passed round it near the knee (Fig. 331). The farther the foal is pushed back, the more the retained limb is straightened and comes into the hand. Now pull up wards on cord attached to forearm, continue the repulsion, and in this way bring the leg into the position shown in Fig. 331. Then proceed as directed. The head is always the chief difficulty. When lying near the pelvic entrance it is easily forced back into the womb; at the vulva, however, it should be promptly amputated, as above, and the stump pushed in an upward direction during repulsion. For the foal is dead, and the calf, if alive, must be sacrificed to save the dam. It is seldom or never justifiable to pull away the foal or calf by main force without correcting the deviation. Nevertheless the lamb and kid are sometimes successfully delivered in this position.
Variations. (1) Both fore limbs completely retained. This is called"Shoulder Presentation"by some writers, because the shoulders are presented at the pelvic inlet— indeed, they can get no farther—while the head is at, or near, the vulva. Proceed as before. Remove head, leaving plenty of skin tied over bone, and end of cord hanging outside. Press stump upwards and backwards into uterus, and get legs up, one at a time.
(2) Head and one fore limb far back, other fore limb presented (see Fig. 331).
(3) One fore limb crossed over neck. Both feet on same side of head, the crossed one being much farther back in the passage. Mostly seen in mare, but very uncommon. Check straining, raise hind quarters of dam, secure feet and head, cover crossed foot with hand, and lift it over poll into position. First see that the rectum (back bowel) is empty, and straighten limb before pulling. The principal difficulty is the violent straining of mare, which may drive foot through roof of vagina, and even into the rectum and through the anus.
FIG. 332. Anterior Presentation: Lateral Deviation of Head.Both fore limbs in passage; head turned back on side of chest, often beyond reach. The fore foot on same side as head is less advanced, indicating side on which head lies. This presentation in the foal is almost as frequent as, and certainly more serious than, retention of a limb. The foal's long neck is readily bent round, so that head lies on posterior ribs or flank; whereas the calf's short neck does not permit head to pass beyond shoulder or chest wall. With the pig, on the other hand, this serious deviation seldom or never occurs. Traction on the fore limbs only makes matters worse by forcing head farther back and wedging foal in the pelvic entrance. Pulling on the fore feet without examining the position of head is a very common fault. The head may be deviated upwards, downwards, or to one side. As a rule, it is displaced laterally, as in the figure, and the bent neck then blocks the pelvis. When the head is missing, deter mine its position by feeling the withers and mane above and the windpipe below. The presentation is aggravated by the early death of the foal, traction on the limbs, and the expulsive efforts of the dam. The calf's head is generally within reach, although only tip of ear may be felt at first. Delivery. Observe the preliminaries men tioned. If recumbent, never allow dam to lie on the side to which head is turned. Give sedatives for the straining, elevate hind parts, and attend to lubrication and repulsion. The statement that the farther the fcetal body is repelled the more the head is likely to advance is not a paradox; it is a fact. Therefore place crutch against sternum (brisket) and keep it there, pressing steadily away from the side to which head is turned. Once the ear is reached, it is only a matter of time before the eye socket is secured with a blunt hook. Pull on cord attached to this hook, reach the nose, and rope the lower jaw. Then bring head into the straight. In place of a cord on jaw, some prefer to insert a hook in angle of mouth. In the calf, however, unless the head is far back, hooks may often be dispensed with. Not infrequently the foal's head is quite out of range; if so, try alternate raising and lowering of hind quarters, change mare's position, pull out and repel the fore limbs, and fill the uterus with fluid to float the fcetus.
These simple measures are, in some instances, surprisingly successful. Nevertheless, in most cases, embryotomy is required; for it is seldom that a calf or foal can be delivered with the head back without fatal results. Embryotomy (amputation of a limb, etc.) is also required when the fcetus is so wedged in the pelvic inlet that it cannot be moved backward or forward. In such cases it may be impossible to pass hand into uterus. The operation is practised by skinning and removing a fore leg at the shoulder, the one which is more advanced away from the head. Owing to the calf's large head, both limbs may have to be amputated in order to secure plenty of room in which to bring the head round; or, under very favour able conditions, to extract the foetus with the head back.
But it may also be necessary to incise the entrance to the chest, remove the first ribs, and tear away all the viscera.
The fetal body then collapses. In all cases of deviation of the head, including the variations 1, 2, and 3, the hand should be kept alongside the head as it traverses the passage of the dam. This prevents further deviation after the neck has been straightened.
Variations. (l) Head and one fore leg back; other fore leg presented. Secure the latter; push back foetus; get up the missing limb, as in Figs. 330 and 331; then proceed to get the head as above.
(2) Downward deviation of head. Here the fore legs are presented, as in Fig. 332, but head is depressed between them. This presentation is uncommon. Nose of foetus drops towards sternum, and poll, or upper part of neck and mane, is presented together with one or two fore limbs.
Traction on limbs, or even each succeeding labour pain, pushes head nearer bottom of womb. On examining a bad case in the mare, only the withers may be felt; but the calf's ears can generally be reached. In either animal the nose may be lying only a short distance below the pelvic brim, allowing hand to be placed under it., and a hook in the orbit, sometimes even the fingers in the nostrils, by which means head is lifted into the passage during repulsion. A slip-noose in the mouth round the upper law may assist in raising head. Begin by cording fore feet and repelling in an upward direction, in order to separate the fore legs and allow head to rise between them. If unsuccessful, amputate a limb.
(3) Upward deviation of head, one or both fore limbs in vagina. In this variation, head is turned backwards and upwards on back of foetus. The presentation is rare.
The hand encounters lower part of neck, or front of chest, at the pelvic entrance, and the windpipe is easily manipu lated. Proceed as before. Repulsion of fetus as far back as possible with crutch firmly fixed against chest gives head a chance to drop. Pull head downwards when reached, and straighten it. Remove 111. fore limb, if necessary.
(4) Wry-neck in foal. This is a form of lateral deviation confined to the foal, associated with deformity and dis tortion of head and neck. The presentation, which is a most serious one, is often anterior, with both fore limbs in passage. Occasionally it is transverse, the foal lying across the uterus, as in Fig. 338. The foetus grows in this false position from an early stage of gestation; and the muscles, etc., of neck are so contracted and rigid that it is impossible to straighten neck either inside or outside the womb. The head is frequently beyond reach on the flank or quarter. Delivery is effected by removing both fore limbs. Occasionally one limb may suffice, provided evisceration (removal of the internal organs) is carried out. Amputation of the neck is a much more difficult operation.
Fm. 333. Dog-sitting (Anterior) Presentation. Foal doubled up; hind limbs forward under belly; five ex tremities presented inpassage or pelvic inlet. The soles of both fore and hind feet are directed downwards, a fact which assists diagnosis. The presentation is fortunately uncommon, and mainly confined to the mare; but it is one of the worst with which the obstetrician has to deal. The foal is generally upright, that is, in the dorso-sacral position. The vagina is filled with head, neck, and three or four limbs, so that it is very difficult to introduce the hand. As a rule, progress ceases when the head and fore limbs are at or near the vulva. These extremities are first encountered, and the temptation is great to cord and pull on them without examining the position of the hind feet, which lie farther back. Traction so exerted, or the violent straining of the mare, often drives the hind feet, or points of hocks, through floor of uterus or vagina, causing rupture and death of dam from uterine hemorrhage. If labour pains suddenly cease, suspect rupture (see"Post partum Hemorrhage and Rupture"). Delivery. Send for veterinary surgeon if moderate traction fails to advance foal, or immediately the hind feet are met with. Make a pit for mare's fore feet, or pack hind ones high up. Also check the straining. Frequently the foal is found too far advanced, and firmly jammed in the pelvis, when formid able embryotomy operations must be performed. The bulk of the foal may, however, lie in the uterus, and its extraction as it lies has been attempted by pulling on all the extremities, and drawing the hind limbs upwards; but the mare nearly always dies, while the foal is already dead. In the early stages (and delay is fatal, as a rule) straight porte-cords, as described under"Obstetrical Opera tions,"are attached to ropes round the hind pasterns, in order to repel the foetus. It may then be possible to straighten the hind legs far back in the uterus. The presentation is one in which it is important to distinguish between the fore and hind extremities (p. 1057, obsv. 2).
Remarks under Fig. 328 apply here. Although early pressure on umbilical cord causes death of foal sooner than in the anterior presentation, many calves coming the wrong way are born alive.
Fro. 335. Posterior Presentation: Lumbo-pubic Position. —Foal on its back; hind feet pressed against roof of vagina; buttocks sunk below the pubic brim, forming the chief obstacle to birth. Note that foal's lumbar region (loins) is opposed to the maternal pubis (floor of pelvis); hence the term"lumbo-pubic."In some cases the hind feet are still in the uterus, doubled up at the fetlocks; and the straining efforts may force them towards the rectum instead of through the neck of womb. On examination it may be found that the"os"is imperfectly opened up. If so, never attempt hasty and forcible delivery. Rather exercise gentle traction on hind limbs for a considerable time in order to excite uterine action, and complete the dilatation of the os. Delivery. See Fig. 329, and proceed in the same manner to turn the foetus round into the upright, or extract in the false, position according to circumstances. The latter, broadly speaking, should only be attempted in mares, and when the dam is roomy and the foal moderate in size. In delivering the foal as it lies, attach cords to hind feet and pull downwards. When progress is arrested through points of hocks catching on the pelvic brim, pass hand palm upward beneath the hocks, and lift them, one at a time, into the pelvic canal. As soon as hocks and feet are clear, pull in an upward direction to lift the buttocks.
Fro. 336. Posterior (Hock) Presentation: Partial Reten tion of both Hind Limbs. Hocks fully flexed at entrance to pelvis; hind feet pointing backwards away from the vulva; fcetus upright in lumbo-sacral position; hind limbs completely folded or doubled up, constituting an effectual barrier to birth. On examination the hand meets points of hocks in passage, at pelvic inlet, or below it. The tail may be close at hand, or turned over back, while the buttocks are felt just above hocks. Sometimes called"tarsal flexion,"the presentation is analogous to"knee flexion"(Fig. 330). But it is more serious on account of the extra length of the hind legs, and the fact that the hock and fetlock flex in opposite directions. This makes a hind limb more difficult to push back and turn round in the uterus, and necessitates greater care to avoid injury to the dam. Delivery. Observe the usual preliminaries (straining, elevation, and injection of fluids, etc.); then proceed as in"carpal flexion"(Fig. 330). Place crutch under tail, keep it there with steady pressure, and repel in an upward direction to clear the hocks and enable hand to reach lower part of limb; then attach a cord to call's fetlock. With the foal, and occasionally the call, the foot can seldom be reached for some time. It is necessary in the first place to pass a cord round the limb just below the hock, as in the case of the knee. This is accomplished by seizing end of cord from opposite side of limb, bringing the end thus passed outside the vulva, and making a noose or loop on it, if a spliced loop is not already present. The other end of cord is now inserted in the loop, and the running-noose which is formed is slipped up round the limb, and drawn tight. A proper calving rope has a fixed loop at one end intended for the purpose. When the calf's hind legs are extended downwards towards the udder, it is often possible with the exercise of a little patience to reach lower down the limb, and to slip the running-noose adjusted below the hock down as far as the fetlock before pulling it tight, thus dispensing with a second rope. Pulling on the upper cord, when this is in position, gradually brings the foot of the foal into the hand, provided repulsion is steadily and continuously practised by an assistant. Push also on the point of hock during the straining in tervals, and get it well back into the womb. Now slip a second noose over the foot round the pastern, pull on this cord, press hock upwards and outwards toward the mare's flank, bend toe back into hollow of heel, keep it covered with hand, and in this way bring it round inwards into the passage. Needless to say, much of the necessary traction and repulsion is performed by assistants, who must be thoroughly under the control of the operator, while the latter concentrates his attention on the various manipulations required within the womb, and, incidentally, husbands his own strength (see"Traction,"p. 1066). With one hind limb adjusted, the other is brought round in the same way. It cannot be too strongly emphasized that the somewhat dangerous manoeuvre of turning a hind limb can only be safely accomplished with the fcetus, foal, or calf pushed back very far into the uterus so as to obtain the maximum amount of room. With both limbs in position, delivery by easy traction is accomplished. Another method is occasionally adopted, as in other presentations, consisting in the extraction of the fcetus as it lies, without straightening the limbs. The method can seldom be recommended, for it more often proves fatal to the mother, although small foetuses, especially twins, may be successfully delivered in this way. If attempted, cut through the tendon known as the"ham string,"a little above point of hock, and take care that delivery is accomplished before the maternal parts become dry, swollen, and bruised. In heifers we have no hesitation in saying that the calf should seldom or never bo brought away with the hocks flexed. Yet it must be admitted that roomy mares now and then manage, by violent efforts, to expel the foal spontaneously; but they are very liable to tear and lacerate the vagina and neck of womb (cervix). A better plan, particularly when fcetus is tightly jammed in the pelvic inlet, is to cord lower part of thigh, and amputate limb through the bock-joint, removing lower portion of limb with the hand. After treating the other leg in a similar manner, the foetus is withdrawn by pulling on the cords attached to the thighs.
Variation. One hind limb presented, foot near or outside vulva; other hind limb partially retained, as in Fig. 336, with point of hock in vagina or at pelvic inlet. Delivery in this false position is easier than when both legs are back, especially if the"hamstring"of a dead fetus is divided. It is safer, however, to repel foetus, and to proceed as above. The choice of method depends on the circumstances of the case, and these show considerable variation.
