CYCLOP/EDI A 
OBSTETRICS AND GYNECOLOGY 
Obstetric Operations 
THE PATHOLOGY of the PUERPERIUM 
BEING VOLUME FOUR OF 
A PRACTICAL TREATISE ON 
OBSTETRICS 
BY 
DR. A. CHARPENTIER, 
ADJUNCT PROFESSOR AT THE ACADEMY OF MEDICINE, PARIS. 
TRANSLA TED UNDER THE SUPERVISION OF, AND WITH NOTESAND ADDITIONS 
BY 
EGBERT H. GRANDIN, M.D., 
OBSTETRIC SURGEON TO THE NEW YORK MATERNITY HOSPITAL J INSTRUCTOR IN GYNECOLOGY 
AT THE NEW YORK POLYCLINIC ; FELLOW OF THE OBSTETRICAL SOCIETY, ETC. 
Tn jfour Volumes 
ONE HUNDRED AND NINETY-ONE WOOD ENGRAVINGS AND ONE COLORED PLATE. 
NEW YORK 
WILLIAM WOOD & COMPANY 
1887 Copyright, 1887, 
WILLIAM WOOD & COMPANY. 
The Pvblishers' 
Book Composition and Electrotyping Co. 
157 and 159 William Street 
New York CONTENTS OF VOLUME IV 
PART VII. 
OBSTETRIC OPERATION 
CHAPTER I. 
Version : by external manipulations; bi-polar; by internal manipulations; obsta- 
cles and difficulties to version, .... pages 3-49 
CHAPTER II. 
The forceps: varieties and description ; the indications for the use ; rules for 
application; method of action; application in the various presentations; fre- 
quency of use; prognosis, ..... pages 50-149 
CHAPTER III. 
The filet; the sericeps, ...... pages 150-156 
CHAPTER IV. 
The lever, ........ pages 157-162 
CHAPTER V. 
The induction of artificial labor, . . . . pages 163-198 
CHAPTER VI. 
Induced miscarriage, ...... pages 199-204 
CHAPTER VII. 
The Cesarean section: statistics; laparo-elytrotomy; description of the operation; 
prognosis, ....... pages 205-226 
CHAPTER VIH. 
Porro's operation, ....... pages 227-232 
CHAPTER IX. 
Post-mortem Cesarean section, ..... pages 233-234 CONTENTS. 
IV 
CHAPTER X. 
Delivery per vias naturales as a substitute for the post-mortem Cesarean sec- 
tion, ........ pages 235-237 
CHAPTER XI. 
Symphyseotomy, ....... pages 238-239 
CHAPTER XII. 
Embryotomy: perforation, cranioclasty, cephalotripsy, cephalotomy, intra-cra- 
nial cephalotripsy, . . . • . . . pages 240-284 
PART VIII. 
THE PATHOLOGY OF THE PUERPER1UM. 
CHAPTER I. 
The pathogeny of puerperal fever, .... pages 287-318 
CHAPTER II. 
Forms of the disease: puerperal metritis; metro-peritonitis; putrid infection; pur- 
ulent infection; puerperal septicemia; puerperal diphtheria ; plegmasia alba 
dolens; sudden death in the puerperal state, . . pages 319-345 
CHAPTER III. 
Pathological anatomy, ... ... pages 346-354 
CHAPTER IV. 
Prognosis, ........ pages 355-359 
CHAPTER V. 
Treatment: prophylactic; curative, .... pages 360-388 PART VII. 
Obstetric Operations. CHAPTER I. 
VERSION. 
'^TERSION is an operation which changes one presenting fetal part 
for another. There are two varieties, according as it is the head 
or the breech which is brought to the pelvic brim: Cephalic version, 
Podalic or pelvic version. Each one of these methods may be practised 
by either external or internal manoeuvres; but, although cephalic version 
is usually performed by external manipulation, podalic version, on the 
other hand, almost exclusively calls for internal manipulations. Latterly, 
both internal and external manipulations have been conjoined, under the 
names of combined or mixed version, or bipolar of Braxton Hicks. 
To-day the advantages of pure external version are so generally re- 
cognized, especially for cephalic version, that it has become the routine 
method. By means of it we are able to remedy vicious presentations of 
the foetus, such as those of the shoulder, and it thus renders unnecessary 
resort to operations as dangerous, almost, for the mother as for the 
child. 
Version by External Manipulations. 
Struck by the infinitely better prognosis both for the mother and the 
child offered by vertex presentations, naturally the earlier obstetricians 
aimed at substituting the vertex for every other presentation. This 
practice, indeed, is found to have been prevalent amongst the very earliest 
races, and the Mexicans and the Japanese resorted to more or less crude 
methods to cause the foetus to present in normal fashion. Thus, amongst 
the Mexicans, the woman, from the beginning of the seventh month, was 
subjected to massage in order to force on the foetus presentation by the 
vertex, and if this did not suffice, she was seized by the feet, held head 
downward, and shaken until the desired end was attained. In Japan, a 
special family constitute the accoucheurs, and their method of action is 
the following: " If the vertex does not present, the woman loosens her 4 
A TREATISE ON OBSTETRICS. 
clothing, and, lying on her back, the physician massages downward from 
the thorax towards the epigastric regions. If the foetus is on the right 
side, the physician places his knees against the woman's left side, and 
with his hands pulls the foetus over. If faecal masses obstruct on the 
right side, these are pushed down by the physician's left hand, whilst his 
right shoves the foetus where it belongs. No force is ever used in these 
manoeuvres. During labor, if the arm or the elbow presents, this is 
pushed back into the uterus, and held there by the right hand externally, 
whilst the left hand seizes the foetus through the abdominal walls, and it 
is turned from right to left till the vertex presents." (Kangawa.) 
Hippocrates advised succussion; the Arabian physicians and Rhazes 
advised transferring all presentations into that of the vertex, the latter 
even going so far as to counsel amputation of the presenting part in order 
to gain space for the vertex. 
Roesslein (1513) and Rueff (1554) counselled cephalic version even in 
case of breech presentation; but at this date, Ambroise Pare (1550) and 
his pupil Guillemeau, advise podalic version by internal manipulation, 
and under the influence of Mauriceau (1668) and of Lamotte (1721) 
cephalic version nearly disappeared from French practice. In 1690 
Siegmundin again advocated cephalic version by internal manipulations. 
Again neglected for a while, it reappeared in 1750, through the influence 
of Smellie, who soon gave it up, and then it was advocated by Aitken in 
1784, who advised an attempt at cephalic version always before recourse 
to podalic. It was not, however, until Wigand's time (1817) that cephalic 
version was carefully described, and its indications laid down. 
In Germany, external version was practised from the time of the ap- 
pearance of Wigand's monograph, by d'Outrepont (1812), Siebold (1821), 
Busch (1826), Michaelis (1833 to 1838), Kilian (1834), Lumpe (1843), 
Martin (1849), Naegele and Grenser (1854), Scanzoni (1855), Crede (1853), 
C. Braun (1859), Spaeth (1857), Hegar (1869), and above all, by Schroeder 
(1874 to 1876), Esterle (1878), and Spiegelberg (1878-1880). 
In England, external version was not recognized by Ashwell (1828), 
Blundell (1830), Ramsbotham (1844); and although Rigby (1841) and 
Churchill (1842) were familiar with Wigand's monograph, they did not 
appreciate all the advantages to be derived from this operation. It is only 
since the appearance of the works of Barnes, Duncan, and Playfair, that 
it has become classic. VERSION. 
5 
In America the same holds true, and it is only of late years that ex- 
ternal version has acquired place amongst the obstetrical operations. 
In France, in 1845, Hubert de Louvain demonstrated the advantages 
of external version, but it is only latterly that Tarnier and his pupils, 
Chantreuil, Pinard, and Budin, have made the method a familiar one to 
all. 
" External version, " says Pinard, " ought to be practised in pregnancy 
in every case where, after the eighth month, the vertex lies in one of the 
iliac fossae, or in the upper uterine segment." For our part, we do not 
agree entirely with our colleague in regard to external version, for we 
make an exception in case of breech presentations. 
Basing his deductions on the figures given by Hegar and Hecker in 
regard to the mortality in pelvic presentations, Pinard, in accord with 
Maffei, Hegar, Chantreuil, and Budin, forcibly insists on external version 
in case of pelvic presentations, and declares that : " 1. In breech presen- 
tations, cephalic version is possible; 2. It is dangerous neither for mother, 
nor for child." If these two propositions are perfectly true, they are still 
open to certain objections, one of which has already been mentioned by 
Pmard himself: "The breech may recur again after a number of ver- 
sions." It is true that this may be prevented by the application of a 
binder, but we have seen that certain women will not tolerate the binder. 
If, however, we grant this objection, there is another, which we believe 
to be grave, and it is the following: Pelvic presentations are especially 
serious in primiparae, for in them the resistance offered by the cervix and 
the soft parts is much greater than in multiparae. In the latter, pelvic 
presentations are not very grave, and for our part we have always seen 
such presentations, whether complete or incomplete, terminate happily in 
them. If there is an instance where external version ought to be practised 
by preference, in pelvic presentations, it is in primiparae. Now, amongst 
the contra-indications to cephalic version, Pinard cites presentations of 
the breech in the primipara. Whence the dilemma, either version is use- 
ful in case of primiparae, and therefore why in such instance is it contra- 
indicated ? or it is useless and impossible, and why then attempt it ? Why, 
above all, reserve version for multiparae, where labor is easy, and entails 
danger neither for the mother nor for the child? If it be true that 
cephalic version by external manipulation is without risk for either mother 
or child, it is also, we think, useless in multiparae, often impracticable in 6 
A TREATISE OX OBSTETRICS. 
primiparse, that is to say, just where it is really useful. Therefore do we 
reject it in both cases, and here we are in agreement with Pajot and with 
Depaul. 
The first, the great indication for external version, and for us it is abso- 
lute, is presentation of the trunk. Herein all authorities agree. When, 
during pregnancy, the position is transverse, we must perform cephalic 
version, and endeavor by every means in oui' power to maintain the new 
position. 
The second indication is, for us, pelvic deformity, and herein we accord 
fully with Tarnier and his pupils, but we hasten to add where pregnancy 
has reached term. Pelvic presentations, it has been seen, are more favor- 
able before term, (Milne, Goodell, Budin), and therefore podalic version 
is indicated; but, at term, vertex presentations are more favorable, and, 
therefore, cephalic version should have the preference. 
The third indication is abnormal insertion of the placenta, all the more 
so since abnormal presentations are usually associated. 
According to Pinard, external version is contra-indicated: 1. In certain 
pelvic presentations, in primi par re especially; 2. In multiple pregnancy; 
3. In certain cases of shoulder presentation, where there exists uterine 
deformity; 4. During labor. 
Here, again, we differ from our colleague. In regard to his third 
contra-indication, we believe it theoretical rather than practical, for it is 
difficult, if not impossible, to recognize, during pregnancy, the uterine 
deformity to which he has reference, (median partition), and in the pre- 
sence of a transverse presentation we believe in always attempting ex- 
ternal version. 
In multiple pregnancy, it is only after the birth of the first foetus that 
external version is possible, and then it is very easy. 
The contra-indication as to labor seems to us too absolute. Wigand 
states as conditions where it is possible: The waters have not entirely 
escaped, or but a little while; the uterine pains are neither irregular 
nor spasmodic. Hubert says that external version may succeed during 
labor, at times even after the waters have entirely escaped. We believe 
that version by external manipulations should be attempted in transverse 
presentations, even at the beginning of labor. It is difficult; it will often 
fail; but the fear lest thereby we cause prolapse of the cord or of a limb, 
or produce a face presentation, does not appear to us well founded. Even VERSION. 
7 
where it fails, we may still resort either to the bi-polar method or else at 
the right time to podalic version. 
The conditions necessary for success in external version are: 1. The 
diagnosis of abnormal presentation must be precise; 2. The uterus must 
not be too irritable; 3. The foetus must be moveable enough to allow of 
change of position without injury to the uterus. The membranes must 
be intact, or at least there must remain in the uterus considerable liquor 
amnii; 4. Version once performed, the vertex must be maintained in 
its position. (See Transverse Presentations, Vol. I.) 
External Version before Labor. - Operative Method.-The oldest and 
simplest method, but so useless that it has long been renounced, was to 
cause the woman to lie on her side, to the right if the head was deviated 
to that side, and vice versa, a pillow under the abdomen, and to leave her 
in this position until the vertex had lodged at the superior strait. In 
transverse presentations this method always fails, and to-day all authori- 
ties resort to the following manoeuvre, as described in Pinard's work: 
" Before operating, the woman should be made to assume the dorsal posi- 
tion, the legs extended, and slightly separated. If, during the manipula- 
tions* the uterus should contract, we must stop, and await relaxation. 
1. " The head is in one of the iliac fossa, and the breech is in the opposite 
flank.-One hand is to be applied to the vertex, the other to the breech, 
and by slow, sustained pressure exercised in opposite directions on the 
foetal poles, bring them into the median line." 
Nivert, on the contrary, counsels that pressure be alone made on the 
cephalic end, for the reason that pressure applied to both poles in op- 
posite directions simply amounts to nothing. We cannot agree in this, 
but believe with Pinard that pressure on the breech is much more effica- 
cious than that on the vertex, since it is more readily transmitted to the 
vertebral column; and further, where the infant is large, or the uterine 
axis transverse or oblique, exclusive pressure on the head amounts to 
nothing. 
2. " The head is in the upper segment of the uterus, the breech below.- 
We must first mobilize the foetus, by either pressing down the head 
laterally, or by lifting up the breech on a finger in the vagina, and press- 
ing down the head in the opposite direction; tlje two poles being now 
accessible, slow and sustained pressure must be made so as to make the 
head ascend, and the breech descend by the shortest route. The pressure 
on the breech has always seemed more effective than that on the head." 8 
A TREATISE ON- OBSTETRICS. 
External Version during Labor.-E. Martin manipulates as follows: 
" The woman lies on her back, the pelvis slightly elevated, the operator 
sitting by preference with his back to the woman's face. One hand is 
applied over the inferior portion of the abdomen so as to push towards 
the superior strait the foetal pole nearest it, whilst the other hand is ap- 
plied above, and pushes towards the fundus the higher foetal pole. These 
manoeuvres are applied only between the pains. During a pain, the ob- 
Fig. 1.-External Cephalic Version. Transverse Presentation. (Pinard.) 
ject is simply to retain the ground gained. After an interval the manoeuvres 
are repeated. If the hands tire the nurse may be entrusted with the 
uterus during a pain. At times it is advantageous to make the woman lie 
on that side towards which the inferior extremity is deviated, usually the 
head, and pressure is applied to it either by the hand or by a cushion. 
Once the head engaged, the woman should retain her position, or else 
the membranes may be ruptured, and the foetal part thus fixed." 
According to Playfair, " external version should never be resorted to, VERSION. 
9 
except where the abnormal presentation has been recognized before labor, 
or at least before rupture of the membranes. It is only applicable to 
transverse presentations, for we must not expect to obtain complete evo- 
lution of the foetus, but only a substitution of the head for the lower ex- 
tremity." It is thus seen that we are in complete accord with the opinion 
of the English accoucheur. 
Combined External and Internal Version.-Bi-polar Version.- 
Fig. 2.-Cephalic External Version. Presentation or the Breech- (Pinard.') 
This consists in acting with one hand externally on one foetal pole, 
while the finger in the vagina acts on the other. In the hands of 
d'Outrepont, Esterle, Rigby, Simpson, Robert Lee, it was a method ap- 
plicable to cephalic version, and Hohl, according to Naegele and Grenser, 
practised it as follows: " The parturient lies horizontally, until the head 
has engaged. When the uterus is inclined to one side, the woman re- 
o o 7 
clines on the opposed side. The uterus is steadied by an assistant, whose 
hands are applied flat against the lateral superior sides of the uterus. At 10 
A TREATISE ON OBSTETRICS. 
the moment when, by manipulation, the head is brought towards the 
superior strait, the assistant gently pushes the uterus towards the same 
side, for example, to the left, when the head is deviated to the left. 
Then we place the left hand above the horizontal rami of the pubes on the 
side of the head, while the index and the middle finger of the righthand, 
in the vagina, rest on the foetal shoulder. These fingers gently lift the 
body and push it towards the mother's right, during the intervals of a 
pain if the membranes are intact, constantly if they have ruptured, while 
Fig. 3.-Bipolar Version. Cephalic Version. (After Braxton~Hicks.') 
with the left hand the head is pushed towards the superior strait. The 
head once engaged, we rupture the membranes, but only when the liquor 
amnii is abundant." 
Braxton-Hicks applies these manoeuvres to every variety of version, 
both cephalic and podalic, whatever the presentation, and this not only 
when the presenting part is above the brim, but also after the waters have 
escaped, even though the foetus is deep in the cavity, and the cord or an 
atm have prolapsed. (Figs. 3 and 4.) 
He thus describes his method: "Introduce the left hand into the 
vagina, place the right hand on the abdomen, in order to recognize the 
position of the foetus, and the direction of the head and the feet. If, for 11 
VERSION. 
example, the shoulder presents, it should be pushed by one or two fingers 
in the direction of the feet; at the same time pressure is exercised with 
the other hand on the pelvic extremity of the child. (Fig. 3.) 
"This pressure will bring the head towards the orifice. It is received on 
the ends of the internal fingers, and it may be placed in any desired posi- 
tion. If the breech do not rise easily towards the fundus, after the head 
has been applied over the brim, the hand should be withdrawn from the 
vagina, and applied to the breech to cause it to rise. The head should 
Fig. 4.-Bipolar Version. Podalic Version. (After Braxton-Hicks.) 
be steadied gently for a while, until the pains have fixed the child in its 
new position, and until the uterine walls have accommodated themselves 
to the new form. If the membranes are intact, it is useful to rupture 
them as soon as the head is over the internal os. The head will then 
retain its position. ' ' 
This method, which requires a certain degree of cervical dilatation and 
consecutive rupture of the membranes, is applicable only to the begin- 
ning of labor; for we doubt its success when the waters have escaped, the 
uterine contractions are energetic, and the uterus has contracted down 
on the foetus. 
To resume then: Perform cephalic version at the end of pregnancy, 12 
A treatise on obstetrics. 
and at the beginning of labor, in every case of transverse presentation; at 
the end of pregnancy retain tbe head in its position by means of Pinard's 
binder, whenever it is borne; if not, await the onset of labor, do cephalic 
version, and rupture the membranes to fix the head; such is our advice. 
Abstain from cephalic version in case of presentation of the pelvic extrem- 
ity, for it is often impossible in primiparae, and it is useless in multi parge. 
Nevertheless, since it is not injurious, the accoucheurs who try it are not 
to blame. 
Version by Internal Manipulations. 
This may be either cephalic or podalic. The first, practised almost 
exclusively by the ancients, has to-day been rejected, and the latter sub- 
stituted to such a degree that, when the word version is used unqualified, 
it refers to podalic version by internal manipulations. 
Internal Cephalic Version. 
Up to the times of Ambroise Pare and of his pupil Guillemeau, this 
form was alone practised, although hardly with success, since in 1122 we 
find Albucasis saying, with resignation worthy of a Mahommedan, " Ver- 
sion will succeed in case it please God." It was Siegmundin, Busch, 
d'Outrepont, and others, who first laid down exact rules for its perform- 
ance. The method recommended was (Busch) to rupture the membranes 
with the right hand where the head was to the left, and vice versa, and, 
seizing the head by the neck, to bring it to the superior strait. Two 
fingers steadied the head, and with the other hand the uterus was mas- 
saged to excite it to contract, and the fingers in the vagina were only 
withdrawn when the head was firmly engaged. 
D'Outrepont, and others, advised action on the trunk by means of the 
hand in the vagina, while the external hand endeavored to depress the 
head towards the superior strait. Here is seen the germ of Braxton- 
Hicks' method. Hohl and Wright counselled placing the right hand, 
where the head was to the left, on the head, the left hand in the vagina, 
and its fingers in the axilla. These fingers lift the body and press it 
towards the maternal right side, while the right hand pushes the head 
towards the superior strait, an assistant, at the same time, pushing the 
fundus uteri to the left. (Fig* 6.) 
Rigby (1844), Simpson (1845), Robert Lee, Braxton-Hicks, thus used VERSION. 
13 
both hands; but, as has been pointed out by Barnes, it is the external 
hand which does most of the work, and to-day, therefore, cephalic ver- 
Fig. 5.-Cephalic Version. (After Busch.) 
sion is performed by pure external manipulations at the end of preg- 
nancy, and at the beginning of labor. 
During labor, indeed, internal cephalic version has been justly aban- 
doned. Usually it is impossible, or, if possible, podalic version is more 
Fig. 6.-Cephalic Version. After D'&utrepont.) 14 
A TREATISE ON OBSTETRICS. 
so, and should be chosen, since then we may end labor at will; the risk 
to the child will not be greater, and podalic version is always quicker 
than cephalic. 
Podalic Version. 
It is in the works of Celsus that we find the first rules applicable to 
this form of version-applicable, however, only when the foetus is dead. 
Although Villanova, (1312), Benivieni, (1502), and Rosslein, (1513), knew 
this method, it is not till the times of Ambroise Parc, 1560, that we find 
a description of this method of version and extraction. In 1561, Franco 
reproduced the text of Parc's work, and in 1609, Guillemeau modified 
somewhat the operative method. From the time of Mauriceau (1668), 
Lamotte (1721), Puzos (1753), podalic version replaced cephalic version. 
In 1685, Portal performed version by one foot, and Puzos and Deleurye 
made clear the advantages of using a single foot. The latter, also, care- 
fully differentiated version from extraction, and Denman (1788), and 
Boer (1791), insisted on this point. Finally, Osiander, Levret, Smellie, 
Stein, carefully studied the indications and operative technique, and 
Osiander showed that version may succeed, at times even when the head 
has already engaged, and this too, as he says, non vi sed arte. 
Podalic version is then an operation which consists in bringing to the 
superior strait the pelvic extremity of the foetus, no matter what the 
previous presentation. 
It is indicated whenever normal labor is impossible on account of ab- 
normal presentation of the foetus, and where cephalic version is im- 
practicable. The indications, then, are: 
1. Transverse presentations during labor. 
2. Every complication which endangers the life of the mother and of the 
child, and which calls, consequently, for rapid termination of the labor. 
Such, for instance, are hemorrhage, eclampsia, rupture of the uterus, 
certain face presentations, prolapse of the cord, certain monstrosities, 
pelvic tumors causing dystocia, etc. 
3. Pelvic deformity. 
a. The indication is absolute in case of transverse presentations which 
could not be remedied before labor, or which were not recognized, after 
the seventh month. Up to six months, the foetus is small enough to 
allow us to count on spontaneous evolution. Before resorting to podalic VERSION. 
15 
version, the diagnosis must be exact, that is to say, we must know not 
only that the shoulder presents, but which shoulder, and consequently, 
the location of the head, and the ventral surface of the foetus. 
b. Here version only aims at rescuing the mother and the infant from 
threatened danger, and not alone to modify the foetal presentation. In 
many instances, then, the forceps will answer, and the accoucheur must 
decide as to which method of interference will answer the best for the 
individual case. 
c. We have already spoken at length of version in case of contracted 
pelvis. Although authorities here differ on certain points, they all agree 
in favor of version in case of oblique contraction, since then the ac- 
coucheur may direct the foetal part towards the greater pelvic space. 
Finally, we must not forget that extraction is not necessarily the im- 
mediate consequence of version, and that, in many instances, the change 
of foetal position having been obtained, it is possible, advantageous at 
times, to leave the case to Nature. 
Fig. 7.-Podalic Version. 16 
A TREATISE ON OBSTETRICS. 
Conditions necessary for the successful Performance of Version.-Cer- 
tain ones are absolutely indispensable, and others only favorable. 
The indispensable conditions are: 1. The dilatation, or at least com- 
plete dilatability of the cervix. 2. Foetal part not firmly engaged. 3. 
Pelvis not too contracted. 4. Uterus not too contracted. 
A favorable condition, if not absolutely indispensable, is the integrity 
of the membranes, or at least the presence of enough liquor amnii to 
allow of foetal motion, and th as prevent too great contraction of the 
uterus. 
1. Dilated or Dilatable Os.-By complete dilatation is understood that 
condition where the Avails merge with those of the vagina, so that the 
uterine, cervical, and vaginal canals are one; by dilatibility is understood 
such softness that the cervix may readily be converted into the state of 
dilatation. We are thus opposed to Schroeder, who claims that it is not 
absolutely indispensable that dilatation should be such as to allow the 
introduction of the hand, and that version is most likely to succeed when 
attempted early. Podalic version, through an undilated os, is very diffi- 
cult and very dangerous, for it is like accouchement force, and, therefore, 
except under stringent necessity, it should never be resorted to unless the 
cervix is dilated or dilatable. Otherwise we may lacerate the cervix and 
do injury of serious import to the woman. When version is attempted 
prematurely, there are two accidents likely to occur: Extension of the 
arms, and contraction of the cervix around the neck. If this first com- 
plication is readily overcome, it is not so with the second. The extended 
head is imprisoned, the foetus dies of asphyxia, or if we make violent 
traction this may result in detaching the head from the body, and leav- 
ing it in the uterus. 
There is a time of election for version, and this when the cervix is 
dilated or dilatable, and the membranes are intact. If now the mem- 
branes are ruptured, and the hand passed at once to the fundus, so as to 
lose as little of the liquor amnii as possible, the feet may be seized with 
great ease, and version, except in case of pelvic deformity, may be per- 
formed with ease and rapidity. 
2. Version consists in evolution of the foetus. If, now, the foetus is 
deeply engaged, or immobilized, the passage of the hand, in the first 
place, is difficult, if not impossible, and, again, it will be necessary to 
push up the foetal part, and this may be impossible, and effort result in VERSION. 
17 
rupture of the uterus. We run the risk then both of killing the mother 
and the infant. 
3. We must never forget that although the flat hand may pass through 
a contracted pelvis, this hand must come out holding the foetal foot, and, 
therefore, no longer flat but closed-that is to say, it must make its exit 
increased in volume by the foetal part, as well as by the fact that it is 
troubled on itself. We must never then attempt version in a pelvis con- 
tracted below 2.7 inches. 
4. The uterus must not only allow the introduction of the hand, but 
it must also be yielding enough to permit foetal evolution, and to allow 
retractility without danger of rupture. Sometimes the uterus is irrita- 
ble, and then, if we wait a little, it will be possible to do version with ease. 
All depends on the necessity of rapid delivery, which, if it does not exist, 
may render embryotomy out of the question. 
There are, above all, two causes of exaggerated uterine contractions: 
Total escape, and for long, of the liquor amnii; premature administration 
of ergot. 
1. The most favorable, if not indispensable condition for version, is the 
integrity of the membranes. This condition, however, is rarely fulfilled, 
for the presentation being above the brim, premature rupture often oc- 
curs, and the waters flow off readily, the uterus contracting on the foetus 
the less the amount of liquor amnii present. Enough water, then, must 
at least remain in the uterus to prevent such contraction, and to allow 
foetal evolution. Unfortunately, it must be said, premature escape of the- 
waters is often the result of error on the part of the physician, oftener 
still of the midwife. The membranes are ruptured before the assurance 
has been gained, by palpation, of the presentation, in the hope that the 
foetal part will engage. The rule should be to wait for complete dilata- 
tion before rupturing the membranes. Once the time of election at hand, 
rupture, and at once insert the hand into the uterus, thus effectively 
tamponing the cervix and preventing entire escape of the waters. In case 
the head presents, if in the interests of the mother and the infant it is 
necessary to end labor, push this up, search for a foot, turn and deliver, 
or else have recourse to the forceps. 
2. We have already stated that we are absolutely opposed to the ad- 
ministration of ergot as long as there is anything in the uterus. Particu- 
larly does this apply to cases of abnormal presentation. Unfortunately 
Vol. IV.-2 18 
A TREATISE ON OBSTETRICS. 
the error is often committed of administering ergot in these cases, and it 
is then that we see supervene those tetanic contractions, which are but 
too often followed by spontaneous rupture of the uterus, a rupture all 
the more certain if we attempt version. Here version is contra-indicated, 
and embryotomy must be resorted to, and this is also indicated by the 
fact that the foetus is usually dead. 
Preliminary Precautions.-Before practising version, there are a num- 
ber of precautions to be taken, certain of which are indispensable to suc- 
cess. We must above all be sure of our diagnosis. If the head presents, 
make out whether it be vertex or face, to what point of the pelvis the oc- 
ciput or the chin points-in other words, not only diagnosticate the pres- 
entation, but the position, in order to know whore the feet are. If the 
body presents, recognize by which shoulder; sometimes such exact diag- 
nosis is not possible, until the hand is in the uterus. Further, any in- 
struments which might be required, such as the filet, laryngeal tube, 
scissors, etc., should be at hand. The bed should have considerable ele- 
vation, and be resisting, for, since it is necessary for the hand to pass to 
the fundus, the operator will have to depress the arm greatly. It is often 
necessary to place a board under the mattress in order that the woman's 
nates may not sink too much. Usually, the woman is placed in the dor- 
sal position, the nates at the very edge of the bed, the feet resting on a 
couple of chairs, and the limbs separated. An assistant should hold each 
leg, flexing the thigh on the trunk. If necessary a pillow or cushion may 
be placed under the nates, to elevate them. 
In certain instances, where the feet are in front, or difficult to reach, 
the woman may be placed, for the time being, in the lateral position. 
The knee-chest position, advocated by certain gentlemen, appears to us 
•objectionable, because it is our habit to anaesthetize during version. 
If version is practised at the time of election, and in a woman with 
large pelvis, chloroform may be dispensed with. Otherwise it is abso- 
lutely indicated. The anaesthesia should be complete, surgical, adminis- 
tered by a competent assistant, and should continue during the entire 
period of the operation. Thus is obtained absolute passivity on the part 
of the woman, and the operator may act more quickly, aside from the 
fact that the woman is spared pain. 
The bladder and rectum should be emptied, in particular the former 
by the catheter. 19 
VERSION. 
As for the choice of hand to operate with, authorities are not in accord. 
The general rule is to take that hand which, placed between pronation 
and supination, corresponds by its palmar surface to the ventral surface 
of the foetus. In vertex presentations, for instance, in the left occipital 
the left hand, in the right occipital the right hand-that is to say, left 
hand if the feet are to the right, and vice versa. 
This is the custom in Germany. In England, where version is performed 
with the woman lying on the left side, the left hand is always used. 
For our part, we consider the choice of hand a matter of secondary im- 
portance. For if version is easy, one hand will answer as -well as the 
other, and if it is difficult, there is one circumstance which forces us to 
deviate from theoretical rules. When the liquor amnii has escaped for 
some time, the inserted hand awakens contraction of the uterus, and the 
hand is squeezed so that it is deprived of sensation, and we must, of ne- 
cessity, insert the other hand instead. I have often been obliged to make 
this substitution a number of times. The best we can do to save the 
hand is to straighten it out during the contraction, and wait for relaxa- 
tion before continuing the operation. 
It goes without saying that the coat should be removed and the shirt 
sleeves rolled up. The nails should be cut short, on a level -with the 
pulp of the fingers, and the arm should be well greased, never, however, 
greasing the hand which is to seize the foot. 
Having made the above preparations, we proceed to the operative 
method. 
This, according to most authorities, is composed of three stages: 
1. Introduction of the hand and search for the foot. 
2. Evolution of the foetus. 
3. Extraction of the foetus. This latter stage does not in reality belong 
to version, because, once the foetus turned, version is completed, and we 
may often leave the rest to Nature. Thus, most German writers describe 
version under breech presentations. But since immediate extraction after 
version is the rule, we will follow the example of French writers, and de- 
scribe extraction in this place. 