FIG. 337. Posterior (Breech) Presentation, or Thigh and Croup: Lumbo-sacral Position. Complete retention of both hind limbs; tail and buttocks at pelvic inlet, blocking the birth canal; hind limbs fully extended under abdomen and chest of foetus. Sometimes, in pot-bellied cows and mares, the legs are directed almost straight down towards the udder. The presentation is most serious in these animals, but gravest in the mare, in which it ranks with"dog-sitting"(Fig. 333) as the most formidable and dangerous of abnormal presentations. In any animal, delay in rendering assistance, or the straining efforts of the dam, may cause the incomplete or"hock"presentation to become a complete or"breech"presentation. To add to the difficulties of the case, the strong expulsive efforts of the mare prove a great hindrance to manipulation, besides tending to wedge the fcetus firmly in the pelvis. Furthermore, rupture of the vagina or uterus is not un common from penetration of the feet or points of hocks. Examine in the standing position; or, if recumbent, turn the dam on her back. With the hand in the vagina, feel the buttocks, the anus, and perhaps the tail pressed against the pelvic inlet. The hocks are generally beyond reach; indeed, it may be quite impossible to force the hand into the uterus. Delivery. Before anything can be accom plished, it is essential to administer a powerful sedative, and to elevate the hind quarters to a marked extent (p. 1058, obsv. 7). In all cases in the mare, our advice is to chloroform without delay, and place in the dorsal position. that is, on the back. Cows are also more easily handled in this position, and both animals may with advantage be suspended, or slung up, by means of ropes attached above the hocks. As soon as the foetus gives or slips back a little, permitting the introduction of a stout rubber tube into the uterus, pump in several quarts of linseed tea, etc. Then push back foetus by means of a stout repeller, with the crutch end firmly implanted in the region of the anus, or against the buttocks. This allows the hand to enter uterus, and affords room to pass a half-inch cord round thigh in the manner described under knee and tarsal flexion (Figs. 330 and 336). Pulling on this cord in an upward direction, while continuing the repulsion, raises and flexes the hock, and brings the limb into the position shown in Fig. 336. The other limb is similarly handled, when the presentation becomes one of tarsal flexion, which is dealt with as described. Unfortunately, efforts to repel the foetus may prove of no avail on account of the wedging of the buttocks in the pelvic inlet, the powerful straining excited by the pressure of the crutch in the absence of anaesthesia, together with the dry, swollen, and contracted condition of the maternal passage and womb— impediments to delivery which can only be partially over come by the methods already enumerated. A less serious difficulty occurs through the hocks catching below, or on the edge of, the pelvic brim. Further repulsion, especially in an upward direction, will, as a rule, remove this obstacle, and permit the hocks to be raised. Full use should also be made of the strong cords attached to the thighs, traction and repulsion being employed simultaneously. Never theless firm wedging of the f cetus generally means the knife, the use of which should not be delayed in the mare if the hocks cannot be reached. The embryotomy opera tions include the amputation of one or both hind limbs, and sometimes the removal of the internal organs. It is possible for a comparatively small calf or foal to be born with the hind legs right back without causing the death of the mother; but rupture is very liable to occur from the excessive force required to drag a large foetal mass through the small birth canal. The procedure should never be attempted in complete retention of both hind limbs.
Variation. One hind limb presented, with foot near or outside vulva; other hind leg fully retained under foetal body. The presentation, although still serious, is less grave than Fig. 337. It is analogous to Fig. 331. Proceed as indicated above. Extraction in this wrong position is not so difficult in small animals. In mare and cow it may be attempted, in the favourable conditions mentioned, by securing the presented limb, cording the other thigh, and inserting one or two blunt hooks in the foetal pelvis to which strong half-inch cords are attached. The in sertion of sharp single or double hooks in the hips, recom mended by some writers, is a dangerous practice. Unless parturition has been too long delayed, a better plan is to cord the presented limb and push it back with the aid of a straight porte-cord (cord-carrier), while the body of foetus is repelled, if necessary, with the hand or crutch. This enables the operator to get hold of the missing limb.
FIG. 338. Transverse (Sterno-abdominal) Presentation: Left Cephalo-ilial Position. Foal lying across the uterus; lower surface of chest and abdomen towards pelvis; all four limbs in passage. Head rests on left ilium (pelvic bone) of mother, hence the term"left cephalo-ilial,"indicating side on which head lies. The heavy head frequently drops towards floor of womb (not shown in figure). The limbs, too, are often crossed, and only partially extended or straightened; they com pletely occupy the passage, rendering it very diffi cult to introduce the hand and make a proper ex amination. The presenta tion, like Figs. 333 and 337, is more or less grave.
An embarrassing feature is the presence of a bunch of limbs in the vagina, which may easily lead one to suspect twins, or even a monster. According as the front or rear limbs are more advanced, the pre sentation approaches the anterior or the posterior, rather than the trans verse. With three or four feet near the vulva, it is clear that birth cannot proceed owing to the body of the fcetus being unable to enter the pelvis. Delivery. Cord all the feet after carefully distinguishing fore and hind legs; mark the ropes. As soon as possible determine whether the limbs belong to the same foetus, i.e. that it is not a case of twins. Trace the legs upwards towards the body, and try the effect of repelling one end of foetus and advancing the other. When called in early, the veterinary surgeon is often able to turn the calf, and deliver the hind legs first. Elevate, attend to straining and lubricating fluids, push back fore feet with band, press against point of shoulder when reached, and flex the knees as they slip back into the womb. Assistants then pull on the hind feet, while the fore parts are continuously repelled, and delivery is effected in the longitudinal (posterior) presentation. The turning movement, it will be remembered, can only be carried out back in the womb; but it may prove impossible to execute in the case of the foal on account of the length of limb, the. excessive and powerful straining, and the malposition of the head (often round on the side of foal and out of reach). Indeed, the legs may be jammed in the pelvis, and repulsion is then impossible. The condition known as"wry-neck"may be present as a complication (Fig. 332, variation 4). Never theless, if circumstances permit, adopt the same procedure as in cow. Delivery in the posterior presentation is to be preferred, because the operator has but two extremities to handle, while the fore legs are easier to repel. It may, however, prove a simpler matter to push back the hind and advance the fore parts; but the head is a disadvantage, owing to the difficulty in securing and straightening it, and bringing it into the passage. With the mare it is advisable to east and chloroform, place on either side or on back according to position of head, etc., raise hind parts high, inject fluids, and apply crutch provided with a sharp spike against breast-bone or in arm-pit of foal. In the event of failure, push back hind legs, pull out the fore ones, one at a time, and amputate at the shoulder, or as high up as possible. It then becomes an easy matter to repel the chest, advance the hind feet, and extract the foal. The same method may require to be adopted with the calf.
Variations. The foetus may present at the pelvic inlet with the limbs in different positions. For example, the vagina is empty, the foal lies across the pelvic inlet as before, but its body is doubled up, and its limbs are drawn up under the body in a flexed position. No part of the foal has entered, or can enter, the pelvis. In some in stances the points of the hocks are encountered, and the bind limbs are firmly fixed across the womb. Here the foetus may be hamstrung, as in Fig. 336. The obstetrician must act according to circumstances, and deal with com plications as they arise. Amputation at joints below the shoulder and hip has often to be performed. Trans verse presentations may also require the opening of the foal's chest or abdomen and the removal of the viscera.
FIG. 339. Transverse (Dorso - lumbar) Presentation: Right Cephalo-ilial Position. Foal across the uterus, but head to the right, with back and loins presenting at the pelvic inlet. It will be observed that the foetus reaches the pelvis by its back and loins, whereas in Fig. 338 it pre sents in the opposite way. The presentation is even more serious than the latter, but fortunately it is rare, and, like Fig. 338, mostly confined to the mare. No part of the foetus can possibly enter the vagina, the limbs being beyond reach and directed away from the pelvis. On manual ex amination, a hairy mass is recognizes pressed against the pelvic en trance, sometimes covered by the placental mem branes. On tearing these away, the hand encounters the curved backbone and the ribs, while on further manipulation it is generally possible to distinguish the shoulders or hips. The foetus often lies in an oblique, not exactly transverse, position, presenting at one time the loins, croup, and tail , at another, the neck and shoulders, and, occasionally, some part of the head. As in all transverse presentations, the heavier hind quarters sink to a lower level. Delivery. Attend to the usual preliminaries; then attempt repulsion of the fore parts in an oblique direction by means of the crutch, with sharp spike embedded in a convenient spot. As soon as the tail comes round, seize it and endeavour to get hold of the hind legs. If the fore parts are more accessible, it may be simpler to press back the hind quarters of foetus, and to deliver in the anterior presentation (see Fig. 338). When these manipulations fail—and both are difficult of accom plishment—advance the trunk with hooks; divide it with knife, saw, and chisel; tear away the viscera; and, with the aid of hooks and strong cords, extract each half of foetus separately. The operation is thus a formidable one.
Variation. The writer had occasion to attend a rather unique case, in which a pair of bull-calves were successfully delivered. The first calf was presented as in Fig. 339, but half on its back, with the head missing. Efforts to repel the hind parts proved more successful than the fore, and led to a fore limb being at length drawn into the passage, and its amputation at the shoulder The other fore leg was next secured, followed by the head upside down, and the calf was eventually extracted on its back in the anterior presentation. Further examination resulted in the dis covery of a. second foetus enveloped in its membranes presenting anteriorly by the occiput and poll, the fore limb being directed backwards under the body. After rupturing the membranes the head was secured, straightened, and repelled, permitting the fore legs to be brought round, one at a time. The calf being small, this was easily accom plished.
Difficult Parturition independent of the Pre sentation. Cases show material differences, and the measures adopted must vary in accord ance with circumstances, the best use being made of the means at hand. It need, perhaps, hardly be mentioned that the above list is necessarily incomplete, both in regard to the variations which may be encountered, and the cases of difficult birth which are independent of the presentation and position of the fcetal body, as well as the arrangement of its limbs and head. The latter include: (1) Monsters and malformations of all descriptions. (2) Twins. (3) Disparity in size—fcetus too large for the birth canal. (4) Diseases of the fcetus, such as hydrocephalus or dropsy of the cranium. (5) Difficult birth arising from maternal, not fcetal, causes due to some disease, stricture, malformation, or displacement of the maternal organs. But the same general principles will guide the attendant, no less than the surgeon, in rendering proper mechanical aid at the right time. Cautious perseverance will often succeed in effecting delivery with safety to the dam, and frequently to the foetus. It is not pro posed in the space of this article to enter into details regarding the dystocias arising from diseased conditions of the fcetus or mother, concerning which full information can be obtained from text-books on veterinary ob stetrics. A monster, it may be explained, is a freak which exhibits some marked con genital deformity in one or more of its parts. The deformity is generally considered to be duc to arrest in development of certain portions of the body or limbs, while other portions grow to an excessive extent. Monsters are not of common occurrence; in fact, they are rare in animals other than the cow and ewe. But they frequently give rise to difficult labour on account of their unnatural size and shape. Examples are met with in the bulldog calf; distorted monsters with curvature of spine and body doubled on itself; wry-neck in foals (Fig. 332, variation 4); double-headed calves; two fcetuses joined together, etc. The writer has had several distorted calves presenting transversely as in Fig. 338, but with the viscera lying free in the vagina or uterus (a peculiar and at first alarming condition), three or four limbs in the passage, ribs bare, chest and abdominal cavities absent, and the skin reflected forward over the head like an umbrella turned inside out. Owing to the existence of a double spinal curvature, the shoulders, hips, and tail were brought very close together. In such cases efforts to advance or repel the fcetus often prove fruitless, particularly when injudi cious traction has jammed the parts in the pelvic inlet. If the fcetus can be moved backwards or forwards, it is noticed that the hind and fore parts invariably move in the same direction, so that it is impossible to repel, say, the fore limbs and bring forward the hind ones; the whole mass advances or recedes in one piece, and the fore parts accompany the hind during repulsion. On the other hand, in twins, for which the monster may be mistaken, it is gener ally a simple matter to push back one fcetus into the uterus and to pull forward and extract the other. This distinction is of considerable value to the operator in determining what he has to deal with when confronted with a bunch of legs in the passage. Even so, the diagnosis may remain in doubt for some time. One advantage in twin foals and calves is that they are generally small; there is more room in which to correct the unnatural presentation when it exists. Twins, however, usually cause dystocia by advancing simultaneously into the pelvis, certain extremities of each fcetus entering the canal at one and the same time. Thus the hand may meet with the hind leg of one twin lying in the posterior presentation, and one or both fore limbs, and even the head of the other coming anteriorly. More often, in cows and ewes, the head of one twin and the fore limbs of the other are presented; and the novice is much tempted to pull on these three extremities under the impression that they belong to the same animal. The rational procedure is to make a careful examination with the hand, try a little traction and repulsion to make sure, and then to push one fcetus well back to permit the other to be brought forward. A case of double dystocia in which each calf was presented in an unnatural position, but not simultaneously, is described on p. 1064 (Fig. 339, variation).
Obstetric Operations and Manipulations. Reference to the minor procedures indicated in difficult labour has been repeatedly made in connection with the various abnormal pre sentations of the fcetus, while on pp. 1057-8 a number of directions are given for the guidance of the stock-owner and his assistants. Some of the mistakes habitually made by the un skilled hand have also been mentioned. These mistakes, it will be remembered, greatly increase the difficulties encountered by the veterinary surgeon, and so lessen the chances of recovery. It remains to describe the use of assistants, the application of traction, and some of the simpler operations which have for their object the reduction in size of the fcetus. The opera tions of which a more minute description is given are those which the owner might have to perform himself in cases of emergency, when help cannot be obtained. But such occasions should seldom arise. As a rule, the amateur should place most reliance upon the intelligent use of his hands and arms; and, with the excep tion of simple cords,. he should be content to dispense with instruments, with the handling of which he is naturally unacquainted. In this way much useful work may be accomplished without serious or fatal injury to the dam. The writer's object is to present the principles of veterinary obstetrics in a simple and practical light. At the same time the application of the principles must be based on expert knowledge and extensive experience, which the surgeon alone possesses. After all, the bed-rock essentials for rational and successful interference are: (1) Plenty of common sense, perseverance, and the knack of making the best use of one's hands; (2) an elementary knowledge of anatomy and mechanics. While there is a general consensus of opinion that brains are better than force, the possession of a long head plus a long strong arm is often necessary to success. The problem which confronts us is to make the young animal occupy the least possible space. In fcetal dystocia this can only be accomplished by altering the pre sentation, the position, or the arrangement of its extremities without injuring the mother. At the same time, in deciding whether it is advisable to render assistance, not only the presentation, but the signs of parturition, the degree of relaxation of the maternal parts (especially the os), and the duration of the labour should be taken into consideration. Where any doubt exists as to the animal's preparedness to calve or foal, the introduction of the hand into the bowel or passage will furnish satisfactory evidence. At an early stage of labour, about the time that the water bladder appears and ruptures, the cow's os or cervix (neck of womb) should have a diameter of at least 5 inches, allowing the fist to move round freely. Later on, when the foetal parts complete the dilatation, the constriction caused by the os disappears altogether, and the vagina and uterus form one large cavity.
Traction.By traction is meant the applica tion of force to extract the foetus. As a rule, the force applied is the strength of three or four men pulling steadily, strongly, and simultane ously on ropes attached to the head and feet; for the mare, six is a good, safe, and controllable number. These numbers should rarely be exceeded, except in some of the posterior pre sentations. We have already remarked that assistants should be thoroughly under the control of the operator. If little or no progress is made, there is generally something radically wrong with the position of the foal or calf, and the traction should cease until a further examination has been made. It may happen that the foetus is coming all right, but the maternal parts are dry and contracted or im perfectly dilated. Again, insufficient help may be available, and the foetus must perforce be delivered by the efforts of two men. In order to make the best use of their strength, the animal, unless recumbent, should be cast or induced to lie down; the men sit facing her hind quarters, against which their feet are firmly implanted, pulling at the same time on cords ,attached, if possible, above the knees or hocks. Needless to say, these cords must be strong. More purchase is obtained by tying a cross-stick to the cord close to the vulva, such as a piece of broom shank 1 to 12 feet in length. Mechanical con trivances are very useful in certain circumstances, when assistants are few in number and power ful traction is required; nevertheless they are capable of great abuse. We shall mention only the lever and pulleys. The lever is a pole about three yards long, one end of which is used as a fulcrum in a hole in the ground, or against a stake, post, door, or other fixed object. Cords connected with the foetus are attached to the pole a certain distance from the lower end, say two feet, according to the direction of the traction. Considerable power is obtained by manipulating the upper end of the lever. It is obvious that this method has the advantage of being simple and easily controlled. It is also efficient. A great deal of force, more than with the lever, may be obtained by the employ ment of a set of light pulleys mounted on ball bearings. This appliance, although excellent for certain purposes, possesses the disadvantage of not being readily procurable, nor can its use by unskilled persons be recommended on account of the danger of rupturing the dam. There is no doubt that good calving ropes or"cords"are the simplest and most useful means of traction. Not only do they take up very little room in the passage and womb, but, being flexible, they seldom or never chafe the mother, the fetus, or the arm of the operator; and they may be pulled in any desired direc tion. Again, if the cord should happen to slip, no harm results; but slipping may be prevented by first tearing away the membranes and main taining a constant slight pull on the cord, even when it is not being used to extract the foetus. No cord should be larger than necessary for the purpose for which it is required; a small cord is less likely to slip, and it takes up less room. Although any soft, clean rope may have to be utilized, special cords are highly desirable, if only to avoid the presence of knots in the birth canal. They should be at least four in number, six if possible, soft with the strands not too tightly twisted, and made of cotton, manila hemp, or part cotton and part hemp. Cotton ropes are to be recommended owing to their softness and flexibility. A very useful pattern for practically all purposes has a spliced loop at one end through which the free end is passed to form an ordinary slip-noose, thus preventing the formation of an objectionable knot. Some cords have a running - noose at one end and a large loop for the hand at the other. In place of the loop, a cross-bar of wood may be attached, both to distinguish the rope and to obtain a better hold. The same purpose is attained by including wisps of straw at in tervals in a turn of the rope. A good outfit should include one or two such ropes inch in diameter, two or three iths of an inch, and one I inch, each about 5 feet long. The thick ropes are suitable for severe traction, the thin ones for the lower jaw, while the remainder may be termed general purposes ropes for securing the limbs and certain parts of the body. A metal ring, instead of a spliced loop, is sometimes fitted on one end of the thin rope, but it possesses no advantage; on the contrary, it is more liable to slip and to injure the soft tissues. Cords are generally attached to the pasterns of the foal, the fetlocks of the calf, and the lower jaw of either animal. Stronger cords should, however, be applied above the knees or hocks as soon as the foetus is sufficiently advanced, in order to prevent the fetlocks being torn through, or the toes being pulled off. An ordinary halter can only be adjusted when the head is close to the vulva, or actually outside the body. If the head is back in the passage, and the lower jaw threatens to give way from the excessive traction exerted upon it, the best plan is to pass the middle of a rope over the poll, bring the ends outside, and twist them until the loop is drawn tight round the throat. As the head advances, however, the nose tends to drop to one side; hence it is advisable to keep the hand alongside the head, and to apply a half-hitch to the lower jaw as it approaches the vulva. Attaching a running noose to a foot lying far back in the vagina or uterus is not always an easy matter on account of the cramped space, the membranes of the young animal, and the straining of the mother. The procedure usually adopted is to slip the noose a short distance over the fingers and thumb, taking care to maintain a slight pull on the cord with the other hand; after reaching the foot, the fingers are bent, and a gentle pull causes the noose to slip over the foot. Even this simple manoeuvre requires practice. Some times it happens that the foot is beyond reach, and the cord must be passed round the limb higher up, as described in knee and tarsal flexion (Figs. 330 and 336). For this purpose an instrument called a porte-cord or cord-carrier is often useful to hold the cord in position while it is being grasped from the other side of the limb. It consists of a steel rod with an eye in the end through which the looped end of the cord is passed; the other end of the cord is held in the hand outside the vulva. When the looped end has been secured, the porte-cord is withdrawn, the free end is threaded through the loop brought outside the body, and the running-noose formed in this way is slipped up round the limb. The instrument may be made in the form of a blunt hook with an eye near the point and a shaft as long as the arm, thus fulfilling the threefold purpose of a blunt hook, a cord-carrier, and a repeller. A straight porte cord is sometimes used to repel the hind limbs.
Amputation of the Head and Limbs.Not in frequently, simple measures of extraction fail, and certain parts of the fcetus require to be removed, either within or without the mother, in order to reduce its size and to obtain room for turning and other manipulative movements. These embryotomy operations, as they are called, have for their object the saving of the mother at the expense of the young animal; the latter, however, is generally dead or in a dying condition. It need hardly be mentioned that the amputation should not be delayed until the dam or the operator has become exhausted. In every case the part to be removed should be brought forward as far as possible, while the remainder of the fcetus is pushed well back into the uterus, and kept there either with the hand or the crutch. In this way extension and counter-extension are practised to an equal extent, and the risk of injury to the passage and womb is minimized. The injection of large quantities of lubricative fluids also assists the operation. It should be remembered that the skin is tough and offers the greatest resistance to dismemberment; so that particular care should be directed to its division and complete separation all round the leg, including the upper portion close to the body. The rule is to save as much skin as possible, and to tie or stitch the flaps in order that they may cover any portions of exposed bone. The thin cord attached to the flaps is brought outside the vulva, and is available for traction. A fore limb is amputated as follows: Use a hooked knife with a spring blade con cealed in the handle, which is provided with an eye for the attachment of a cord to the wrist; keep skin tense by pulling on a rope attached to the fetlock or pastern; carry the knife high up over the shoulder-blade, and cut the skin down outside of limb its whole length to the fetlock; detach skin carefully all round limb in an upward direction from fetlock to shoulder as far as the hand can reach by means of the fingers and a skinning spatula; with the fingers tear away the muscles attaching limb to chest wall, and divide them, if necessary, with the knife; lastly, make a circular incision through the skin all round the fetlock just above the rope. The leg is now ready to come away, and strong traction is applied to ropes round fet lock and just above knee. While assistants are pulling on these ropes, the operator's hand, or the crutch, is pressed firmly against the breast-bone. If this procedure is adopted, two or three men suffice to jerk away the limb with the shoulder-blade attached. A thin cord is then fastened to the skin flaps and left hanging outside the body. The next step is to pull on the cords attached to the head and other fore leg. If the latter requires to be removed, the head should first be repelled. Amputation of a hind limb is more difficult; the muscles and skin are stronger, and the skin is less easily separated than in the case of the fore extremity. Proceed in the same manner, commencing the incision through skin above the hip, or as high up as possible, and terminating at hock. Separate skin all round with spatula; divide the muscles both inside and outside the thigh; attach a second strong rope above the hock; and jerk limb away with four or five men on the ropes. More often, removal of a hind limb is rcquired in breech presentations (Fig. 337), when the leg is completely retained under the fcetus and pointing away from the vulva. Here the skin is cut through deeply from the neighbourhood of the stifle, across the hip-joint, as far as the rump. The muscles of thigh are then divided, the hip-joint cut into, and the head of the femur or thigh-bone liberated and secured by a cord on which powerful traction is exerted. Mean while the operator completes the skinning process all round the leg nearly to the hock, where the skin is cut through in a circular manner, and the flap afterwards carefully tied with cord to cover the bone. The leg is thus drawn out thigh foremost with the skin still attached below the hock-joint. Needless to say, the operation is a somewhat formidable one, and should only be carried out by an expert. Amputation of the head, or decapita tion, may be necessary in presentations such as Figs. 330 and 331 (pp. 1059, 1060).
Difficult Labour in the Ewe, Goat, Sow, Bitch, and Cat.The general principles which have been laid down for the mare and cow apply to the smaller animals. It is true that wide differences exist in the management and habits of the latter, and in the circumstances under which they come in labour, while their com paratively small size compels the surgeon to modify his methods and to rely mainly on his hands and fingers, which are, unquestionably, the best and safest instruments. Nevertheless, the unnatural presentations already described are common to all species; and the indications for their treatment are essentially the same.
Ewes and goats may be classed together. The shepherd will be able to exercise better supervision if those ewes which are likely to yean first are kept separate from the others. Whenever circumstances permit, the lambing pens should be situated near a house or shed in which a good fire is kept going; this assures a constant supply of hot water, and the heat will help to revive exhausted ewes and lambs. Warm drinks, such as gruel, beer, etc., may also be prepared. The shed may also contain a bench on which ewes with unnatural presenta tions may conveniently be placed. Needless to say, the pens should be clean, free from infection of any kind, and properly constructed so as to afford adequate protection in bad weather. Most shepherds have to rely on their own un aided exertions and experience, and many become expert in saving both foetus and dam. It is also the ease that the conditions under which they have to work are often far from ideal, and call for the exercise of much patience, perseverance, and endurance. They should, however, never neglect to pare and file the finger-nails, and wash and disinfect the hands (as well as cords, hooks, etc., if used) before, during, and after the handling of each ewe. The precaution is all the more necessary in the case of dead and decomposing lambs, and when septic metritis is prevalent in the flock; for infection is very often conveyed from animal to animal, and is the cause of considerable annual loss to flock-masters. The shepherd would do well to provide himself with: (1) Plenty of pure lard with which to lubricate the passage and hands; (2) soap, hot water, and disinfeetant—an ordinary coal-tar dip in weak solution answers the purpose for the hands and external parts of the ewe; (3) a few small clean cords, two short small hooks (one sharp, the other blunt), and a useful knife of a pattern to which he is accustomed—all instruments to be boiled after use; (4) a pint brass syringe fitted with one or two lengths of good thick rubber tubing for washing out the womb if the lamb is putrid, or injecting lubricants when the maternal passage becomes dry and swollen. The rubber tubing should be slipped over the wooden nozzle of the syringe, but it is well to remember that only the best rubber will stand the necessary boiling, without which the injection will do more harm than good. Ewes which are restless, isolate themselves, and strain at intervals for some hours should be watched, but premature interference is undesirable, unless it is evident that there is something wrong. Although birth may require several hours, as with the cow, and time is required for the birth canal to dilate, there is no harm in inserting the fingers, or the whole hand in aged, roomy animals, in order to ascertain the nature of the presentation. The lamb should come head and fore feet, or hind legs and tail first, all other positions being unnatural. In protracted labour the ewe often lies down after a time, when it is an easy matter to place straw under the hind quarters. In the standing posture she may be tied in a corner between two hurdles with the fore feet in a hole in the ground. In exceptional eases it may be advisable to administer a sedative draught consisting of a full tablespoonful of laudanum in half a pint of warm gruel. If the patient becomes exhausted, a little warm beer or whisky may be given with advantage, but in the majority of instances stimulants are best given after the birth of the lamb, not during a difficult labour. This remark applies to all the domestic animals. When it becomes necessary to extract the lamb, care must be taken to place it in a natural position before employing much force. But the retention of one fore leg need not delay delivery. Cord the head and other fore foot, pull them upwards and forwards towards the tail, and press the bent limb close against the chest of the foetus. Unless in roomy, old animals, retention of both fore limbs (Fig. 330) calls for repulsion of the head after securing it with a cord or blunt hook. This brings a leg into the hand and finally into the passage. Even when the head is outside the body and swollen, the lamb is frequently born showing some signs of life; and it is remarkable how quickly it re covers. Nevertheless, with the fore legs miss ing, the ewe exhausted, or the lamb dead, amputate head without delay, as in Figs. 330 and 331. Pushing back the stump then enables the fore legs to be reached. Amputation of the latter is seldom required in the ewe. The frequency with which twin lambs advance simultaneously into the pelvis should be borne in mind. One lamb should, of course, be repelled and the other brought forward. Monsters appear to be rather more common in ewes than in the cow.