1. Introduction of the Hand and search for the Feet.-The hand should 
ever be introduced during the interval in the pains. The fingers should 
be brought together in the shape of a cone, the thumb against them, and 
penetrate slowly, rotate as it were, into the vagina, the dorsal surface be- 20 
A TREATISE ON OBSTETRICS. 
ing turned towards the sacrum when the bottom of the vagina has been 
reached. At the same time, it is absolutely requisite to control the uterus 
with the other hand, or by the hands of an assistant, in order that as the 
fingers enter the uterus the vaginal attachments may not be dragged upon 
or torn, and again in order that the uterus may be depressed as much as 
possible nearer the internal hand. Another important point is that the 
hand be made to traverse the vagina in the axis of its curvature, and in 
order to do this, as the hand penetrates it is necessary to depress the 
elbow. The hand once at the cervix, which we suppose to be widely 
dilated, the membranes are either ruptured or intact. 
If ruptured, we must immediately enter the uterus as deeply as possi- 
ble, even to the fundus, if necessary. The feet, indeed, are usually higher 
up than is supposed, and many inexperienced operators fail in version 
because they do not dare pass the hand deep enough. When the hand 
has reached the fundus, only the thickness of the walls separates it from 
the external hand. We must, hence, manipulate carefully, and with ex- 
treme gentleness. 
If the membranes are intact, they must be ruptured. Here opinions 
vary. Peu, Smellie, Deleurye, Boer, and latterly, Huter and Naegelc 
and Grenser, advise introducing the hand between the uterine walls and 
the membranes, until the feet are reached, and only then to rupture. 
IIliter has even been able to perform version without rupturing the mem- 
branes. For our part we are opposed to this, and we believe the mem- 
branes should always be ruptured over the cervix, always, however, at 
once introducing the hand, and thus tamponing with the wrist, to pre- 
vent escape of'the liquor amnii. Our reasons for this opinion are: 1. 
While the hand is passing between the uterine walls and the membranes, 
these often rupture over the cervix, and version is rendered difficult from 
the fact that the ruptured membranes are applied closely against the foetus. 
2. If we seize the foot through the membranes, we may pull on the mem- 
branes as well as on the foot, and thus cause partial detachment of the 
placenta. 3. In passing between the uterus and the membranes we may 
detach the placenta, in case of lateral insertion. 4. Searching for the 
feet through the membranes necessitates more exact knowledge of their 
position than we are often able to obtain. 5. As for the possibility of 
turning without rupturing the membranes, this necessitates very tough 
membranes, and a very acquiescent uterus; and further, as Schroeder 
points out, the foot slips in the membranes and is difficult to seize. VERSION. 
21 
Wherefore, again, we recommend rupture of the membranes at the level 
of the cervix. Three methods of searching for the feet are in vogue. 
The first, derived from Madame Lachapelle, consists in going directly 
to them, seizing them, and bringing them down. This constitutes hasty 
version, and requires very exact diagnosis, and while excellent in such an 
event, in case of error it exposes us to trouble. 
Fis. 8. -Podalic Version. (1st stage.) Introduction of hand to seize the feet. 
The second, advocated by Dubois, consists in passing behind the foetus, 
lifting it up, following the posterior wall of the uterus up to the fundus. 
The hand is then turned so that its dorsal surface lies against the anterior 
wall of the uterus, and the feet are at once found by the concavity of the 
hand. This is an excellent method, true enough, when the ventral sur- 
face of the foetus is posterior, and the feet there as well. But if the feet 
are in front, they cannot thus be found. 
The third is the classic method. The road is longer, but more certain. 22 
A TREATISE ON OBSTETRICS. 
The hand in the cavity seeks the lateral or posterior surface of the foetus. 
Following this surface to the nates, and thence along the thighs, and 
thence along the leg, it surely finds the feet. Bailly advises following the 
anterior surface of the foetus, but in order that this method may succeed, 
there must exist considerable liquor amnii, the foetus be fairly moveable, 
the uterus not irritable, and often these conditions are not present. This 
proposition of Bailly's then is impracticable. 
Each one of these methods possesses ad vantages,but requires special con- 
ditions. The best plan is to follow the advice of Lachapelle, having made 
as precise a diagnosis as possible beforehand. If necessary, we can grope 
our way to the feet, until we seize a foot or a knee, or even hook the 
finger, as we will see, in the groin. 
Seizure of the Feet.-Must we seize both feet, or one, or, in the latter 
event, which? 
Whenever it is possible to grasp both, this is advantageous, but this 
only happens in easy version. Barnes prefers the knee to the foot, and 
insists upon this. Portal first proved that we might turn by one foot. 
Puzos insisted on but one foot, and this is the practice of almost every 
accoucheur in France, in England, in Germany. V ersion thus performed 
is, they say, easier, quicker, less painful for the mother, less dangerous 
for the child. "In case of incomplete presentation of the feet, " says 
Schroder, "we are better able to leave the termination of labor to Nature, 
than where both the feet present. The first part of delivery is, true 
enough, a little slower and more difficult, but the after-coming head passes 
the more readily, because of the dilatation of the soft parts by the breech 
and one thigh. In the interest of the child the inferior portion of the 
body need not be delivered rapidly, but the superior portion ought to 
pass quickly." 
Which foot ought we to grasp? Authorities differ. The greater num- 
ber are in favor of the nearest, or lowest foot. (Kilian, Lumpe, Scanzoni, 
Martin, Lange, Depaul, Bailly, etc.) It is not only easier to grasp, but it 
further appears anterior at the moment of extraction, that is to say be- 
hind the symphysis. This is our practice, and that of Tarnier. Others, 
on the contrary, advise grasping the superior foot. (Roederer, Joerg, 
Hohl, Simpson, Kristeller.) Barnes says that thus evolution is more 
complete, while Scharlau and Haselberg point out that by pulling on the 
superior foot it may lock with the inferior, and thus render version im- 
practicable. VERSION. 
23 
For our part, whether one or another foot is seized matters little in 
general. Only when the back is posterior may it be advantageous to grasp 
the superior foot. As Pajot says, with truth: The best foot is that which 
is grasped the best. 
To distinguish the superior from the inferior foot, we must remember 
the position of the foetus, and follow the border of the foot. In case of 
the superior foot, the internal border faces below, and in case of the in- 
ferior foot, it faces above. 
If we cannot reach the foot, we must grasp the knee. This is particu- 
larly practised and recommended by Simpson, Barnes and Simon Thomas 
Fig. 9.-Grasp of the Upper (Superior) Foot. 
de Leyde. According to the latter, version by the knee offers the follow- 
ing advantages: " 1. Whenever the uterns is not too much contracted, 
whatever the presentation, we reach the knee more readily than the foot. 
2. Often we know more certainly, beforehand, the position of the knee. 
3. In podalic version the force which changes the presentation acts with 
greater advantage on the knee, and further we may use more force on it, 
without endangering the foetus, in case of difficult version." Barnes adds 
that the knee is nearer than the foot, and while the latter must be seized 
by the full hand, the finger bent on itself is enough to pull down the for- 
mer. 
When the inferior extremities are too far from the superior strait, 
Deutsch advises the following procedure: 1. Make the foetus undergo a 24 
A TREATISE ON OBSTETRICS. 
movement of rotation around its longitudinal axis. 2. Disengage the 
feet. " As for the choice of hand, this is according to rule. If we are 
dealing with a shoulder presentation, for example, the dorsal surface of 
the foetus being posterior, the palmar surface of the hand is applied to 
the thorax or the shoulder of the foetus, and by pressure from in front 
back, and from below above, the foetus is turned on its longitudinal axis 
Fig. 10.-Podalic Version. (Second stage.) Evolution of the foetus. 
so that its anterior surface looks downward, and the thorax is elevated. 
Often many attempts are necessary for the success of this manoeuvre. 
The foetus is held in this position by the thumb, and the four other fin- 
gers are turned downwards, and passed along the back to the nates, the 
legs are pushed towards the sacro-iliac synchondrosis, and the feet fall 
of themselves into the hand of the operator." (Naegelc and Grenser.) 
According to Deutsch, by this method the uterus is less irritated, version 
is easier, and the danger of fracturing the limbs is slight. The method VERSION. 
25 
does not seem to us practicable, except in the presence of much liquor 
amnii, a small foetus, and a non-irritable uterus, and here the usual 
method will succeed as well. 
Finally Gueniot advises, in difficult cases, a method already used by 
Cazeaux, and which he calls the ano-pelvic. 
" 1. The weight of the body is to be used to penetrate to the fundus. 
2. To take as the fulcrum of the tractions on the foetus, the pubic arch, 
or the sacro-coccygeal joint, by means of the curved finger in the rectum. 
3. Thence to proceed as in ordinary version." The advantages of this 
method are: 1. The foetal pelvis is usually easier to find than the feet. 
2. The fulcrum chosen is most solid, and does not yield. 3. Traction 
being direct, no force is wasted. 4. Whatever the direction of the trac- 
tion, the evolution of the foetus may be affected. 5. When podalic ver- 
sion has failed, the ano-pelvic method may still be resorted to with suc- 
cess. 
2. Evolution of the Foetus.-This consists in making the foetus turn on 
itself, so as to convert the existing presentation into the pelvic. In order 
that the foetus may turn, it must not be fixed in the uterus. We must 
hence act between the uterine contractions. 
Wigand has described two methods of action: " The foot seized, trac- 
tion is made during the pains, taking the precaution to bend the child 
along its anterior surface, flexion thus being easier and more complete. 
Formerly this was called the great tzirn. Usually, however, we make 
•traction by flexing the foetus, first anteriorly, and then laterally, without 
fear of compression of the spine. This has been called the little turn. " 
These divisions are rather theoretical than practical, for if evolution 
be easy, it is accomplished as well by the great as by the little turn, and 
if it be difficult, that method which is the most rapid is the best, and the 
accoucheur must act according to circumstances. 
Having firmly grasped the foot, traction is made, and we feel the foetus 
move. In a general way these tractions should be made downward and 
forward, in order to bend the foetus anteriorly. At the same time the 
other hand, on the abdomen over the head, endeavors to push this up 
towards the fundus. The tractions should ever be slow and continuous. 
If the version be easy evolution is rapid, but it may happen that either 
the head or the shoulder do not move, and evolution doesnot occur. We 
then, according to Naegel e and Grenser, try to push up this shoulder or 26 
A TREATISE ON OBSTETRICS. 
head towards the side of the pelvis with the thumb or the palm of the 
operating hand, at the same time that the feet are pulled down. If this 
does not succeed, we may resort to what has been called double manipu- 
lation. (Fig. 11.) 
This consists in applying a loop over the foot, and of pulling on it, 
Fig. 11.-The Double Manipulation. 
while the hand in the uterus tries to push the presenting part upward. 
The uterus must be well steadied by an assistant. 
This procedure was known to the Japanese. Numerous instruments 
have been devised for pushing up the foetal part, such as those of May- 
grier, Burton, Aitken, Otto, etc. All these instruments we believe are 
inferior to the hand, and if the hand fail, we do not think that any in- 
strument will succeed. 
Madame Lachapelle has noted in cephalic presentation a cause of diffi- VERSION. 
27 
culty when traction is made on but one foot. It depends on the fact that 
the nates may prevent the ascent of the head. If this cannot be pushed 
up, traction should be made on both feet. In certain instances version 
is not possible, and then our recourse must be to embryotomy. 
We have said that traction should be made downward and forward; but 
this anterior movement must not be exaggerated, else it may happen that, 
when evolution is complete, the foot which was not grasped lies across the 
symphysis, and thus prevents further progress. Then it will be necessary 
to make traction directly backward, oi* else to rotate the dorsum of the foetus 
backward, or at least laterally, in order that the thigh caught on the 
symphysis may disengage itself. It is always, be it understood, the an- 
terior hip which thus gives rise to trouble. 
The breech once at the superior strait, and at the level of the cervix, 
version may be considered at an end, and often the case may be left to 
Nature. We are dealing simply with a breech presentation. But if the 
pains are slight, if there exist disproportion between the foetus and the 
genital canal, if version has been indicated by complications threatening 
the life of mother and child, then extraction should follow at once on 
version. 
3. Extraction of the Foetus.-The extraction, according to Naegelc and 
Grenser, may be divided into three stages: 1. The body of the foetus as 
far as the shoulders. 2. Extraction of the arms. 3. Extraction of the 
head. Only, however, in difficult cases, are these stages marked; in case 
of favorable conditions and of strong contractions, extraction is so easy 
that the three stages are merged in one. 
While efforts at version are to be made in the interval of, extraction is 
made during, the pains, and it succeeds the better the stronger and more 
regular the pains. If the two feet have been grasped and brought to the 
vulva, they are wrapped in a towel, and they are seized with the thumbs 
above the heels, and the remaining fingers on the ventral surface of the 
leg. (Fig. 12.) The same rule holds where but one foot has been 
brought down, the hands being moved upwards as the legs and the nates 
descend, keeping as near as possible to the joints. The hands thus are 
applied successively to the feet, the legs, the knees, the nates, as close as 
possible to the maternal parts. (Fig. 13.) 
If traction is made on a single foot, as soon as the breech is extracted 
the second foot appears of its own accord. Only when the second leg 28 
A TREATISE ON OBSTETRICS. 
has extended on the abdomen of the foetus, need we artificially disengage 
it. The finger must then be inserted in the groin, in order to pull down 
the thigh, and then must seek the second foot and endeavor to extract it, 
but direct traction must never be made, else fracture will result. The 
best practice, in such cases, is to continue extraction irrespective of the 
second foot, when, sooner or later, this will spontaneously appear. If, 
Fig. 12.-Position of Hands in Extraction. Delivery of the Inferior Extremities. 
when the nates appear, the foetus is found astride of the cord, we must 
try to loosen this by passing it over the natis belonging to the undelivered 
foot. If the cord cannot be loosened, then it may be ligated in two 
places and cut between. Of course, in such event, very rapid extraction 
is indicated. 
The breech delivered, the thumbs are applied over the sacrum, the VERSION. 
29 
other fingers over the anterior of the pelvis, (Fig. 13,) and traction is 
made downwards and slightly backwards, until the thorax appears. If 
the cord is tense at the navel, it is pulled gently downward, in order to 
avoid traction on it. If it cannot be disengaged, it must be cut and the 
foetal end compressed by an assistant till extraction is completed. Usu- 
ally, as the body descends the foetus rotates, so that the dorsum looks for- 
Fig. 13.-Extraction of the Breech. 
ward. If this rotation does not occui' spontaneously, it must be made 
artificially. In order to effect this, while downward traction is being 
made, the foetus is turned in the desired direction, and this is ordinarily 
an easy matter. But if the body resists, rather than use force we had 
best desist. 
Where version is easy and contractions good, the arms remain flexed 
on the chest; but if the uterus retracts more, the arms extend along the 30 
A TREATISE ON OBSTETRICS. 
head, and must be disengaged. The posterior arm should be first ex- 
tracted, and then the anterior, and there remains only the head. 
The head may be flexed or extended, the occiput anterior or posterior. 
If the uterine contractions are not sufficient, we must extract it rapidly, 
lest the infant endeavor to breathe, and asphyxiate. Since the extraction 
of the arms and head offers difficulties, we will describe this later on. 
Fig. 14.-Loosening of the Cord. 
The child born, the cord is to be cut as usual, and the same care is 
given to infant and mother as is customary after normal labor. 
Version, as we have described it, is simple version. It is not always so 
easy, and, as we will see, the operation may become one of the most deli- 
cate and difficult the accoucheur is called upon to perform. We will 
pass the difficulties successively in review. VERSION, 
31 
Obstacles and Difficulties to Version. 
I, Introduction of the Hand. 
The causes of difficulty may lie in the vulva or vagina, (edema, nar- 
rowness, rigidity), or be due to obstacles in the canal, (prolapse of the arm 
or the cord), in the cervix (resistance, rigidity, placenta praevia), in the 
uterus itself (retraction, tumors, etc.) 
a. N irrowness, rigidity, of the vulva or vagina, are rarely so pronounced 
as to constitute genuine obstacles. Edema and traumatic swelling of the 
vulva and the external parts are the most frequent obstacles. 
Edema of the vulva may depend on albuminuria, and in certain cases 
it is necessary to puncture the labia in order to affect introduction of the 
hand. In such cases great care is necessary in order not to bruise the 
parts overmuch, and thus lead to gangrene. 
b. Prolapse of the cord of itself is not an obstacle to version, but the 
life of the child is compromised, and, therefore, active intervention is 
called for, and extraction should at once follow version. If the foetus 
is dead, the only necessary precaution is not to pull on the cord and thus 
separate the placenta. If the cord be in the way it may be cut, the pla- 
cental end being alone ligated, since the foetus is dead. But we must 
never forget that absence of pulsation in the cord is not a sure sign of 
foetal death, and that for absolute certainty we must listen for the foetal 
heart. If, on the other hand, the foetus is alive, we must particularly 
avoid compression of the cord. The best plan is to replace it in the 
uterus above the foetal part, and if it will not stay there, to terminate 
version as rapidly as possible. 
c. In shoulder presentations, when labor is prolonged, and the liquor 
amnii has in great part escaped, the shoulder is pushed more and more 
into the superior strait, and the arm belonging to the shoulder extends, 
and prolapses into the vagina, often appearing at the vulva. At times 
the arm is brought down by the inexperienced operator, being mistaken 
for the leg. The arm thus prolapsed swells, becomes livid, and at times 
looks gangrenous. 
The older writers often placed a piece of ice in the hand to cause it to 
retire. Mauriceau and others advocated efforts at replacement. Portal 
(1665) and Deventer (1701) first proved that such efforts were often un- 32 
A TREATISE ON OBSTETRICS. 
necessary. Smellie, Levret, Puzos, Lamotte, Van Hoorn, proved that 
such efforts were not only useless, but often dangerous. 
To-day, this prolapse of the arm is considered an advantage, in the first 
place because we are enabled to make a correct diagnosis, and in the 
second place, because we may fix this arm and prevent it from extending 
along the head. We have already seen how, by looking at the hand, or 
by following the arm up to the axilla, we may at once differentiate the 
presenting shoulder, and thus know exactly where to hunt for the feet. 
We must not judge the infant dead by the condition of the arm, and, 
as has happened, amputate it; such amputation is never necessary, how- 
Fig. 15.-Shoulder Presentation, with Prolapse of Arm. 
ever swollen it be. Our efforts must be limited to passing a sling over the 
arm, and thus preventing its extension along the head during extrac- 
tion. 
There are instances, however, where the accoucheur's hand cannot be 
inserted, because during previous attempts at version the other arm or 
foot has been brought down. Then, in case of vertex presentation, de- 
struction of the foetus is necessary. But first we must always assure our- 
selves of the death of the foetus. If the foot, as well as the arm and the 
head, is in the vagina, we have seen that we may have recourse to the 
double manoeuvre, and if this fail, to perforation or cephalotripsy. 
cl. Obstacles in the cervix may be due to incomplete dilatation, to rigid- VERSION. 
33 
ity, to spasmodic retraction, to placenta praevia, or to tumors of one or 
another kind opposing dilatation. 
1. Incomplete Dilatation and Retraction of the Cervix.-In certain 
cases, the life of the mother or child depends on labor being terminated 
before complete dilatation; otherwise we must wait for complete dilata- 
tion. Baths, hot injections, chloral, chloroform, belladonna ointment, 
will usually, at the end of a few hours, overcome rigidity. 
[In instances where these measures fail, the faradic current, weak, and 
never passed through the two poles of the foetus, should always be tried. 
A number of instances are on record where it overcame rigidity, and 
from our experience in cases of uterine inertia, we should be inclined to 
rank it in value after chloral, which drug is of the greatest possible util- 
ity.-Ed.] 
If the mother's life or that of the infant is in danger, we must proceed 
to dilate the cervix. In such cases, chloroform pushed to its fullest ex- 
tent has been advised. We have but little confidence in it, because the 
uterine muscle resists above all others the action of chloroform; its con- 
tractions have often persisted after the heart has ceased to beat. The ac- 
tion of chloroform is too dangerous and variable for us to be willing to 
compromise the life of the mother when we have at our disposal other 
less dangerous means. 
Dilatation of the cervix may be effected in a number of ways. Gradu- 
ally by the hand, or by Barnes' dilators, and then with the greatest care. 
We reject absolutely the metallic dilators. If gradual dilatation of the 
cervix be not possible, we much prefer incision. This incision, it is un- 
derstood, can only be practised when the resistance is at the external os. 
At the internal os, the hand and Barnes' dilators should alone be used. 
When these fail, our only resource is in the accouchement force, however 
dangerous it be. Venesection, pushed to syncope, often fails. 
2. Placenta Prcevia.-The cervix, on the other hand, may at least be 
dilatable, and the hand is opposed by the placenta, either partially, or en- 
tirely previa. We have seen, when studying this subject, that then the 
placenta must be partially separated, and the hand introduced above it. 
3. Tumors of the Cervix.-In such instances, as we have seen, we must 
await sufficient dilatation of the cervix, especially in the case of fibrous 
tumors; in case of cancer we must incise the cervix, and if this fail, re- 
sort to perforation, or to embryotomy. 
Vol. IV.-3 34 
A TREATISE ON OBSTETRICS, 
4. Obstacles in the Body of the Uterus.-Here it is not usually so easy 
to overcome the difficulties. Often, indeed, either because of premature 
escape of the waters, or prolonged labor, or premature administration of 
ergot, or repeated and inexpert attempts at version, the entire body of 
the uterus is contracted, in a state of tetanus as it were, and the body of 
the foetus is held so tightly that it is impossible to pass the hand. We 
must not then attempt version. To do so would inevitably cause rup- 
ture of the uterus. The foetus must be mutilated, for thus alone can we 
save the mother. 
II. The Search for the Feet. 
There are a number of conditions which may interfere, and of these 
we mention mobility of the foetus or of the uterus. This may be reme- 
died, in part, by allowing a little of the liquor amnii to escape, and in part 
by fixing the uterus. There are two other more frequent causes, how- 
ever, and these are the displacement of the feet at previous attempts 
at version, and the difficulty of grasping them. When the feet have been 
displaced, we must hunt for them by following along the back of the 
foetus to the nates, thence to the thighs, and to the knees, and these, 
as we have seen, are firm enough to permit of version. 
A further difficulty consists in anterior position of the feet. They are 
then situated above the pubes, in the hypogastric region, and, with the 
woman on her back, the hand cannot reach them, but is stopped by the 
inferior border of the symphysis. Then it is that the lateral position, and 
particularly the knee-elbow, are absolutely indispensable. The woman 
in such position, the feet become posterior, the introduction of the hand 
is easy, and version as well, whereas before this seemed impossible. 
A more serious difficulty is, at times, inability to firmly grasp the feet. 
In many cases, the foot may be brought down to the upper part of the 
vagina, but no further, the fingers slipping, and, in order to obtain firm 
hold, we must pass a sling over the foot, above the ankle, in order to 
make sufficient traction. The application of the sling is not as easy as 
one might think. When the foot is outside the vulva nothing simpler; 
but when the foot is in the vagina, particularly high up, the operation is 
a very delicate one. A running loop is made, and this is passed around 
the left fist. Introducing this hand into the vagina, the foot is seized 
by the fingers as high up as possible, and pulled down. With the fin- VERSION. 
35 
gers of the right hand, the loop is pushed over the left hand, and its 
fingers on to the foot. Once on the foot it is pushed beyond the heel. 
When the two ends of the loop are pulled upon, the foetal limb is held 
firmly. Unfortunately, this method, very simple in theory, is very diffi- 
cult in practice. In the first place, the loop, wet by the discharges, does 
Fig. 17. 
Fig. 16. Fig. 18. 
Figs. 16 and 17.-Application of Loop, by means of Dressing Forceps. 
Fig. 18.-Van Huevel's Instrument. 
not slide easily over the fist and the fingers; then again, the foot may 
escape from the fingers, or it is difficult to push the loop over the heel, 
for we have introduced if not two hands, at least one and a portion of 
the other into the vagina. 
Since the time of J.' Siegmundin, many instruments have been devised 36 
A TREATISE ON OBSTETRICS. 
for carrying up the loop, analogous to those for the cord. For instance, 
those of Walbaum, Stein, Van lluevpl, (Fig. 18), Wasseige (Fig. 19), 
Fig. 19.-Wasseige's Instrument. 
Figs. 20 and 21.-Lambert's Instruments. 
Lambert (Figs. 20, 21, 22), Trefurt (Fig. 23), Hyernaux (Fig. 24), 
Morales (Fig. 25, 26), and all have about the same value. VERSION. 
37 
Fig. 24.-Hyernaux's Instruments. 
Fig. 22.-Lambert's 
• Instruments. 
Fig. 23.-Trefurt's 
Instruments. 
Figs. 25 and 26.-Morales' Slings. 38 
A TREATISE ON OBSTETRICS. 
The same is true of the forceps invented to carry the loop (Figs. 16 and 
17), and those for seizing and bringing down the feet. (Those of Bang, 
Groning, Nevermann, Lazarewitz.) 
Of all the abov« instruments, the best is the hand. It is not often that 
the method by the hand fails, and the loop once in place we may make 
every necessary traction to extract the foot. 
Ill Evolution. 
Here the obstacles are dependent on foetal mobility. Whenever the 
obstacles to evolution are very great, we must desist from version, and 
resort to embryotomy. 
IV. Extraction of the Foetus. 
We have already mentioned short and tense cord, and the means at 
onr disposal. We must now study the difficulties offered by the arms 
and the head. If, indeed, uterine contractions are weak, if the cervix re- 
sists delivery, if tractions are made in the pain-intervals, the arms are 
extended above the head, and this is a grave complication, seeing that 
the body of the foetus having been delivered, the infant may endeavor 
to breathe, and asphyxiates. 
1. Extraction of the Arms.-The arms may be extended in two ways: 
either from above below, and from behind in front, or else from above 
below, and from in front behind, that is to say, crossing behind the neck. 
We must first determine in which of these two ways extension has oc- 
curred, for we must always, in order to extract them, make them follow 
the same route traversed in extension. The angle of the scapula will 
tell us this. If the arms have extended from behind in front, the in- 
ferior angle of the scapula will be at some distance from the vertebral 
column, while if extension has occurred from in front behind, then this an- 
gle will be near the vertebral column. 
Extraction of the arms must be performed gently, beginning with the 
posterior, for we thus gain space for the extraction of the anterior and 
more difficult arm. Often extraction of one arm is sufficient, for the 
other, as we have seen, may be in the vagina, and to prevent the ascent VERSION. 
39 
of this during evolution, a noose is slipped over the wrist and gentle 
traction made. 
In order to extract the posterior arm, the body of the foetus must be 
lifted upward by one hand, while the fingers of the other are gently in- 
sinuated towards the axilla. The thumb is then placed on one side of 
the humerus, and the remaining fingers on the other; the fingers are slid 
along this bone to the elbow. Seizing this joint, the arm is pulled from 
behind to the front, passing successively over the face and the chest, out 
Fig. 27.-Extraction of the Posterior Arm. 
at the vulva. (Fig. 27.) In a word, traction should ever be made at 
the joint, in order not to fracture the bone, and the arm be made to fol- 
low the inverse course it took during extension. Where the arm is ex- 
tended from in front back, the same manoeuvre is indicated, except that 
the arm is passed over the occiput and the neck of the foetus. This latter 
form is rare. 
The posterior arm disengaged, we turn to the anterior. The body of 
the foetus is depressed as much as possible and the arm disengaged in the 
same manner. In general the left hand is used for the posterior arm, and 
the right for the anterior. Before extracting the arms, Baudelocque and 40 
A TREATISE ON OBSTETRICS. 
Rossirth advise traction on the shoulders, thus approaching the arms one 
to another, and the neck is more readily accessible. 
Hiiter recommends the following method: " He seizes with both hands 
the thighs, lifts them up and brings them together, drawing them more 
and more towards the maternal abdomen. Then introducing the hand, 
he finds the posterior shoulder so low, that he can readily reach the 
elbow and extricate the arm. He then seizes the thorax with both 
hands, and turns the foetus on its longitudinal axis, so as to make the an- 
terior arm posterior, and its extraction is easy. A necessary consequence 
of the elevation of the lower extremities is descent of the posterior shoulder, 
only we must be careful in lifting up the thighs not to pull so hard as 
to cause descent of the head, which would greatly complicate mat- 
ters." This method, it is seen, is only a modification of Naegelc and 
Grenser's. 
Madame Lachapelle, Simpson, Cazeaux and Barnes, have especially 
drawn attention to the arm behind the head. Barnes believes that it is 
often the result of inexpertness, while Duges and Cazeaux believe that 
this accident may be produced in two ways: either the arm crosses the 
neck, after it has extended above the head, or else the arm extended 
along the back and was stopped at the occiput. 
When the ventral surface of the foetus has remained forward until the 
delivery of the shoulders, extraction of the hands is no longer difficult, 
as is pointed out by Dubois and Madame Lachapelle. The shoulders are 
still oblique, and it suffices to extract the posterior arm first. If it is not 
possible to bring the arm in front of the face and the thorax, Naegele and 
Grenser advocate pushing back the elbow to the outside and behind, and 
at once to extract the anterior arm first. 
2. Extraction of the Head.-The first obstacle which may offer, is the 
retraction of the cervix around the neck. If energetic traction is made, 
the result may be separation of the body from the head. If we do not 
act rapidly, the child will die. When the foetus is dead, we can wait for 
the cervix to relax, but otherwise we must try every means, baths, inunc- 
tions of belladonna on the cervix, chloroform, venesection to syncope, 
etc., to overcome the spasm. If the spasm is limited to the external os, 
we may try incision of the cervix and the forceps. If, however, the spasm 
is at the internal os, and we cannot reach it with the fingers to dilate, 
we must wait till the foetus is dead, and then resort to perforation or the VERSION. 
41 
cephalotribe. Even when we resort to incision and the forceps, we 
rarely save the foetus, for, however quick our actions, the infant has time 
to make efforts at inspiration, and dies. 
Besides this obstacle, there are four difficulties dependent on the man- 
ner in which the head engages: 
1. Occiput in front, and head flexed. 
2. Occiput in front, and head extended. 
3. Occiput behind, and head flexed. 
4. Occiput behind, and head extended. 
1. The head is extracted without the least trouble. It suffices to lift 
Fig. 28.-Veit's Method. (Mauriceau's Method.) 
the body towards the maternal abdomen, in order to extract the head. 
The perineum calls for special care. 
2. The first thing to do is to flex the head. In 1G68 Mauriceau de- 42 
A TREATISE ON OBSTETRICS. 
scribed at length the operative method which, to-day, bears the name of 
Smellie, or of Veit, and which should in reality be called after Mauriceau. 
(Fig. 28.) The method consists in lifting the body of the foetus upward 
with one hand, and applying the index and the middle finger of the other 
Fig. 29.-Prague Method, First Stage, 
hand each side of the nose, on the superior maxilla, and pulling the face 
downward the head is flexed. If we do not thus obtain flexion, one or 
two fingers are introduced into the mouth to the base of the tongue, and 
using the inferior maxilla as a fulcrum, the face is pulled down. The VERSIOX. 
43 
head once in the excavation, the two fingers are again placed on the 
superior maxilla, and while by them we seek to lower the face, the occi- 
put is pushed upward by the index and the middle finger of the other 
hand, so as to assist in flexion. This once accomplished, the body is 
lifted towards the abdomen of the woman, and, as in the preceding in- 
stance, the foetus is delivered with its back to the mother's abdomen. 
Traction should always be made backwards. 
Fig. 30.-Prague Method, Second Stage. 
Under the name of the Prague method, Kiwisch and Seyfert have de- 
scribed a process which varies but little from that already advocated by 
Puzos, and used by P. Dubois. It may be performed in two stages: 1. 
When the head is high up, the body of the foetus is carried backward 
towards the perineum, the fingers are applied over the shoulders, and 
traction is made downward and backward. If uterine contractions are 
defective, Kiwisch adds to this traction pressure exercised over the head 
through the abdominal walls. 44 
A TREATISE ON OBSTETRICS. 