Sows seldom require assistance during par turition; the little pigs are generally smaller than the maternal pelvis, so that birth takes place quite easily. In the anterior presentation it is not uncommon for the fore limbs to be retained—bent back—under the body of the fcetus; yet, as long as the head is straight and able to pass through the pelvic inlet, no trouble arises. The procedure in difficult labour in the sow resembles that adopted for the cow and bitch. Unlike the calf, however, the short thick neck of the pig is very seldom deviated (Fig. 332). The most difficult proposition, as in the bitch, is a dead pig lying far back in the uterus, especially if the labour pains are ex hausted. The surgical treatment of such cases includes the raising of the hind quarters in order to fill the uterus with a quantity of warm water containing a little boracic acid; the hind parts are then lowered and the abdomen vigorously manipulated so as to press the fcetus back towards the pelvis. In any malpresenta tion use hooks and forceps very cautiously, if at all. As in other multiparous animals, the head is the chief obstacle to delivery; the short limbs, fore or hind, seldom give rise to serious dystocia.
Bitches and Cats.While all breeds are subject to dystocia, the short-nosed breeds of dogs with large dome-shaped heads, and well bred Persian cats, are most liable. Like the sow, the head is most likely to cause obstruction to birth. Whereas the terrier pup's long, low head acts like a wedge in dilating the birth canal, the blocky, upright head of the Blenheim, for example, not infrequently sticks at the pelvic entrance or in the passage. Pugs, bulldogs, Japs, King Charles and similar breeds suffer to an equal extent. As in other animals, there are two natural presentations of the puppy and kitten; namely, nose and two fore feet, or tail and hind legs first. When coming anteriorly, however, it is not uncommon for one or both fore legs to be bent back under the body of the fcetus without material obstruction to birth.
Difficult labour with small, as well as large, animals may be due to the mother or the fcetus, occasionally to both. One of the commonest maternal causes in the bitch is a weakness, or want of expulsive power, in the womb, to which the term"uterine inertia"is applied. Pam pering and lack of sufficient exercise are among the factors which give rise to it. This serious condition must be promptly and vigorously dealt with if the life of the mother is to be saved. The aim of the surgeon is to stimulate the natural contractions of the uterine walls by means of heat, massage, warm douches, and, in the event of the puppy being reached, by exercising gentle but steady and continuous traction upon it. Certain drugs, such as pituitrin and ergot, which act directly upon the uterine muscle, are also indicated. The worst cases are those in which the fcetus, one or more, is dead and lying beyond reach towards the extremity of the uterine horn. When this contretemps occurs, the retained puppy under goes rapid decomposition, and the mother, un less relieved, soon succumbs to septic poisoning (see"Metritis"). Various conditions give rise to foetal dystocia, of which the following are the chief: (1) The pup is too large to pass through the pelvic canal. As a rule the bitch has been lined by a dog of a much larger breed; but it sometimes happens that the disparity in size is due to a small litter, consisting of one, two, or at most three puppies. Naturally these attain a larger size than in multiple pregnancies. (2) Two foetuses approach the pelvic inlet simultaneously, blocking the entrance to the passage. This accident, it will be remembered, occurs rather frequently in twin lambs, and to a less extent in twin foals and calves. (3) A malpresentation, or a monster, obstructs delivery.
Dog-owners and dog-lovers naturally wish to know when and how to give assistance in what, at the outset, appears to be a normal parturition. If they cannot consult a pro fessional man, they should pay particular attention to the duration of the labour and the strength of the patient. Speaking generally, when straining continues for some hours and no progress is made, either with the first fcetus or with those which follow, no time should be lost in placing the bitch on the table in the raised dorsal or lateral position, that is, on the back or side. With antiseptic precautions the finger is introduced into the vagina, while the abdomen is manipulated with the other hand, and the puppy pressed back towards the pelvis. At the same time the lips of the vulva may be drawn apart by an assistant, or a vaginal speculum may be inserted. If the young animal can be felt in the passage, continued manipulation with the finger and lowering the hind quarters may in time effect its removal. But a long button-hook, a pair of good forceps, or a wire loop may be needed to secure the presented parts and exercise gentle and con tinuous traction upon them. Much time and patience may be necessary before these efforts are successful. Yet instruments often prove dangerous weapons in unskilled hands; and when the pup is still in the uterus their use should be discouraged. From the foregoing
remarks it will be gathered that the chief thing is to secure and deliver the head, supposing the foetus is presenting anteriorly. In all mal positions much assistance is obtained by the intelligent manipulation of the head through the abdominal wall; but too much force should never be exerted on any of the extremities. Too often, powerful or jerky traction causes the foetus to become broken up; bits of the puppy come away with the forceps, while the remainder is left behind to undergo putrefaction, and obstruct delivery of those still within the womb. Birth is also facilitated by the free use of lard or boracic ointment for the double purpose of protecting the maternal passage and lubricating the finger and vagina. The uterus, as in the sow, may be filled with warm boracic solution, which serves to excite uterine action and force the pup in the right direction. The hind legs should be raised during the injection, and afterwards lowered. In carrying out these manipulations, especial care should be taken to avoid wounding the mucous mem brane of the vagina and uterus, owing to the great danger of metritis and septic poisoning supervening in the bitch. Injuries are easily produced by forceps, hooks, the finger-nails, or the sharp projecting bones of a broken-up foetus. The failure of simple measures in serious cases of dystocia calls for the performance of one or other of the operations known as Caesarean section, and excision of the uterus. But these operations, to be successful, must be performed in good time before the pup (or puppies) has become putrid and the dam exhausted. In both, the patient is chloroformed, and the uterus is exposed through an incision in the abdomen. In Caesarean section, however, which has the advantage of conserving the breeding powers of the bitch and cat, the opening made in the uterus for the removal of its contents is afterwards stitched up, and the organ is returned into the abdominal cavity. As might be imagined, the operation is much less successful than the more drastic procedure of excision of the entire uterus and ovaries, which gives a good percentage of recoveries.
Inversion of the Uterus. Prolapse of the Womb.These names are applied to a common and dreaded accident in which the womb is turned inside out immediately or shortly after a full-term birth, seldom after abortion. All animals are liable to inversion, but the cow is the most frequent sufferer, followed somewhat closely by the ewe. Occurring occasionally in the mare, it is comparatively uncommon in sows and bitches, although we have met with more cases in sows than mares. Prolapse of the vagina may be mistaken for the womb by the uninitiated, especially in small animals like the bitch (see"Inversion of Vagina"). In the mare and cow the return of the uterus is accomplished with great difficulty owing to the severe and continued straining, and the weight of the protruded viscus, which becomes much swollen and full of blood and fluid. The powerful expulsive efforts of the mare, and her susceptibility to inflammation of the womb and its covering (metro-peritonitis), often lead to a fatal result in this animal; whereas cows, ewes, and goats, subjected to early rational treatment, frequently recover. Yet any animal may die in a short time from exhaustion, or, later on, from inflammation, mortification, or septic poisoning. The mechanism by which the accident is brought about is not thoroughly understood, for it occurs under widely varied circumstances. It would appear that, whilst the uterus is in a weak relaxed state, its extremity suddenly becomes contracted and slips into the dilated portion immediately behind it, until the whole or the greater portion of the womb hangs outside the passage, with its red mucous lining forming the external covering. The telescoping process may be compared to turning the finger of a glove inside out. In the cow the"bed"usually comes down within four to six hours of calving; indeed it may follow the calf almost imme diately, or its appearance may be delayed any time up to the forty-eighth hour. Late cases, however, are rare, and are mostly preceded by early partial inversion in the vaginal passage, followed by complete inversion after a certain time. As in woman, it is highly probable that the process begins at, or very shortly after, birth; although it may fail to attract attention until the final stage is reached. The accident depends mainly on three factors, a knowledge of which is essential from the point of view of prevention: in the first place, the neck of the womb must be wide open to enable the large organ to pass through—for this reason, inversion can only take place at parturition, or shortly after; secondly, strong expulsive efforts are necessary to force out the uterus — these depend, as a rule, on infection, injuries, and retention of the afterbirth, all of which excite irritation and straining; thirdly, the hind quarters are generally at a lower level. Too much importance cannot be attached to the relative positions of the fore and hind extremi ties. The cow is often a roomy animal, has bred several calves, and has been allowed to lie down within half an hour of birth on a sloping floor, frequently with her hind parts resting in the gutter. According to some observers, inversion is liable to follow a difficult parturition. On the contrary, the majority of cows and sheep give birth quite easily without assistance. That some cases do follow difficult labour, more especially in the mare in our experience, must be admitted. The accident may even occur during delivery. Thus, when the uterus is dry and tightly contracted on the foetus, owing to the natural waters being long expelled, it is possible, by the exercise of excessive traction, to pull out both the organ and its contents; but such cases are of rare occurrence.
Symptoms in the Cow, Ewe, and Goat.In the first stage, before anything appears at the vulva, the animal becomes very restless, exhibits uneasy movements of the hind feet and tail, and lies down and rises repeatedly. During the bearing-down pains, which increase in frequency and severity, a rounded, red, fleshy mass is seen between the lips of the vulva. So far the inversion is only partial, and prompt measures often succeed in preventing complete prolapse; but, as a rule, the animal is unattended, and the uterus is quickly pro truded, and hangs down over the hocks. The neck of the organ is constricted, impeding the circulation, and the viscus thus becomes increasingly congested, swollen, and dark in colour, thickened and jelly-like from fluid passing out of the blood-vessels into and under the mucous tissue. The irritation produced by exposure to the air and contact with the floor, bedding, excretions, etc., soon causes inflamma tion of the mucous membrane and constant straining, which continues until the patient becomes exhausted and unable to rise. The surface of the womb is covered with large red projections, termed cotyledons, to which portions of the placental membranes are often attached. These cotyledons readily bleed when handled, but the haemorrhage is never profuse or dangerous. We have never yet encountered a case of"flooding"in the lower animals. Furthermore, the unprotected organ is fre quently injured by the animal's feet, the ground in lying, rubbing against the wall or side of the stall, the hands of attendants, and even by the bites of dogs; it also becomes covered with filth. In these ways the delicate covering is lacerated and torn, and complete rupture may take place. Mortification (gangrene) may also follow prolonged exposure and injury, especially when the accident recurs. This complication, which is always fatal, is met with more com monly in the ewe; for powerful straining efforts, following the natural expulsion of the lamb and membranes, may cause the whole uterus to again protrude after it has been successfully replaced.
Prevention and Treatment (Cow, Ewe, Goat). Prevention consists in keeping the dam on her feet and under observation for a short time after parturition. The control of excessive straining, the elevation, if necessary, of the hind parts, the avoidance of injury to, or infection of, the genital passages from the hands or instruments of attendants during delivery, are also important preventive measures which should never be neglected. Nor should too much traction be exerted on the foetal membranes (afterbirth) in cases of retention. Animals which have once suffered from inversion are generally considered to be liable to a recurrence at a subsequent parturition; but, according to our observations, they may be bred from with impunity, provided ordinary precautions are observed.