Once the head in the pelvis, the other hand seizes the limbs of the 
foetus, and lifting the body rapidly towards the body of the mother, keep- 
ing up traction through the fingers applied over the shoulders, the foetus 
is delivered. 
If this method do not succeed, forceps must be applied and the head 
extracted. 
While this method often does succeed, it nevertheless frequently ex- 
poses the infant to serious accidents, such as dislocations, fractures of the 
vertebrae, etc. Hecker, Martin, Gusserow, have cited examples of frac- 
turg of the vertebral column, and of decapitation, and Kuge, in his mon- 
ograph on the foetal lesions following on extractions in pelvic presentations, 
reports a number of accidents to which this method exposes the foetus. 
Scanzoni, nevertheless, is greatly in favor of a method which saved the 
lives of 117 infants out of 152 delivered at the Prague Maternity. 
Finally, Champetier de Kibes from a careful study of all these methods, 
and from his own experience, draws the following conclusions: "The 
best method of making the head pass through the pelvis after delivery of 
the trunk is: 1. Make the inferior maxilla the fulcrum in order to deter- 
mine the flexion of the head. 2. At the same time make backward trac- 
tion. 3. Associate with these manoeuvres abdominal expression made by 
the hand of an assistant, not over the entire head, but more particularly 
over the frontal region of the foetus, in the direction of the superior 
strait. " 
If Champetier de Ribes has thus been able to cause a head to pass 
through a pelvis contracted to 2.9 inches, this method ought to succeed 
where the pelvis is normal. 
3. Extraction in these cases is nearly as simple as when the occiput is 
in front and the head flexed. The body of the foetus should be carried 
forward towards the abdomen of the mother. Delivery is thus accom- 
plished belly to belly; only, since the occiput is posterior, we must watch 
the perineum all the more carefully. 
4. In this case, the chin being more or less fixed behind the pubes, to 
pull on the body before having extracted the chin will only complicate 
matters. As long as the head occupies the antero-posterior diameter of 
the pelvis, the chin cannot be depressed. We must then, before attempt- 
ing flexion, cause the head to rotate. For our part, the only way to ob- 
tain a living infant, is to apply the forceps, artificially rotate the head, and VERSION. 
45 
deliver at once. It has been advocated, nevertheless, in these cases, to 
rotate the head with the hand. Such is the advice given by Madame 
Lachapelle, and Naegele and Grenser; but, while Madame Lachapelle im- 
mediately extracts the head with the hand, the latter apply the forceps 
after rotation. The following is the method of Madame Lachapelle: The 
hand is introduced into the concavity of the sacrum, and surrounds the 
head until it reaches the mouth, and the index and the middle fingers are 
Fig. 31.-Extraction of the Head. Method of Madame Lachapelle modified by Naegel6 and 
Grenser. 
introduced into the mouth, and while the other hand or an assistant pulls 
on the trunk, the head is made to rotate. At the same time, the attempt 
is ma e to depress the chin, and to make the head descend. As soon as 
the chin points backward, flexion is completed and the head delivered as 
usual. Naegele and Grenser rarely seize the child by the mouth, but 
passing the hand around the head to the opposite cheek, and seizing the 
face in the open palm, they try to bring the head down and at the same 46 
time to rotate it backward. This manoeuvre can only succeed where the 
head is large and the pelvis small. 
Finally, in addition to the above complications, version may be ren- 
dered difficult by disproportion between the foetus and the pelvic diameters. 
The reader is referred to the subject of contracted pelvis for informa- 
tion on this point. 
A TREATISE ON OBSTETRICS. 
Frequency and Prognosis of Version. 
It is nearly impassible to make any distinct statements in regard to ver- 
sion, for aside from transverse presentations, many authors prefer it to the 
forceps, while others, and we are of this number, much prefer the for- 
ceps when it is possible to use it. 
Thus while Sickel found the proportion to be nearly 1.3 in 100 labors, 
Ricker found it to be .81 in 100, and in 530 cases where the cause was 
noted, we find: 
Transverse presentations, . . . 73.2 per cent. 
Placenta praevia, . . . . . 15.4 " 
Prolapse of the cord . . . . 5.2 " 
Ploss, from his researches found: 3,575 versions in 316,891 labors in 
the German hospitals, or 1 in 88 cases, 214 versions in 67,129 labors, in 
England, or 1 in 313. In France, 1 in 110. 
The following statistical tables show the differences, according to the 
authority and country: 
No. of 
Cases. 
Mothers. 
Children. 
No. of 
Labors. 
Mortality. 
Living. 
Dead. 
Living. 
Dead. 
Mothers. 
Infants. 
From 1852 to 1880. 
172 
148 
24 
86 
86 
21.615 
13.9$ 
50$ 
Versions at the Paris Clinic. {Depaul.) 
[The table has been condensed so as simply to give the totals. A 
second elaborate table gives the results in the German, Swiss and Russian 
Maternities from 1789 to 1865. The total number of confinements was 
316,891 with 3,575 versions, or 1 in 88 labors.-Ed.] 
As for the prognosis, if version, practised at the time of election, that 
is to say, under the most favorable conditions, is, in general, not a seri- VERSION. 
47 
ous operation for either the mother or for the child, it is not always so, 
and unfortunately favorable conditions are rarely present in the majority 
of cases where we are called upon to perform version. (We are speaking 
now, of course, purely of podalic version by internal manipulation.) The 
less the amount of liquor amnii, the longer the duration of labor, the 
greater the contraction of the uterus, particularly if repeated attempts at 
version have been made, the more difficult the operation, and the graver the 
prognosis for mother and for child. The more expert the operator, the 
greater the chances of success. As for the mortality statistics, it is im- 
possible to give accurate figures, for the reason that the cases where ver- 
sion was easy have not been separated from those where it was difficult, 
nor, further, into classes according to the indication calling for opera- 
tion. The most we can say is that the infantile mortality is far in excess 
of the maternal. 
From Zweifel's figures we learn that of 53 cephalic versions, 70 per 
cent, of the children were born alive, and only one mother died; the 
infantile mortality rate was thus 28.3 per cent., and the maternal 2 per 
cent. These figures seem high, but many of the versions were performed 
during labor by Braxton Hicks's method; whilst cephalic version as we 
practise it, purely by external manipulation made during pregnancy only, 
is absolutely inoffensive both for the mother and the foetus. 
Podalic version, interna], is, on the other hand, more serious. Accord- 
ing to Zweifel, of 3,475 cases, 1,434 infants, 41.2 percent, were born alive, 
whilst 58.9 died. Of 3,475 versions, 8.4 per cent, of the mothers died. 
Madame Lachapelle lost one child out of every 3.96; Carus, Osiander, 
Kiwisch, Michaelis, 1 out of 2; Ricker, 1 out of 10; Huter, 1 out of 14; 
and Churchill, out of 542 versions, taken indiscriminately, lost 1 child 
out of 3 and 1 mother out of 15. 
Sickel, out of 447,163 children, noted 3,781 versions-that is to say, 1 
out of 118.10; of which 3,703 were podalic version, by one or two feet,- 
1 out of 120.28; and 78 cephalic, 1 out of 5,732; of 3,475 infants born by 
podalic version, 1,434 were born alive, and 2,041 dead. Of the same 
number of mothers, 3,184 were living and 291 dead. 
The reason for the gravity of this operation is evident, when we re- 
member the complications and the obstacles which we have noted. When- 
ever, then, there is room for choice, we much prefer the forceps to ver- 
sion. The forceps, in skillful hands, is an inoffensive instrument. 48 
A TREATISE ON OBSTETRICS. 
Version, in skillful hands, is always a serious operation, and we cannot 
better impress this than by repeating the words of our master, Depaul: 
" With my forceps, I am perfectly at ease, for I am sure of never doing 
harm, while I never perform version without apprehensions." We must 
remember, however, that what complicates version is the extraction of 
the foetus. Aside from traumatic lesions to which it is liable, the grav- 
est danger for the foetus is the retention of the head and the consequent 
asphyxia. Therefore certain authors have endeavored to make the infant 
breathe, while the head is still in the pelvis. Pugh advocated introduc- 
ing two fingers into the mouth, forming a gutter with the hand for the 
air to pass along, and later devised a special canula for bringing the air 
to the foetus. Similarly with Weidmann, Hecking, Blick, the younger 
Baudelocque. 
All these methods seem to us theoretical rather than practical, and we 
had better spend all our time in extracting the foetus. The same criti- 
cism applies to the proposal of Wigand and of Ritgen, to apply a ligature 
to the cord as soon as the body is born, and thus to prevent cerebral 
anaemia. It is not anaemia which kills, but asphyxia, and again, there- 
fore, the best remedy is to deliver the child as soon as possible. 
We append Pajot's table, wherein are resumed the rules for podalic 
version. 
Pelvic Version after Pajot. 
We must not think of version unless', the os is dilated or dilatable: the 
head must be above the brim: intact membranes are favorable. 
Version is indicated whenever the life of the child or mother is in dan- 
ger. When circumstances allow of choice, forceps should be preferred. 
Version may be divided into: 
1st Position not known: Endeavor 
to make out as exactly as possible. 
2d. Narrow vagina: Not serious. 3d. 
Arm in the vagina: Never ampu- 
tate. If version is possible, a loop 
around the hand to prevent retraction 
during evolution. If version is im- 
practicable, embryotomy. 4th. The 
foetal part is in the way: Push it up. 
5th. The feet cannot be found: Hunt 
for them along the lateral and poste- 
rior surface of the foetus. Pass the 
hand to the fundus and search care- 
fully, but thoroughly. 
Is# Stage. 
Introduction 
of the hand 
and search 
for the foot. 
Manipulate 
only in the 
pain inter- 
vals. 
Introduce hand, cone- 
shaped, into vagina: Rup- 
ture membranes: Enter 
uterus gently: Seek the 
feet by the shortest route: 
Seize the feet-one is 
enough. The diagnosis of 
position has been made, 
if possible, beforehand. 49 
VERSION. 
2nd Stage. 
Evolution. 
Same in re- 
gard to ma- 
ninulations. 
Extend the leg gently: 
Pull the foot to the vulva, 
bending the foetus on it- 
self, so as to bring the ver- 
tex to the fundus, and the 
back towards one of the 
cotyloid cavities. 
Uterine contraction about the only 
obstacle. If the head tends to en- 
gage with the feet or foot, noose 
over the feet, and push the head 
up with one hand, while making 
traction on the noose by the 
other. 
1st. If it is impossible to finish with 
one foot, bring down the other, 
placing first a noose over the first. 
2d. Extension of the arms over the 
head: Bring down the posterior arm 
first. 3d. The head does not rotate: 
Cause artificial rotation. 4th. The 
occiput is in the sacral excavation: 
Head flexed-carry the back of the 
foetus backward. Head extended- 
carry the foetus towards the belly of 
the mother. If extraction is impos- 
sible-forceps. 
3rd Stage. 
Extraction. 
Manipulate 
only during 
contractions 
- except in 
emergency, 
inertia, hem- 
orrhage. 
Wrap the foot, or feet, 
in a towel: Make trac- 
tion in the axis: Seize 
the parts near to the 
mother: Be careful of the 
cord: If the arms make 
exit spontaneously, 
simply lift forward the 
_body. 
Vol IV.-4 CHAPTER II. 
THE FORCEPS. 
History. 
S Schroeder has well said, obstetrics remained so long in the hands 
of the midwives, from the lack of proper instruments to save the 
mother and the child, and because the accoucheur only interfered in case 
of foetal death. Not that the ancients did not endeavor to devise means 
for extracting living infants, but they had recourse either to more or less 
complicated manual means, or else to dangerous or imperfect instruments, 
and, therefore, the death of the foetus was necessarily the result of their 
manipulations. 
In the eleventh century, Avicenne devised an instrument for saving the 
child, and in 1554 Jacques Rueff described a similar one. It was not, 
however, till 1647, that the Chamberlens invented the true forceps. Up 
to 1721 the instrument had to fight its way into favor, for, in that 
year, we find Lamotte absolutely condemning it. Times changed, how- 
ever, and to-day this remarkable and inoffensive instrument saves an in- 
calcujable number of children, who otherwise would almost infallibly die. 
And what modifications in the instrument since the days of the Chamber- 
lens. From Chamberlen to Tarnier! We simply aim below to describe 
the most important modifications of an instrument which now resembles 
only in principle the first forceps of Chamberlen and of Palfyn. 
Description of the Principal. Forceps. 
In 1618 Dr. Causardine found, in an old chest in a house formerly in- 
habited by the Chamberlens, four models of forceps, and it is thus proved 
that to them belongs the honor of having devised this instrument, al- 
though, to their shame be it said, they concealed for many years an in- 
strument so useful to humanity. In 1688 the forceps was sold to Roon- 
huysen, and by him to Nicholas Boelkmann and to Ruysch, and it was not THE FORCEPS. 
51 
generally known till 1753, when Jacob de Vischer, and Hugo de Poli, 
who had bought it from the wife of Jean de Bruyn, under the name of 
Roonhuysen's lever, described it. The original Chamberlen forceps con- 
sisted of two fenestrated branches, crossed, and articulated by a pivot, 
like that of a pair of scissors. (Figs. 32, 33, 34.) 
In England, from 1668 to 1728, Drinkwater, Giffard, and Chapman, 
Fig. 32.- 
Chamberlen Forceps. 
Fig. 33.- 
Male Blade. 
Fig. 34.- 
Female Blade. 
Fig. 35.- 
Palfyn's Forceps. 
used the Chamberlen instrument, and in 1713 Palfyn, of Gand, presented 
to the Paris Academy of Medicine a forceps composed of two blades, not 
crossed, not fenestrated, greatly curved. (Fig- 35.) 
In 1733, Dusee modified this forceps by increasing the curve of the 
blades, and adapting to the handles two hooks turned outward. 
In 1734 to 1735,Giffard and Chapman used fenestrated blades. It was not, 
however, till 1747, Levret, and 1752, Smellie, that the forceps was much 52 
A TREATISE ON OBSTETRICS. 
perfected. Up to the time of the former it was straight, and he gave it the 
pelvic curve. Five years after, Smellie gave it a still greater curve in 
order to adapt the instrument to the head above the brim, and further 
lengthened the blades. (Figs. 36, 37, 38.) 
Since then the modifications in the forceps of Levret and of Smellie 
are only in slight details, and Levret's forceps is still the type of all others. 
Fig. 36.- 
Levret's Forceps. 
Fig. 37.- 
The Same, in Profile. 
Fig. 38.- 
Smellie's Forceps. 
Every forceps is composed of two blades-the male, the left blade, be- 
cause it goes to the left of the pelvis, the pivot blade; and the female, the 
right blade, the lock blade. Each blade is made up of a fenestrated por- 
tion, an articulai' portion, a handle. 
The blades are always fenestrated, in order to make the instrument 
light, and that it may the better adapt itself to the head. They present 
a double curve along the borders and along the inner surface. The 
former is Levret's pelvic curve. The blades alone enter the pelvis. THE FORCEPS. 
53 
The articular portion varies with the country and the instrument. 
The handles are for manipulating the instrument, and are terminated 
by two hooks turned outward. They unite at the lock, or articular por- 
tion. 
Levret's Forceps were variously modified, and are thus described by 
Naegele and Grenser: "His first instrument was 18.9 inches long, of 
which 6.8 belonged to the blades. It was fenestrated, and the internal 
surface was scooped out like a gutter. The handles were of metal, and 
ended in hooks turned outward. The cephalic curve was slight, and the 
ends of the fenestra? were 2.7 inches apart. His second instrument pos- 
sessed the new curve; the extremities of the fenestra? were 3.4 inches 
above the horizontal line when the forceps lay flat. Its length was 17.2 
inches, 7 inches of which belonged to the handles; the greatest width 
between the fenestrae was 3.6 inches. It had a scrfiw lock. 
Finally in 1760, Levret perfected his instrument, and it is described by 
his pupil Stein. It is 16.4 inches long, the pelvic curve is 2.3 inches, 
the greatest width of the fenestra? 2.1 inches. The extremities nearly 
meet. The fenestras are prolonged to the lock, so that a filet may be 
passed. The lock is a key. (Fig. 36 and 37.) 
Smellie's Forceps.-Two in number, a long and a short. "The.short 
(Fig. 38) has no pelvic curve. It is 11.7 inches long, 4.7 for the handles, 
and 1.9 between the fenestrae, the extremities of which meet. The 
handles are of metal lined with wood. They have a sink lock. The long 
forceps, is 13.3 inches long, 5 inches of which is handle; it has a pelvic 
curve, 1.8 inches high." (Naegele and Grenser.) 
Classic Forceps.-French Forceps.-Forceps of Dubois, Pajot. 
(Figs. 39, 40, 41.) 
This is simply Levret's, slightly modified. It is composed of two 
branches, each divided into blade, lock, handle. The instrument is of 
steel, light and solid. It is nickel-plated. The mean length is 17.5 
inches, from the end of the fenestrae to the lock 9.3 inches, from the lock 
to the end of the handles 8.1 inches. When the instrument is flat the 
fenestrated portion is 3.1 inches above the horizontal line. The greatest 
width between the blades is, at 1.5 inches from the extremity, 1.9 inches. 
The fenestra is 1.1 inches wide. The weight is about two pounds. The 54 
A TREATISE ON OBSTETRICS. 
instrument has both a cephalic and a pelvic curve. In order that the 
pelvic curve may be exact, Tarnier says that the extremities of the fenes- 
tra? should be 3.4 inches above the horizontal line. The handle-ends 
have hooks, the one concave and sharp, and the other, curved nearly at 
right angles, is also sharp and may answer for a perforator. 
Fig. 39. Fig. 40. Fig. 41. 
Fig. 39.-Classic Forceps.-A, Lock. B, Olive, holding sharp point. D. Blunt hook, contain- 
ing a perforator. 
Figs. 40 and 41.-Blades of Forceps of Pajot, with Disarticular Branches. 
The articulation is by a pivot lock. 
Figs. 40 and 41 represent the jointed forceps of Paj'ot. This joint 
makes the long forceps more portable without taking away from its so- 
lidity. 
When the head is below the brim, Pajot uses a short forceps, which is THE FORCEPS. 
55 
only 12 in. long. (Fig. 44.) The branches disarticulate at their middle, 
to receive blades of larger size. (Figs. 42, 43.) 
The Forceps of Brunninghausen has a lateral articular cleft, but the 
pivot lock is replaced by a flat projection, and the articulation is made 
firm by the pressure of the two hands. 
Naegele's Forceps (Figs. 45, 46, 47) is simply Brunninghausen's modi- 
fied. Its length is 15.8 inches, of which 6.8 inches is for the handles. 
When the instrument is closed, the blades are separated, above the lock, 
at an angle of 39 degrees. The superior extremities are .42 of an inch 
Fig. 42. Fig. 43. Fig. 44. 
Fig. 42.-Pajot's Forceps. 
Fig. 43.-Small Blades, attachable to Handles of preceding Instrument, to make a sec- 
ond Straight or Curved Instrument. 
Fig. 44.-Pajot's Forceps.-Lateral cleff, for use at inferior stiait. 
apart. The greatest width between the fenestrated portions is 2.6 inches. 
The length of the blades is 8.9 inches, the greatest width is 1.6 inches. 
They narrow down towards the lock. The handles are of metal lined 
with wood. The lock is like that of Brunninghausems. The handles 
have lateral projections. 
Simpson's Forceps is 14 inches long, according to Tarnier; the length 
of the handle is 5 inches, that of the blade, from the lock to the curve, 
is 2.34 inches, the fenestra measures 6.24 inches, the greatest width is 
.46 inches from the extremity, and measures 1.6 inches. When the for- 
ceps is Ipcked, the greatest width between the blades is 2.9 inches; the 56 
A TREATISE ON OBSTETRICS. 
distance between the extremities is .97 inches. There is one special point 
in the construction: Immediately above the lock, the blades separate 
sharply, and then turn at about a right angle to proceed parallel up to the 
fenestra?. The lock is like Smellie's. The handles are of metal covered 
with wood. 
Stoltz's Forceps (Fig. 49) is thus described by Aubenas, the translator of 
Naegele and Grenser: " This forceps is not quite as long as the Parisian, 
Fig. 45.- 
Naegele's Forceps. 
Fig. 46.- 
Male Blade. 
Fig. 47.- 
Female Blade. 
Fig. 48.- 
Simpson's Forceps. 
and a little longer than the usual German forceps. It is 16.3 inches long, 
measuring 8.5 inches from the lock to the end of the fenestra?, and from the 
lock to the end of the handles 7.8 inches. The blades are fenestrated 
for 5.4 inches. The greatest width of the fenestra? is at the junction of 
the upper with the middle third, and is .078 of an inch. The greatest dis- 
tance apart of the fenestrae is at the upper third of the ellipsoid, and is 
2.73 of an inch. The separation begins at 1.5 inches from the lock, and 
the curve begins at 3.9 inches from this point. At the extremity the 
blades are .39 of an inch apart. The blades are concave. THE FORCEPS. 
57 
" It results from this disposition of the blades that they are longer than 
is customary; the fenestras are wider open; the curve on the flat is more 
pronounced; the separation is greater than usual; the ellipsoid is near the 
extremities. 
" The handles are of roughened wood, with two lateral wings, with arti- 
culations, whereby they may open and shut. 
Fig. 49.-A, Stoltz's Forceps Closed 
B, Lock. C, Male Branch. 
Fig. 50.- 
Trelat's Forceps. 
' ' Such is the instrument which Prof. Stoltz has used for twenty-nine 
years, and which is praised by all who use it." 
Trelat's Forceps (Fig. 50) is less massive and heavy than the ordinary. 
It is 15.9 inches long, and the greatest width of the fenestras is 1.8 
inches. The blades are rounded, and polished on both surfaces. The 
lock is Brunninghausen's. The handles have no hooks, and near the end 
are perforated for a steel rod, which aids in traction. This forceps is 58 
A TREATISE ON OBSTETRICS. 
peculiar from the great elasticity of its blades, and therefore they can 
adapt themselves to the foetal head with less risk of injury. 
All the above forceps necessitate the introduction of the right blade 
first, else the blades will cross, and to obviate this the following forms 
have been devised. 
Forceps of Thenance (Fig. 51); of Valette (Fig. 52); of Tarsitani (Fig. 
53); of Antoine Petit (Fig. 54); of Baumers (Fig. 55); of Campbell 
(Fig. 56); of Mattei (Fig. 57.) 
Fig. 51. Fig. 52. Fig. 53. 
Fig. 51.-Thenance's Forceps. 
Fig. 52.-Valette's Forceps. 
Fig. 53.-Tarsitani's Forceps.-.4, Pivot. B, Screw in right blade when forceps is articulated 
above. D, Projection of left blade. C, Articulation of right blade. F, Screw,' from right to left. E, 
Right blade. G, Projection of left blade. 
Finally, we may mention the leniceps of Mattei (Fig. 58), and the re- 
troceps of Hamon (Fig. 59). The latter, in common with all others but 
the inventor, we reject absolutely. Its acceptance would, as Tarnier says, 
be going back two hundred years. 
Chassagny's Forceps. (Fig. 60.) Chassagny was the first to endeav- 
or to apply to difficult labor in the human species mechanical traction, 
used for a long time by veterinary surgeons in parturition of the larger 
animals. THE FORCEPS. 
59 
In his forceps the ellipsoid of the ordinary instrument is done away 
with. " The handles are straight, except at the ends where they are 
slightly bent. The lock is through a transverse piece, which may sepa- 
rate the blades, which are thus held apart throughout their entire length. 
The blades are flexible and elastic." (See Chassagny's book, Method of 
Continuous Traction, for complete description of instrument.) 
Traction is not made by the handles of the instrument, but through 
Fig. 54.- 
Petit's Forceps. 
Fig. 55.- 
Baumer's Forceps. 
Fig. 56.- 
Campbell's Forceps. 
two cords attached to the middle of the blades, at the extremity of a fixed 
line, passing through the bi-parietal diameter. The pelvis, and not the 
accoucheur, directs the head; it is free to turn, in every sense, around its 
transverse and longitudinal axes. 
Traction-forceps of Joulin.-This instrument is composed of: 1. A 
steel rod, 13 inches long, in which turns a second rod, as the handle c is 
revolved. 2. A fulcrum, f, of metal, and which is applied to the ischi- 
atic tuberosities of the woman. 3. A small dynamometer, which measures 60 
A TREATISE ON OBSTETRICS. 
Fig. 57 Fig. 58. 
Fig. 57.-Mattei's Forceps.-A, B, Blades. C, Lock of both blades. D, E, Extremity of blades. 
M, Lock seen separate. E G, Screw for fixing lock apparatus. H, Depression for superior blade. 
L, Opening through which inferior blade passes. 
Fig. 58.-Leniceps of Mattei. 
Fig. 59.-Retroceps of Hamom.-A, Screw to lock right blade. B. Right blade. C, Left. G, 
Lock, a', Pubes, b, End of right blade, d, End of left. e. Concavity of Sacrum. 61 
THE FORCEPS. 
the force applied. 4. Finally, a filet, .19 of an inch in diameter. The 
instrument is furnished with an ecraseur, II, which articulates with the 
Fig. 60.-Chassagny's Forceps.-1, Complete apparatus. 2, Apparatus with sunken hooks 
projecting at will, for seizing the head after craniotomy. 3, Method of insertion of the filets on the 
blades. DD, Projections on the blades, for holding the filets. 
canula, and may be worked by means of the Chassagny or Maisonneuve 
chain. 62 
A TREATISE ON OBSTETRICS. 
Method of Application. 
The forceps, whatever the model, having been applied to the foetal 
head, in accordance with the usual rules, the filets are passed through 
Fig. 61.-Sustained Traction Forceps of Chassagny. 
Fig. 62.-Traction Forceps of Joulin.-A, Canula. B. Screw. C, Handle of second rod. D, 
Extremity joining E. F, Metal fulcrum. G, Filet. H, Point of the ecraseur articulating with the 
canula. 
the fenestra. The metal disk, articulated with the canula, is placed 
over the ischial tuberosities of the woman. The ends of the filets are THE FORCEPS. 
63 
attached to the dynamometer, and this is fixed to B, which moves when 
the handle, C, of the canula, is turned. The filets act doubly; they 
not only pull the forceps, but they approach the blades, so that the 
pressure exerted on the foetal head is certain, and is measured by the 
•Fig. 63.-Dynamometer of Joulin. 
dynamometer. (Fig. 63.) When the head emerges, the tension of the 
filets becomes lessened. The dynamometer, further, serves to regu- 
late the operation. Whenever the needle tends to swing quickly, the 
Fk>. 64.-Joulin's Apparatus Applied, and Working.-A, Canula and movable screw. B, 
Handle of instrument. C, Dynamometer attached to screw. E, Filets, passing from fenestrae to 
dynamometer. F, Metal plate. The filets glide over the lower border. 
operator should stop for awhile. The duration of the operation is from 
ten to thirty minutes. The canula must be held horizontally. The first 
tractions compress the soft parts against which the disk is applied. Trac- 64 
A TREATISE ON OBSTETRICS. 
tion in the pelvic axis-is maintained by the point of reflexion of the lower 
border of the disk, which partially occludes the vulva. 
Joulin has proved experimentally that manual tractions with the for- 
Fig. 65.-Apparatus of Pros de la Rochelle. 
ceps, instead of being regular and continuous, are abrupt and broken at 
short intervals, the force employed varying from 84 to 132 pounds, while 
mechanical tractions are regularly sustained, and may always be graduated 
by the dynamometer. THE FORCEPS. 
65 
Apparatus of Pros de la Rochelle.-Pros is also a partisan of mechani- 
cal traction, and uses the following apparatus, (Fig. 65), consisting of: 
1. A movable shelf, to be placed on a bed or a table, on which the 
woman lies, and allowing of different positions. It is 16x7.8x3.9 inches 
in dimensions. 
2. Bracelets, not indispensable, for holding the woman in place. 
3. A movable rod, 21 to 26 inches long, articulating with the shelf. 
Extremely movable, it allows the accoucheur to make traction on the 
forceps with almost mathematical precision in the axis of the strait, even 
where the pelvis is oblique or oval. The attached handle has simply to 
be depressed in a half circle to exert a force of 28 to 31 pounds. 
4. A slender forceps, 15.6 inches long, the fenestra 1.36 inches deep, 
the curve being like Levret's. 
5. A traction bar and a dynamometer. 
6. A rounded wooden canula, for receiving the traction rods of the for- 
ceps. 
7. A transverse rod to the forceps, graduated in hundredths of an inch, 
to indicate the amount of separation of the blades. 
8. An intra-pelvic traction rod, to be used in case of narrowing at the 
pelvic strait. 
9. A belt to be applied around the waist of the woman, to correct 
uterine obliquity, to control the uterus, and to compress somewhat the 
foetus. 
Apparatuses of P outlet.-Poullet, of Lyons, has devised two instru- 
ments: one, called the sericeps, to take the place of the forceps (see fur- 
ther on); the other, a tractor (Figs. 66, 67), to be used either with the 
sericeps, or the forceps. 
It is composed of three portions: 1. A pelvic arc, a, b, c, d. 2. A 
straight rod, e, f. 2. A canula. 
The pelvic arc is terminated at each end by a quadrangular loop, cov- 
ered by rubber, and intended to receive the tuberosities of the ischium. 
The dimensions of the arc are important. From a to c 3.5 inches, from 
b to d 4 inches. The width of the loops from a to b and from c to d is 
2.7 inches. 
The arc is in two pieces, joining and holding firmly the rod at e. The 
instrument may thus be taken apart, and the arc increased, where the 
head is large. 
Vol. IV. -5 66 
A TREATISE ON OBSTETRICS. 
Fig. 66.-New Tractor of Poullet. 
EJi 
FINITE 
B3.I. THE FORCEPS. 
67 
The rod ef is straight to/, where it bends forward, making an angle at 
/with the canula gf of 140°. 
The canula fg incloses a rod which is moved by turning the transverse 
handle, and this rod imparts motion to t. It is to t that the loops of the 
rods of the forceps, or the lower sling of the sericeps, are attached. At the 
beginning of labor t is at /, at the end of labor t is at g. 
At o each blade of the forceps is pierced for the passage of the traction 
chains, which are thus inserted (and this is important) at the level of 
the centre of the foetal head. 
This tractor rests on the pelvis, in front, and behind each tuberosity. 
These four points, a, b, c, d, form a quadrangle through which pass the 
traction cords. The instrument holds the position given it, each turn of 
the handle simply applying it closer against the pelvis. 
The operatoi- may dispense with an assistant, and he may manipulate 
the instrument with one hand, while the other sustains the perineum. 
He is further able to alter the axis of the tractor at will; thus, at the be- 
ginning of labor, as far back as possible, in the middle of labor, as far 
forward as possible. The instrument makes, at first, traction backward, 
perpendicularly about to the inlet, and later tractions forward, perpen- 
dicularly to the inferior strait. Figure 67 shows the tractor pulling the 
forceps, the head at the superior strait. The dotted lines show the posi- 
tion of the instrument at the end of labor. 
My colleague, Bailly, has brought forward the following objections 
against the use of mechanical tractors in labor: 
1. These tractors substitute blind force for that of the sentient guiding 
hand. 
2. They act in only one direction, and do not allow us to change the 
traction line according to the change in the pelvic axis; consequently ob- 
lique force is applied to the pelvic walls, which, from mechanical princi- 
ples, results in loss of direct force. 
3. Mechanical tractors interfere with lateral movements of the forceps. 
4. They may slip from the head before the accoucheur knows it; and, 
if a force of 17 to 18 pounds is being exerted, what may not happen to 
the maternal parts? 
5. If manual traction be sufficient to bring down the head through a 
contracted pelvis, whenever this is at all possible, what scope or necessity 
is there for mechanical tractions? 68 
A TREATISE ON OBSTETRICS. 
Fig. 67.-New Tractor of Poullet, in action. THE FORCEPS. 
69 
6. The time requisite for the introduction of these instruments must 
add to the maternal suffering. 