Treatment, needless to say, should be com menced immediately in order to avoid a fatal termination; for the longer the uterus is outside the body and allowed to hang down, the more swollen it becomes, and the greater the difficulty experienced in returning it. Often, we have marvelled at the neglect of the most elementary common-sense precautions. First aid should be directed to cleansing the viscus with warm water, or milk and water, and suspending it with a clean sheet held by two assistants, one on each side of the cow, who should endeavour to keep the mass level with, or even higher than, the vulva. In the first stage, before the inversion has passed much beyond the external orifice, the hands and arms should be washed and disinfected, and the fist, covered with a soft cloth, placed against the extremity of the mass, which is pressed back as far as possible into the vagina. The hand is kept in position until the arrival of veterinary assistance, while every means should be adopted to check the straining. The standing posture is undoubtedly best. Elevate the hind quarters one foot or more by filling up the channel behind the stall, and spreading a thick layer of short litter over the rear of the standing. When the cow is in a box, tie her up short, and either make a hole for the fore feet or raise the hind ones with straw, etc. In order to keep the, hind feet on the heap, battens, bundles of straw, or similar material, may be placed on each side of the animal. The raised position, it is scarcely necessary to point out, takes advantage of the force of gravity, throws the weight forward, and lessens the power to strain. For sheep, two hurdles may be placed in the form of a V, the head being tied in the corner of the hurdles, and a hole made for the fore feet. Too much importance cannot be attached to the relative position of the fore and hind extremities in all species. The ewe, or any other animal, may be placed on her back. To a large cow (or mare), one to two wirieglassfuls of laudanum, or one to two ounces of chloral hydrate, may also be given with advantage as a sedative; the latter should be dissolved in a quart of tepid water to which a little treacle or gruel is added; the laudanum is readily administered in a pint of cold Straining may also be checked by pinching the back, or by tying a soft rope loosely round the chest and tightening it up with a stick. Excessive pressure, however, will cause the cow to lie down. The uterus having by this time been thoroughly washed and cleansed, a continuous stream of cold water may be applied. The veterinary surgeon then proceeds to remove the membranes, empties the bladder at once or later on, and makes a careful examination of the womb for injuries, stitching wounds if they require it. The latter procedure is, however, seldom necessary. When the cow is recumbent, she should be placed on her right side with straw under the hind quarters, or ropes may be attached above the hocks and passed over a beam or through pulleys, especially if the animal is turned on her back. The next important step is to reduce the size of the uterus by squeezing out the greater portion of the fluid and blood which it contains. This is accomplished by twisting the ends of the suspensory sheet and pulling in opposite directions; or a cloth may be folded over the organ and a long, broad bandage tightly and evenly applied over the cloth from the extremity as far forward as the vulva. Pressure and kneading with the hands is also of great assist ance, but scarification of the mucous membrane should not be lightly undertaken. During these manipulations the doughy mass should be continually moistened and cleansed with a mild astringent and antiseptic solution; a one per cent solution of alum in cold or hot water can be recommended, best results being obtained by using cold and hot applica tions alternately. The uterus is now ready to return to its natural position. In simple cases this is easily accomplished, as already indicated, by placing the fist against the most dependent part, which has been raised level with the vulva, and pressing back the protruded mass during the intervals of -straining, taking care to main tain sufficient pressure during the expulsive efforts to prevent further inversion taking place. When the uterus enters the passage, one hand replaces the other, the cloth is removed by a twisting movement, and the organ is finally straightened out in the abdominal cavity by introducing the arm to its full length, and leaving it in position for fully ten minutes until the straining has abated. Unfortunately, the whole uterus is generally found inverted, when this simple method of replacement is inappli cable. Here the surgeon begins with the portion nearest the vulva, returning the suspended viscus by degrees, until, after laborious work, the greater part has been pushed back into its natural cavity. The fist, or a bulbous wooden For dose for ewe see"Inversion of Vagina." instrument, is now used, as before. Finally, the womb is filled with a warm, non-irritating antiseptic fluid, e.g. per cent carbolic or creosol solution, which not only cleanses, dis infects, and straightens out the organ, but stimulates its contractions and consequent reduction in size, on which so much depends. Contraction of the whole reproductive apparatus is also assisted by allowing the calf or other young animal to suck. The operation is com pleted by allowing most of the injected fluid to be expelled naturally, after which the remainder is siphoned off, and a sedative anti septic pessary may be left in the empty uterus. Some means of retention, is now generally adopted in order to prevent a recurrence of the accident, although it should be remembered that complete replacement of the clean, unin jured uterus is the best safeguard. The insertion of a champagne bottle or pig's bladder is an old method of bringing pressure to bear on the"os"or neck of the womb; a stick, fixed in the neck of the bottle, protrudes from the vulva and is tied to a surcingle, or, more commonly, to stitches in the vulva or to a truss. But the pessary, as it is called, tends to irritate the parts and to excite straining, hence we have long since discontinued its use. A less objectionable method, and one frequently employed, is to pass three stitches of waxed cord tape, or wire, deeply through the lips of the vulva, taking care to leave the lower portion unstitched for the passage of urine. The stitches, however, are liable to tear out and cause ugly wounds during the straining efforts, and for this reason the cord or tape may with advantage be tied on each side to pieces of solid rubber tubing, which can be easily kept clean. Wire sutures, being non-absorbent, are to be recommended, provided the ends of the horizontal pieces which traverse the vulva are long enough to enable them to be bent round with pliers to form rings or hooks through which a vertical wire pin is inserted on each side, and clamped with forceps. This simple bolting arrangement enables the stitches to withstand considerable pressure. The well known West's clamp, of which small sizes are made for sheep and other animals, answers the same purpose. In the ewe it is a good and common plan to tie a lock of wool over the external opening. Some form of truss should always be applied, with or without the insertion of stitches. Whilst advocating the double precaution of stitching and the application of a truss, we would point out that all mechanical appliances must needs fail when the animal is allowed to strain violently and lower her hind quarters. For the truss no special apparatus is required. Take a full-length plough line, or a clothes line not less than 25 feet long; place the middle of the rope over the back a little behind the withers, bring the ends down on each side of the chest, and tie in a single knot below; then pass the ends forward between the fore legs, tie a single knot at the brisket or lower part of the neck, and another at the top of the neck, thus making a collar of the rope. Now carry each rope back along the spine, take a turn round the first part applied to the chest, and, standing behind the cow, cross and recross the ropes. A single knot may now be made below the tail, and another below the vulva, but a better plan is to apply a special loop or knot, for example, a simple figure-of eight knot made flat and broad to cover the vulvar aperture. The truss iron is an alter native method much in vogue. Each rope is next passed between the hind legs on each side of the udder and carried forward and upward to the loins, where they are finally tied together. It will be readily understood that the truss requires frequent tightening and adjustment, owing to the slackening and displacement of the ropes when the animal lies down. To tighten the truss commence with the first portion round the chest, on the adjustment of which the animal's ability to strain greatly depends. The truss iron is a V-shaped instru ment, applied to the vulva, which may be made by any blacksmith. The base of the V is uppermost, each arm being provided with a ring through which the truss rope is passed. Both ropes are then threaded through a larger ring situated at the apex of the triangle placed just below the vulva. The French pattern is also easily made and very ingenious, consisting of steel wire jointed in the centre, and designed to constrict and pinch the lips of the aperture without injury or inconvenience to the patient.
The subsequent treatment varies according to the symptoms presented by each individual case. Should the cow strain a good deal after the operation, a second and even a third dose of sedative medicine may be administered . on the other hand, when there is much weakness, exhaustion, or collapse, alcoholic- stimulants are indicated. As a rule a purgative is given, followed by a little fever medicine, but com plications require special handling on the part of the veterinary attendant. On the second day we have found it advisable to repeat the washing-out and disinfection of the uterus. Although this procedure is not always necessary, and necessitates the removal of the stitches, it will be found to give a larger percentage of recoveries. There is less chance of septic poisoning and inflammation of the womb super vening (see"Metritis"). The animal should, of course, be kept quiet and made as comfort able as possible, the surroundings should be clean, and the external parts frequently rinsed with an antiseptic. The hind quarters may be gradually lowered after the second day. In a short time the cow is removed to a loose-box with a good bed, and given a little gentle exercise. In favourable cases the animal is little, if any, the worse for the accident, and the appetite and secretion of milk quickly return. But injuries and septic complications, which do not prove fatal, cause loss of milk and condition, a discharge from the vagina, and more or less sterility. The cow goes over repeatedly to the bull."How long may the uterus be out and yet be successfully returned ?"The question is often raised in regard to the cow and mare. The answer is:"Four or five hours; some cows, but very few mares, recover after prolonged exposures up to twelve hours." Inversion in the Mare.Inversion is less common in the mare, but considerably more dangerous and more difficult to remedy than in ruminants. In our experience it follows a wrong presentation more frequently than in the cow, although foaling may take place quite easily and naturally. Unlike the cow, the membranes are seldom attached to the inverted womb. The mare is very uneasy, paws with her fore feet, and may roll in great pain as in spasmodic colic. A few mares even attempt to kick or bite the prolapsed organ. Reduction is effected in the same way as in the cow, the chief difficulty being the control of the mare, especially in the case of young vigorous animals. The twitch, rope hobbles, chloral or even chloroform, with considerable elevation of the hind quarters, may be required to prevent injury and to abate the violent expulsive efforts. Another plan is to open the windpipe and insert a tracheotomy tube; but this somewhat extreme measure is seldom required. Keep the mare on her feet if possible, but, when recumbent, tie the feet and keep the head down. Subsequently, in applying the truss, see that a pad is placed under the tail. Avoid sutures.
Inversion in the Sow, Bitch, and Cat. Not uncommonly the inversion is incomplete, only a portion of the womb being turned inside out and protruding from the vulva. Few successful cases have been recorded in the sow. The great length and size of the two horns of the uterus, often as large as the vagina itself, make reduction very difficult; and the sow generally succumbs within twelve hours, unless amputa tion is promptly performed. One horn or branch of the uterus may be followed by the other, but the small size of the sow's vagina seldom permits the passage of both horns at one and the same time. Serious injury to the prolapsed organ also takes place, and the animal becomes rapidly prostrated. In bitches, it occasionally happens that one horn becomes inverted, imprisoning the puppies in the other horn, which remains in its natural position. One difficulty in the smaller species is the small size of the pelvis, which may admit only one or two fingers, requiring the use of a pestle or wooden pessary provided with a bulbous end like a constable's staff, or an ordinary tallow candle, in order to return the womb. Another is the trouble experienced in keeping the viscus in its place after reposition. Trusses are useless, but morphia is invaluable in the bitch, whilst the same principles of elevation, massage, and retention by means of stitches are observed as in the cow. The animal should be suspended by its hind legs on a bench or table; the uterus, after return, is then filled with fluid, which is expelled by lowering the hind parts and pressing gently on the walls of the abdomen. Generally speaking, when both horns have been inverted for some time, or re-inverted, amputation should be resorted to. Yet the surgeon has certain advantages in dealing with small animals which he does not possess in the larger species. Not only are the expulsive efforts and the weight of the uterus less formidable obstacles, but the abdomen of small patients may be opened, and the uterus drawn into position and stitched to the side. Again, amputation is more successful than in the cow and mare.
Amputation of the Uterus.This operation, like most of the above procedures, demands the services of a qualified surgeon; yet in stances may arise which require the intelligent stock-owner to rely on his own unaided efforts. Excision becomes necessary when it is impos sible to return the womb, or to retain it in the abdomen after replacement; also in cases of serious injury or gangrene, when grave risk would be incurred by pushing back the uterus. In the sow, as already indicated, amputation is often the only means of saving life. We have seen several mares recover, but the operation is always most serious in this animal. After thorough cleansing and disinfection of the womb and hind parts, a small incision is made in the viscus to admit the finger, in order to ascertain that no portion of the urinary bladder, or small intestine, is included in the cavity. These organs, if present, are easily returned into the abdomen. A straight sacking needle, or other instrument, threaded with a double cord or strong silk, the whole previously boiled, is then passed through the neck of the womb close to the vulva, taking care to avoid the opening into the bladder. The ends of the cord are tied tightly on each side, and then all round the neck of the tumour. This old method of ligation can be recommended as a safe procedure in any animal, owing to the fact that the ligature cannot slip, no bleeding can take place, whilst the stump soon sloughs away. The uterus is now cut off an inch or more below the ligature, the stump, after disinfection, is returned through the vagina, and the passage itself is syringed out for ten days or longer, until the discharge ceases.
Chloroform, morphia, or some other narcotic should be administered in this, as in all other painful operations. The uterus should also be reduced in size, and handled as described under the head of inversion. As soon as possible after the operation, the young animal should be returned to the dam to keep up the secretion of milk. Ruminants and pigs are fattened, although a good cow may remain in milk for a long time. Some animals become excited, or strain a good deal after amputation; others, already weak and exhausted, show symptoms of collapse. Hence sedatives or stimulants may be required according to the case, with plenty of nourishing gruels and teas, milk and eggs, port wine, etc.
Inversion or Prolapse of the Vagina.Whilst inversion of the vagina or passage may occur in any species, it is mainly confined to the cow, ewe, and bitch. These animals also suffer from this accident during advanced pregnancy, especially roomy fat cows and ewes which are closely confined during the winter months, warmly housed, and highly fed for the produc tion of milk or early lambs. A relaxed, dilated condition of the vagina is thus induced which renders the subject liable to the more serious form of inversion which occurs after birth. Standing and lying on sloping floors is also a predisposing cause in the cow. The exciting cause is any irritation in the genital passages which excites straining and backward pressure on the pelvic cavity in which the vagina is lodged. Thus the vagina, like the uterus, may be turned inside out during attempts to expel the retained afterbirth, and the straining efforts due to the presence of infected wounds and inflammatory conditions of the uterus and the vagina itself. Not uncommonly inversion is a sequel to difficult birth, especially when the parts are dry and contracted and much force has been employed in the extraction of the foetus.
Symptoms. — A rounded reddish swelling appears during the straining at the orifice of the vulva, which shows no tendency to dis appear. On the contrary, it increases in size until the whole organ may be outside the body. In the mare and cow the mass may attain the size of a man's head. It undergoes the same changes as the uterus, becoming much swollen and inflamed, dark in colour from prolonged exposure, and injury to the delicate mucous covering is of frequent occurrence. The pressure on the urethra, or opening of the bladder, also leads to distension of the latter organ and difficulty in passing urine. The causes and symptoms therefore bear considerable resem blance to inversion of the uterus, but there are important differences which should be borne in mind. In the first place, vaginal prolapse is a comparatively mild accident; there is less straining, less general disturbance and danger to life. Secondly, the mucous membrane covering the vagina is quite smooth in recent cases, free from foetal membranes (afterbirth), or the eminences for placental attachment peculiar to ruminants known as"cotyledons."Thirdly, when the whole of the passage is inverted, a distinct depression, or circular opening, is present at its inferior extremity, into which the finger may be passed into the neck of the uterus. Nor should the vagina be mistaken for the urinary bladder (see"Inversion of Bladder"), the cleansing or afterbirth, or a tumour adhering to the mucous membrane. A careful examination will enable the experienced layman, as well as the expert, to recognize the true nature of the protrusion. Veterinary surgeons are frequently summoned hurriedly to such cases, and must be prepared to deal with any accident or complication. Chronic inversion is also met with, and may prove very troublesome.