7. Facts have proved that not only are mechanical tractions dangerous 
for the mother, but that further the very foetal lesions which they aim to 
prevent are more frequent than after the use of the ordinary forceps. 
Although the modifications of Pros and of Poullet have negatived cer- 
tain of the above objections, the others are still valid, and we are in per- 
Fig. 68.-Insertion of Blade with Loop for Continuous Traction. (After Tarnier.) 
feet accord with Bailly, Depaul and Pajot, who absolutely reject mechani- 
cal tractors. Tarnier is less positive, and he believes that, in the future, 
all these objections against mechanical tractors will be overcome. 
Starting with the assumption that manual traction varies with the mus- 
cular force of each individual, and from moment to moment, he proves 
that mechanical traction is, on the contrary, progressive, and may fur- 
thermore be limited and gauged by means of the dynamometer, and this 
latter adjunct is indispensable. 70 
A TREATISE ON OBSTETRICS. 
The principal objection, in his opinion, resides in the constant action 
of mechanical tractors. lie has endeavored to overcome this as follows: 
" Through the fenestras of an ordinary forceps he passes a double sling, 
the ends of which are tied together externally, and looped over a dyna- 
mometer. (Vide Figs. 68, 69 and 70.) This dynamometer is connected 
with a fixed point, a hook in the floor, six feet distant. 
" The woman is placed in the usual position, held by assistants, and 
tractions need only be made on the cord which commands the loops, when 
Fig. 69.-Insertion of right Blade with Loop. 
the fenestras are brought together with a force proportionate to the trac- 
tions, and the infant's head is firmly held. (Fig. 70.) 
"With one hand the tractions are regulated at will, according to the index 
of the dynamometer; the other hand guides the handles of the forceps 
as may be desired, up or down, to the right or to the left. The opera- 
tion is simple, and the tractions, although mechanical, may be made in 
any direction as readily as in the purely manual operation." 
Lately Tarnier has devised a forceps which we will soon describe. 
The above method has, in Tarnier's hands, resulted in four dead infants 
and two mothers out of seven cases. 
The movable rod of Prosand of Poullet is another valuable modification THE FORCEPS. 
71 
of mechanical tractors, but is not sufficient to overcome our objections, 
for still the head must be seized either in the bi-temporal or bi-parietal 
diameter, and although this is possible in the excavation, it is nearly im- 
Fig. 70.-A, Hand pulling on the Cord which controls the Loops. B, Hand directing the Forceps. C, One of the Pulleys 
qf the Cord. D, Dynamometer. 
possible at the superior strait, in particular when there is marked pelvic 
deformity, and this is, above all, the case in which the advocates of 72 
A TREATISE ON OBSTETRICS. 
mechanical tractors claim the greatest utility. Further, mechanical trac- 
tors do not allow us to take cognizance of rotation movements. For these 
reasons, chiefly, we are in favor of relegating mechanical tractors to the 
armamentarium of the veterinary surgeon, never forgetting that the lives 
entrusted to our care are far more valuable than those of the cow and her 
calf, with both of whom we may, if we please, in full conscience, experi- 
ment with any curious contrivance. With the mother and the child we 
are never so justified. 
Brute force is not what the accoucheur aims at, but intelligent reason- 
ing force; and although I may need only a force of 88 pounds with a 
mechanical tractor, I would far rather exert one of 135 with my hand, 
Fig. 71.-Hermann's Forceps. 
convinced, as I am, that thus there is less likelihood of injury than with 
88 used blindly. 
While now certain gentlemen have been trying to apply mechanical 
traction to labor, others have aimed at modifying the forceps so as to 
make it less dangerous to the perineum, and to allow of traction in the 
axes of the strait and of the excavation. 
Hermann's Forceps.-In 1844, Hermann, of Berne, had constructed a 
forceps, (Figs. 71, 72), which possessed not only a perineal curve, like 
that in the forceps of Mulder and of Johnson, but also a considerable pel- 
vic curve, with long blades, and a special rod applicable either above or 
below the instrument, according to the high or the low situation of the 
head. THE FORCEPS. 
73 
Hubert's Forceps.-In 1860, Hubert de Louvain, struck by the fact 
that the shape of Levret's forceps prevented traction in the axis of the 
Fig. 72.-Hermann's Forceps. 
superior strait, without injury to the perineum, modified them by fixing 
between the handles a steel rod, directed backwards, and traction by 
which is possible in the desired direction. (Fig. 73.) 
Fig. 73.-Hubert's Forceps at the Superior Strait. S, P, Shortest sacro-pubic diameter. 
A, B, Axis of the superior strait. A. G, Direction of the traction force applied through the handle 
of the forceps. A, D, N, M, Parallelogram of the forceps. A, Centre of supposed foetal head. C 
Traction rod. P, Pubes. R, Perineum. S, Promontory. H, Horizontal Plane. F, Vertical plane. 
Hartmanri's Forceps.-In 1870, Hartmann added to the forceps a rod 
like that of Hubert, but he placed it above the lock. (Fig. 74.) "If, 74 
A TREATISE ON OBSTETRICS. 
he says, "the ordinary forceps is applied to the head at the brim, 
traction will not be made in the axis of the pelvis, but from above down- 
wards, and particularly forwards, and the tendency of the head, hence, is 
to press against the anterior wall of the pelvis. 
" When, however, the rod ad is applied, if the operator presses with his 
arm in the direction e to e, through the lock, the action on the foetal head 
will be, at the same time, from i to i, and the resultant of the forces is 
the diagonal fl. But since the operator does not press perpendicularly, 
but obliquely, that is to say, from above backwards, below and in front, 
Fig. 74.-Hartmann's Forceps. 
about in the direction frorm m to m, the head is compressed from u to w, 
and the resultant is consequently the diagonal fr. If, on the contrary, 
pressure be applied to the handle d of the rod ad, from in front back- 
wards, the direction of the pressure becomes dff, and the direction of the 
traction remaining ff, the diagonal of the forces and^" will become fk. 
If now we exaggerate pressure beyond traction, the diagonal will alter 
from k to k', and the head, as it descends, will do so in the axis of the 
pelvis, and will not press against the anterior pelvic wall." 
Morales has also devised two forceps, which, although progressive mod- 
ifications, are open to serious objections. 
Finally, Tarnier, from 1877 to 1879, invented over thirty forceps, of THE FORCEPS. 
75 
which we will describe here only the first and the last model. (Figs. 75 
and 76.) 
The following are the peculiarities of the first model, that of 1877. 
" It is composed of two handles, and of two traction rods. (Fig. 75.) 
The rods are inserted into a transverse bar atjc, and are parallel as in the 
forceps of Thenance. The fenestrae are not as long as in the classic for- 
ceps; the instrument has a perineal curve, that of Morales modified; the 
traction rods and the handles are united by a freely movable articulation. 
To apply this forceps: Articulate each traction rod to its corresponding 
blade, and this is easily done. Holding both in the hand the fenestra is 
Fig. 75.-Tarnier's first Forceps. 
applied to the head in the usual fashion. When both blades have been 
introduced, the forceps is locked with the traction rods below. Com- 
pression is applied to the head by means of a screw, working from one 
handle to the other. The traction rods are inserted into the transverse 
traction bar at During traction on this bar, the handles act as an in- 
dex of the direction in which traction should be made, and the operator 
has only to follow the oscillations of these handles, keeping the traction 
rods about one-half an inch apart from the handles." (Aubenas.) 
According to Tarnier, the above instrument is preferable to the ordi- 
nary: " 1. Traction need not be so energetic. The whole of the traction 
force is utilized. If the head resists with a force of 37 pounds, then 
only 17 pounds traction force need be exerted by the instrument, while 76 
A TREATISE ON OBSTETRICS. 
with the ordinary forceps greater force would be requisite on account of 
the necessary decomposition of this force. 2. With this instrument all 
the utilized force acts on the head in the pelvic axis without any 
compression of the maternal parts. 3. Since traction is made 
in the pelvic axis, the head has no tendency to escape from 
the fenestrae. 4. The traction handle being transverse, the grasp 
of the operator's hand is firmer. 5. Compression once made by 
the screw r, this is not increased during traction; while with the ordinary 
instrument, the hands of the operator make greater compression the 
greater the traction, and the antero-posterior diameter of the head is 
thus elongated, and the obstacles to labor increased when the pelvis is 
narrowed in its antero-posterior diameter. 6. The fenestrae being short, 
we may always make traction in the pelvic axis without fear of tearing 
the posterior commissure. 7. Not only may axis-traction be made, but 
the head is at liberty to follow the vaginal curve. Owing, further, to the 
movable point at the articulation of the traction rods and the handles, 
the head may spontaneously execute its rotatory movement around the 
pelvic axis. When, however, it is desired to make this rotation artifi- 
cially, then care must be taken to seize the rods and the handles together, 
for if the endeavor is made to rotate the head by means of the rods alone, 
they might be broken. 8. Finally the new instrument has an indicator 
needle, wherein it is peculiar over all other forceps." 
While Tarnier's pupils accepted this instrument with the greatest en- 
thusiasm, far otherwise was it with Stoltz, Depaul, and, above all, Pajot. 
The latter, in his discussion with Tarnier, thus compares the classic and 
the new instrument: " Tarnier's Forceps: A complicated instrument, 
deprived of all lever property, less easy to introduce and to manage, only 
able to do what all other forceps may. 2. An instrument still unproved, 
of value where the head is movable above the superior strait. 3. An in- 
strument with an indicator needle, of no use when the operator knows his 
business. 4. Fenestrae useful in cases where delivery may be accom- 
plished with dressing-forceps, but useless otherwise on account of their 
small size. 5. An instrument said to be of value because by it traction 
may be made in the pelvic axis, a superfluous advantage in 90 cases out 
of 100, and still to be proved true in the remaining 10. Classical For- 
ceps: 1. An instrument, simple, handy, easy of introduction and of man- 
agement, with two branches instead of four, without screw, successful in THE FORCEPS. 
77 
innumerable cases, according to need, tractor, lever, compressor, accord- 
ing to exercised traction, less likely, hence, to slip in difficult cases, and 
when it does slip, at once notifying the operator. 2. An instrument giv- 
ing full scope to the head between the tractions, and more than Tarnier's 
instrument during the tractions, the head never being elongated antero- 
posteriorly more than a firm hold necessitates. 3. The masters in the art 
consider the principle even of Tarnier's instrument superfluous." 
Fig. 76.-Tarnier's Last Model. B, Movable handle. P, T, V, Forceps closed. 
The last model of Tarnier's instrument differs markedly from the first, 
for the perineal curve no longer exists, and the fenestrae are similar to 
those in the classic forceps. It is, in brief, the classic forceps to which 
traction rods are attached. (Figs. 76, 77, 78, 79.) 
The following is the description of the instrument: It is 16^ inches long. 
When lying flat, the end of the blades projects 3.12 inches above the plane. 
Fig. 77.-Traction Rods separated from Handles. 
The blade and the curve are exactly similar to those of the ordinary for- 
ceps, with the single exception that the fenestrae are not quite as long. 
The distance from the end of the fenestrae to the lock is 10| inches; from 
the same point to the ends of the traction rods it is 9^ inches. There 
is a space of f of an inch between the ends of the blades when the instru- 
ment is locked. The greatest distance between the blades is 2f inches as 
in the classical forceps. The introduction and use is the same as the 78 
A TREATISE ON OBSTETRICS. 
latter, except in the following respects: The compression screw; traction 
is made by rods, always at about | of an inch from the handles; as soon 
Fig. 78.-Movable Handle adjusted, and Hand holding the Transverse Bar. 
as the head is about to escape at the vulva both the handles and rods are 
Fig. 79.-Forceps seized by the Hand, below, and near the Blades. 
seized near the blades, to prevent too rapid exit of the head. (Tide 
Fig. 79.) 
Thus modified, Tarnier's instrument is an excellent one, for to the classic THE FORCEPS. 
79 
forceps he has added, in our opinion, two improvements, in the pelvic 
excavation, certainly. The indicator needle, by showing the direction in 
which traction should be made, is of great utility, and less force has to 
be employed in traction than with the classic forceps. The same is not 
true at the superior strait, for the last model lacking the perineal curve, 
there is the same difficulty with Tarnier's instrument as with the classic 
in carrying it sufficiently backwards, and the force to be used is identical 
in both instances. 
The objections to the instrument are, in our opinion, still numerous: 
1. A two-fold manipulation is requisite, the one for articulation of the han- 
dles even as in the classic forceps, the other for the insertion of the trac- 
tion rods. In order that these rods may functionate properly, they must 
be absolutely parallel-that is to say, the head must be seized symmetri- 
cally, and this, while easy enough in the cavity or at the inferior strait, 
is difficult, if not impossible, at or above the superior strait. Further, 
when the head is high up, the lock is at the vulva, and the traction rods, 
being shorter than the handles, must, necessarily, be adapted within the 
vulva. This objection, however, is not insurmountable, and may readily 
be rectified. Tarnier's figures, as Pajot points out, represent the forceps 
applied to the head already engaged, and not above the superior strait, 
which is what Tarnier aims at. It is evident that the difficulty of appli- 
cation is far greater above than at or within the superior strait. 2. The 
instrument is, above all, intended to pull m the mathematical axis of the 
pelvis, and yet, as Pajot points out, it is not possible to limit this mathe- 
matical axis, for it differs in each pelvis, and, according to Dubois and 
Naegele, " there are gentlemen who have endeavored to be mathemati- 
cally exact in their researches, and who, to attain their end, have invoked 
the aid of geometry for the settlement of scientific questions, when this 
aid is not only useless, but really superfluous." Tarnier himself has not 
pretended to make traction with his instrument in the exact mathematical 
pelvic axis, for he says, " it will doubtless be said that the expert accou- 
cheur knows how to give to the forceps a direction which gives to the head 
a movement in exact accord with the pelvic curvature. In order that 
this may be true, while making traction the handle should follow a line 
exactly like that represented by the letters f, m, n, f. (Fig. 80.) Even 
though they have as a guide only uncertain anatomical rules, since the 
shape of the female pelvis is ever variable, a skilled artist would have 80 
A TREATISE ON OBSTETRICS. 
trouble in exactly reproducing this line. How then can an accoucheur be 
expected to follow it, especially when, at the same time, he must make 
the traction ? ' ' 
The above objection, stated by Tarnier himself, applies perfectly to his 
Fig. 80. External Curve Traversed by the Forceps when the Head follows exactly 
the Pelvic Curve. S, P, Least sacro-pubic diameter. A, B, Axis of superior strait. A', B', 
Axis of the vulvar orifice. A, F, Traction line with forceps above the superior strait. A', F', 
Traction line with head at vulva. F, M, N, F', External curve described by the forceps. A, Centre 
of supposed head, at superior strait. A', Centre of supposed head at vulva. P, Pubes. R, Undis- 
tended perineum. R', Perineum distended. S, Promontory. H, Vertical plane of border of bed. 
forceps. How, says Pajot, can Tarnier make traction in an axis which is 
unknown to him ? 
2. With Tarnier's forceps, before making traction, the precaution must 
be taken to turn the compression screw in order to fix the head. As 
stronger traction is made, the head is compressed by the walls of the canal THE FORCEPS. 
81 
through which it is passing, and the head, therefore, tends to become 
smaller, of necessity; then the screw must from time to time be tightened. 
3. The greatest objection we have to Tarnier's instrument is the follow- 
ing: With the classic forceps, the accoucheur is at all times conscious of 
the progress made by the foetal head; with Tarnier's, however, he is not 
at all. When the head resists, greater traction is made. If it descends, 
all the better, if it does not we pull harder still; thus nothing indicates 
the limit. Traction, therefore, may readily be exaggerated, and serious 
damage be done. 
4. Although Tarnier s forceps is just as firm m hold as the classic, it is 
nevertheless the compression screw alone which retains the handles in appo- 
sition. The head may be seized incompletely with this instrument, even 
as with the classic, and consequently it is just as likely to slip. This has 
happened to us twice, and to Budin once. Now with the classic forceps 
held in the hand, we know at once when it is slipping, and this may be 
prevented. Not so with Tarnier's forceps. The hand pulls on the trans- 
verse bar of the traction rods, and is no longer conscious of slipping of 
the instrument from the head, which may result in vaginal and vulvar 
lesions, not to speak of uterine, the greater the stronger the exerted trac- 
tion. 
5. When Tarnier's forceps is applied at or above the superior strait, 
since the perineal curve is absent, the disadvantages are as great as in the 
classic forceps. 
6. The indicator needle is at times faulty, as happened to us twice, in 
cases of delivery at the superior strait. Here the indicator approached 
the vulva, but although we followed it in our traction, we could not budge 
the head, and were obliged finally to resort tb the classic forceps, and ex- 
tracted the head at the first attempt. The same thing happened to Porak 
at the Clinic, in a case of persistent occiput posterior. 
7. In posterior positions rotation occurs less readily than with the clas- 
sic forceps. Both the handles and the rods must be seized together if we 
wish to rotate artificially. 
Such are the objections we make to Tarnier's forceps. Let us add, fur- 
ther, that, notwithstanding the assertion of its greatest advocates, it does 
endanger the integrity of the perineum as much as the classic forceps. 
We have seen an instance where the instrument was being used by one 
of Tarnier's most distinguished pupils. It is evident, indeed, that we 
Vol. IV.-6 82 
A TREATISE ON OBSTETRICS. 
are less enthusiastic in regard to Tarnier's instrument than his pupils, 
biit we still recognize its utility in the cavity. Once the head has passed 
the superior strait, it is an excellent instrument, possessing over the clas- 
sic forceps the superior advantages of having an indicator needle, and of 
requiring less traction force. At the level of the superior strait, when 
the head is largely engaged, it may also be of great use. But when the 
head is but little engaged at the superior strait or entirely above, we pre- 
fer the classic forceps. We have far more confidence in ourselves, we fear 
less the danger of slipping and the risks implied, for we know at once 
when the blades are beginning to slip. 
We believe, hence, that we ought not to give up, as entirely as the 
younger French practitioners would have us, the classic forceps which 
Fig. 81.-Lusk's Axis Traction Forceps. 
has perfectly done its duty. The accoucheur will do well to have both 
in his obstetric bags. Indeed Tarnier's last model being simply the clas- 
sic forceps with attachable traction rods, it might be used indifferently. 
[This is what has been aimed at recently by Wells, of New York, who 
devised a traction rod which is applicable to the Eliot forceps. We have 
personally never tried Wells' device, but in appearance it would seem to 
possess the properties of the Tarnier instrument, and we have been in- 
formed that it has practically fulfilled its purpose, that of an axis-tractor. 
Lusk, of New York, has modified Tarnier's original model, by having 
the blades made lighter, and shaping them somewhat like Wallace's in- 
strument. He has thus made the application of the blades in contracted 
pelves a simpler matter. He has also improved the manner of adjustment 
of the traction rods to the traction bar.-Ed.] THE FORCEPS. 
83 
The Indications for the Forceps. 
The forceps being an instrument intended to be applied to the foetal 
head, and for the extraction of the foetus from the mother, will be indi- 
cated whenever, the head presenting and the sine qua non conditions for 
its application existing, any danger menaces the life of the mother or of 
the child during labor. 
We have already seen that the instrument may also be used in case of 
pelvic presentations, and the sphere of applicability of the instrument is 
thus widened. 
The forceps thus is indicated: 
1. Whenever, in head presentations, normal labor becomes difficult or 
impossible, owing to feebleness or absence of expulsory pains. 
2. Whenever there exists disproportion between the size of the foetus 
and the dimensions of the pelvis, whether this disproportion depends on 
excess in foetal size, contraction of the pelvis, prolapse of a foetal part, 
extended vertex presentations, face presentations, or on resistance of the 
soft parts. 
3. Whenever an accident supervenes compromising the life of the 
mother or of the child, such as hemorrhage, syncope, eclampsia, hernias, 
retention of urine not to be relieved by the catheter, rupture of the 
uterus or of the vagina, short funis, absence of rotation, etc.-in a word, 
in every instance of dystocia, where, the head presenting, the termination 
of labor is called for in the interest of the mother or of the child. 
4. Occasionally in pelvic presentations. 
Of the above indications there are three, in particular, which most 
frequently necessitate resort to the forceps: 
a. Resistance of the perineum, and the inertia uteri which is a conse- 
quence. 
b. Persistent occiput posterior presentations. 
c. The arrest of the head above, or at the level of the superior strait, 
by a contraction of the pelvis. 
Of these three, the two first are the most frequent, particularly in primi- 
parae. Where the forceps is called for in case of the urgent complica- 
tions of labor, such as hemorrhage, the indication is often urgent, instan- 
taneous so to speak. Not so, however, in case of the two indications we 
have just noted. Here we must, on the one hand, avoid too quick action, 
and, on the other, too tardy. 84 
A TREATISE on obstetrics. 
a. Resistance of the Perineum.-Our practice is entirely in accord with 
that of our teachers Pajot and Depaul. When the head reaches the peri- 
neum, if, at the end of an hour and a half to two hours, it makes no pro- 
gress, we terminate labor by applying the forceps, no matter what the 
intensity of the contractions. Usually, however, in these instances, con- 
tractions are absent or inefficient, so that we are in face of a two-fold in- 
dication for the forceps, resistance of the perineum and insufficient pains. 
To act sooner seems to us useless, for frequently, within this interval, 
weak contractions become intensified, and the head is quickly expelled. 
To act later seems to us reprehensible, for arrest of the head means com- 
pression of the maternal soft parts, and there may result gangrene, the 
consequences of which, aside from sepsis, will be fistula?, rectal or vesical, 
etc. 
b. Absence of Rotation.-We give Nature here also a chance, but if 
within two hours the head does not rotate, we interfere at once by caus- 
ing artificial rotation. In case of face presentation, we act a little sooner, 
in order to prevent deep engagement of the chin, which would complicate 
matters. 
It goes without saying, that in these cases, particularly, the foetal heart 
should be listened for from time to'time, in order that we may interfere 
sooner still, if the life of the child appears endangered. 
c. Contraction of the Pelvis.-Here we never hurry. Labor is always 
longer. Before the head can pass the superior strait it must become 
moulded, and for this process time is requisite, relatively long. Without 
referring again to the degree of contraction calling for interference, (vide 
Deformities of the Pelvis, Vol. III.), it is above all the state of the mother 
and of the child which should be our guide. 
As for the other indications, the time for interference varies, of course, 
according to the complication threatening the mother and the infant, 
and it is impossible to fix the limit. Finally we must not forget that the 
forceps is not the only means of terminating labor, and that frequently 
we may chose between forceps and version. 
Conditions requisite for the Application of the Forceps. 
These are four in number: 
1. The os must be dilated or dilatable. 
2. The membranes must have ruptured. 85 
THE FORCEPS. 
3. The forceps should be applied only to the head. 
4. The pelvis must not be too contracted. 
These four fundamental conditions seem to exclude the application of 
the forceps to the pelvic extremity. We believe, however, that the dangers 
of so doing have been very much exaggerated, and in a case of breech 
presentation, where the hand could not reach the feet, we would follow 
the example of Depaul, Dubois, Stoltz and Tarnier, and apply the for- 
ceps. We cannot sum up this question better than in the words of Tar- 
nier: " The reasons given by those who reject forceps to the breech, seem 
at first sight excellent. In fact the blades do fit badly over the nates, 
and are very likely to slip; further the pelvic bones are too slight to stand 
readily the compression necessary for solid hold, and the blades, by pres- 
sure on the abdomen, may tear the viscera. But what are we to do in a 
case of pelvic presentation, when it is urgently necessary to end labor 
promptly, and the hand does not suffice ? Shall we use the blunt hook ? 
But this has its disadvantages; and so, in such cases. Stoltz and Dubois 
have used the forceps and extracted living children. " Tarnier has him- 
self done so successfully in a number of cases, and, under the head of 
Presentation of the Pelvic Extremity, we saw that this method had suc- 
ceeded with a number of German and English accoucheurs. 
5. Finally Pajot, without making of it an indispensable condition, men- 
tions engagement and fixation of the head at the superior strait as a very 
favorable circumstance. 
1. The Os must be Dilated or Dilatable.-1This is the prime indispensable 
condition for the application of the forceps, and we have already dwelt 
sufficiently at length on the meaning of dilatation and dilatability. It is 
usually when the head is retained at the superior strait that the cervix is 
dilatable rather than dilated. We must recognize this dilatability, there- 
fore, and in urgent cases act without waiting for dilatation. If the cervix 
is rigid, and delivery is imperative, we must, without hesitation, knick 
the external os in several places, which will suffice to make the cervix 
supple enough to not only allow the introduction of an instrument, but 
also its removal increased in size by the contained foetal head. 
If nothing urgent calls for the termination of labor, we ought to wait 
as long as the state of the mother and the child will allow. This is an 
absolute rule, unfortunately for the mother and the foetus too often in- 
fringed. One of the qualities which we as medical men should, possess, 86 
A TREATISE ON OBSTETRICS. 
is the ability to resist the entreaties of friends and the patient, particu- 
larly a primipara-to know how to wait, and do nothing. IIow many labors 
would have ended happily, and yet have terminated in the death of the 
mother and the child, because inexperienced or hurried physicians have 
used the forceps prematurely, and thus compromised through ignorance 
the issue of labor 1 How many unfortunate women die, as the result of 
dangerous premature use of the forceps, which not only does not allow 
the termination of labor, but produces grave lesions of the vagina or the 
cervix I It is particularly in primiparae that we note these effects, so that 
we cannot emphasize enough the fact that every application of the forceps, 
where the cervix is neither dilated nor dilatable, is not only useless, but is 
also dangerous. 
We should never forget that, in primiparae, dilatation of the cervix takes 
place always slowly, especially when the membranes have ruptured pre- 
maturely; that it is not exceptional, in such cases, for dilatation, even 
where the head is deeply engaged, to require from fifteen to twenty-four 
hours, and that application of the forceps before dilatation is completed 
will not only prove an exceedingly difficult and delicate operation, but 
possibly dangerous. It is only exceptionally that we are called upon to 
interfere before dilatation is completed, and where only, in case of absolute 
necessity, is it allowable to knick the external os. Aside from absolute 
necessity, the rule is absolute, wait for dilatation, and only interfere when 
the condition of mother or of child calls for it. 
2. The Membranes must have Ruptured.-This condition is as indis- 
pensable as the preceding; for if we should apply the forceps before rup- 
ture, we might separate the placenta, and have more or less serious hem- 
orrhage. 
3. The Forceps should only be applied to the Head.-This condition, we 
have seen, is too absolute, for we are fortunate at times, in pelvic presen- 
tations, to be able to extract the foetus by it. It is otherwise exact. 
The instrument may be applied either to the before-coming or to the 
after-coming head; or again to the head left behind in the uterus after 
decapitation. (We will consider this later.) 
4. The Pelvis must not be too contracted.-(Founder head of con- 
tracted pelvis, comparison between forceps and version.) 
5. Finally, we have seen that Pajot considers it a favorable condition 
that the head is engaged and fixed at the superior strait. 87 
THE FORCEPS. 
Up to the time of Smellie, all authorities agreed in preferring version 
with the head above the brim; as for instance, Levret, Mme. Lachapelle, 
Baudelocque. Depaul, Cazeaux and Tarnier, without entirely rejecting 
the forceps, reserve it for cases where the pelvis is deformed. Abroad 
version is preferred. 
In these instances, indeed, the application of the forceps is very diffi- 
cult. Aside from the mobility of the head, it is rarely seized regularly 
and symmetrically ; the instrument can only rarely be directed sufficiently 
backwards to engage the head readily ; it further slips easily, and we may 
thus injure deeply the cervix and the vagina. It is, therefore, to version 
that we ought to resort above the superior strait. But if the uterus, on 
account of the escape of the liquor amnii, has contracted on the foetus, 
then version is impossible, and, before resorting to embryotomy, it is our 
duty to try the forceps. 
The same holds true of relatively marked contraction of the pelvis. If 
the child is alive we should try the forceps, but we must never use over- 
much traction-force. The accoucheur alone should make it, in order 
that the woman may not be so injured that complications result which 
may threaten, if not end, her life. 
When, on the contrary, the head is engaged, and more or less fixed at 
the pelvic brim, the forceps only is indicated. The head being immovable, 
the blades are more readily applied. The lock must often lie in the vagina, 
otherwise the head will be imperfectly seized, the instrument may slip, 
and produce damage which we will speak of later. 
Preliminary Precautions. 
Without goingasfar as Baudelocque and Mme. Lachapelle, who advised 
showing the woman the forceps and explaining its method of action be- 
fore application, we believe that it is of advantage to prepare her for it, 
by making her understand the necessity of terminating labor in her inter- 
est as well as in that of the child, by calming her fear of pain, by appeal- 
ing, in a word, to her heart and her reason. The aid of both friends and 
relatives should also be invoked, and it is exceptional then that we cannot 
triumph over her instinctive repugnance, which varies, indeed, with the 
woman, for many from previous personal experience, or from what they 
have heard from their friends, call loudly for the instrument. Chloro- 
form is of great assistance, of course. 88 
A TREATISE ON OBSTETRICS. 
[We are decidedly opposed to saying anything to the woman about in- 
strumental interference. The friends, of course, should be informed, but 
as for the woman herself, the mere thought of instruments will often 
alarm her, so that when we come to the administration of the anaesthetic 
this is the more difficult owing to the nervous fears of the patient. See- 
ing that only exceptionally ought we to apply the forceps without anaes- 
thetizing, any pretext may be found for the latter, even if the woman 
does not call for it herself, and she usually does, and when once under the 
influence of the anaesthetic we may place the woman in the proper posi- 
tion, and only then produce our forceps.-Ed.] 
As for chloroform, although we need not use it where the forceps are 
applied at the inferior strait or at the vulva, that is to say in the simple 
cases, we believe it to our interest to resort to it whenever the head is high 
up, or we anticipate any trouble. We should always call to our aid a 
professional friend or trained assistant, and this may frighten the woman, 
still we ought not to dispense, on this account, with one of the things 
which make anaesthesia safe. The anaesthesia should be deep, to the sur- 
gical degree. 
Even as in case of version, everything which might be needed should be 
ready; bath for the infant, laryngeal tube, etc. The bed should be high, 
resisting, and the instruments within reach of the accoucheur. 
Position of the Patient.-If the head is at the vulva, or at the inferior 
strait, the woman may lie in her bed, pulled to the edge, each leg rest- 
ing on a chair, and flexed by an assistant. But if the head is high up, 
or we expect trouble, the obstetrical position should be assumed. In 
England, the woman is placed in the lateral decubitus when the straight 
and short forceps is used, the dorsal decubitus being reserved for high 
forceps. We much prefer, in every instance, the dorsal decubitus. 
Before introducing the instrument, we must warm it, and grease it on 
the convex surface so that it may slide well, and we should always, when- 
ever possible, assure ourselves of the exact position of the head-in a word, 
complete our diagnosis. 
The operative manual is in three stages: 1. Introduction of the blades. 
2. Locking of the blades. 3. Extraction of the foetus,' and special rules 
are applicable to each stage. 89 
THE FORCEPS. 
General Rules. 
Cazeaux has enumerated these with a master hand, and we follow him 
in his description; but, as we will see, they are not all of equal importance. 
1. The Instrument should only be applied to the foetal Head.-This rule 
is too absolute, for although the forceps is constructed to seize the foetal 
head, we have seen that in breech presentations, Dubois, Depaul, Tar- 
nier, Stoltz, and a number of foreign accoucheurs, have employed the in- 
strument with success in a number of instances. We would make, then, 
the following general rule: the forceps should only be applied to the head, 
whether flexed or extended, before-coming or after-coming, or left in the 
uterus after decapitation. Exceptionally, it may be applied to the breech, 
when it is to the interest of mother or of child to end labor, and this can- 
not be done by the hand alone. 
2. The Blades should be applied as nearly as possible to the Sides of the 
Head, with the Concavities of the Borders directed towards the Point of 
the Head which we wish to bring under the Symphysis.-This may be 
called the French, in contradistinction to the foreign method, and we 
must explain here what is meant by direct and oblique application of the 
forceps. When the head is in the occipito-pubic, or occipito-sacral posi- 
tion, and it is seized in its bi-parietal diameter, since this diameter corre- 
sponds to the transverse of the pelvis, the forceps is applied at once sym- 
metrically to the head and to the pelvis-that is to say, the lesser curve of 
the instrument is under the pubic arch, at the anterior extremity of the 
antero-posterior diameter of the pelvis, and the greater curve is in the 
concavity of the sacrum, at the posterior extremity of the same diameter; 
the convexity of the blades corresponds to the extremity of the transverse 
diameter of the pelvis, the concavity seizes the head at its bi-parietal di- 
ameter. The forceps is both parallel to the head and to the pelvis; the 
application is direct. 
But the position of the head may be oblique or transverse, and then the 
application of the forceps is oblique. If the instrument is applied parallel 
to the head, it is oblique to the pelvis; if it is parallel to the pelvis, the 
head cannot be seized in its bi-parietal diameter, and the application is 
oblique to the head. Hence, then, the French and the foreign methods. 
While in France we always aim to grasp the head in the bi-parietal diam- 
eter, in England, and above all in Germany, the blades are always in- 90 
A TREATISE ON OBSTETRICS. 
sorted parallel to the pelvis. In the oblique presentation of the head, 
whether first, second, third or fourth positions, it is always possible to 
seize the head in the bi-parietal diameter. The forceps once locked, then, 
they will be oblique to the pelvic walls, and will cross the vulva obliquely, 
the lesser curve not towards the symphysis, but to the right or left, ac- 
cording to the case. The same holds for face presentations. 
In transverse presentations it is no longer possible to seize the head in 
the bi-parietal diameter. The head lying in the transverse diameter of 
the pelvis, if we endeavor to apply the forceps in the bi-parietal diameter, 
one of the blades would lie against the sacral curve and the sacro-verte- 
bral angle, the other against the symphysis, and this is practically impos- 
sible, whether with the classic or with Tarnier's forceps. To attain this 
aim, Uytterhoeven and Baumers gave to their forceps a peculiar curve. 
On the other hand, if we endeavor to apply the forceps symmetrically 
to the pelvis, one blade, in case of vertex presentations, is applied over 
the forehead, and the other over the occiput; in case of face presentation, 
one over the chin or the face, the other over the occiput, that is to say, 
not to mention the possible lesions on the face, in the last instance parti- 
cularly, the head is seized in its greatest diameters, and extraction will be 
all the more difficult. 
Hence, in France, we have recourse to another method: The applica- 
tion is made obliquely both to the head and to the pelvis-that is to say, 
without seeking to seize the head exactly in the bi-parietal diameter, the 
instrument is applied in such a manner, that the blades are in a diameter 
intermediate between the bi-parietal and occipito-frontal in vertex pres- 
entations, between the bi-parietal and the fronto-mental in face presenta- 
tions. In a word, the head is grasped obliquely posterior to the parietal 
region of one side, and to the frontal of the opposite side. The head is 
thus seized obliquely, both to it and to the pelvis, in an irregular manner, 
but we believe this preferable to the German fashion ; for although the 
diameter in which we grasp the head is not the shortest, it is at least not 
as long as the occipito-frontal or the occipito-mental. 
Finally, when the head is at the superior strait, we can only exception- 
ally grasp it in the bi-parietal diameter, but must in an oblique. 
The accoucheur has exact information in regard to the way in which 
the head has been grasped. When it has been seized symmetrically, the 
blades, when the instrument is locked, are but little separated at the level THE FORCEPS. 
91 
of the handles, but are notably so when the head has been grasped irreg- 
ularly or asymmetrically. Then we must be all the more on the watch 
against slipping. 
In many cases, however, we admit that it is impossible, notwithstand- 
ing every attempt, to grasp the head symmetrically ; and, as it were of 
themselves, the blades are applied in the intermediate diameter, for it is 
here there is the most room. 
3. The posterior Blade should usually be inserted first.-Where it is 
resistance of the perineum which calls for interference, the occiput is usu- 
ally to the pubes; where the head has rotated backwards, we may apply 
the forceps directly, although usually the application must be oblique. 
One of the most frequent calls for interference is absence of rotation, the 
head being often transverse, but usually oblique, since these positions, as 
we have seen, are the fundamental, the others being simply varieties or 
consequences. One side of the head, hence, is in front, and the other 
is behind, and in order that the head may be grasped symmetrically at 
the sides, one blade must be directed backward, and remain posterior 
when the instrument is locked ; the other must be directed anteriorly and 
remain there. The posterior blade is ordinarily introduced first, and 
placed at the posterior extremity of the bi-parietal diameter. This rule, 
however, is not at all absolute; there are many exceptions, and, as Cazeaux 
well says, " it is habit and discernment of the accoucheur which guide him 
at the bedside in the insertion of the one or the other blade first." 
4. The male or left Blade is always held in the left Hand, and is always 
applied to the left Side of the Pelvis. (Fig. 82.) The female or right Blade 
is always held in the right Hand, and is always applied to the right Side of 
the Pelvis. (Fig. 83.)-This is about the only rule without an exception. 
The forceps, indeed, is so constructed that it ought not and cannot be 
applied otherwise. But the rule is not so absolute in regard to the hand 
which ought to hold the blades. Hatin, indeed, has proposed introducing 
both blades with the same hand. ' ' One hand is introduced, by preference 
the left, up to the fundus, or at least as far as the fenestrae must pene- 
trate. The first blade having been passed along this guiding hand, this, 
without being removed, is simply turned to the opposite side of the foetal 
head, in order to receive and guide the second blade." This method, 
which should be reserved for very exceptional cases, is really far inferior 
to the ordinary and classic method, and the above rule is almost abso- 92 
lute: Right blade, to the right, right hand; Left blade, to the left, left 
hand. 
5. The Hand intended to guide the Blade, should ever be introduced 
first.-This rule is perhaps more absolute still than the preceding. The 
object is both to protect the maternal and infantile parts, and to guide 
the blade. We cannot, therefore, be too careful, and if, when the head 
A TREATISE ON OBSTETRICS. 
Fig. 82.-Application of the Forceps, Head at the Vulva. Introduction of Left Blade. 
is at the vulva, or at the level of the inferior strait, one or two fingers, 
between the head and the vaginal walls, suffice, the palm of the hand 
must always be introduced when the head is higher up, and the thumb 
as well when the head is at or above the superior strait. In the latter in- 
stances, indeed, the ends of the fingers must be within the uterus, between 
the head and the cervix, to be sure not to seize the cervix between the 
blades, and to be sure that we are in the uterus and not in one of the THE FORCEPS. 
93 
culs-de-sac. ' It is imperative, also, whenever the instrument is introduced 
within the uterus, to cause the fundus to be depressed, and the head 
steadied by an assistant, in order to bring the cervix and the head as near 
as possible to the operator. 
We believe that it is always better, even when the head is at the infe- 
rior strait, to introduce the entire hand, exclusive of the thumb, into the 
vagina. For it often happens, as Pinard has shown, that the fee tai head 
is less freed from the cervix than is supposed. Often one of the cervical 
Fig. 83.-Introduction of the Right Blade. 
borders is in front of the head, and the other far up, and the cervix is 
more or less wounded when the blades are introduced. 
We must never forget, further, that the use of the instrument requires 
long apprenticeship, and that in the beginning of practice, we cannot take 
too many precautions. The insertion of the entire hand gives perfect 
security to the accoucheur and his patient, and, by facilitating the intro- 
duction of the blades, allows of more regular application without increas- 
ing the suffering of the woman. 
When the occiput is towards the pubes, or the sacrum, the guiding 
hand may be placed directly at the sides of the vulva; but when we are 
dealing with oblique presentations, it is better to place the hand flat at 94 
A TREATISE ON OBSTETRICS. 
tlie posterior commissure, along the posterior vaginal wall. Ilere we find 
the most room, and the hand will penetrate the more readily, and then 
again we may depress the perineum with the back of the hand, which 
gives more space for manipulation. 
6. The second Blade should always be inserted above the first.-This 
rule is to be taken in conjunction with the fourth. We have already seen 
that the posterior blade must first be introduced. Now this blade may, 
according to the case, be the right or the left. It results that when the 
left blade has been inserted first, locking is not at all difficult, since the 
pivot is beneath the right blade, which is inserted second and above, 
(Fig. 83), but when the right blade has been inserted first, the conditions 
are not the same. In this case the left blade being inserted second, that 
is, above the right blade, the lock-surface is on the opposite side to the 
pivot. In order to lock, therefore, it is necessary to pass the left blade 
beneath the right. This is called crossing the blades. To accomplish 
it, the extremities of the handles are gently held, without making any 
traction, and they are passed one above the other, so that the right blade 
will lie above the left. The difficulties and the dangers of this little 
manoeuvre have been much exaggerated. It succeeds usually without 
trouble. In order to avoid this crossing, Tureaux, Tarsitani, Thenance, 
Valette, have modified the forceps. Stoltz goes further still, and does 
away with crossing altogether. Seeing that the insertion of the right 
blade is usually more difficult than the left, whatever the position of the 
head, he first inserts the right blade, and then, to avoid crossing, he lifts 
this blade up, and introduces the second blade, the left, not above, but 
below the right. lie then brings down the right, and the blades readily 
lock. We have used this method several times, and have succeeded with- 
out trouble. This proves again that there is nothing absolute as to the 
choice of the first blade for introduction. Everything depends indeed on 
the peculiarities of the case. The main point is not to insist on inserting 
the one or the other blade first or second, and if, the first in place, there 
is difficulty in inserting the second, we must take out the one in place, 
and try again with the other first. We will thus often in a surprisingly 
easy manner be able to insert and to lock the blades. 
7. At what Point of the Pelvis must the Blade be first introduced ?-We 
have seen that the blades should as far as possible be applied parallel to 
the head, and there are a number of ways of doing so, as, for instance, THE FORCEPS. 
95 
the methods of Levret, Baudelocque, Mme. Lachapelle. Whatever the 
method, however, the absolute rule is never to endeavor to introduce the 
blades except during the intervals between the contractions. 
A. Levret's Method.-The blade is seized, like a pen, near the lock, or 
at the end of the handle, no matter how, according to Tarnier, provided 
it be convenient for the operator. The convex surface of the fenestra is 
laid flat against the guiding hand at the vulva, and it is insinuated along 
this hand into the vagina, remembering that the latter's axis is from be- 
low above, and that consequently the handle must be depressed as the 
blade penetrates. To recognize the posterior and the anterior blades, it 
suffices to recall the position of the head, and the lesser curve being against 
that portion of the head which must come under the symphysis, the for- 
ceps need only be locked and placed in the situation it must occupy in the 
pelvis, in order to know which blade must be posterior, and which ante- 
rior. This little preliminary precaution, of utility in anterior positions, 
would lead us into error in posterior positions. In anterior positions we 
must take as our guide the occiput, in posterior the brow, and the reason 
is given further on. 
The posterior blade in position, it should be directed backwards towards 
the sacro-iliac synchondrosis, and it is thus, in oblique positions, placed 
at the extremity of the bi-parietal diameter, where it remains fixed. The 
second blade, the anterior, is similarly directed backwards towards the 
opposite synchondrosis, and then it is placed behind the cotyloid cavity, 
that is to say anteriorly, making it traverse the entire lateral half of the 
pelvis. The manoeuvre is accomplished by forcibly depressing the left 
blade, and carrying it from before backward, towards the anus. (We are 
speaking now, be it understood, of oblique positions, where the blades are 
applied directly to the right and left.) Velpeau has adopted this method. 
B. Baudelocque's Method.-He supposes that the position of the head 
is always known, and that consequently we know d priori what point of 
the pelvis corresponds exactly to the bi-parietal diameter of the foetal 
head, and, therefore, the position which must be assumed by each blade. 
He, therefore, places at once one blade in front, and the other behind. 
C. Mme. Lachapelle's Method.-The two methods we have described 
possess serious disadvantages, and hence Mme. Lachapelle has modified 
them after the following manner, which has been adopted by all French 
accoucheurs and numerous foreign: 96 
A TREATISE ON OBSTETRICS. 
" If the blades are to be placed diagonally, one behind and to the side, 
the other in front and to the opposite side, it suffices to push the poste- 
rior blade directly along the sacro-sciatic ligament; nothing will stop it. 
I can then manage the othei' easier, by beginning with it. I hold it like 
a pen inclined over the groin, opposed to the side of introduction, and I 
insinuate the point of the fenestra in front of the sacro-sciatic ligament, 
and, as it enters, I depress the handle between the thighs till it lies below 
the anus. In this way, I make the point of the fenestra describe a spiral, 
which is guided perfectly by the fingers in the vagina. The fenestra is 
thus carried in front and above. The movement is rapid, and painless. 
It differs from Levret's method in that here it is the extremity, while in 
his method it is the border of the fenestra which leads the way. I ought 
to add that the spiral movement is only easy when the head is below the 
superior strait; when it is above, this movement is no longer possible, and 
we can only introduce it, if at all, after Levret's method." 
Above the superior strait, indeed, the two blades are applied to the sides 
of the pelvis, and the head is grasped no longer regularly, but, as far as 
possible, diagonally from brow to occiput. The greater or less separation 
of the handles tells us that the head has been seized regularly or irregu- 
larly. 
8. The Blades must never be forcibly introduced.-When the direction 
given to the blades is good and regular, it is surprising with what ease 
they penetrate. We should always proceed with the utmost gentleness, 
and be in no hurry; any resistance indicates a bad direction given to the 
instrument. Obstacles may depend on folds in the vagina or on the foetal 
head. We must then lift or depress the blade, and find, with the hand 
in the vagina, free space. This is why we insist on the hand being in the 
vagina. Especially is this important when the head is high up, for then 
the end of the fenestra must enter the uterine cavity, and, at times, 
scarcely the finger-tips can reach the cervix and guide the fenestra, which 
must penetrate deeper even than these fingers. Let us add, too, that the 
cervix itself often runs away from the fingers. Here, then, we must re- 
double our care and gentleness. The fundus of the uterus must be de- 
pressed as much as is possible by the hand of an assistant, which, at the 
same time, steadies the head at the superior strait. This assistant may 
often thus feel the blades through the abdominal wall, and be cognizant 
of the fact that they grasp the head exactly. THE FORCEPS. 
97 
In one word, the blades should penetrate easily, and adapt themselves, 
as it were, and, in case of obstacle, they should be withdrawn and rein- 
troduced in an inverse manner. In taking out the blades, they must fol- 
low, of course, the direction opposite to that in which they were intro- 
duced. 
The Locking.-When the first blade has been applied, it should be held 
in place by an assistant, without the least traction, and the second, gen- 
Fig.' 84.-Locking of the Blades. 
erally the right, is inserted in the classic manner, and the instrument is 
to be locked. t 
If the blades have been well placed, and the head well grasped in its 
bi-parietal diameter, nothing is easier, usually, than the locking. It 
suffices to seize both handles, and to bring them together, the pivot inside 
the mortise, in which it fits exactly, and the pivot need only be turned to 
firmly join the handles. (Fig. 84.) But this is not always the case, and 
the obstacles to locking may be three: 
1. Locking cannot take place, because t'he right blade is below the left. 
The blades must be crossed. 
Vol. IV.-7 98 
A TREATISE ON OBSTETRICS. 
2. It is impossible because the blades have not been introduced to the 
same depth, and the pivot does not correspond to the mortise. Then, 
say the authorities, we must pull out or push in one of the blades, to bring 
them to the same level. We are opposed absolutely to this. We must 
not forget that, in such cases, there is nothing to guide the blade which 
we are endeavoring to push deeper, and hence we may wound the foetus 
or the maternal parts. We prefer to withdraw one blade, usually the 
right, and apply it anew. 
Fig. 85.-Locking of the Blades when they do not exactly correspond. 
3. Locking is not possible because, although pivot and mortise are at 
the same level, the two blades are in different planes. Here again author- 
ities advise seizing the blades, and by rotating them inversely to bring 
them into the same plane. (Fig- 85.) 
We are absolutely opposed, in every sense, to this manoeuvre. Either 
the head is well grasped and locking is easy; or else the head is badly 
grasped and locking impossible, and then the rule should be to begin over 
a hundred times, if need be, rather than to use any force. We must not 
forget that each blade of the forceps is a lever, and that every motion im- THE FORCEPS. 
99 
parted to the handles is communicated, greatly exaggerated, to the extremi- 
ties of the fenestrae. Torsion, however slight at the handles, becomes 
considerable at the points of the fenestrae, and we might wound the foetus 
or the mother. 
Once locked, we must assure ourselves that the head is well grasped, 
and grasped alone (without cord, cervix, or limb), and that the instrument 
firmly holds the head. 
The finger in the vagina will assure us of the two first. As for the last, 
a few tractions on the forceps will tell us of the hold on the head, and the 
Fig. 86.-Introduction of the Finger to assure exact Application of the Instrument. 
separation of the handles as to whether the head is grasped regularly or 
not. (Fig. 86.) 
With Tarnier's forceps, we must gently compress the head with the 
handles, bring the screw in contact with the handles, turning the more 
as we expect greater resistance. The traction rods are articulated to the 
transverse bar, and we proceed to extraction. 
Extraction.-The foetus need now only be delivered by traction on the 
handles, and delivery will be the easier when we make the head execute 
by means of the instrument the movements which it would spontaneously 
make in normal labor. The tractions then must not only engage the 
head, but must make it traverse the vagina as nearly as possible in the 
pelvic axis, and in certain posterior positions we must make the head ro- 100 
A TREATISE ON OBSTETRICS. 
tate, in order that, in vertex presentations, the occiput may come under 
the symphysis, and the chin, in face presentations. Although, if need 
be, we can deliver with the occiput posterior in case of vertex presenta- 
tions, we must bring the chin under the symphysis in order to deliver in 
face presentations. 
The tractions, then, must be different according to the elevation of 
the head. 
If it is above or at the superior strait, we must, at the outset, make 
traction backwards and below, in order to engage the head and bring it 
Fig. 87.-The Forceps at the Superior Strait. 
below this strait. Unfortunately these tractions can never be sufficiently 
directed backwards, on account of the perineum against which the for- 
ceps press, and to remedy this Hubert and Morales devised their forceps, 
and Tarnier gave to his first model the perineal curve nearly similar to 
that in Morales' instrument. 
Once the head in the cavity, the tractions should be directed a little 
more forwards, so that when the head has reached the level of the inferior 
strait, or when the forceps are there applied at the outset, tractions are 
nearly horizontal. (Fig. 88.) 101 
THE FORCEPS. 
The head at the vulva, traction is made from below upward, that is to 
say, the forceps are lifted up towards the abdomen of the mother. Here, 
indeed, traction is nearly useless, the head has simply to be disengaged, 
and once the occiput under the symphysis, not only must we no longer 
pull on the forceps, but, with the instrument towards the mother's ab- 
domen, we must firmly hold the head, oppose its too rapid exit, and allow 
it to issue from the maternal parts but very slowly. (Figs. 89 to 91.) 
It is not enough, indeed, to sustain the perineum, as is represented in 
Fig. 89. To prevent its rupture, we must give it time to relax, and if we 
do not hold back the head enough, the perineum will tear under the sup- 
porting hand. Often, indeed, at this very moment, the woman, against 
Fig. 88.-The Forceps at the Inferior Strait. 
her will, makes violent expulsory efforts, and the head, driven violently 
outside, tears the perineum notwithstanding the accoucheur's hand. The 
better plan is to slowly disengage the head, holding it back as much as 
possible, and completing delivery between the pains, and if the perineum 
seems too distended and ready to tear, to make a lateral incision, and 
thus avoid deep laceration. 
[The above method will succeed very well in multi parse, but in primi- 
parae, where the integrity of the perineum is much more in danger, we 
believe the following to be far preferable: As soon as the occiput has been 
brought well under the pubes, and the perineum begins to distend, ad- 
minister chloroform to the surgical degree, in order to abolish entirely 
involuntary expulsory efforts on the part of the patient, and then, remov- 102 
A TREATISE ON OBSTETRICS. 
Fig. 89.-The Forceps with the Head at the Vulva. (The left-hand on the perineum is in 
the position recommended by the German School.) 
Fra. 90.-Delivery of the Head with the classic Forceps. (French method.) 103 
THE FORCEPS. 
ing with care the forceps, proceed to gradually shell out, as it were, the 
head, holding it back with one hand, and with the fingers of the other 
gradually relaxing and pushing back the perineum over the head. One 
finger in the rectum may be used to slowly extend the head, but this is 
not at all necessary. By this means it will often be possible to deliver 
without any laceration of the perineum whatsoever, and without resorting 
Fig. 91.-Direction of the Forceps as the Head is being Delivered. 
to episiotomy. It is at this stage that, for us, chloroform is of greatest 
utility in labor, but it must be pushed to the surgical degree.-Ed.] 
We cannot emphasize enough the fact that the best way to save the 
perineum is to extract the head very slowly, except of course where there 
is indication for haste in the interest of mother or of child. Here es- 
pecially is» it wise to perform episiotomy. 
When all that remains is to disengage the head, it suffices to seize the 
instrument in one hand, the left usually, (in case of Tarnier's forceps, 
the four branches together), and to lift the instrument slowly towards the 
mother's abdomen (See Fig. 91); the other hand may sustain the peri- 104 
A TREATISE OX OBSTETRICS. 
neum, or do episiotomy, if need be. Again, then, here no traction is to 
be made, and retain tne head, when necessary, to Drevent too rapid exit. 
Fig. 92.-Delivery of the Head by means of Tarnier's Forceps.] 
Fig. 93.-Traction by Tarnier's Forceps. Position of the hands on the transverse bar. 
When traction is made with the classic forceps, we must avoid great 
compression on the handles. Now this is, unfortunately, instinctive and 105 
THE FORCEPS. 
involuntary. As we increase the traction, the hands involuntarily squeeze 
the bandies and augment* compression, and so it is advised to place be- 
tween the handles a rolled napkin, which serves to limit compression. It 
is in order to fix the head, and avoid exaggerated compression, that Tar- 
nier united his prehensile branches by a transverse screw, destined to 
make fixed and regular compression on the foetal head. 
But as we have seen, this compression cannot be limited; for we are 
often obliged to screw tighter when the head has descended somewhat, 
diminished in size by the compression of the pelvic walls. In order to 
avoid this repeated tightening of the screw, Tarnier recommends that 
when the screw has first been tightened, the handles be pulled on a little 
in order to mould the head, and then we may turn the compression screw 
firmly, and the head is tightly held and so retained. 
Method of Action of the Forceps. 
All authorities are agreed in assigning to the forceps three methods of 
action. It isa tractor; it is a compressor; it acts dynamically, by awaken- 
ing uterine contraction. 
These three methods are incontestable, but there is one above all which 
leads the others, and for which the forceps was constructed-it is an agent 
for traction. As for compression, it is a mere accessory, and may even 
become dangerous. We should never count on compression when we 
wish to end delivery by means of the forceps. 
The Forceps as a Tractor.-In order that it may be perfect in this re- 
spect, the traction should be always directed in the axis of the pelvis, 
whether we use the ordinary instrument with great pelvic curve, or the 
straight forceps. Now all authorities are agreed that when the head is 
at the superior strait, and, therefore, of course, when above this strait, 
we cannot make traction backwards, since the perineum opposes.^ Even 
at the inferior strait, and at the vulva, says Tarnier, traction is always 
badly made, on account of the form of the instrument. Therefore it is 
that all authorities are agreed in varying the traction according to the 
height of the foetal head. Make traction downward and backward when 
the head is above the superior strait; make traction downward in the 
cavity; make traction horizontally at the inferior strait; lift up the in- 
strument as the head descends, and pull gently upwards when the head 
is at the vulva. 106 
TREATISE ON OBSTETRICS. 
But, as said Pajot, in 1877, " to pull downwards does not mean, as all 
accoucheurs seem to think, to pull the entire instrument down by hang- 
ing on the handles. It means to pull so that the upper extremity of the 
fenestrae shall come down and backwards, an impossible manoeuvre when 
we pull directly on the handles in this direction, for then the extremities 
of the fenestras, which should come downwards and backwards, tend 
downward and forward. But if the left hand seizes the instrument firmly 
near the vulva (Fig. 94), and if the handles are carried by the other hand, 
at first downward and a little forwards, and then, as the head descends, 
Fig. 94.-Position of the Hands executing Pajot's Manceuvhe. 
if the left hand depresses the blades, until both hands end by lifting up 
the instrument, never letting them touch the abdomen of the mother, if- 
this manoeuvre is executed, we approach the true axis, and exact realiza- 
tion could scarcely be more advantageous." 
''Tarnier says that the forceps, thus used, is no longer an agent of pure 
traction. It is transformed into a lever, the fulcrum of which is at the 
end of the handles, the force at the lock, and the resistance at the head. 
It acts, hence, according to the curve which the fenestra? tend to describe, 
and since this curve is first directed backwards, the force is also in this 
direction. The head, hence, is directed too far backward and it tends to 
flatten itself against the sacro-vertebral angle." Tarnier vehemently at- 
tacks Pajot's method, and declares it impracticable when the head is at 
the superior strait, for the lock of the Instrument is between the labia THE FORCEPS. 
107 
majora. " When the centre of the head has reached the level of the 
superior strait, this manoeuvre, possible perhaps, although inconvenient, 
would be dangerous, because the fenestrse would cut the perineum each 
time the instrument slipped. Finally, at the inferior strait and the vulva, 
the extremities of the blades tend to tear the perineum. " 
Although we accept the objections which Tarnier has brought against 
Pajot's manoeuvre at the superior strait, we reject them when the head 
has passed it, and has arrived in the cavity. Where the head, in occipito- 
posterior position, is above the cavity, and resists direct traction, Pajot's 
manoeuvre may be of great service. It has assisted us in two cases. The 
forceps, if you please, no longer acts as a tractor, but it acts certainly as 
an agent for extraction, since it brings the head down which resists pure 
attempts at traction. But at the inferior strait, Pajot's manoeuvre neces- 
sarily extends the head, and ruptures the perineum, and we much prefer 
to cause the head to rotate artificially; and then to reapply the instrument, 
and deliver the head, occiput to the pubes. We are, it is true, forced to 
make two applications of the forceps, but we avoid rupture of the perine- 
um. Pajot's method, therefore, we believe, is only of use to bring the 
head into the cavity, and thus to allow rotation of the head, which has 
not occurred spontaneously. 
Thus it is then that, particularly at the superior strait, the forceps is 
lacking as a tractor, and this is why Hubert, Morales, Hermann and Hart- 
mann endeavored to modify the instrument, so as to enable traction to be 
made in the axis of the pelvic strait. Tarnier's forceps, with its indicator 
needle and its traction rods, constitutes, to a degree, real progress in this 
direction. Unfortunately it is, in particular, in the cavity and at the 
inferior strait that this forceps can be used to the greatest advantage, and. 
here the classic forceps can exert traction better in the axis of the pelvis. 
At the superior strait, above all higher, the classic forceps and that of 
Tarnier present the same disadvantages. Whatever the instrument, it 
cannot make traction backwards. But with Levret's forceps we are aware 
of resistance offered, we can vary the direction of traction, we are con- 
scious of all the force we employ, and of the results. Nothing of the kind 
with Tarnier's instrument. It is the needle alone which guides the ac- 
coucheur, it is it alone which registers the amount of traction. Do we 
make traction in the pelvic axis? Not at all at the superior strait; only 
a trifle in the cavity and at the inferior strait, since it is impossible to 
know the mathematical axis of the pelvis. Nevertheless, the younger 108 
A TREATISE ON OBSTETRICS. 
French practitioners are daily making greater nse of the Tarnier instru- 
ment. In England, Alexander Russell Simpson reported on this instru- 
ment before the Edinburgh Obstetrical Society in July, 1884. He has 
adapted the principle of axis traction to Simpson's forceps. 
[In this country the opinion of those who have used Tarnier's forceps 
is not in agreement with that expressed by Charpentier. For ourselves, 
it is at the superior strait or above it that we should use Tarnier's instru- 
ment, or one similar to it, for the reason that here, in particular, back- 
ward traction is indispensable to a greater extent than is possible by means 
of the Simpson or Eliot forceps, which are the favorites with us. In the 
cavity, or at the inferior strait and outlet, we personally do not desire a 
better instrument than the Vienna Simpson. At the superior strait we 
do not contend that any axis-tractor as yet devised will allow us to pull 
in a mathematical axis. All we believe we accomplish is to make our 
traction more in the axis of the pelvic inlet, for the very reason that we 
are enabled to pull in a direction further backwards. We have never 
noted in such cases that the result of our traction seemed to be rather 
to tilt the head forward. 
In regard to Tarnier's instrument, Lusk says: " In all high operations 
I cannot too strongly recommend the ingenious forceps of M. Tarnier. 
To one accustomed only to the familiar forceps, the facility with which 
delivery can be accomplished by Tarnier's instrument is incredible. It 
is a question whether axis traction forceps should be employed at all at 
the inferior strait."-Ed.] 
The Forceps as a Compressor.-The forceps compresses the foetal head, 
and thus diminishes its volume. But this compression has its limits, and 
is purely accessory to traction. Hersent, Baudelocque, Petrequin, Delore, 
Chassagny, Budin, have made interesting researches on this point, which 
agree in the essentials. 
Baudelocque drew the following conclusions: The diminution in the 
foetal head varies according to the state of ossification of the sutures 
and the fontanelles, but it is never as great as has been claimed, rarely 
exceeding four to five lines when the instrument is applied to the sides. 
The divergence of the blades is not an accurate measure of the com- 
pression force. The diameter in which the head is compressed does 
not diminish in the same proportion in which the other is increased. 
The increase is scarcely one quarter of a line. THE FORCEPS. 
109 
Petreq uin, on the other hand, claims that the diameter opposed to the 
one grasped by the forceps increases almost constantly. In agreement 
with Baudelocque, he points out that the bi-parietal diameter diminishes 
but little, and that the occipito-frontal is always more reducible. 
Delore (1865), in studying this subject, drew up the following tables: 
Pressure between the Blades of a Forceps. 
Diameter O.F., pressure of 231 pounds, no fracture; Diameter B.F., 
pressure of 220 pounds, no fracture. 
Pressure made either by a forceps which slips and compresses at the 
extremities of the fenestroe, or else at the sacro-vertebral angle and the 
pubes, in case of sacro-pubic contraction. 
Compressed 
diameter. 
Agent. 
Force. 
Effects. 
B. P. 
Convex body. 
41 lbs. 
Transitory. 
CC 
Ci 
50 lbs. 
Ci 
cc 
i c 
57 lbs. 
a 
CC 
cc 
112 lbs. 
Depression with fracture. 
cc 
CC 
132 lbs. 
Fracture. 
0. F. 
cc 
177 lbs. 
No effect. 
cc 
cc 
99 lbs. 
Depression, reducible. 
a 
C i 
121 lbs. 
Depression. 
B. P. 
Angular body. 
44 lbs. 
Persistent depression, without 
fracture. 
Ci 
CC 
176 lbs. 
Enormous depression with 
fracture. 
Diminution of the Head by the Forceps. 
Diameters. 
Pressure. 
Reduction. 
Increase of 
opposite 
diameter. 
Results. 
Baudelocque, 
B. P. 
0. F. 
Enormous. 
.15 in. 
.35 in. 
Frequently fractures. 
Petrequin, 
B. P. 
0. F. 
CC 
.39 in. 
.117 in. 
.117 in. 
B. P. 
0. F. 
121 lbs. 
.39 in. 
.234 in. 
Rigid head. 
Delore, x 
0. F. 
132 lbs. 
.58 in. 
.312 in. 
Soft head. 110 
A TREATISE ON OBSTETRICS. 
Diminution through Limited Compression 
Head. 
Convex pressure 
on one parietal. 