Prevention and treatment should follow the lines laid down for inversion of the cow's uterus. We have little to add to the directions already given. When the prolapse occurs at birth, it is washed and pushed back at once with little or no manipulation; but the swollen, inflamed, exposed mass must be thoroughly cleansed, disinfected, and its volume reduced, before it is returned by steady gentle pressure with the fingers and palms of the hands. If necessary, it may be painted with cocaine and a sedative given to the patient to keep her quiet. The operator must attend to his finger nails and remember that it is quite easy to push a finger through the inversion and rupture it. As the vagina slips back into its place, it should be followed by the hand to make sure that all the parts are properly straightened out. The vagina is retained by mechanical means, and precautions are taken to prevent recurrence, in the same way as the uterus. These include suturing or clamping the vulva, the application of a truss, raising the hind or lowering the fore parts, sedative applications like extract of belladonna, and other measures which lessen the animal's power or inclination to strain. The average dose of laudanum for the ewe is one tablespoonful (maximum li) in half a pint of gruel, water, or rather less of linseed oil. It is also necessary to combat the uterine infection which frequently coexists and keeps up the irritation. For this reason an examination of the uterus should always be made in order to remove any fragments of afterbirth, and to wash out and disinfect the cavity.
Inversion of the Vagina in the Bitch. Middle-aged and old animals are most subject to this accident, especially after parturition; but partial prolapse is not uncommon during heat (cestrum). At such times the animal's behaviour—rubbing, licking, and straining— draws attention to the presence of a rounded tumour projecting beyond the vulva. The vagina may even be pushed out before or during birth, interfering with the delivery of the puppies. In size, the protrusion varies from a small plum or pullet's egg to a large orange or child's head. Small and white at first, the colour changes with the length of exposure to air and dirt, becoming dark red or almost black. The condition is serious in brood bitches, for it is always liable to recur, and prevent conception when the bitch is mated. Apart from sterility, the constant irritation in old - standing and recurrent cases may give rise to ulceration, injury, and even mortification of the vagina, whilst there is generally some difficulty in the passage of urine. Furthermore, the mucous lining becomes dry and roughened, thickened and wrinkled, until the parts become almost unrecognizable, and impossible to retain in position after replacement. The fact that the vagina of the bitch is more likely to be mis taken for the uterus than in other animals should be borne in mind. Treatment is a simple matter when the freshly inverted organ is washed and promptly replaced, and the patient kept quiet, clean, and short of food. Even in neglected cases an attempt should be made to effect a cure by simple measures— bathing with hot, or hot and cold water, con taining a little alum or Condy's fluid, lubricating with olive-oil or boric ointment, raising the hind parts, compressing and squeezing the tumour with the fingers, and, if necessary, injecting one grain of morphia under the skin to prevent present and after straining. With the same object the surface of the vagina, as mentioned above, is also painted with cocaine. Lastly, when the whole of the inversion has been returned and straightened out, the usual stitches are inserted deeply through the lips of the vulva. In bad cases, hoWever, amputation is often the only resort. The operation, although less formidable, resembles amputation of the uterus, and it is performed for the same reasons, care being taken to avoid the opening for the passage of urine. Unfortunately, amputation renders the bitch useless for breeding purposes. In younger animals, therefore, an alternative method may be tried by the surgeon. This consists in opening the abdomen, and pulling gently on the uterus, to draw the vagina into its natural position. The uterus is then stitched to the side of the abdominal wall. A cure effected in this way possesses the great advantage of conserving the breeding powers of valuable animals.
Inversion or Prolapse of the Bladder.This uncommon accident is met with mainly in the mare as the result of violent expulsive efforts during and after foaling. Somewhat rare cases occur in the bitch, sow, and cow; but we shall confine our remarks to the mare. In this animal the urethral opening is of large size and situated on the floor of the vagina a few inches from the vulva. Two fingers can easily be inserted through the opening into the bladder, which lies immediately beneath the vagina or passage. When inversion takes place the empty bladder is forced through the wide urethral opening, and turned inside out like the finger of a glove. The red mucous lining then forms the external covering, the orifice through which it has passed cannot be felt, whilst the ureters (tubes which convey the urine from the kidneys) can be seen opening, one on each side, near the neck of the bladder close to the vulva. Occa sionally the accident occurs before foaling, when great care is required to prevent serious injury to, or rupture of, the bladder during birth. Although the inversion may not obstruct delivery to any extent, it undoubtedly compli cates a wrong presentation of the foal. In one case which we attended, the bladder appeared outside the vulva 24 hours after parturition, during the efforts of the mare to expel a portion of cleansing from the womb. In appearance the mass is red, fleshy-looking, and somewhat pear shaped, becoming in time much swollen, rough, and dark in colour or black from exposure to air and dirt, and interference with the circula tion. In recent cases, however, the surface is quite smooth and fresh, and little of the bladder may be seen during the intervals of straining. A constant and characteristic symptom is the dribbling of urine from the mouths of the ureters. Seeing that no urine can collect within the bladder, it continues to trickle down the thighs, irritating the skin and removing the hair. The urine is often ejected in a considerable stream during the straining efforts, particularly when the bladder is touched with the fingers. The attendant or owner who bears these facts in mind need have no fear of mistaking the bladder for the cleansing, the uterus or vagina, or even for a vaginal tumour; but it is always advisable to insert the hand and trace the inversion as far as the urethral opening, from which it appears to arise. Although the condition is more dangerous than inversion of the vagina, recovery is the rule when the mass is returned without delay. A great deal depends upon the length of exposure, and the presence or absence of injuries and complica tions. Treatment consists in checking the straining and returning the organ, after thorough cleansing, through the urethral orifice. In the early stages this is not difficult, unless the bladder suddenly appears during foaling, and reappears immediately it is replaced in position. When this happens the mare should be turned sharply round, and cold water dashed over the loins. The twitch also serves to distract her attention until a dose of sedative medicine has had time to act. Inflammatory changes, with thickening of the bladder walls, call for gentle massage and firm pressure with the hands to reduce the swelling. Manipulation is also assisted by douching with hot and cold water alternately; a little common salt, alum, or boracic acid may be added to the water. Both to assist reduction and to prevent recurrence, the mare and cow are kept quiet with chloral hydrate, the bitch with morphia, the hind quarters being elevated, and the bladder, after return, filled with cold boracic or salt solution. When reduction is partly effected, we have found a metal catheter covered with rubber tubing a useful instrument with which to push back the remainder of the organ. After several days' exposure it may be necessary for the veterinary surgeon to cast and chloroform the mare. He may also have recourse to amputation by means of the ligature and knife when the bladder is torn or ruptured, or impossible to return or keep in position. The ligature is applied behind the orifices of the ureters; but the constant dribbling of thine which follows the operation is a great drawback.
Retention of the Foetal Membranes, After birth, or Cleansing. The fatal membranes or"cleansing"are generally shed a short time after birth. The manner in which this important natural act takes place requires some considera tion in order to understand the changes which take place in disease. As soon as the umbilical cord connecting the fetus with its membranes is ruptured, the blood supply is cut off, and the placenta shrivels up. Soon the uterine contrac tions (after - pains) recommence, the womb becomes progressively smaller, and the after birth is gradually pushed out. The process varies in the different animals according to the attachment of the placenta. In the first place the reader should have a clear idea of what is meant by the placenta. Briefly, it is the arrangement by which the young animal is attached to the womb for purposes of nourish ment and growth. It consists of two portions, maternal and fatal, which are closely united. The fatal placenta comprises a number of processes or projections on the chorion, the outermost of the three foetal membranes, which is closely applied and moulded to the uterus. In other words, the strong, thick, vascular chorion carries the foetal portion of the placenta. The maternal placenta, on the other hand, is represented by numerous pits or recesses in the uterine wall into which these processes are fitted. When we examine the cow and ewe, we find the mucous lining of the womb studded at intervals by large oval prominences, the maternal cotyledons, into which clumps of long, branched processes are inserted. The latter, called foetal cotyledons, can be distinctly seen when the membranes are expelled. The placental attachment is obviously most intricate in ruminants, and it is confined to certain areas covered by the maternal and fcetal cotyledons. In the mare, however, the whole surface of the chorion is covered with short, red processes which fit into corresponding recesses all over the surface of the uterus. The simple placenta of the mare is thus easily separated, the cleansing following the foal in a few minutes. But the cow takes much longer to cleanse, often two or three hours or more. The explanation is that separation of the placenta in the cow takes place slowly owing to the intricate, and very intimate, connection between the maternal and fcetal cotyledons. To a certain extent, perhaps, this anatomical peculiarity explains why cows are far more subject to retention of the after birth than other animals. Against this theory is the fact that ewes, with the same placental attachment, are, comparatively speaking, seldom affected with the disease. In the bitch and other multiparous animals retention is quite uncommon, and is limited to the last set of envelopes. The envelopes or membranes appear along with, or immediately after, each foetus.
We propose to describe this condition in the cow, and, later on, to point out certain differ ences or special features in other animals.
Retention of the Afterbirth in the Cow and Ewe.This is one of the commonest diseases with which the country veterinary surgeon has to deal, for it attacks a large number of cows of all breeds and ages, especially in abortion infected districts. Retention is chiefly respon sible for the production of sterility, and various chronic diseases of the generative organs, which are the cause of much economic loss and disappointment to breeders and dairy farmers. The fact that many animals are not visibly affected in general health accounts for the natural, but unfortunate, tendency to leave the uterus, with its attached membranes, to take care of itself. It is true that milk secretion is diminished until the cleansing comes away and the subsequent discharge ceases; some cows lose condition; not a few go over to bull, or prove permanently barren; while a small number die from septic inflammation of the womb and blood poisoning. But, in the main, the immediate effects are trifling, and the remote effects are either imperfectly understood or ignored. The causes of retention are not always clear, although vastly important from the preventive point of view. Anything which lowers the tone of the system acts as a pre disposing or contributory cause, e.g. weakness, debility, confinement, old age, exposure, chills, and travelling. It is well known that cows travelled long distances by rail and sea, and those which are taken from market to market, are liable to hold their cleansing. Again, any thing which lowers the tone of the uterus predisposes to retention. Thus in twins and dropsy of the membranes, the weakened and dilated uterus is often powerless to contract, and so squeeze the maternal cotyledons and detach the chorion. This want of contractile power is spoken of as inertia. Aged cows, more often, suffer from retention, particularly in bad seasons and after a difficult calving. The actual or exciting cause is infection from many different organisms, including, the abortion bacillus. Our own experience is that over 75 per cent of aborting cows fail to cleanse. Infection of the womb -most often arises during (sometimes after) parturition from wounds inflicted by the call, or the hands and instruments of the oper ator; infection from the abortion organism may occur at any time during pregnancy or during the act of service; while some writers are of opinion that infection, other than abortion, may in some cases be already present at time of service. Although easy calvers are by no means exempt, infection of the womb and consequent retention is more common in difficult births. In such cases two important factors appear to coexist—infection and inertia—or one may follow the other. The question naturally arises"How does infection act ?"Unquestionably it gives rise to a mild metritis or inflammation of the mucous membrane of the uterus, with swelling and firm adhesion of the two portions of the placenta. Lastly, an uncommon cause of retained afterbirth is a twist or entanglement of the membranes round one or more of thematernal cotyledons.
Symptoms. A portion of the membranes hangs from the vulva, sometimes reaching the hocks, or the ground, when the cow is standing; the remainder is attached to certain cotyledons in the uterus. The retention is thus only partial, some of the cotyledons having already"peeled."In the recumbent position only the umbilical cord may be seen, and even this is absent in those uncommon cases in which the afterbirth is completely retained. It is clear that the weight of the membranes outside the body exerts steady traction on the attached portion within the womb, and that the process of separation is assisted thereby. Unfortun ately, the hanging portion may break off, the cow may tread on it, or, worse still, the dealer may cut it off—a practice which is followed by retraction of the stump within the passage, and which favours retention. During the twenty four hours following a full-term birth, the membranes are fresh, slimy, and reddish in colour, containing little pockets or sacs filled with fluid; in abortion they have a sickly odour, and frequently they are dropsical. In both instances putrefaction is well established at the forty-eighth hour, the colour changes to a dirty grey, the odour is offensive, and an irritating, greyish or chocolate-coloured dis charge makes its appearance. The veterinary surgeon is often consulted as to whether new purchases have cleansed. In doubtful cases he may require to introduce his hand into the back bowel (rectum), when the firm, unyielding mass can be distinctly felt in the dilated horn of the uterus. Seeing that the neck of the womb in full births does not contract to any extent until the third day, palpation through the vaginal passage also reveals an open"os."The aperture soon becomes too small to admit the hand, and masses of decomposing placenta are liable to become imprisoned within the uterus. When the cow or heifer has aborted, contraction of the os commences at an earlier stage, and earlier still when the uterus is empty and the membranes have been naturally expelled. The owner or attendant may, however, satisfy him self that the animal has not cleansed by observ ing the following local symptoms: uneasy movements of the hind quarters, kinking and switching of the tail, occasional straining, dis coloration of the passage, foetid odour, and the presence of a discharge. The latter may be absent, but the mucous lining, on parting the lips of the vulva, is seen to be swollen and dis coloured, while the sense of smell is a good guide. General symptoms, with the exception of loss of milk, and sometimes loss of condition, are often looked for in vain. But the cow may be dull and off her feed, a little stiff and feverish, when she quickly recovers, or rapidly becomes worse and exhibits symptoms indicative of inflammation of the womb and blood-poisoning (see"Septic Metritis").