Reduction. 
Soft and large, 
. 41 lbs. 
.66 inches. 
cc 
83 lbs. 
.98 " 
Harder 
57 lbs. 
.39 " 
Studying, further, the force used with the forceps, his results were: 
Traction. 
A man without fulcrum, ..... 88 lbs. 
" with " 198 lbs. 
Two men without il ..... 176 lbs. 
" with " 286 lbs. 
Presszire.. 
'Small, elastic, constriction at end of blades, 22 lbs. 
il " " at middle of blades, 44 lbs. 
Mean 11 at end of blades, 99 lbs. 
" at middle of blades, 121 lbs. 
Very large, " at end of blades, 110 lbs. 
" 11 at middle of blades, 143 lbs. 
Forceps 
To what pressure on the head corresponds a known force ? The fol- 
lowing table shows the dynamometric measurements with his forceps: 
44 lbs. traction corresponds to . . . 19| lbs. pressure. 
66 " " " ... 39 " 
86 " " " ... 46 " 
105 " " ... 77 " 
110 " " " ... 52| " " 
132 " " 11 ... 59f " " 
176 " " " ... 110 " 
Resuming, he believes that the force should never exceed 176 pounds, 
and from his researches he deduces the following conclusions: 
1. The head resists the more, the greater the pressure surface. 
2. It is difficult to foretell the amount of pressure which will produce 
a fracture. 
3. A persistent depression is not always accompanied by fracture. 
4. Compression in the occipito-frontal diameter is better supported 
than in the bi-parietal. THE FORCEPS. 
111 
5. The head compressed transversely augments in particular in the 
trachelo-bregmatic diameter. 
6. The pressure exerted by the blades is about equal to one half the 
traction force. 
Budin has made similar researches: " After having, by means of trac- 
tions measured by the dynamometer, caused the head to partially pass 
through the superior strait of a contracted pelvis, I froze it in this posi- 
tion. Then removing it, hard as a rock, I measured directly the diame- 
ters, and proved, with Petrequin and Delore, that if the head is com- 
pressed in one direction, the opposite diameters increase. Further, the 
sub-occipito bregmatic suffered the greatest modification, and also the 
trachelo-bregmatic. " 
The following table gives Budin's results: 
Experi- 
ments . 
Diameters of the nor- 
mal head. 
Degree of pelvic 
contraction. 
Forceps 
applied at. 
Traction exerted. 
Changes 
in the di- 
ameters. 
No. 
1. 
Inches. 
fO.M. 3.74 
O.M.Max'm,3.9 
O.F. 3.35 
S.O.B. 2.93 
2.06 inches. 
Forehead 
to 
35 1-5 lbs. 
Inches. 
3.97 
3.12 
3.51 
No. 
2. 
B.P. 2.69 
B.T. 2.16 
Bi-Mast'd, 2.18 
fO.M. 3.61 
O.F. 3.19 
B.P. 2.5 
The head was 
frozen lying- 
occiput. 
Forehead 
to 
Great 
compression. 
2.06 
3.27 
3.08 
2.84 
No. 
3. 
B.T. 2.3 
S.O.B. 2.8 
fO.M. 5.07 
0. M. Max'm, 5.18 
O.F. 4.7 
S.O.B. 4.05 
on the table. 
3.12 inches. 
occiput. 
From right 
coronal protu- 
berance to left 
Head en- 
gaged with 
44 lbs., trac- 
2.57 
3.39 
5.42 
5.57 
4.87 
4.32 
No. 
4. 
B.P. 3.7 
B.T. 3.3 
Bi-Mast'd, 2.9 
O.M. 4.95 
O.M.Max'm,5.18 
O.F. 4.42 
B.P. 3.7 
Head frozen 
lying on the 
occipito parie- 
tal region. 
Forehead 
to 
tion at 19 4-5 
lbs. 
Great 
compression. 
3.15 
4.79 
5.26 
4.21 
3.80 
B.T. 3.12 
Bi-Mast'd, 3.04 
.S.O.B. 3.74 
table. 
occiput. 
3.97 
The diminution in the head, therefore, to be inoffensive, should scarcely 
exceed .39 of an inch, and this, according to the advocates, is one of the 
advantages of Tarnier's forceps. The compression exerted by the screw 
is determined before traction is made, and this traction being made through 112 
A TREATISE ON OBSTETRICS. 
rods independent of the handles, and on parallel rods, compression will 
remain constant and will not vary, as must happen with the classic for- 
ceps, where the accoucheur instinctively compresses with the increase in 
the resistance to traction. We have elsewhere seen that this proposition 
is not absolutely exact, because we are often obliged to screw down further, 
a proof that the head is more compressed at the end than at the begin- 
ning of the tractions. 
The Forceps as a Dynamic, or Oxytocic Agent.-The forceps, further, 
awakens uterine contractions, often, indeed, to such an extent as to in- 
terfere considerably with the introduction of the second blade. This 
action, however, is far from being constant, and it has been much ex- 
aggerated by Baudelocque, Stein, Kilian, etc. At times they are only 
momentarily increased; and then, again, they are entirely wanting. 
Special Rules. 
The forceps, we have seen, may be applied in presentations of the head, 
of the face, of the after-coming head, of the decapitated head. In each 
instance the head may be more or less elevated, and it may be situated: 
1. Below the superior strait, in the excavation, and more or less near the 
inferior strait. 2. At the level of the superior strait, in part engaged, 
but projecting more or less above the excavation. 3. Entirely above the 
superior strait, and more or less movable. 
The general rules, of course, are the same in each instance, but the par- 
ticular rules vary not only in each case, but also in the different positions 
of the head. We will study each in succession. 
Application of the Forceps in Vertex Presentations. 
A. The Head in the Cavity, or at the Level of the Inferior Strait.- 
The vertex may present in O.P., O.S., O.I.L.A., O.I.L.P., O.I.L.T., 
O.I.R.A., O.I.R.P., O.I.R.T. 
1. Occipito-pubic Position.-The occiput, according to the descent of 
the head, is situated either behind the symphysis or beneath. The fore- 
head is backward, the bi-parietal diameter is in the transverse of the cav- 
ity, or of the inferior strait-in other words, the sides of the head corre- 
spond to the sides of the pelvis. The forceps are applied directly, that is 
to say, the blades are parallel both to the head and to the pelvis. There- 113 
THE FORCEPS. 
fore left blade to left side of head, and right blade to right side of head. 
The forceps applied, the lesser curve lies directly under the lower border 
of the symphysis. The blades must be pushed in less deeply the lower 
the head. It is in every way advantageous to begin here with the left 
blade. Extraction is usually easy. We must simply make traction at 
first downward, and then in front, until the occiput is engaged under 
the symphysis (this is very important), and then only, slowly lift the handles 
to extend the head outwardly, even as in normal labor, by its sub-occipito- 
bregmatic, sub-occipito frontal, sub-occipito-mental, diameters. (See 
Fig. 91.) (We are speaking now of the classic forceps, that of Tarnier 
telling us by its needle in what direction we must make traction.) Never 
hurry, unless the interest of mother or of child calls for haste. Give the 
soft parts time to relax; watch carefully the perineum, ready to perform 
episiotomy in case of rapid delivery being needed, always bearing in mind 
the principle that except in an emergency, it is far better to work slowly 
than hastily in the delivery of the head. Let the perineum relax, hold 
back the head if need be, and allow it, as far as is possible, to be born 
only in the intervals of the pains. (See Figs. 91 and 92.) The head 
delivered and, then alone, remove the forceps, contrarywise to the opinion 
of Mme. Lachapelle, [and contrary also to the opinion of the generality 
of American accoucheurs, for reasons we have already given-Ed. ], who 
taught that the forceps should be removed as soon as the head was free 
from the bony walls. 
2. Occipito-sacral Position.-The bi-parietal diameter of the head still 
corresponds to the transverse of the pelvis, and the sides of the head to 
those of the pelvis, but the occiput lies backward, the forehead anteriorly. 
Here, also, the forceps are applied directly, left blade to left, and right to 
right side. We are, therefore, in opposition to the rule which says that 
the lesser curve of the forceps should be directed towards the part of the 
head which is to come under the symphysis, that is to say, the occiput; it 
would be impossible, indeed, to conform to this rule in the present in- 
stance, for we would be obliged to insert the left blade to the right, and 
the right to the left, and we have seen that the only absolute rule for the 
forceps is left blade to left, and right to right. [Richardson, of Boston, 
advocates, in posterior positions, the insertion of the blades inversely to 
the ordinary way, then bringing down the head to the pelvic floor, re- 
moving the blades, and, if rotation does not occur spontaneously, re-ap- 
Vol. IV.-8 114 
A TREATISE ON OBSTETRICS. 
plying them in the classic fashion. This manoeuvre has answered us 
well.-Ed.] The forceps then is applied as in the preceding instance, 
and the lesser curve corresponds to the forehead. The left blade, here 
as well, had better be introduced first. (See Fig. 95.) 
When the head has been regularly grasped, the instrument is parallel 
both to the head and to the pelvis. All that remains is delivery. Here 
authorities are not in accord. Some are in favor of delivering with the 
occiput posterior, others counsel artificial rotation in order to bring the 
occiput under the pubes, and then to re-apply the forceps. 
We believe in always attempting rotation. But this attempt should 
Fig. 95.-Delivery of the Occiput Posterior. 
only be made when the head has reached the pelvic floor, and then either 
rotate, or deliver with the occiput posterior. (Figs. 96 and 97.) At the 
outset traction must be made downward and backward, in order to bring 
down the occiput. This is far from easy, and hence various methods. 
Hubert (de Louvain) advises placing a firm filet over the pivot, an as- 
sistant pulls by this strongly downward, while the operator makes traction 
with one hand at the lock, the other holding the handles. 
Couzot (de Dinan) presses downward with his knee at the lock, while 
the hands simply control the handles. Chailly knelt before the bed, placed 
the handles under his shoulder, the two hands at the lock, and pulled 
downwards with all his might. 
Above all these manoeuvres, more or less violent, we much prefer that 115 
THE FORCEPS. 
of Pajot. (See Fig. 94.) Seize the instrument firmly near the vulva, 
carry the handles with the other hand at first downward and a little out- 
ward; then, as the head descends more and more, the hand near the vulva 
endeavors to depress the blades. Finally, when the head reaches the peri- 
neum, depress the handles so as to extend the head. (Fig. 97.) The 
forehead thus comes behind the symphysis, as the occiput descends along 
the posterior vaginal wall. 
Pajot's method is certainly less violent than the others, but the deliv- 
Fig. 96.-Delivery of the Occiput Posterior. 
< 
ery of the occiput posterior necessarily entails laceration of the perineum, 
to say nothing of the fact that the head, in passing along the posterior wall 
of the pelvis, greatly distends it, and exposes it to bruising, which may be 
of great consequence. Finally the blades may slip, if the head does not 
descend, or only with difficulty. Hence, as soon as the head reaches the 
bottom of the cavity, we proceed no further with Pajot's method, but 
endeavor to rotate artificially. We only deliver the occiput posteriorly 116 
A TREATISE ON OBSTETRICS. 
when we are forced to do so, that is to say, when we cannot rotate with 
the forceps. Often this is possible, but then again not at all so, and then 
the efforts we make may damage the mother as well as the infant, and 
we must extract the occiput posterior, even if we do tear the perineum; 
and this we can limit by lateral incisions. 
The method which consists in bringing the occiput forward is not ad- 
mitted by all accoucheurs. Smellie was the first to practise it, and Puzos, 
Levret, Deleurye, Petit, Astruc, Solayres, Baudelocque, Herbiniaux, 
Capuron, Moreau, Naegele, Chailly and Cazeaux rejected it. To-day, 
neither Stoltz, Pajot, Grenser, Hyernaux, Chassagny, Villeneuve nor 
Fig. 97.-Delivery of the Occiput Posterior. 
Sentex, will adopt it. Exceptionally resorted to by P. Dubois and Dan- 
yau, it has become customary with Depaul, Blot, Joulin, Bailly, Tarnier 
and his pupils, and we are ourselves partisans in its favor. The adversa- 
ries of the method say that it makes the head rotate more than a quarter, 
while the body is immobilized by the contraction of the uterus, and that 
hence it exposes the infant to grave lesions in the cervical region, about 
the atlo-axoid articulation. Although facts are against this protest, Tar- 
nier, from his personal experiences, has routed all the objectors. 11 From 
experiments on many cadavers of new-born infants I have proved that 
when the head is turned one-half the circumference, the shoulders being 
steadied, the motion does not alone occur at the atlo-axoid joint, but THE FORCEPS. 
117 
throughout the whole extent of the cervical, and a portion of the dorsal 
spine, the vertebrae twisting spirally. In order to make the head thus 
rotate, great force must be used, and yet careful dissection has failed* to 
reveal the slightest lesions in the membranes or the spinal marrow. But, 
it may be said, if the vertebrae are twisted, the spinal cord must be com- 
pressed. To guard against this objection, I substituted for the cord a 
fluid column, connected with an external glass tube. Every compression 
of the canal caused the fluid to mount in the tube, and yet torsion of the 
head did not. Strong flexion of the head did cause it to rise. I am thus 
convinced that exaggerated rotation compresses the cord less than as great 
flexion as we are obliged to produce in order to extract the occiput in 
posterior positions." Ribemont resumed the experiments of Tarnier, and 
reached the same conclusions. After having frozen a foetus in a position 
where the chin looked backward and the occiput anteriorly, he made hori- 
zontal sections at different levels of the vertebral column, and vertical 
sections antero-posteriorly, and his studies of the sections resulted in the 
following conclusions: 
1. As Tarnier has shown, torsion of the neck affects the whole cervical 
column, and six or seven of the dorsal vertebra?. 
2. This torsion is not greater at the first than in the last cervical verte- 
brae. 
3. At no point is there deformity or flattening of the rachidian canal. 
4. The spinal marrow is at the centre of this canal. It is, therefore, 
not compressed, but is turned on its axis, parallel to that of the verte- 
brae. 
Bailly has very exactly described the manoeuvre: 11 The diagnosis of the 
position having been made with the greatest care, the forceps is applied 
as usual. The head is grasped by its sides, the concavity of the border 
of the blades being turned towards the fronto-bregmatic region. If the 
head be already near the vulva, we may at once begin to rotate. If, how- 
ever, it be still above the inferior strait, it is brought down to the pelvic 
floor until this musculo-membranous plane is considerably distended. 
This lowering of the head is to me of the greatest importance. On the 
one hand, we thus conform more nearly to the natural process, when, in 
general, the head does not rotate till it reaches the pelvic floor; and, on 
the other hand, artificial rotation is easier, and freer from danger to the 
mother, since the head and the instrument are turned in but one axis, and 118 
A TREATISE ON OBSTETRICS. 
where the surroundings are largely soft and mobile, instead of being turned 
at the centre of a curved and a rigid canal. (Fig. 98.) 
'The head, then, having been lowered, and the perineum partially dis- 
tended, movements of rotation are applied to it, to bring the occiput 
under the pubes. To accomplish this, the handles of the forceps are care- 
fully and slowly turned towards the side of the pelvis opposed to 
which the occiput must follow, and this latter must be conducted along 
the line it would naturally pursue, that is to say, forwards and to the 
Fig. 98.-Artificial Rotation in Position O.I.R.P. 
right in the left postero-lateral position, forwards and to the left in the 
occipito-iliac right posterior position. This manoeuvre never requires 
effort on the part of the accoucheur, but only, at the start, moderate im- 
pulsion. As soon as the occiput has crossed the transverse diameter of 
the genital tract, especially if uterine contractions are present, rotation 
takes place alone and quickly, and the occiput is in front, and the concave 
border of the forceps against the fourchette. 
Notwithstanding this reversal of the normal position of the forceps, the 
head may still be extended and delivered. A new and regular applica- 119 
THE FORCEPS. 
tion of the instrument seems to me, therefore, superfluous in the great 
majority of cases. In many cases, indeed, both the head and the instru- 
ment are expelled together by a uterine contraction, as soon as rotation 
has been completed. 
It is surprising, indeed, with what ease this rotation is made. With 
Bailly we believe it useless, ordinarily, to remove and re apply the for- 
ceps, at least in multipart®; but in primiparee, with narrow vulva, it is 
frequently of great advantage to remove the forceps, and re-apply it to 
the head with occiput under the pubes. 
[The absolute lack of reference to the practice of American accou- 
cheurs in the delivery of occiput posterior positions, is valid excuse for 
reference to the matter here. It is generally agreed that the main factor 
interfering with anterior rotation, in a normal pelvis, is lack of flexion of 
the head. When flexion is complete, in the large proportion of cases, as 
soon as the occiput reaches the pelvic floor, other conditions normal, it 
will rotate spontaneously forward. Where flexion is not complete, we 
are satisfied that application of the forceps in the reverse direction and 
completion by them of flexion, will often be sufficient to cause the head 
to rotate spontaneously. If this be the case, an effort in this direction 
should ever be made before attempting artificial rotation by either the 
hand or the forceps. Lusk says that "an attempt to rotate the occiput 
around to the symphysis by instrumental means, is rarely successful." 
In a discussion in 1881 before the American Gynecological Society, Saw- 
yer stated that he was opposed to dragging the head posterior by means 
of the forceps, and counsels rotation under an anaesthetic by means of the 
entire hand in the vagina. This, to us, seems far preferable to the arti- 
ficial rotation by the forceps, since the hand is a sentient agent. Richard- 
son stated that, in a large experience, he had never failed to see the occi- 
put rotate spontaneously. Reamy nearly agreed with him; the late Albert 
H. Smith said that in his experience, with a normal head and a normal 
pelvis, rotation always occurred. In a number of cases seen by us, in 
certainly the majority, spontaneous rotation occurred as soon as the head 
reached the floor of the pelvis; in one case lack of rotation was due to 
lack of flexion, and, on correcting this with the forceps applied inversely, 
spontaneous rotation immediately occurred. In three or four cases, the 
position was persistent, and the head and shoulders so firmly pressed 
down, that any attempt at artificial rotation could only have resulted in 120 
A TREATISE ON OBSTETRICS. 
failure, and in possible injury, so that we delivered with the forceps, sav- 
ing the children, but of course ploughing up the perineum.-Ed.] 
3. Position O.I.L.A.-The occipito-frontal diameter lies in the left 
oblique of the pelvis, the bi-parietal in the right oblique. The left side 
of the head is backward and to the left; the right forward and to the 
right. The forceps, then, applied symmetrically to the head, will be 
oblique to the pelvis. One blade being in front, and the other behind, 
the application is oblique. The posterior, first applied, is the left blade, 
Fig. 99.-Application of Forceps in O.I.L.A. 
and lies in front of the left sacro-iliac synchondrosis on the left lateral 
side of the head. The right blade, at first directed backward, in front of 
the sciatic ligament, should be brought forward behind the cotyloid cav- 
ity, on the right side of the head, after Mme. Lachapelle's method. The 
forceps, when locked, will seize the occiput by its lesser curve directed 
towards the left thigh of the mother. (Fig. 99.) The first tractions 
should aim at bringing the head down to the pelvic floor, and then it is 
to be rotated from left to right, to bring the occiput under the pubes. 
This once accomplished, the instrument is symmetrical to head and to 121 
THE FORCEPS. 
pelvis, and extraction is proceeded with as in case of occipito-pubic posi- 
tions. 
4. Position O.I.L. T.- Here it is impossible to grasp the head in the 
bi-parietal diameter. One of the parietal protuberances corresponding 
directly with the posterior portion of the pelvis (sacro-vertebral angle), 
the other to the anterior portion, that is to say, to the symphysis, it is 
not possible to apply the forceps symmetrically to the head. In case we 
try, on the other hand, to apply symmetrically to the pelvis, we will grasp 
the head in the occipito-frontal diameter, the greatest of the head. We 
Fig. 100.-Application of Forceps in O.I.L.T. 
aim, hence, to grasp the head in the diameter intermediate between the 
bi-parietal and the occipito-frontal. The left blade is again first intro- 
duced to the left and behind, on the left side of the occiput. The right 
blade, introduced the second, is first directed behind and to the right, 
and then brought spirally over the right frontal protuberance. The in- 
strument, when locked, faces the left thigh of the mother. (Fig. 100.) 
The lesser curve is, therefore, again turned, although not exactly, towards 
the occiput. First, tractions are to be made downward, to bring the head 
to the pelvic floor, and it is then rotated from left to right, to bring the 
occiput under the pubes. 122 
A TREATISE ON OBSTETRICS. 
5. Position O.L.P.-The occipito-frontal diameter lies in the right 
oblique of the pelvis. The occiput points to the left sacro-iliac synchon- 
drosis, the forehead to the right cotyloid cavity. The bi-parietal diame- 
ter lies in the left oblique of the pelvis, the right side of the head is in 
front and to the left, the left side behind and to the right. Here again 
application is oblique. 
The left blade necessarily occupying the left side of the pelvis, in order 
to be applied symmetrically to the head, must be placed at the extremity 
of the left oblique diameter, that is to say, in front and on the right side 
of the head. The right blade will be posterior, and should be inserted 
first, behind, on the left side of the head. Therefore, we will be obliged 
to cross the blades, unless we resort to Stoltz's method. The left blade, 
introduced the second, must be brought forward by the spiral movement 
of Mme. Lachapelle. If the head is well grasped, the lesser curve of the 
forceps will cross the forehead and be directed towards the right thigh of 
the mother. 
The occiput being posterior, there are two methods of extraction: by 
Pajot's method, and extract the occiput posterior; or else, as we prefer, 
first pull the head down, and, once the head on the pelvic floor, rotate 
it from left to right, and from behind forward. The occiput under the 
pubes, the forceps will be applied inversely, and then, in multipart, 
we proceed to extract, or, in primiparae, we remove the forceps and re- 
apply it directly. 
When the head is high up, the difficulty is sometimes great in bringing 
down the head. It is a good plan then to begin artificial rotation before 
the head has quite reached the inferior strait. 
6. Position O.R.A.- The occipito-frontal diameter lies in the right 
of the pelvis; the right side of the head points backward and to the right, 
the left side forwards and to the left, the bi-parietal diameter being in 
the left oblique pelvic diameter. The forceps is applied symmetrically 
to the head, and oblique to the pelvis. The right blade, inserted first, is 
carried to the right side of the head, behind and to the right. The left 
blade is inserted second and to the left, and carried from behind forward, 
to the anterior extremity of the left oblique diametei' of the pelvis, that 
is, on the left side of the head, in front and to the left, after Mme. La- 
chapelle's method. When locked, the lesser curve crosses the occiput, 
and points to the right thigh of the mother. At first traction is made THE FORCEPS. 
123 
downward, and as soon as the head reaches the pelvic floor it is rotated 
from right to left to bring the occiput under the pubes. Since the right 
blade was inserted first, the blades must be crossed to lock, or else Stoltz's 
method used. The occiput under the pubes, the forceps is applied sym- 
metrically to head and pelvis. Extraction is made as in the ordinary 
occipito-pubic position. 
7. Position O.I.R.T., The occipito-frontal diameter lies in the trans- 
verse of the pelvis. The forehead is to the left, the occiput to the right. 
Fig. 101.-Application of the Forceps, Position O.I.R.T. 
the bi-parietal diameter is in the antero-posterior of the pelvis, the right 
side of the head is posterior, the left anterior. The forceps cannot be 
applied symmetrically to the head. The same is true of the pelvis, since 
the head would be seized in its longest diameter, O.F. We seek, hence, 
as in O.I.L.P., to grasp the head in a diameter between the bi-parietal 
and the occipito-frontal, and the head is seized irregularly. (Fig. 101.) 
The right blade, inserted first, is placed behind and to the right, over 
the right lateral portion of the occipital bone, at the level of the right 
sacro-iliac synchondrosis. The left blade, inserted second, behind and to 124 
A TREATISE ON OBSTETRICS. 
the left, is brought forward by the spiral movement behind the left coty- 
loid cavity, at the level of the left frontal protuberance. Here again, the 
blades must be crossed, or Stoltz's method used. The instrument once 
locked, has its lesser curve turned towards the right thigh of the woman, 
traction is made downward to bring the head to the pelvic floor, then it 
is rotated from right to left, and, the occiput once under the symphysis, 
we extract immediately in multiparas, or else we remove the forceps in 
primiparae, and make a direct application. 
In Germany, Scanzoni, Zweifel, and others, apply the forceps differ- 
ently. They place the left blade behind, on the right frontal protuber- 
ance, and the right blade, introduced second and underneath the left, is 
brought forward to the left lateral portion of the occipital bone. The 
forceps, therefore, is applied with its lesser curve, not to the occiput, but 
to the forehead, and directed towards the left thigh of the woman. 
We much prefer our method which, when rotation has been made, 
allows us, in multiparae at least, to extract without a new application of 
the forceps, while by the German method the forceps being in inverse 
application, we must re-apply it, or else bring the forehead to the 
pubes, and deliver the occiput posterior. 
8. Position O.LR.P.-The occipito-frontal diameter is in the left 
oblique' of the pelvis, the bi-parietal in the right oblique. The occiput 
is behind and to the right, at the level of the right sacro-iliac synchon- 
drosis, the forehead in front and to the left, at the left cotyloid cavity; 
the right side of the head is behind and to the left, the left side in front 
and to the right. The forceps is applied symmetrically to the head, and 
asymmetrically to the pelvis, an oblique application. The left blade is 
first introduced to the left and behind, on the right side of the head; 
the right blade, directed first behind, is brought forward, by the spiral 
movement, to the left side of the head. The lesser curve is applied to 
the forehead, and directed towards the left thigh of the mother, as in the 
position O.I.L.A. (Fig. 102.) Traction is made first downward, to 
bring the head to the perineum, and then rotation is made from right to 
left, to bring the occiput under the pubes. If rotation is impossible, we 
resort to Pajot's method, and when the forehead is under the symphysis, 
we extract the occiput posterior. 
We see then that the rule, requiring the lesser curvature of the forceps 
to be directed towards the side of the head which we intend bringing THE FORCEPS. 
125 
under the pubes, is not absolute, is true, indeed, only when in posterior 
positions we wish to deliver the occiput posteriorly. Then it is towards 
the forehead that the lesser curve is placed; but when rotation is to be 
attempted, the forceps is applied according to rule, only in anterior posi- 
tions. In fact, in the positions O.LL.A and O.I.R.A., the lesser curve 
is directed towards the occiput, only in O.I.L.A., this curve points towards 
the left thigh, since the occiput is in front and to the left, while in 
Fig. 102.-Appi ication of the Forceps in O.I.R.P. 
O.I.R.A., it looks toward the right thigh, the occiput being in front and 
to the right. 
In the positions O.I.L.P and O.I.R.P., on the contrary, the occiput is 
posterior, and the rule is not applicable, for if we wish the lesser curve 
to be directed at the outset towards the occiput, we would be obliged 
either to grasp the head irregularly, that is to say, from one frontal pro- 
tuberance to the opposed portion of the occiput, as in transverse posi- 
tions; or, if we wished to grasp the head regularly, we would have to 
apply the forceps with left blade to right, and right to left, which is in- 
admissible. The forceps, then, is applied as though the occiput were in 126 
A TREATISE ON OBSTETRICS. 
front, and the lesser curve is at the forehead, pointing towards the right 
thigh in 0.1.L.P., and towards the left in O.I.R.P. The head is then 
rotated and brought under the symphysis, and the forceps is in inverse 
application. In case of a multipara we at once deliver; in case of a 
primipara the blades are removed, and re-applied directly to the head. 
If in a few words we resume the principles applicable to the placing of 
the blades: In anterior and transverse positions, the first is the posterior 
blade, and the second is applied over the occiput, occiput to left, left 
blade, to right, right blade. In posterior positions, the first blade behind, 
the second over the side opposed to the occiput, occiput to left, right 
blade, occiput to right, left blade. 
The higher the head, the greater the necessity of bringing it down before 
attempting rotation. If we use Tarnier's instrument, never attempt ro- 
tation with the traction-rods alone, but unite the four branches (those of 
traction, those of prehension) in one hand, and then try. This, it will be 
remembered, is one of the objections we made to Tarnier's instrument. 
The following table shows the different applications of the forceps in 
vertex presentations. 
Table Resuming the Different Applications of the Forceps. 
Left blade 1st, to left side 
of head. 
Right blade 2d, to right side 
of head. 
The lesser curve grasps the 
occiput and is turned towards 
symphysis. 
1, O.P.: 
Left blade to left 1st, on right 
sideof head. 
Right blade to right 2d, on left 
side of head. 
The lesser curve toward sym- 
physis, grasping forehead. Ro- 
tation. Re-application of the 
forceps, or delivery of occiput 
posterior. 
2. O.S.: 
Left blade to left 1st, and be- 
hind, to left side of head. 
Right blade to right 2d, and 
in front to right side of head. 
Lesser curve toward left thigh 
of mother, and grasps occiput. 
Traction downward to engage 
head. Rotation from left to 
right. Delivery in O.P. 
3. O.I.L.A.: 
Left blade to left 1st, and be- 
hind, to left side of occipital 
bone. 
Right blade to right 2d, and 
in front, on the right frontal 
protuberance. 
Lesser curve to mother's left 
t high. Head grasped i rregul arly 
Downward traction to engage 
head. Rotation from left to 
right. Delivery in O.P. 
4. O.I.L.T.: 
Lesser curve to right thign, 
and grasping forehead. Cross- 
ing or Stoltz's method. Traction, 
then rotation left to right. Re- 
application of blades to deliver 
in O.P., or else method of Pajot 
L and extraction in O.S 
Left blade 1st and behind, to 
left side of head. 
Right blade 2d and in front, 
to right side of head. 
5. O.I.L.P.: THE FORCEPS. 
127 
6. O.I.R.A. 
Right blade to right 1 st and 
behind, to right side of head. 
Left blade to left 2d and in 
front, to left side of head. 
Lesser curve to right thigh 
and grasping occiput. Crossing, 
or Stoltz's method. Traction 
downward, rotation from right 
to left, extraction in O.P. 
Right blade to right, 1st and 
behind, to right side of occipi- 
tal bone. 
Left blade to left 2d and in 
front, on left frontal protuber- 
ance. 
Lesser curve to right thigh. 
Head irregularly grasped. Trac- 
tion downward, rotation from 
right to le ft. Crossing or Stoltz's 
method. 
7. O.I.R.T. 
Left blade to left 1st and be- 
hind, on right side of head. 
Right blade to right 2d and 
in front, on left side of head. 
Lesser curve to left thigh and 
grasps forehead. Downward 
traction. Rotation right to 
left. Re-application of blades 
to extract in O.P., or Pajot's 
method and extraction occiput 
posterior. 
8. O.I.R.P. 
Positions O.LL, A. andO.I.L.T.: Left blade 
behind and to left 1st. 
Positions O.I.R.A. and O.I.R.T.: Right 
blade behind and to right 1st. 
Blade of same name as side 
where occiput lies. 
Position O.I.L.P.: Right blade to right and 
behind 1st. 
Position O.I.R.P.: Left blade to left and be- 
hind 1st. 
Blade of opposite name to side 
where occiput lies. 
B. The Head is only partially engaged at the Superior Strait.-In this 
case the obstacle to the engagement of the head is usually due to a con- 
traction of the pelvis or to prolapse of a foetal part. The head is almost 
always transverse; direct anterior and posterior positions are not possible. 
The oblique may be met with when the contraction is moderate, and the 
head not very large. The transverse position is the rule, and it is hence 
usually impossible to grasp the head regularly; and to endeavor to apply 
the forceps, according to the German method, parallel to the pelvis, is to 
grasp the head from occiput to pubes, and consequently to increase the 
obstacle. We must, therefore, act as in transverse positions with the head 
in the cavity, seize the head by one frontal protuberance and the opposed 
side of the occiput. 
The choice of the anterior and the posterior blades is here again subor- 
dinated to the side where the occiput lies. 
In the position O.I.L.T., the head is grasped between the posterior 
portion of the occipital bone and the anterior portion of the forehead; 
the left blade is inserted first, to the left, and applied to the left portion 
of the occiput, the right blade is inserted second, to the right and behind, 
then brought forward by the spiral movement over the right frontal pro- 
tuberance. The lesser curve is directed towards the left thigh of the 128 
A TREATISE ON OBSTETRICS. 
mother. The head is grasped irregularly. At the outset traction is 
made downwards, rotation occurs from left to right, and extraction with 
the occiput to the pubes. 
In the position O.I.R.T., the right blade is inserted first, behind and 
to the right, over the right side of the occipital bone; the left blade, in- 
serted second and behind, is brought forward over the left frontal 
protuberance. We must, therefore, either cross the blades, or else use 
Stoltz's method. When the forceps is locked, the lesser curve points to 
the mother's right thigh; the head is grasped irregularly. Traction is 
first made downward, to engage the head, and to bring it down as far as 
is possible, then it is rotated from right to left, and extracted with the 
occiput to the pubes. 
The capital point, in order to thoroughly grasp the head, is to intro- 
duce the blades deeply enough. In such cases the pivot of the instru- 
ment is almost at the vulva. The hand, then, which is to guide the blade, 
must be passed deeply between the head and the cervix to protect the 
maternal parts, and the head must be steadied from the outside by an as- 
sistant, when the blades are being placed, for it tends to escape above the 
brim. 
Traction must be made in the axis of the pelvis, and this, as all au- 
thorities agree, is the true difficulty. To remedy it, Pajot devised his 
method, and Hubert, Fabri, Morales devised the perineal curve of the 
forceps, which Tarnier himself adopted in his first model. 
Tarnier tries to solve the problem by placing the woman on the side, 
in order to be able to make traction as far back as possible without being 
inconvenienced by the side of the bed, and he makes the woman resume 
the dorsal position as soon as the head has reached the cavity. But it is 
not only the border of the bed which is in the way, but the perineum 
itself, against which the blades press as soon as the forceps is carried 
enough backwards. Now, if it is difficult, if not impossible, to carry the 
classic forceps far enough back, it is even more so Tarnier's, the indicator 
needle of which is made to tell us the direction in which traction must be 
made. In these cases, the indicator calls for that which is impossible, for 
we cannot make traction far enough back, and it is only, indeed, when 
the head is below the superior strait that the indicator can give real indi- 
cations, for then we can fulfill them. Such an ardent advocate of Tar- 
nier's forceps as is Pinard, is obliged to admit that, in oblique applica- 129 
THE FORCEPS. 
tions, the head being above the superior strait, traction by means of the 
instrument is not perfect, for the perineum interferes with its being 
placed in the pelvic axis occupied by the head. 
Now this is one of the marked advantages of Pajot's method. It is said 
that, in this method, the forceps does not act as a tractor, but as a lever. 
Of what use, however, here mathematical rules, which are at the best 
simply problematical, since the pelvic axis changes with each woman, ac- 
cording to the form, dimensions, and deformities of the pelvis? The 
main point is to make the head descend with the least damage to mother 
and to child. .Whether, then, the forceps acts as tractor or as lever, the 
best method is that which permits the head to pass easily and rapidly 
through the superior strait, and it is admitted that in many cases this is 
possible by Pajot's method, where simple tractions fail. Further, in 
these cases, the lateral movements, carefully made, are of great utility. 
In these instances, therefore, we prefer the classic forceps, and if trac- 
tion downward and backward do not suffice, we try Pajot's method, and 
the head once at the inferior strait, we try artificial rotation, ready, if this 
fail, to deliver the occiput posterior. 
If, notwithstanding these methods, we fail in dislodging the head, 
then, in the interests of the mother, we must sacrifice the child, and it is 
preferable to do this, and give to the mother greater chances of health, 
than to endeavor at all hazards to make the head descend; for, on the 
one hand, the injuries to the mother compromise greatly the puerperium, 
and, on the other hand, granting that the child is born alive, the lesions 
resulting from exaggerated traction and compression almost fatally mean 
its death in from twenty-four to forty-eight hours after birth. 
C. Head movable above the Superior Strait. -Most authorities here prefer 
version to the forceps, whenever possible. But it has been proved by 
the researches of Budin, Milne, Goodell and Champetier, that although 
version is preferable to forceps in pelvic deformity before term, it is not 
so at term. 
The causes which ordinarily retain the head above the superior strait 
may be reduced to two: oblique positions of the head, and pronounced 
pelvic contraction. The first, we have seen, almost always correct them- 
selves in course of time, if the pelvis is normal, and the accoucheur has 
simply to wait. If, on the other hand, we are dealing with great pelvic 
contraction, it is not forcens which we must use, but perforation, or 
Vol. IV.-9 130 
A TREATISE ON OBSTETRICS. 
cephalotripsy, or the Caesarean section, [or better still, in suitable cases, 
laparo-elytrotomy. -Ed. ] 
There remain then for consideration the cases of considerable contrac- 
tion, where we can hope to deliver the child at term without mutilation. 
The application of the forceps then becomes very difficult and delicate. 
Aside from the fact that the mobility of the head makes it difficult to 
apply the blades, the hand cannot be inserted far enough to guide them. 
We must first, then, make one or two efforts at traction to be sure that 
the head is grasped firmly, for above all we must take precautions 
against the instrument slipping. Sometimes the head is grasped too far 
in front, and it escapes from the forceps behind, or inversely, with 
the first tractions. Altogether, indeed, the accoucheur is not at liberty 
to do as he would wish; he must do the best he can; and if he is fortu- 
nate enough to grasp the head firmly, if after a few sustained tractions 
the head does not budge, it is advisable to perforate, or to resort to 
cephalotripsy. 
Applications of the Forceps in Face Presentations. 
« 
The face, even as the vertex, may lie at the level of the inferior strait, 
in the cavity, at the superior strait, above it. Usually, in each of these 
instances, the head is diagonal or transverse. The antero-posterior di- 
ameter of the pelvis is too small for the occipito-mental, and therefore a 
mento-sacral position, properly so-called, does not exist, and the same is 
true of the mento-pubic. We may have a mento-sub-pubic position-that 
is to say, rotation has been affected, and the chin is under the pubes. 
Direct application of the forceps is exceptional in face presentations, and 
it is usually the oblique which is practised. 
The general and special rules are the same as for the vertex; two con- 
ditions, however, lead all the others: 
1. The instrument must be applied to the sides of the face, to avoid 
wounding it anteriorly, or the neck. Occasionally, as we will see, we have 
no choice in this matter. 
2. The absolute necessity of making the face rotate, in order to bring 
the chin under the symphysis. Indeed this rotation may alone allow us 
to terminate labor without mutilating the foetus. 
In these instances, more even than in case of the vertex, the hand must THE FORCEPS. 
131 
be introduced deeply to protect the maternal and the foetal parts. The 
chin must always be brought under the symphysis, because transforma- 
tion into the vertex is only possible when the position of the face is 
frontal, or when it is above the superior strait. In the first we must 
wait, for this transformation may occur spontaneously; in the second, it 
is version to which we should resort, and not to the forceps. 
We must never forget that in face presentations labor is always pro- 
longed, and that, therefore, we must have plenty of patience. 
Pinard advocates placing the blades nearer to the chin than to the 
brow, ready to remove them, and re-apply as soon as the chin has been 
brought down. This is good advice, but although easy of performance 
on the manikin, it is far from being so on the living female. The great 
difficulty in face presentations is to apply the forceps to the sides of the 
face, and while this is possible when the head is in the cavity, it is not so 
when the face is still elevated. Usually we must be content with grasping 
the head obliquely, from one frontal protuberance to the maxillary angle. 
We must remember, further, that transverse presentations of the face 
are relatively frequent compared to the others, and that in such cases we 
are obliged to grasp the head obliquely as in transverse presentations of the 
vertex, the very situation of the face preventing its being seized laterally. 
All the authorities agree in regard to the difficulties of application and 
of delivery in face presentations. The chin must not only be brought 
down, but it must, as well, be brought forward; the face must not only be 
brought down, but it must, in particular, be rotated in order to bring 
the chin under the symphysis. Often all our efforts fail and we are obliged 
to mutilate the foetus. The greater the reason for this, if, as not infre- 
quently happens, with the face presentation there is prolapse of a foetal 
part. 
A. The Face is in the Cavity, having passed through the superior Strait. 
1. Mento-pubic, or, better, mento-sub-pubic.-The forceps is applied 
directly, the chin being under the symphysis and the forehead in the pel- 
vic curve; that is to say, the fronto-mental diameter lies in the antero- 
posterior of the pelvis. The bi-malar diameter is in the transverse of the 
pelvis. The left blade is inserted first to the left on the right side of the 
face, the right blade second to the right on the left side of the face, the 132 
A TREATISE ON OBSTETRICS. 
lesser curve pointing towards the symphysis. It will be sufficient to 
gently lift up the forceps, and the head will appear, in succession, by its 
sub-mento-frontal, sub-mento-bregmatic, sub-mento-occipital diameters. 
(Fig. 103.) 
2. Mento-sacral Position.-Is purely theoretical, and does not exist in 
practice, the chin being always to the right or to the left, towards one of 
the sacro-iliac synchondroses, and the position thus really is mento-posterior 
(right or left). 
3. Position M.I.L.A.-The position of the head is diagonal, the 
mento-frental diameter lies in the left oblique of the pelvis, the forehead 
points towards the right sacro-iliac symphysis, the chin towards the left 
Fig. 103.-Application of the Forceps Mento-sttb-pitbic Position. 
cotyloid cavity. The left side of the head is forward and to the right, 
the right side backward and to the left. The bi-malar diameter is in 
the right oblique of the pelvis. The face may be grasped laterally, but 
one of the blades will be in front and the other behind. The forceps 
will be applied symmetrically to the head, and asymmetrically to the pel- 
vis. The left blade, first inserted, will lie to the left and behind, over 
the right malar region; the right blade will be inserted to the right and 
behind, and then brought spirally forward over the left malar region. 
The lesser curve will point towards the left maternal thigh. First, trac- 
tions must be made downwards to lower the chin, then rotation is made 
from left to right to bring the chin under the symphysis, and extraction 
follows, chin to the pubes. (Fig. 104.) 133 
THE FORCEPS. 
4. Position M.I.L.T,-The head is transverse, the fronto-mental di- 
ameter in the transverse of the pelvis, the bi-malar in the antero-posterior. 
The left side of the head is in front, the right side to the rear. The head 
cannot be exactly seized laterally, and we cannot apply the forceps to 
the sides of the pelvis, after the German method, since the head would 
be grasped from chin to forehead, which would expose the foetal neck to 
great injury. The head, hence, must be seized irregularly, from one 
frontal protuberance to the maxillary angle. The left blade is first in- 
serted to the left and posteriorly, as far as possible near the end of the 
Fig. 104.-Application of the Forceps in Face Presentations. Head in the Cavity. 
Rotation has occurred. 
bi-malar diameter; the right blade, inserted second, to the right and be- 
hind, then brought forward, by the spiral movement, over the left 
frontal protuberance. The lesser curve is towards the mother's left thigh. 
Traction is made downward, the chin thus lowered, the face is rotated, 
and it is extracted, chin to the pubes. 
5. Position M.l.L.P.-TXxe fronto-mental diameter is in the right 
oblique of the pelvis, the bi-malar in the left oblique. The left side of 
head is to the left, and the right to the right of the pelvis. The forceps 
must be applied as though we intended bringing the forehead to the sym- 
physis. The posterior blade will be the right, and is applied, first, behind 134 
A TREATISE ON OBSTETRICS. 
and to the right over the right side of the face, then the left blade, second, 
is inserted behind and to the left, and brought forward over the left side 
of the face. The lesser curve points towards the right thigh of the 
mother. Before locking, the blades must be crossed, or else Stoltz's 
method used. The application is oblique. Traction at first is downward 
and backward to lower the chin before rotation. But even as we saw in ver- 
tex presentations in case of the occiput posterior, so in face it is difficult 
to bring it down when high up. It is not possible to make traction far 
enough backwards. Danyau has advised applying the blades inversely, 
in order to make traction sufficiently backward. Aside from the fact 
that this recommendation is extremely difficult to follow, and contrary to 
all rule, the method has not given good results even in the master-hands 
of Danyau. It is better hence to apply the blades as we have advised, and 
to pull as far backward and downward as is possible. The chin once low- 
ered, rotate, and then remove the forceps, and re-apply directly, and de- 
liver with chin to the pubes. If the difficulty is very great, it is better to 
mutilate the foetus than to expose the mother to great injury. 
6. Position M.l. R.A.-The fronto-mental diameter is in the left oblique 
of the pelvis, the bi-malar in the right oblique. The right side of the 
face is to the left and forwards, the left side to the right and backwards. 
The right blade is inserted first, behind and to the right, and is placed 
over the left lateral side of the face. The left blade is inserted second, 
behind and to the left, and is brought forward spirally, and placed over 
the right lateral side of the face. The application is symmetrical to the 
head, and oblique to the pelvis. The lesser curve points to the right 
thigh of the mother. The blades must be crossed, or Stoltz's method 
used. Traction is made downward to depress the chin, and then rota- 
tion from right to left, to bring it under the symphysis. Extraction, 
chin to the pubes. 
7. Position M.l.R.T.-Face is transverse in the pelvis. The fronto- 
mental diameter is in the transverse of the pelvis, the bi-malar in the 
antero-posterior. The left side of the face looks directly backward, and 
the right forwards. The face cannot be seized regularly, and we try to 
grasp it as far as possible in the bi-malar diameter. The right blade is 
inserted first, behind and to the right, over the left maxillary angle, the 
left blade, second, behind, is brought forward spirally and placed over 
the right frontal protuberance. The lesser curve is towards the mother's 135 
THE FORCEPS. 
right thigh. Crossing, or Stoltz's method, is necessary. Traction down- 
ward to bring down the face and chin rotation from right to left, extrac- 
tion with chin to pubes. 
8. Position M.I.R.P.-The fronto-mental diameter points by the chin 
to the right sacro-iliac synchondrosis, by the forehead to the left cotyloid 
cavity. The right side of face is forwards and to the right, the left side 
behind and to the left, the bi-malar diameter is in the right oblique of 
the pelvis. The forceps is symmetrical to head, and oblique to pelvis. 
The left blade is inserted first, behind and to the left, on the left lateral 
side of the face; the right blade, second, behind and to the right, and 
then is brought forward spirally over the right lateral side of the face. 
Fig. 105.-Application of the Forceps to Face in M.LR.P. 
(Fig. 105.) The lesser curve is over the forehead towards the left thigh 
of the mother. Traction downwards, rotation from right to left, re-ap- 
plication of the blades, and extraction, chin to the pubes. The difficul- 
ties are the same as in M. I. L. P. 
We see, therefore, that the special rules for the forceps in face presen- 
tations are identical with those applicable to the vertex. 
In anterior and transverse presentations: First blade behind, second 
blade to side where the chin points. 
In posterior presentations: First blade behind, and to the side opposed 
to the position of chin. 
In the following table are resumed the rules applicable to the forceps 
in face presentations: 136 
A TREATISE ON OBSTETRICS. 
Rules Applicable to Forceps in Face Presentations. 
Left blade to left and 1st, 
on right side of face. 
Right blade to right and 
2d, on left side of face. 
Direct application. Lesser 
curve towards Symphysis. Ex- 
traction, bv lifting the handles, 
in S.M.F., S.M.B., S.M.O. 
1. Mento-pubic 
2. Mento-sacral 
Practically does not exist. Transformed always into M.I.L P 
or M.LR.P. 
Left blade to left, 1st, be- 
hind, on right side of face. 
Right blade to right, 2d, in 
front, on left side of face. 
Oblique application. Lesser 
curve towards mother's left 
thigh. Traction downward. 
Rotation from left to right. 
Extraction in M.P. 
3. M.I.L.A. 
Left blade to left, 1st, be- 
hind, on right maxillary an- 
gle. 
Right blade to right, 2d, in 
front, on left frontal protu- 
berance. 
Head irregularly grasped- 
Lesser curve towards left thigh 
Downward traction. Rotation 
from left to right. Extraction 
in M. P. Danger of slipping. 
4. M.LL.T. 
Right blade to right, 1st, 
behind, to right side of face. 
Left blade to left, 2d, in 
front, to left side of face. 
Forceps symmetrical to head, 
oblique to pelvis. Lesser curve 
to right thigh. Crossing or 
Stoltz's method. Rotation from 
left to right. Extraction in M. 
P. Perhaps mutilation. Reap- 
plication of blades after rota- 
tion. 
5. M.I.L.P. 
Right blade, 1st, behind, to 
left side of face. 
Left blade, 2d, in front, to 
right side of face. 
Oblique application. Lesser 
curve to right thigh. Crossing 
or Stoltz's method. Downward 
traction. Rotation from right 
to left. Extraction in M.P. 
6. M.I.R.A. 
Right blade, right, 1st, be- 
hind, over left maxillary an- 
gle. 
Left blade, left, 2d, in front 
over right frontal protuber- 
ance. 
Irregular grasp. Lesser curve 
to right thigh. Crossing or 
Stoltz. Downward traction. 
Rotation right to left. Extrac- 
tion in M.P. 
7. M.I.R.T. 
Symmetrical to face, oblique 
to pelvis. Lesser curve towards 
mother's left thigh. Traction 
downwards. Rotation from 
right to left. Reapplication of 
blades. Extraction in M.P. 
Perhaps mutilation. 
Left blade, left, 1st, behind, 
to left side of head. 
Right blade, right, 2d, in 
front, to right side of head. 
8. M.I.R.P. 
Positions 
M.I.L.A. and 
M.I.L.T. 
Left blade, 1st, left, behind. 
Right blade, 2d, right, in 
' front. 
Blade corresponding to side 
where chin points, 1st and be- 
hind. Chin to left, left blade; 
chin to right, right blade. 
Positions 
M.I R.A. and 
M.I.R.T. 
Right blade, 1st, right, be- 
hind. 
Left made, 2d, left, in front. 
Position 
M.I.L.P. 
Right blade, right, 1st, be- 
hind. 
Left blade, left, 2d,in front. 
Blade opposed to side where 
chin points, 1st and behind. 
Chin to left, right blade; chin 
to right, left blade. 
Left blade, left, 1st,behind. 
Right blade, right, 2d, in 
front. 
Position 
M.I.R.P. THE FORCEPS. 
137 
B. The Forceps to the After-coming Head. 
Without going as far as Mme. Lachapelle, Chailly and Pajot, who say 
that when, the body having been delivered, we cannot extract the head, 
it is because the method employed is not a good one, or the force em- 
ployed not sufficient, and that the hand ought to complete labor; we 
must, in general, admit that the cases requiring the forceps are, if not 
exceptional, at least relatively rare. They tend to become rarer still, since 
Tarnier and his pupils have shown the utility of pressure exercised from 
above below through the abdominal walls on the head at the superior 
strait. Champetier de Ribes, in particular, has insisted on this, and he 
Fig. 106.-Application of the Forceps to the after-coming Head. 
has shown that pressure on the forehead from above, combined with trac- 
tion in the inferior maxilla, will often certainly cause the descent of the 
head, even where the pelvis is contracted, with surprising ease. Never- 
theless, in infrequent cases, the forceps is indispensable, and we dwell on 
it briefly. 
In 1874 and 1875 G-rynfeltt, adjunct at Montpelier, studied this ques- 
tion. After having shown that Chailly, Cazeaux, Tarnier and Barnes are 
not opposed to the method, and that Busch, Rigby, Meigs, are greatly in 
favor of it, he endeavors to prove that, contrary wise to the opinion in 
France and abroad, the forceps should always be applied underneath the 
sternal plane of the foetus, (Fig. 106), and exceptionally only above the 
dorsal plane. 138 
A TREATISE ON OBSTETRICS. 
After delivery of the body, the head may be retained at the superior 
strait, in the cavity, at the inferior strait. 
I. Head in the Inferior Strait, or in the Cavity, a. Occipito-pubic 
Position.-Rarely requires the forceps, but when used it must be applied 
so as to lower the chin to the perineum, and then extract, the mouth, 
nose, brow, bregma, and vertex, appearing successively. In a word, the 
head must be flexed. 
To seek the face in the sacral excavation, the best plan is to lift the 
body forward towards the mother's belly, and to insert the blades below 
Fig. 107.-The Forceps to after-coming Head. Head flexed and in occipito-sacral position. 
it on the anterior or sternal plane. To extract, the handles are progress- 
ively lifted, and traction made. 
b. Occipito-sacral Position.-The head may be flexed or extended. 
1. Head flexed.-The body of the foetus must be pulled downward, the 
forceps blades introduced above. The handles are then carried downward 
and backward to increase flexion, and deliver the occiput over the peri- 
neum. (Fig. 107.) 
2. Head extended.-The chin is in front and high up, behind the sym- 
physis. The body must be lifted above, the blades inserted below the 
foetal body, and carry the handles upwards to deliver belly to belly. 
(Fig-108-) 
c. Oblique Positions.-Make forward rotation if possible, and, accord- 
ing as the head is flexed or extended, deliver in O.P or in O.S. The 139 
THE FORCEPS. 
blades, hence, are applied according to the case, above or below the foetal 
body. 
d. Transverse Positions.-The head is grasped irregularly, and this 
is the only difference in the manoeuvre. 
In this case Grynfeltt advises rotation by the hand, or by a single blade 
of the forceps acting as a lever. 
II. Head at Superior Strait.-Usually Champetier de Ribes' method, 
described above, answers here-the infant, however, ordinarily dies. It 
is not the forceps, then, which should be used, but cranioclasty or cepha- 
Fig. 108.-Head posterior and extended. 
lotripsy. Certain authors advise decapitation, and then forceps to the 
head in the uterus. 
III. Head after Decapitation.-The head must be fixed at the superior 
strait by an assistant, and then the entire hand in the uterus places the 
head in the most favorable situation, and the blades are applied to the 
sides of the head. The operation is very difficult. Happily, the hand 
alone suffices usually to extract the head. 
C. Forceps to the Breech. 
If the child is dead, the blades are applied, after the German fashion, 
at the sides of the pelvis. But if the child is alive, the breech must be 
grasped in its bi-iliac or bi-trochanteric diameter. Exaggerated com- 
pression must be avoided, and, therefore, the blades often slip. We must. 140 
A TREATISE ON OBSTETRICS. 
hence make traction gently. Tarnier's forceps, not allowing variation in 
compression, is, according to his pupils, more advantageous than the 
classic. (Fig. 109.) 
[The following pages are inserted here instead of later on, as in the 
original, because here they are in natural sequence, and Charpentier 
would have done so, he tells us, had Olivier's thesis on the subject ap- 
peared in time to have allowed him.-Ed.] 
This subject has been studied in detail by Budin, Pinard, Cantacuzene, 
Lefour and Olivier. Budin has, in particular, insisted on the fact that 
in a greater number of cases than is generally believed-we have ourselves 
observed three cases-the pelvic extremity is far more engaged than is gen- 
erally stated, and that this deep engagement is met with exclusively in 
case of the decomposed breech. Palpation and touch suggest a cephalic 
presentation, and it is only when the woman assumes the lateral, or, if 
need be, knee-chest position, that we obtain the cephalic ballotement 
which is characteristic of a breech presentation. As for the touch, it is 
only by carrying the finger high up into the posterior cul-de-sac, and thus 
exploring carefully the foetal presenting part, that we correct the error 
in diagnosis of cephalic presentation. 
Lefour and Olivier look at the matter from a different standpoint. 
Both recalling the fact that breech presentations usually call for interven- 
Fig. 109-Forceps to the Breech. 141 
THE FORCEPS. 
tion, and that this interference, whether manual or instrumental, is dan- 
gerous for the infant, have endeavored to find out not only the causes 
which render descent and expulsion difficult, but the instances in which 
intervention is most dangerous, and both have proposed different methods. 
While Lefour rejects the forceps, except when the infant is dead, 
Olivier, on the strength of experiments made on the manikin, and clini- 
cally, advises strongly the forceps, but applied after a peculiar manner. 
Lefour counsels as follows: During pregnancy to beware of version by 
external manipulations, and to await the onset of labor. During labor to 
retain the membranes as long as possible, to wait until the cervix is dilated 
or dilatable, and then to introduce boldly the hand into the uterus and 
bring down one or two feet: in a word, to transform the breech into a 
foot presentation, and to deliver accordingly. If the membranes have 
ruptured prematurely, and the os is neither dilated nor dilatable, to wait 
for deep engagement of the breech. When the anterior hip is under the 
symphysis, and labor cannot be completed,' because the posterior hip 
cannot pass the perineum, he rejects the finger, the blunt hook, the for- 
ceps, except where the infant is dead, and advises the following method, 
which is none other than that of Ritgen, for delivering the head under 
the symphysis by extending it: He inserts the index and the middle fin- 
ger, or the index alone, into the anus of the parturient, the pulp directed 
upwards, and he pushes on the thigh which is hooked and stopped by 
the perineum. The finger of the other hand may assist by making trac- 
tion upward and forwards from the anterior groin. 
Olivier, on the other hand, is a resolute partisan of the forceps, and 
concludes from his experience: The instrument is not only advantageous, 
but is inoffensive to the foetus, if it is applied, not as is ordinarily recom- 
mended to the iliac crests, but to the foetal limbs, and differently accord- 
ing to whether the position is anterior or posterior. 
If we use a filet, aside from the difficulty of placing it, we run the risk 
of fracturing the femur when making traction, and especially in poste- 
rior positions. 
" In anterior positions, that is to say, when the foetal sacrum is towards 
the right or left pectineal eminence, or the symphysis, the limbs, ex- 
tended along the abdomen, make with the filet, the woman in the dorsal 
position, an angle the apex of which looks backward. If now we make 
traction in the axis of the groin we will not fracture the femur, because 142 
A TREATISE ON OBSTETRICS. 
the greatest traction is at the most resisting part of the bone, the neck, 
the reverse of what holds in the adult, especially the aged. 
" In posterior positions, on the contrary, when the sacrum is towards the 
right or the left sacro-iliac synchondrosis, the legs form with the foetal 
ventral surface an angle, the apex of which looks almost directly upward. 
This is strictly true, only when the breech is at the inferior strait. Trac- 
tion made with the filet must be perpendicular to the leg, and it is appar- 
ent why fracture is likely. This is produced when the limb descends 
and it then becomes perpendicular to the tractor, especially since, coin- 
cidently with the descent of the leg, the pelvis rises. Therefore, Olivier 
advises, during traction, to apply the fingers of the free hand to the sa- 
crum, and by pushing the breech forward prevent its rising, and the ex- 
tension of the leg." 
As for the forceps, Olivier, basing his opinion on the experiments of 
Jacquemier, Balochi, and on the clinical data of Stoltz, Tarnier, Depaul 
and others, claims that it is, in the vast majority of cases, inoffensive to 
the child, although the instrument slips. The cause of this slipping, in 
his opinion, depends either on the fact that the handles are not com- 
pressed, or else that the blades are applied to the iliac crests instead of on 
the foetal limbs. The pelvis, he says, offers an insufficient hold, because 
" when we compress the iliac crests, the bi-iliac diameter diminishes, and 
the crests shrink, and therefore a firm hold is not possible. But the 
limbs, close together, make a cone with base downward, and apex above. 
The diameter of the base is the bi-trochanteric. If the forceps is ap- 
plied here, the blades may slip a little, but they are stopped by the in- 
creasing volume of the cone. We thus have a firm hold, and expose the 
child to less risk. " 
" Oliviei* has determined that: 1. The forceps may be applied to the 
limbs. 2. The hold is firm. 3. No lesion is produced. 
" The application of the forceps to the limbs is easy. Is it applied as 
well in every position? With Tarnier's forceps, thanks to the curve, 
which is the same as that of Levret, when the position is posterior, 
S.I.L.P. or S.I.R.P., the blades adapt themselves well to the limbs in the 
bi-trochanteric diameter, and the forceps cannot slip, or only a trifle, 
owing to the increase in the cone downwards. When, however, the 
foetus is in one of the anterior positions, S.LR.A. or S.I.L.A., the blades 
do not adapt themselves as well, although the bi-trochanteric diameter THE FORCEPS. 
143 
is firmly grasped, for the extremity of the blades extends beyond the ante- 
rior surface of the limb, and compresses the abdominal walls, and the 
hold is less firm. This is why in the majority of our experiments, made 
with the foetus in anterior positions, the forceps has begun to slip before 
bringing down the breech. 
" The breech does not come down until the ends of the blades have 
reached the groin. There they meet the bi-trochanteric diameter, and 
they can slip no further. The recognition of this fact explains why, in 
certain cases where, when it only remained to extract the posterior hip, 
we have endeavored to do this with the forceps, carrying it above and for- 
wards, it has unlocked. In thus carrying the forceps the extremity of 
the anterior blade is brought into the groin, and, the breech not descend- 
ing at once, the extremity of the posterioi' blade passes beyond the bi- 
trochanteric diameter, and the instrument slips." 
Hence, in anterior positions, Olivier recommends the forceps which 
Trelat has constructed for extracting the breech, but he rejects it for the 
posterior positions, where, he thinks, the Tarniei' forceps is the best, 
and in none of his experiments did he injure the pelvis or the foetal limbs. 
Finally Olivier draws the following conclusions: 
I. During Pregnancy.-The breech is engaged, or not. When en- 
gaged, no interference; when not engaged, version by external manipula- 
tions, and, in case of success, application of a binder, to be worn till labor. 
2. During Labor.-A. The breech at the superior strait. B. The 
breech more or less engaged. C. The breech at the vulva. 
A. If the membranes are unruptured, when dilatation is complete, rup- 
ture them, bring down a foot and wait; if the cord prolapses, if it is com- 
pressed, if after an interval the breech does not engage, extract. If the 
membranes are ruptured, and intervention is called for, try to bring down 
a foot, and, in case of success, extract; if this fails, apply the forceps; if 
it slips, extract by a filet in the groin. The forceps should be applied as 
far as possible to the limbs, and not to the pelvis. 
B. In anterior positions apply the forceps according to the above 
rules; if it slips, re-apply; in case it slips again, extract by a filet passed 
around the anterior groin. 
In posterior positions, apply the forceps; if it slips twice in succession, 
and this is very exceptional, extract by the filet and use the complemen ■ 
tary manoeuvre of Lefour, finger in parturient's anus. 144 
A TREATISE ON OBSTETRICS. 
In transverse positions extract by a filet in anterior groin. One appli- 
cation of forceps might succeed. 
When the infant is dead, if the preceding manoeuvres do not succeed, 
resort to the cephalotribe or the cranioclast, or any other instrument 
which will hold well. 
C. Resort to the method Ritgen devised for the vertex, and, if this fail, 
the bi-rectal of Lefour. Act with great care. 
The results of these experiments are: The forceps may be of great utility 
in breech presentations, but it should be applied to the limbs and not to 
the foetal pelvis. It is often inefficient, and we have to resort to the 
filet. 
We have no change to make, then, in the opinion expressed under the 
subject of labor in pelvic presentations. Wait as long as possible; then, 
in case of absolute necessity, resort to the forceps and to the filet, in ac- 
cordance with the rules laid down by Olivier. 
It is nearly impossible to give exact statistics, for the frequency varies 
with the accoucheur and with the country. 
Frequency of the Application of the Forceps. 
At the Pans Clinic from 1852 to 1880. 
Number of Applications. 
Mothers 
Infants. 
Total No. 
Labors. 
Mortality. 
Simple. 
Complicated 
by tumors, etc. 
Living. 
Dead. 
Living. 
Dead. 
Mother. 
Infant. 
358 
226 
500 
84 
445 
132 
21,615 
14.48$ 
23.80$ 
The result for 7 infants is not noted. Thus we find about one applica- 
tion in 37 labors taken indifferently. 
At the Maternite of Parts (from Pinard) from 1848 to 1877. 
Total number of 
Labors. 
Number of Applications of Forceps. 