Prevention. The up - to - date stock - owner cannot expect to effect any material reduction in the number of retained afterbirths unless he succeeds in stamping out contagious abortion. Yet he has it in his power to limit the amount of womb infection which gives rise to such dire results. In this connection the causes of the disease require careful consideration. Dry cows heavy in calf should be kept in fair condition, and provided with shelter in bad weather; the uterus should be healthy at time of service— admittedly, a difficult proposition; dairy cows housed during the winter should be let out to water, or exercised daily in a yard; the whole premises, particularly the calving boxes, should be kept very clean; and great care should be exercised in difficult parturitions in regard to the hands, finger-nails, ropes, etc., and also in the turning movements necessary to effect delivery of the calf. Injury to the genital passages, and infection from dirty hands and instruments, must be specially avoided in the case of twins or a dead foetus. These precautions tend to keep the womb active and vigorous in order to expel the afterbirth.
Treatment has given rise to much controversy in the veterinary world."Is it advisable to remove the membranes by hand ?"If so,"When is the best time to perform the opera tion ?"These are questions which can only be answered by the expert after making an internal examination of each individual cow. There is no fixed rule, for rational treatment depends on the circumstances of the case and the firmness of the attachment. In the majority of instances the membranes appear to do no harm for a few days, and it is here that differ ences arise as to the best procedure. Our prac tice is to remove the afterbirth as soon as it can be taken away without upsetting the animal, that is to say, as soon as slight traction and peeling the cotyledons with the thumb and fingers brings it away easily and completely. Occasion ally this may be accomplished even before the twenty-fourth hour, more often on the second or third day, but oftener still on the fifth or sixth day. In our experience, the latter is frequently the best time, particularly in strong cows which have calved at full term. After the third or fourth day, it is true, a little patience may be required to dilate the os with the hand. Severe straining, haemorrhage from the cotyledons, and tearing of the membranes are indications for delay. Yet the possibility, or probability, of inflammation or blood-poisoning supervening must always be borne in mind. Hence it is that in difficult births, decomposing foetuses, general weakness, and dilated paralysed condi tions of the uterus, professional opinion is unanimous in advocating early removal with repeated irrigation or douching of the womb. Energetic treatment, both surgical and medical, is required immediately the appetite begins to fail. This is the first danger-signal. Abortion after mid-term also calls for early separation of the membranes. In ewes, gentle traction (pull ing on the membranes) is often successful within twenty-four hours of lambing. The process of separation is assisted by keeping the animal warm, manipulating the abdomen, and by the use of weak douches as in the cow. In all cases of retention the following measures can be recommended: (1) Douche the vagina twice daily with a very mild antiseptic solution, e.g. Condy's fluid, or a level tablespoonful of common table-salt to a gallon of warm water. The wooden nozzle of an ordinary quart brass enema syringe should be made to plug, not screw, on to the syringe, and should be covered with rubber-tubing. Jeyes' fluid, cresol, and similar agents often burn the delicate mucous mem brane, and excite severe straining. Two per cent solutions, however, are useful for disinfect ing the hind parts of the cow, and the floor, walls, etc., of the box. (2) Roll up and knot the after birth; or, better still, attach a short, heavy, smooth stick, or two flat pieces of wood. Twist up and pull daily without tearing or breaking the membranes. (3) Isolate the animal, and observe strict cleanliness. (4) Attend to nurs ing, keep warm and comfortable, and give laxative, cooling food. (5) Administer a purga tive drench, as a rule, and follow, if desired, with a few cleansing powders. Drugs, however, are of little value in expelling the afterbirth; their chief action is to lower temperature and to keep down infection. Hyposulphite of soda-2 ounce doses twice daily in a pint of water—is harmless, and sometimes beneficial. That old fashioned remedy, sugar, may also be given in 1-pound doses for three or four days. (6) After removal or normal expulsion, the membranes should always be examined to see if they are complete. Sometimes a portion is broken off and remains in the uterus.
The introduction of lard, say two pounds, into the womb is said to assist removal next day. The practice appears to be common in Ireland. Lubricants, such as lard, olive-oil, or vaseline, especially when mixed with a suitable antiseptic, also serve to protect the irritated and inflamed mucous membrane of the vagina and uterus.
To obtain good results in retention, the veterinary surgeon should be given a free hand to watch the case and to complete the disinfec tion of the womb. He may require to pay several visits in order to carry out the after treatment, but the latter is of great importance in the prevention of sterility. Too often, irriga tion is limited to a single injection, with the result that the cow is difficult to get in calf, she aborts during the first few weeks, or she holds her cleansing a second time at the next calving. In conclusion, we would deprecate the practice, fortunately uncommon, of allowing cowmen to syringe the uterus, or handle the membranes within it. We have known serious accidents, even rupture, to occur in this way.
Retention of the Afterbirth in the Mare.The simple placenta of the mare is, as we have seen, more easily and quickly separated than that of the cow. Retention is thus much less frequent than in ruminants. It is, however, much more serious. Total or complete retention is rare, owing to the fact that the thick, tough membrane, called the chorion, is attached all over the surface of the uterus, and the uterus cannot contract without loosening the chorion. Hence we usu ally find a large portion of the membranes hanging from the vulva. Occasionally the protruding portion is broken off, and a remnant is left in the extremity of the uterine horn which carried the foal, leading the attendant to suppose that the mare has cleansed. This is the most dangerous form of retention, as the smallest piece left behind rapidly decomposes and leads to septic inflammation of the womb and lamin itis. Infection is apt to occur very quickly, often with little or no warning, through the large raw surface—practically the whole area of the uterus—which is available for the absorp tion of septic products. The causes and symptoms are much the same as those in the cow, but fever in the feet (laminitis or founder) is a frequent complication; indeed, it may be the first thing noticed. It is imperative that removal of the membranes should be effected not later than the sixth or eighth hour after foaling. Some mares, it is true, will hold the afterbirth for a longer time with impunity. We have known more than one mare go twenty-four hours without harm; but such cases are very exceptional, and it is a safe rule that the sixth hour ought not to be exceeded, whenever possible, in ordinary parturitions. Not un commonly, dystocia (difficult birth) is followed by retention, when manual removal should be carried out immediately or very shortly after the delivery of the foal. In all cases, whether removed by hand or naturally expelled, the membranes should be carefully examined to ascertain if any portion has been broken off and left in the uterus. Manual removal is more easily accomplished than in the cow, the dark coloured chorion being thick, strong, and capable of withstanding considerable traction. There is little fear of rupturing this membrane, and mere pulling on different portions of it is some times successful in bringing it away. More often it is necessary to insert the hand on the flat, using the fingers like a spatula or skinning knife, and working in a forward direction be tween the chorion and the uterine wall. The process of separation, which should be evenly and equally carried out all round the uterus, is analogous to skinning the limb of a foal or calf when its amputation is necessary to effect delivery. Much assistance is afforded by steady, firm traction with the other hand, and by the injection of fluids, both of which measures stimulate the natural contractions of the womb and bring the end of the affected horn within reach of the operator's hand. Complete removal at this point is the only critical stage in the operation. The after-treatment does not differ from that indicated for the cow; but, whenever delay has taken place, it is wise to remove the mare's shoes, if this has not already been done previous to foaling, and watch her closely for symptoms of laminitis, particularly for sudden loss of milk, lack of interest in the foal, stiffness, etc. If the womb becomes inflamed and septic poisoning sets in, treat accordingly (see"Septic Metritis").
Retention of the Afterbirth in the Bitch and other Small Animals. In the bitch and similar animals, which give birth to several young at a time, it is well to remember that the horns of the uterus are very long, the foetuses are developed in each horn, and each foetus is enveloped in its own set of membranes. One young animal is thus born independently of another, and a considerable interval may elapse between the different births. As a rule, the membranes or"placentae"come away with each puppy, but it may happen that one placenta remains in the uterus until the next puppy is born, when both sets of membranes are expelled together, or one after the other. As already stated, retention is more frequent and dangerous in the case of the last placenta, although the accident is not at all common. Frequently it arises from protracted labour, apparently from a weakness or want of tone on the part of the uterus to effect the expulsion—a condi tion to which the useful term"inertia"is applied, and which may be due to want of sufficient exercise during pregnancy. When parturition sets in, labour may continue for twenty-four or even forty-eight hours, the uterine contractions which bring about ex pulsion may be practically abolished, and the mother more or less exhausted, especially when it has been necessary to extract the puppies. If the latter are dead, retention is more likely to occur, and infection of the uterus quickly takes place. It is a well-known fact that membranes or puppies, when retained in the uterus, rapidly decompose, micro-organisms invade the womb from the passage, and a serious, often fatal inflammation is set up, associated with septic poisoning. In this respect the bitch resembles the mare. Reten tion is less dangerous in the sow. It is often recommended to count the placenta, but the liability of the bitch, sow, and other animals to eat the membranes should not be overlooked. Amongst the early symptoms which point to septic infection are: Rise in temperature, dull, miserable appearance, straining, and loss of appetite. The presence of a greenish-black or blood-stained, foul-smelling discharge is also significant. Other symptoms will be mentioned in dealing with septic metritis in the bitch. Before the abdomen becomes very tender to pressure and distended, it may be possible to feel the placenta through the abdominal wall, with the finger or fingers of the other hand in the vagina. Although manual removal is gener ally impossible, treatment is carried out on the same lines as in the larger animals. Needless to say, prompt and energetic measures must be adopted to save the patient's life. As in metritis, the uterus must be thoroughly flushed out with boiled water or sterile salt solution, taking care to use a double-channelled tube to prevent over-distension of the organ. This mechanical cleansing, which removes most if not all the putrid contents, is followed by the injection of a warm, mild, antiseptic solution, such as peroxide of hydrogen (1 in 100); chinosol (1 in 600 to 1000); potassium per manganate (1 in 400 or 500). Condy's fluid added to the water until it becomes a light port wine colour is quite effective. All fluid should be allowed to drain away naturally or siphoned off. The emptying of the uterus is assisted by manipulating the abdomen, and standing the patient upright on her hind legs. She should also be allowed to run about after the injection. The general treatment depends on the gravity of the case. Stimulants, such as frequent teaspoonful doses of brandy or whisky, nutrients, such as beef-tea, etc., and internal antiseptics like salicylate of soda or quinine may have to be administered in order to sustain the strength and counteract the effects of the blood-poisoning. Good nursing is, of course, a sine qua non.
Metritis, Inflammation of the Womb, Septic Metritis.This serious, often fatal, disease affects all animals shortly after parturition or abortion; it is rarely seen at other times. The uterus (womb) becomes acutely inflamed from the entrance into the tissues of septic organisms, which gain access, as a rule, through a wound or abrasion in the mucous membrane lining the genital passage. As the disease is always _ accompanied by more or less septic (blood) poisoning, the term"septic metritis"is often applied. Several organisms, or groups of organisms, acting together appear to be the exciting cause; but their exact nature is of chief interest to the pathologist in the prepara tion of vaccines for purposes of prevention or cure. Prevention is, naturally, the main con cern of the stock-owner, who should understand that he is dealing with a contagious disease, and have a clear conception of the factors which give rise to it. The causes are to be sought for in wounds of the mucous membrane; decom posing afterbirth, or dead and putrid foetuses *retained in the womb; weakness and exhaus tion from exposure to cold and wet; dirty surroundings; and lastly, lowered resistance to infection from travelling by rail or sea and other hardships at the time of, or shortly after, par turition. Abortion is more likely to be followed by metritis than full-term births, for two reasons: (1) The uterus is already infected. (2) The afterbirth is more often retained. It should be remembered, however, that the causal organisms are generally introduced from without, chiefly by the soiled hands and ropes of attendants, but occasionally through the medium of con taminated floors and bedding. Even the syringe employed to douche the vagina of a diseased animal may convey the infection to others. Indeed the disease may be readily carried in various ways from one animal to another. In dealing with parturition difficulties we have already emphasized the need for thorough all round cleanliness and disinfection before, during, and after labour. Sometimes metritis follows a normal birth when the maternal passages have been bruised or torn by the fcetal parts during delivery, or where the afterbirth has not been completely expelled. Yet it is well lmown that the rougher the handling the greater are the chances of infection. Thus metritis is always to be feared in cases where crude attempts have been made to extract the young animal in an improper position. In juries, followed by inflammation, also occur in bringing the head round, or in extending a limb, unless the operator is careful to push the fetus well back into the womb, exercises proper skill, and covers the foot with his hand. If parts of the foetus require to be amputated, and the young creature removed in bits, the exposed ends of bones may scratch or tear the dam. Not infrequently, the bitch is in jured by the forceps or hooks employed to extract the puppies. In the face of so many opportunities for infection the reader will marvel why so many animals escape; but a great deal depends upon the patient's condi tion and surroundings, as well as her suscepti bility and species. A cow, for example, will stand more pulling about than a mare or bitch, or even a ewe; and if she has calved down in a comfortable box under good conditions, and her vital powers are not weakened by poor food, exposure, travelling, or disease, metritis seldom supervenes. Prevention is thus largely a ques tion of good management, although it must be admitted that some animals readily succumb, while others, in similar circumstances, remain unaffected. The latter appear to possess a high degree of immunity. One of the commonest causes of metritis is retention of the placental membranes; these soon swarm with septic germs, whose poisons are absorbed into the blood. Again the attendant's hands may convey the disease. This is not uncommon during the busy lambing season, when the shepherd, working single-handed, is forced to handle both diseased and healthy ewes, with disastrous results. The lambing pens are also a source of danger to the healthy members of the flock. The latter, that is to say, all lambing ewes, should be removed without delay, and put in charge of another shepherd. As might be expected, ewes which lack adequate pro tection in bad weather prove less resistant. Another cause is"Falling down of the Womb"(see"Inversion of the Uterus"). Metritis is likely to ensue when the organ has been subjected to prolonged exposure, torn, or returned into the abdominal cavity along with dirt or faecal matter.
The symptoms vary considerably according to the severity of the inflammation and the degree of septic poisoning. They appear, as a rule, between the second and fifth after birth. All females become dull, weak, depressed and feverish; the appetite and secretion of milk rapidly fail, the udder and teats becoming cold and limp; uneasy movements of the tail and hind quarters, stiffness, pain, and severe straining are present almost from the outset; and a stinking, blood-stained, very irritating discharge issues from the vulva. Some sub jects, like the cow, grind their teeth, moan or groan with the pain, while the majority assume the recumbent position and seem afraid to move. The pulse, too, is always very weak and rapid, the breathing quick and shallow, and the membranes of the eye and nostril assume a dirty-red or reddish - yellow colour. When these symptoms are observed within forty-eight hours of parturition, the prospects of recovery are very remote. Soon a fetid diarrhoea sets in, the abdomen becomes tense and distended, and the patient staggers from weakness, rapidly loses condition, and acquires an anxious expression and most miserable appearance. In such cases, there is marked blood-poisoning, and death ensues in two or three days from exhaustion and heart failure. The discharge from the vulva is frequently dark-red or chocolate-coloured; but, while the passage is swollen, red, and discoloured, the external parts (vulvar labia) are curiously small, shrunken, and retracted, especially in the cow. In the less fatal forms of the disease, symptoms of serious illness may be delayed for several days. There is more local inflammation, tenderness, and swelling of the genital parts, including the vulva; but the signs of septic poisoning are less pronounced, with correspond ing diminution in the amount of prostration and general weakness. In all cases a constant feature is distension of the uterus with putrid material, resembling in character the discharge already mentioned. When the symptoms are thus modified, and later in making their appear ance, patients may live seven to ten days, and a fair percentage recover with prompt and energetic treatment. In both forms of metritis, severe and comparatively mild, the milk of the mare suddenly fails at an early stage, and she loses all interest in the foal. Laminitis is fre quently seen during the first twenty-four or forty-eight hours. Infection occurs earlier than in the cow; so much so that metritis is gener ally established on the second day after foaling. The mare, also, shows a marked preference for the standing position, remaining more or less motionless with the back arched. If made to move she does so very stiffly. Occasionally she suffers from colicky pains, and she may perspire profusely. The cow behaves in a somewhat different fashion, lying a good deal, and sometimes refusing to rise. The prominent symptoms are: groaning, grinding of the teeth, sinking of the eyes in the orbits, tympany, and almost continuous straining. The prog nosis, notwithstanding, is rather more favour able in cows than in other species. In some cases distinct improvement is noticed in a few hours. The ewe becomes weak and prostrated almost from the outset, the rumen (paunch) becomes distended with gas, and many sheep die. The bitch also strains and suffers from vomition; even water, of which she partakes greedily, is not retained. The discharge from the vulva is invariably dark, often a peculiar blackish-green and, as in other animals, very acrid, irritating, and fcetid. The bitch also suffers from septic peritonitis due to the extension of the inflammation from the womb to the serous membrane lining the abdomen. When this complication is present, the abdomen becomes tense, distended, and very tender on pressure, while the pain and stiffness increase, and the puppies die from starvation if left on the mother. The bitch, it will be remembered, is very subject to septic poisoning. According to the virulence of the infection, death generally occurs in from one to four days. Experts agree that some hope of recovery may be entertained if the bitch survives the fourth or fifth day. A fatal complication, sometimes found on post mortem, is ulceration or perforation of the uterus. This is probably the result of an injury during parturition inflicted by the forceps of the obstetrician, or the bones of a broken-up foetus.
Prevention, Mortality, and Complications . The importance of preventing such a fatal disease is obvious. The average mortality in the domesticated animals may be estimated at 60 per cent. Moreover, in non-fatal cases, not only is the patient weak and emaciated for a prolonged period, and lacking in milk for her offspring, but a chronic metritis frequently remains, which temporarily interferes with breeding, or terminates in complete sterility. Another complication, met with occasionally in cows, is a septic inflammation of the udder; but inflammation of the feet (laminitis) is much more common in the mare. For measures of prevention, the reader is referred to"Causes of Metritis and Prevention of Retained After birth."We have little to add to the remarks under these heads, except to advocate strict isolation and disinfection, as in other con tagious diseases. Nor should the attendant be permitted to handle other parturient animals. Good management, cleanliness, care in assisting the birth of the young animal, and the exercise of common sense often succeed in preventing the disease. If metritis develops under these conditions, it is milder in character, as a rule, and more amenable to treatment.
Treatment, to be of any avail, must be adopted in the very first stages directly the appetite and milk begin to fail. Until the veterinary surgeon arrives the patient should be made as comfortable as possible, warmly but lightly clothed, the hind parts washed and disinfected, and the vagina douched in the manner recom mended for retained afterbirth. A little fever medicine, like sweet spirits of nitre, and a little whisky may be administered; but purgatives of any kind should be avoided meantime. The general or internal treatment will, of course, vary with the case; yet it must always be energetic in order to support the rapidly failing strength. Stimulants of various kinds, includ ing alcohol, prove of great service as a rule, provided they are given in quite small doses every two or three hours, both day and night. Gin in 4-ounce doses has given the best results in our cattle practice. Quantities of strong coffee are also beneficial (especially in bitches), or subcutaneous injections of caffeine, with or without small doses of strychnine. In bad cases an injection morning an evening can be recommended. Quinine and other drugs, called internal antiseptics or blood medicines, are also in general use. They certainly lower tempera ture, although they may possess little or no power to neutralize the poisons circulating in the blood, or prevent their continued absorp tion from the womb. But the benefit derived from medication is small unless plenty of nourishment is afforded at frequent intervals. Nutrients, therefore, are essential. They in clude: milk, gruels, linseed and hay tea, barley water, beef-tea, and eggs. Every endeavour should also be made to tempt the appetite with green stuff, boiled food, roots, etc., according to the species of animal and the time of year. The administration of a serum, vaccine, or other special agent must be left to the discretion of the surgeon in charge.
Local treatment has for its object the cleans ing and disinfection of the uterus without excit ing excessive straining and pain, either from the introduction of the hand or the use of irritating chemicals. A good plan is to fill the uterine cavity with boiled water or salt solu Lion (one drachm to the pint of water) until the returning fluid is quite clear. It is got rid of partly by the animal herself, partly by the pressure of the hand in the bowel (in large subjects), while the remainder is siphoned off. Having thus carried out the cleansing process, and removed all traces of afterbirth, fcetus, debris, and septic fluid, the uterus is filled with one of the following solutions: peroxide of hydrogen (1 in 100); chinosol (1 in 600 to 1000); permanganate of potash (1 in 500 to 1000); cresol or carbolic acid (4 per cent—roughly, 5 tablespoonfuls to a 3-gallon pail of water). The first-named may be injected, removed, and followed by any of the others, after which the womb is emptied as thoroughly as possible. A sedative antiseptic pessary containing iodo form or salol may then be introduced to dis solve slowly, and diminish the toxic effects of the septic material, which again collects in the most dependent part of the uterus. The aim of the practitioner is, obviously, to bring every part of the uterine wall in contact with the in jected fluid, the temperature of which should be a little above blood-heat. A rough and ready test consists in pouring the fluid, before injection, over the operator's elbow and arm. But the owner should realize the rationale of the procedure, and the fact that these measures can have but little effect in allaying inflammation and checking absorption unless they are repeated once or twice daily for several days. A long rubber tube with lateral openings will be found very suitable for the purpose. If the dilated uterus can be induced to contract by this treat ment (judged by the hand in the rectum), more hope of recovery may be entertained. Needless to say, the method which we have outlined can only be carried out safely and efficiently by a veterinary surgeon. Again, it must be remem bered that the inflammation generally involves the vagina and other portions of the maternal passage. Hence great care is required to avoid violent straining during the insertion of the hand, thus weakening the patient still further. In some cases it may be advisable to discontinue the injections, both vaginal and uterine, and to rely upon pessaries inserted into the vagina with the fingers. The same principles of treat ment apply to small animals, in which the hand cannot be introduced into the passage. The procedure has already been discussed under"Retention of the Afterbirth in the Bitch."To the remarks under this heading we would add that in most cases in which there is reten tion of a decomposing puppy, or portion of afterbirth, the early removal of the whole uterus through an incision in the abdominal wall offers the only prospect of recovery. But the opera tion must be performed early before the symp toms of blood-poisoning become pronounced.
Postpartum Haemorrhage, Bleeding from the Uterus and Vagina, Rupture of the Uterus. These uncommon accidents incidental to, or following, parturition are most frequent in the mare and cow. As a rule, they take the form of lacerations and ruptures of the vagina, cervix (neck of womb), and uterus. It may happen that injuries are produced in rapid or precipitate labour, a condition almost confined to heifers, in which parturition sets in too hurriedly before the"os"has had time to dilate; but, in spite of the violent and almost continuous straining, during which the rectum may be forced out several inches, lacerations and haemorrhage are of rare occurrence. Not infrequently the inverted uterus and vagina are torn (see"Inversion"). But the great majority of cases occur as the result of difficult protracted labour. Any animal may be slightly, severely, or fatally injured during difficult parturition, either by the hands and instruments of the operator, or by the feet, points of the hocks, and other parts of the fcetus. The danger from the hocks is greatest in hock and breech pre sentations (Figs. 336 and 337). The accident is favoured by forcible attempts to deliver the young animal in the absence, or during the interval, of labour pains, or when the womb is dry and tightly closed round the foetus. Yet the chief cause of rupture is forced extraction while the fcetus is in an improper position. Most commonly it is the feet which tear, or actually penetrate, the passage or uterus. The mare with her strong and violent pains sometimes forces the foal's foot right through the womb, or through the roof of the vagina and floor of the rectum (the foot appearing at the anus). The foal's long limbs, it will be remembered, are also more difficult to straighten, and power ful straining at a critical moment may easily wound the dam. For these reasons rupture of the uterus occurs most frequently and most quickly in the mare. The cow, on the contrary, is seldom seriously injured until she has been in labour for several hours. The wound, in any animal, varies from a slight scratch in the mucous membrane, a non-penetrating lacerated wound in the muscular wall, to a small or large rent perforating all the coats, constituting a complete rupture. More or less bleeding takes place irrespective of the cause, although no blood may appear at the vulva. It should be borne in mind that the haemorrhage which some times takes place in separating the foetal mem branes is never profuse or dangerous, although it is a strong indication for delay of the Afterbirth").
Symptoms. If complete rupture of the uterus happens during birth, three important symptoms claim attention: (1) The labour pains in every case suddenly cease—this is always a bad sign; (2) serious symptoms of internal haemorrhage often supervene; (3) protrusion of the in testines through the rent (which may be in the vagina) occasionally takes place. Death may be expected quickly from profuse bleeding; but the animal may live a day or two until peritonitis sets in from leakage into the abdomen. Wounds on the floor of the uterus are most dangerous on this account, for septic fluids naturally gravitate to the lowest point. Yet death does not always follow rupture. Small wounds, especially those which do not penetrate, may be readily over looked, or even impossible to detect on manual examination; whereas large ruptures are easily located when the hand- is introduced shortly after the accident. While lacerations of the neck of the womb, and wounds of the vagina and vulva, are easily felt, and sometimes seen, in the case of moderate injuries situated far forward there may be no immediate symptoms to warn the attendant. Occasionally there is straining, the passage of a little blood, followed by pain, a discharge, and a rise in temperature. It cannot be too strongly emphasized that parturition wounds are always septic, the infec tion being due to the presence of large numbers of septic organisms. Hence inflammation, ab scess formation, or blood-poisoning may result.
Treatment. Remedial measures will prob ably prove futile in extensive injuries. The first object is to empty the uterus, the second to induce the organ to contract. At the same time the patient must be supported by warmth, stimulants of various kinds, saline injections under the skin or into a large vein, and by the administration of styptics or drugs which check haemorrhage. The foetus, if present, is care fully delivered; blood-clots, afterbirth, debris cleared out of the womb; and the cavity swabbed as completely as possible with an antiseptic or .styptic, such as adrenalin or dilute perchloride of iron. The uterine contractions, on which so much depends, are also stimulated by stroking the surface of the uterus with the hand through the cervix, and by a vigorous massage of the organ through the rectum. Under no circumstances should the womb be douched with fluid, which may easily find its way into the abdominal cavity through the rent. An exception to this rule might be made when it is clear that the wound is superficial and situated not far from the vulva. Such wounds are dressed without much difficulty, and some may even be stitched. To stop the bleeding, the attendant should pour cold water over the loins, keep the animal quiet, and, if necessary, push a clean sheet soaked in cold water far into the passage. In addition to these first-aid measures, the surgeon will prob ably administer adrenalin, ergot, or pituitrin; injections of caffeine and salt solution also prove very beneficial, both to keep the heart going and to take the place of the blood which has been lost. A useful old-fashioned drench, which the owner may administer forthwith to a cow, contains two ounces each of turpentine and perchloride of iron tincture; mix well with white of egg and a little milk, and add milk to make one quart. This large dose should not, however, be repeated without professional advice. Lastly, in the case of the vagina, injections of very hot water may be tried to arrest the haemorrhage when it becomes certain that the wounds do not penetrate.