Normal Pelvis. 
Contracted Pelvis. 
55,355 
541, or 1 in 97 
163, or 1 in 275.3 
Floss has given us the most complete statistics of the German and Eng- 
lish hospitals. The following tables are taken from him : THE FORCEPS. 
145 
German, Russian and Swiss Maternities and Clinics. 
Name of Operator. 
Period. 
Number 
of Appli- 
cations. 
Total 
Number of 
Labors. 
Proportion: 
One Applica- 
tion to 
Osiander (Gottingen) 
1792-1822 
1,016 
2,540 
291 labors. 
Boer (Vienna) 
1789-1822 
119 
39'390 
250 " 
D'Outrepont (Salsburg) 
1804-1815 
3 
518 
175 " 
Richter (Moscow) 
1801-1807 
15 
2,511 
172 " 
Bartsch (Vienna) 
1847-1849 
45 
6,608 
146 " 
Sidorowictz 
1822-1825 
6 
838 
139 " 
Jungmann (Prague) 
1811-1827 
120 
12,134 
102 " 
Weidmann, Leydig and Pizzola 
(Maye nee) 
1806-1848 
79 
7,739 
98 " 
Schilling (Bamberg) 
1818-1821 
4 
309 
77 " 
Roederer (Gottingen) 
1751-1762 
3 
225 
75 " 
Die (Moscow) 
1860-1862 
19 
1,387 
73 " 
Bartsch, Frank 
1833-1841 
61 
4.425 
72 " 
Flugel (Bamberg) 
1819-1847 
65 
4,122 
63 " 
C. Braun and Bartsch (Vienna). .. . 
1857-1859 
413 
25,181 
61 " 
Birnbaum (Cologne) 
1860-1863 
21 
1,274 
60 " 
C Braun and Spaeth 
1860-1865 
770 
42,040 
109 " 
Klein and Bartsch 
1843 
111 
5,792 
52 " 
Martin (Munich) 
1858-1860 
50 
2,497 
49 " 
Andre (Breslau) 
1821-1826 
7 
349 
49 " 
Klein (Vienna) 
1827-1843 
730 
35,417 
48 " 
Martin (Munich). 
1814-1822 
48 
2,251 
47 " 
Klein and Bartsch (Vienna) 
1854-1856 
485 
22,293 
46 " 
Kustner (Breslau) 
1827-1828 
8 
367 
46 " 
Hecker (Munich) 
1860-1867 
131 
5,945 
45 " 
Adelmann (Fulde) 
1836-1838 
4 
136 
40 " 
Ranier (Landshut) 
1824-1826 
8 
289 
36 
Spiegelberg (Freiburg) 
1861-1862 
8 
281 
35 " 
Richard, Tom, (Innsbruck) 
1824-1853 
46 
1,400 
35 " 
Michaelis (Kiel) 
1839-1846 
29 
1,000 
35 " 
Valenta (Leyback) 
1857-1858 
8 
273 
34 " 
Hofmann (Munich) 
1859 
125 
4,172 
34 " 
Naegele (Heidelberg) 
1819-1824 
41 
1,295 
31 " 
Rossi (Gratz.) 
1858-1861 
150 
4,741 
31 " 
D'Outrepont (Wurtzburg) 
1817-1841 
106 
2,223 
30 " 
Hohl (Halle).'. 7' 
1840-1857 
56 
1,700 
30 " 
Hugenberger (St. P.) 
1845-1859 
277 
8,036 
29 " 
Betschler (Breslau) 
1829-1831 
21 
610 
29 " 
C. Braun (Trieste) 
1854-1855 
20 
568 
28 " 
Joerg (Leipsig) 
1843-1846 
21 
563 
27 " 
Behm (Stettin) 
1834-1859 
25 
672 
27 " 
Elsaser (Stuttgart) 
1828-1841 
81 
1,950 
24 " 
Hassmann (Stuttgart) 
1863-1865 
41 
1,000 
24 " 
W alter (Dorpat) 
1806-1852 
59 
1,460 
24 " 
Martin Ed (Berlin) 
1860-1867 
196 
4,677 
27 " 
Nagel (Berlin) 
1856-1862 
72 
1,669 
23 
Siebold (Berlin) 
1823-1828 
43 
983 
23 lL 
Kilian (Bonn) 
1828-1834 
23 
502 
22 " 
Ulsamer (Landshut) 
1829-1842 
67 
1,464 
22 " 
D'Outrepont, Hoffmann 
1842-1845 
29 
637 
22 " 
Hermann (Berne)..., 
1858-1859 
32 
693 
21 " 
Stark and Sucrow (Jena) 
1830-1838 
16 
338 
21 " 
Jungmann (Prague) 
1842-1844 
267 
5,447 
20 " 
Stark, I. and II. (Jena) 
1794-1830 
43 
855 
19 " 
Birnbaum (Trieste) 
1810-1854 
121 
2,580 
19 " 
IIliter (Marburg) 
1833-1843 
58 
1,129 
19 " 
Vol. IV.-10 146 
A TREATISE ON OBSTETRICS. 
Name of Operator. 
Period. 
Number 
of Appli- 
cations. 
Total 
Number of 
Labors. 
Proportion: 
One Applica- 
tion to 
Hecker (Munich) 
1859-1863 
97 
1,911 
19 " 
Helly (Trieste) .. . 
1860-1862 
23 
443 
19 " 
Crede (Berlin) 
1852-1856 
63 
1,220 
19 " 
Grenzer (Dresden) 
1845-1865 
499 
9,140 
19 " 
Schmidt (Berlin) 
1844-1850 
156 
2,631 
17 " 
Abegg (Danzig) 
1840-1863 
306 
5,190 
17 " 
Scanzoni (Wurtzburg). 
1851-1863 
252 
4,170 
17 " 
Mende (Gottingen) 
1823-1832 
73 
1.247 
17 " 
Merrem (Cologne) 
1825-1826 
19 
301 
16 " 
D'Outrepont and Hoffmann 
1805-1845 
379 
6,139 
16 " 
Busch (Marburg) 
1819-1825 
49 
781 
16 " 
Kauffmann (Hanover) 
1834 
18 
273 
15 " 
Carus (Dresden) 
1813-1827 
184 
2,555 
14 " 
Busch (Berlin) 
1829-1847 
853 
1,358 
14 " 
Breslau (Zurich) 
1779-1794 
37 
517 
14 " 
Siebold (Gottingen) 
1860-1863 
245 
3,252 
13 " 
Pernice (Grieswald) . 
1858-1861 
23 
316 
13 " 
Loder (Jena) 
1833-1860 
24 
424 
13 " 
Haase (Dresden) 
1827-1845 
388 
4,445 
13 " 
Brunatti/Dantzig) 
1825-1827 
25 
287 
11 " 
Crede (Leipsig) 
Schultze (Jena) 
1856-1859 
56 
594 
10 " 
1859-1861 
29 
308 
10 " 
Strempfel, Krause, Veit and 
Winckel (Rostock) 
1836-1864 
97 
916 
9 " 
Ritgen (Giessen) 
1814-1818 
30 
282 
9 " 
Martin (Jena) 
1838-1857 
185 
1,662 
9 " 
J. Stein (Marburg) 
1805-1807 
46 
296 
6 " 
Streng (Prague) 
1852-1855 
62 
257 
4 " 
Hohl (Halle) 
1840-1857 
259 
899 
3 " 
10,975 
333,054 
30 
That is to say, 1 in about 30. 
Name. 
Period. 
Number 
of Appli- 
cations. 
Total 
Number of 
Labors. 
Proportion: 
One Applica- 
tion to 
John Clarke (Dublin) 
1803-1847 
1 
3,878 
3,878 labors. 
Davis and Hall (Dublin) 
1842-1857 
6 
7,302 
1'217 " 
Denman (London) 
1842-1857 
6 
7,302 
728 " 
Clarke (Dublin) 
1787-1793 
14 
10.000 
724 " 
F. H. Ramsbotham (London) 
1828-1850 
73 
48,996 
671 " 
Granville (London) 
1828-1850 
73 
16,258 
621 " 
Collins (Dublin) 
1826-1833 
26 
16,654 
574 " 
Churchill (Dublin) 
1826-1833 
26 
16'654 
546 " 
John Ramsbotham (London) 
1820-1827 
39 
19,439 
489 " 
J. Y Simpson (Edinboro') 
1844-1846 
3 
1,417 
472 " 
Lever and Oldham (London) 
1847-1854 
29 
11'224 
400 
Barnes (London) 
1857-1858 
6 
2,418 
400 " 
J S. Beale (London) 
1857-1858 
2 
'700 
350 " 
Hardv and McClintoch (Dublin).... 
1842-1845 
24 
6,634 
276 " 
Laurence (Edinboro') 
1842-1845 
28 
1,000 
250 " 
Wellesley (Dublin) 
1828-1829 
4 
711 
177 " 
Application of Forceps in England. 147 
THE FORCEPS. 
Name. 
Period. 
Number 
of Appli- 
cations. 
Total 
Number of 
Labors. 
Proportion: 
One Applica- 
tion to 
Bland (London) 
1828-1829 
4 
711 
J. H. Beale (London) 
1842-1862 
22 
3,381 
154 " 
Beatty (Dublin) 
1842-1862 
22 
3,381 
154 
Granville-Bozzi (London) 
1818 
5 
640 
128 " 
Harrison (London) 
1818 
11 
1 000 
90 " 
Sinclair Johnston (Dublin) . 
1847-1854 
200 
13,748 
69 " 
Watson (Dublin) 
1847-1854 
3 
200 
68 
Lawrence, Montrose (Edinboro')... 
1847-1854 
28 
1,000 
35 " 
Denham (Dublin) 
1862-1863 
26 
856 
33 
Rigby (London) 
1833 
6 
179 
30 
Moore (London) 
1852-1862 
40 
485 
12 " 
Hamilton (Falkirk) 
1852-1862 
40 
485 
7-8 " 
Jacquemier has collected the following figures from various sources: 
Mme. Boivin 
in 20,517 labors. 
" 22,243 " 
" 10,199 " 
" 16,654 " 
" 3,697 " 
" 26,676 " 
" 9,589 " 
" 1,411 " 
" 2,549 " 
" 1,111 " 
" 2,093 " 
96 forceps = 1 in 214 
76 " =1 " 293 
14 " =1 " 728 
27 " =1 " 617 
21 " =1 " 172 
34 " =1 " 785 
35 " =1 " 274 
22 " =1 " 64 
184 " = 1 " 14 
68 " =1 " 16 
300 " = 1 " 7 
Mme. Lachapelle 
Clark (Dublin) 
Collins (Dublin) 
Merriman ) T 
, v London 
Bland ) 
Ramsbotham 
Boer (Vienna) 
Naegele (Heidelberg) 
Carus (Dresden) 
Kluge (Berlin) 
Siebold (Berlin) 
Prognosis. 
In stating this we meet with the same difficulty as in the preceding. 
The figures vary with the accoucheurs. Aside from the question of oper- 
ative ability, which is of great weight, can we compare the different con- 
ditions which call for the forceps ? Can we compare forceps used in case 
of inertia uteri, or of resistance of the soft parts, or of delay of the head 
at the inferior strait or in the cavity, with the instrument used in case of 
pelvic deformity, or of arrest of the head at the superior strait, or of 
eclampsia, etc.? 
What we can say is that the forceps in the hands of an expert is not 
only inoffensive per se, but is a true savior both of the mother and of the 
child, whilst in clumsy hands, or when used contrary to classical rules, 
it may mean grave injury to the mother and the child. 
Pajot and Budin have mentioned nearly all such injuries in their theses. 148 
A TREATISE ON OBSTETRICS. 
For the mother, injuries of the vulva, perineum, vagina, of the cervix, 
of the uterus, of the rectum, the urinary organs, the pelvic cellular tissue, 
the vessels, nerves, bones of the pelvis, etc. For the child, every lesion 
from simple excoriation to fracture. There is one which is very frequent, 
and happily transitory, and this is facial paralysis. Nadaud, in 1872, 
mentioned two cases of paralysis of the common motor of the eye, (ob- 
served by Dr. Lisbonne, at Dublin), and cases of paralysis of the limbs 
observed by Smellie, Gucniot, Blot, Depaul, Duchenne of Bologne, 
Doherty, and ourselves. 
The danger to the infant increases, of course, with the force used, the 
irregular grasp and elevation of the head. Internally, the vessels of the 
brain may be torn, or the venous sinuses, and there are effects resulting 
from compression of the brain. 
Poppel, in 102 cases of forceps without complication, found 61 living 
children, 36 asphyxiated, of whom 30 were saved, and 5 dead, mortality 
of 10.8 per cent. 
Hugenberger in 100 cases of forceps in pelvic deformity, had 70 sick 
women, 30 of whom died. 
Rigaud and Stanesco have shown that the mortality increases with the 
degree of contraction. 
Sickel, in 475,616 births, found 6,963 applications of the forceps. 
T c 
In l,2bl cases 
' 
Head first ..... 1,228 
After-coming .... 53 
Of 6,228 infants born by forceps, 5,159 living, 1,069 dead. Of 6,685 
labors by forceps 5,501 mothers living, 184 dead. 
As Zweifel says, forceps applications are one-half less dangerous than 
version." 
The following tables taken from Murphy and Harper, give the figures 
of certain English accoucheurs: 149 
THE FORCEPS. 
Accoucheurs. 
Number 
of 
Deliveries. 
Labors Normal 
Duration over 24 hours. 
Forceps. 
Lever. 
• 
Mothers. 
Infants. 
Mothers. 
Infants. 
Mothers. 
Infants. 
Living 
Dead. 
Living 
Dead. 
Living 
Dead. 
Living 
Dead. 
Living 
Dead. 
Living 
Dead. 
Collins 
16,654 
324 
299 
25 
263 
61 
24 
20 
4 
16 
8 
3 
3 
3 
Hardy & McClintock 
6,634 
171 
162 
9 
119 
52 
24 
19 
5 
11 
13 
17 
17 
8 
9 
Johnston & Sinclair 
13,748 
247 
235 
12 
198 
49 
200 
189 
11 
171 
29 
- 
- 
- 
- 
- 
- 
- 
- 
- 
- 
- 
- 
- 
- 
- 
37,036 
742 
696 
46 
580 
162 
248 
228 
20 
198 
50 
20 
20 
11 
9 
Frequency of Application. 
Foetal Mortality. 
Maternal Mortality. 
Duration of Labor. 
Collins 
1:694 
1:26 
1: 329 
38 hours. 
Hardy 
1:555 
1:20 
1: 334 
35 ? 
Johnston 
1:600 
1:30 
1: 502 
29 " 
Harper 
1:260 
1:47 
1:1490 
16 " 
Table from Murphy. 
Table from Harper. CHAPTER TIL 
THE FILET.-THE SERICEPS. 
j^/J-AURICEAU was the first to entertain the idea of extracting the 
foetal head by means of inoffensive instruments. Amand, in 
1714, devised a hood destined to remove from the uterus the decapitated 
Fib. 110.-Poullet's Sericeps. 
head. About one hundred years ago, Mead, in England, thought of using 
a cloth loop to be placed between the chin and the thorax, and Playfair 
mentions, only to condemn, the filet of Earldly Wilson. Precisely the 
same instrument was used in Japan, in 1812, by one of the Kanga was. 151 
THE FILET. THE SERICEPS. 
In 1875, Poullet invented an instrument which he calls the sericeps, 
and a new mechanical tractor to be adapted to the sericeps to increase the 
force of the tractions. The following is the description of the sericeps: 
" It is composed of : 1. A piece of cloth 9£ inches long. 2. Four 
ribbons inserted along the inferior border of this cloth, and united to- 
gether in pairs to make two loops. (Fig. 110.) The transverse band is 
placed around the foetal head, and the borders are laced together. When 
Fig. 111.-Extraction of the Head by means of the Sericeps. 
the ovoid of the head has been well grasped, and we pull on the loops, 
the head is obliged to descend. The transverse band and the ribbons are 
doubly lined, making fingers in which are slipped the metallic rods which 
place the apparatus over the head. When the head has been grasped 
the metallic rods are withdrawn, and the apparatus is ready for traction. 
(Fig. 111.) 
11 In case greater traction is needed than can be applied through the 
loops, the tractor is to be adjusted." (Fig. 112). 
By means of the sericeps Poullet has succeeded in ten cases, but we 152 
A TREATISE ON OBSTETRICS. 
Fig. 112.-Poullet's Tractor applied to the Sericeps. 153 
THE FILET.-THE SERICEPS. 
doubt its utility in the obstetric armamentarium, and we believe it is des- 
tined to be relegated to the obscurity of the retroceps of Hamon, the leni- 
ceps of Mattei, the filets of Mead, Kangawa, Wilmot and others, and the 
air extractor, that monstrosity devised by Simpson. 
Poullet has lately devised another sericeps, and, he has given us the 
description and the illustrations. The new instrument is a modification 
Fig. 113.-New Sericeps. 
of the old, which was very difficult to insert, especially between the head 
and the promontory, and the head and the pubes. The new instrument 
aims at facilitating this. It is composed of two flexible steel blades, un- 
equal in length, the one to be applied to the left, and the other to the 
right of the pelvis. The longer blade consists of two narrow flexible 
steel blades, 5f inches in length, united superiorly by a steel plate, which 
is movable. They are curved on the flat, about like the cephalic curve. 
At their inferior extremity, the one is attached to a steel tube 7 inches 
long, the other to an inner steel rod. A screw on this rod fixes the two 
blades. (Fig. 113.) 
Fig. 114.-New Sericeps, Applied and Acting. 
The short blade is like the other, only it is but 3f inches long, and the 
extremity of the two blades which compose it are united by a silk loop 2| 
inches long. Applied over the face, this loop will not act on the neck. 
The completed instrument in position is shown in Fig. 114. 
The instrument requires more time for application than the forceps, 
but this is not difficult at the superior strait. Its advantages are: 154 
A TREATISE ON OBSTETRICS. 
1. It exercises no compression transversely in the pelvis; on the con- 
trary, it slightly reduces the head in the longest diameter. 
2. It pulls on the entire occiput, and does not engage the head till it 
is flexed; and further it does not in the least interfere with rotation. 
3. The entire transverse portion of the pelvis is left free to the head, 
and it may, therefore, as in version, slide along the lined innominata, and 
Fig. 115.-Aa, Superior extremity and opening of the conducting rod. b, Metallic conducting 
wire, seen in front and in profile. C, Inferior extremity of the handle of the conducting rod, and 
inferior orifice. Ba, Conducting rod. c, Handle of the wire, b, Steel blade, d, Screw slide for 
limiting the amount of wire to be carried over the groin, e, Silk filet. 
may engage in the contracted part of the pelvis in a diameter approaching 
the bi-temporal. 
The Japanese were not content with devising filets for the extraction 
of the foetal head, but also endeavored to facilitate delivery, in case of 
shoulder presentation, by passing a filet over the pelvic extremity. 
Latterly, Wecbecker-Sternfeld has re-advocated this measure in case of 
breech presentations. Rejecting blunt hooks as dangerous, he follows THE FILET. THE SERICEPS. 
155 
the example set by Hecker and Gregory, and uses the filet introduced by 
means of the instruments represented in Figs. 115, 116, 117. 
Fig. 116.--Application of the Filet-Carrier. 
Of his 30 observations, the following are the results. 
Children living. Children dead. 
Primiparaa 21 ... 17 4 
Multiparse 9 ... 7 2 
30 labors 
Of the 21 children born of primiparae, 8 were asphyxiated, and 7 of 
Fig. 117.-The Fingers seeking the Metallic Wire.-(The mechanism of the instrument is 
like Belloc's Sound.) 
these lived. Of the 9 born of multipart, 2 were asphyxiated but survived, 
and one other lived for f hours, and at autopsy showed evidence of vis- 
ceral syphilis. 156 
A TREATISE ON OBSTETRICS. 
The G deaths were due to the following causes: 
Primipane 
" 1. Asphyxia. Extravasation in the brain. 
2, Syphilis. 
3. Difficult labor. 
.4. " " . 
u • 
Multipar® 
1. Interference with intra-uterine circulation. 
2. Compression of the cord. 
The lesions produced by the filet were: 
Traces of deep compression of soft parts, . 4 times. 
Superficial excoriations, . . . . . 2 " 
Non-essential traces of compression, . . 24 " 
In one case the humerus was fractured in disengaging the arms; twice 
the femur, once in the endeavor to bring down a foot, once during ex- 
traction with the filet. 
As for the mothers, the introduction of the filet did no damage. The 
perineum was lacerated eight times in the primiparae, through rapid ex- 
traction of the head. The puerperium was invariably normal. CHAPTER IV. 
THE LEVER. 
JNVENTED by the Chamberlens, probably at the same time as the for- 
ceps, sold secretly to Roonhuysen (Fig. 118), then to Jean de Bruyn, 
bought finally by Jacques de Vischer and Van de Poll, who made it known 
to the profession, the primitive lever was composed, according to Jacque- 
mier's description borrowed from Smellie, of an iron blade If inches long, 
1| wide, and 1| lines thick, presenting at its extremities two slight curves. 
Variously modified, and used successively by Titsing, Rechberger, Cam- 
per, Zeller, Bland, Boeckmann, Rigodeaux (Douai), Warocquier (Lille), 
it found in the forceps a formidable rival. Levret and Smellie were its 
first and most enthusiastic advocates. Baudelocque and his pupils rejected 
it, although the former had modified it advantageously by fenestrating 
the blade. (Fig. 119.) It was again advocated by Herbiniaux, Den- 
man, Sims, Douglas, Nesbit, Cole, Griffith, Ford, Cooper and others, 
and rejected almost absolutely in Germany. It was modified further by 
Verardini (Bologne), (Fig. 120), Bodaert (Figs. 121 to 123,) and used by 
Coppel, Fraeys (Gand), Marchant of Charenton, Fabri (Bologne), Hubert, 
jr., who added to it three inches of blade, and two holes through which 
a cord was passed, (Fig. 124); and finally, of late years, it has been 
studied by Jacquemier and Tarnier. Nevertheless, the forceps'is to-day 
universally admitted superior, and, as Jacquemier says: 11 The real ques- 
tion to-day is, whether in contraction at the pelvic inlet, allowing of the 
passage of the head, but where the forceps is lacking in ease of applica- 
tion and direction of traction, the lever is not a better instrument, a more 
powerful tractor, and less dangerous to mother and to child. Results 
from its use would seem to prove this. It ought only to act, as indeed it 
was alone devised, on the foetal occiput." 
According to Wasseige, the lever may act in three different ways: 
1. Like a lever of the first class, the power of which is at the handle, 
the fulcrum towards the middle of the blade, under the symphysis, and 158 
A TREATISE ON OBSTETRICS. 
the resistance at the foetal head. The power is to the resistance as P. R. 
to P.F.; and hence if Bodaert's lever is inserted three inches (Fig. 121), 
the force is tripled, the fulcrum is submitted to a pressure represented 
by the sum of the forces (power and resistance) 
applied to the two arms of the lever, supposing 
them parallel. 
2. The instrument should be inserted so that 
the power is placed between the resistance and the 
fulcrum-that is to say, the handle is to be fixed 
at P, while the other hand pulls at F, in the 
direction of the arrow. (Fig. 122.) Then there 
is no pressure at the pubes; but in order to over- 
come the resistance, a force superior to it must be 
used. 
3. Finally traction may be 
made on the lever in the di- 
rection of the two arrows 
(Fig. 123); we thus dimin- 
Fig. 118.-Roonhuysen's 
Lever 
Fig. 119.-Baudelocque's 
Lever. 
Fig. 120.-Verardini's 
Lever. 
ish pressure upon the pubes, and the resistance is more easily overcome. 
Herbiniaux aimed at this mixed method when he passed a filet through 
the fenestra of his instrument, by pulling on the cords and lifting by 
little jerks. 
Hubert, the son, advises holding the handles of the instrument, and 159 
THE LEVER. 
making traction only on the filet ends passed through the holes in the 
blade. (Fig. 124.) 
The direction given to the head varies necessarily with the inclination 
of the instrument to the fulcrum, and on the point of application to the 
head. Thus: 1. If the blade be inserted parallel to the symphysis, the 
head is pushed backward by pressure on the handle; and as this is lifted 
the head is finally pushed downward. 2. By lifting the handle, that por- 
Figs. 121,122and 123.-Lever of Bodaert. 
tion of the head on which the blade rests, may be rotated to right or to 
left, or Hexed or extended. In other words, as Hubert, the younger, 
says, we can treat it as we do a billiard ball, by touching it where we 
please. 
The method of using the lever is very much like that of the forceps. 
The blade may be placed at once where it should lie. Tarnier prefers 
to insert it behind near the sacro-sciatic ligament, and then to bring it 
forward spirally. Once well applied, it ought to lie next to the posterior 
surface of the pubes, its action on the head being from in front back- 
wards. • " When, says Tarnier, the lever is well applied, the handle is 
raised, and the instrument taking purchase at the symphysis acts like a 
first-class lever. The head is lowered by the power at the handle, and 
continuing this motion with a few tractions, the head is delivered. To 
avoid contusion of the urethra, the lever should be wrapped with linen, 
or with rubber, and placed to one side of the median line. It easily slips 
when applied as above, and pressure on the ischio-pubic ramus contuses 
it; to prevent this, the handle is firmly grasped in the middle by the left 160 
A TREATISE ON OBSTETRICS. 
hand, to prevent slipping, at the same time making pressure backwards 
to re-enforce the fulcrum and diminish the pressure on the symphysis." 
Struck by the facts cited by Bodaert, and by those of Fabri, and of his 
own experiments, made with the lever, Tarnier concludes that it cannot 
be compared with the forceps as a tractor, since it acts by compressing 
Fig. 124.-Lever of Hubert, the Younger. 
the head from before backwards. But although it cannot take the place 
of the forceps, it may, and it should be used in certain cases. He thinks 
that the action of the lever should be studied in: 1. Vertex presentations. 
2. Face presentations. 3. Presentation of the breech, after the body has 
been delivered, and the head remains. THE LEVER. 
161 
Presentation of the Vertex. 
1. Head at Hie Inferior Strait.-The forceps is superior to the lever, 
which pushes the head towards the coccyx, places it away from the 
centre of the vulva, and exposes the perineum to laceration. Only does 
the lever excel the forceps when the inferior strait is narrowed trans- 
versely by the contiguity of the ischio-pubic rami, or the ischiatic tuber- 
osities. Thanks to its little size, it is then easily applied, and can push 
the head backward where there is more room. 
2. Head in the Cavity.-The forceps still excels the lever, for with it 
we may rotate the head, while in posterior presentations the lever would 
necessarily meet the face, and injure it greatly. Bodaert, nevertheless, 
has used it with success, but on the extended head, and when the anterior 
fontanelle was near the centre of the pelvis. 
3. Head at the Superior Strait.-Tarnier is disposed to use the lever. 
The difficulty of grasping the head regularly, the impossibility of making 
traction in the desire ddirection, make him favor the lever, which is smaller 
than the forceps, and working only on the occiput, tends to flex the head, 
at the same time that it depresses it. Applied behind the pubes, it com- 
presses the head from before backward, while it elongates it transversely, 
or in the diameter which is not shortened. Tarnier, however, is not 
forgetful of the difficulty due to mobility of the head, and the danger of 
inflicting rupture or vesico-vaginal fistulas. 
Presentation of the Face. 
In the cavity or at the inferior strait, the choice should be the for- 
ceps. At the superior strait, the lever might better direct the head into 
the axis of the inlet, and will reduce its size from before backwards. 
But here the lever requires more care than in case of the vertex, since 
it must be applied to the face, or to the occiput, and the injuries possi- 
ble with the instrument are the greater the higher it is placed. We be- 
lieve, therefore, that the forceps should be preferred. 
Head retained after Extraction of the Body. 
Coppee has, in particular, recommended the lever in these cases. We 
have seen that, thanks to compression combined with traction and flexion, 
Vol. IV.-11 162 
A. TREATISE ON OBSTETRICS. 
the forceps are not often needed, and the lever, therefore, would only ex- 
ceptionally be required. 
The lever then must remain an exceptional instrument. When used 
there is one absolute rule, and this is, if the occiput is in front or trans- 
verse, apply the lever to it, or to the mastoid; if the forehead is in front, 
apply the instrument over the temple, so as to seize the brow or the sin- 
ciput, according as it is deeply placed or not. 
Not so bold as Tarnier, Jacquemier absolutely rejects the lever in occi- 
pito-posterior positions, in the cavity, at the inferior strait, in face pres- 
entations. He admits its utility at the superior strait with reserve. Re- 
calling the experiments of Fabri and of Tarnier, he says, " We should judge 
too favorably of the solid grasp of the lever on the head, if we were to 
accept literally those experiments made in full view, where the iwint 
cTappui and the immobility of the head are assured beforehand, advantages 
which we do not ordinarily possess. In case of pelvic deformity, how- 
ever, where the forceps has failed, cranioclasty is not justifiable, neither 
is the Csesarean section if the child be alive, till we have tried the lever." 
These conclusions seem to us too favorable. To attempt, after repeated 
use of the forceps, to extract with the lever is to subject the woman 
to renewed injury, and likely enough not succeed in delivering the head. 
When the forceps is applied at the superior strait, it is only after a long 
labor, and when the waters have for long escaped. We interfere then 
either in the interest of the mother, and must deliver quickly and with 
the least possible violence, or else in those of the child whose life is in 
danger. To attempt with the lever, therefore, what the forceps has failed 
in accomplishing, seems to us worse than useless. Far better, we think, 
to sacrifice the child, and give the mother a chance by lessening the risk 
of injury through reduction in volume of the foetus. CHAPTER V. 
THE INDUCTION OF PREMATURE LABOR 
T first limited, to cases of hemorrhage, later extended to pelvic con- 
traction, and later still to all obstacles which might render labor at 
term difficult, dangerous, or impossible, for both mother and child, the 
induction of premature labor may be defined as an operation performed 
in the interests of the mother or of the child, and aiming at awakening 
uterine contractions, so as to cause the expulsion of the infant before the 
natural term of pregnancy, although at a time when this infant is able to 
live outside of the uterus, that is to say, is viable. Premature labor, then, 
is included between the seventh month of pregnancy and term. 
Although Justin Siegmundin in 1690, Puzos in 1707, and Bohn in 1717, 
advised rupture of the membranes in case of hemorrhage due to placenta 
praevia, and so induced premature labor, it was not for some years after- 
wards that this procedure, in case of deformity of the pelvis too great for 
the passage of the foetal head at term, was admitted into obstetric prac- 
tice, and it was in 1756, Denman tells us, that the most distinguished phy- 
sicians of London gave the method their unanimous sanction, in view of 
the fact that many women with pelvic contraction had been delivered 
prematurely and spontaneously of viable children who had lived. It is 
to England, therefore, that the origin of this operation belongs. 
Practised for the first time, some say by a midwife, Mary Dunally, 
others by Macaulay, or Kelly, the induction of premature labor became 
the rule in practice, through the efforts of Barlow, Denman, Merriman, 
Marshall, Clark, Ramsbotham, Burns, and others. From England, the 
operation passed to Germany, where Mai first advised it in 1799, and he 
was followed by Weidmann; but it was not till 1804 that Wenzel first per- 
formed it. Krauss practised it in 1813, but only on the appearance of the 
monograph of Reisinger, in 1818, was the operation finally adopted. 
The greatest partisans of the operation were Osiander, Joerg, Stein the 
younger, Kluge, Ritgen. In Holland, J. Themmen, Salomon, Vrolik, 
Wellenbergh performed it. In Italy, Lorati, Billi, Ferrario, reported 
successes. In France, although proposed, in 1804, by Roussel de Vau- 164 
A TREATISE ON OBSTETRICS. 
zesmes, it was still rejected by the Academy of Medicine in 1827, owing 
to the influence of Baudelocque; it was not till 1831 that Stoltz resorted to 
it, and so successfully, that he was followed in 1832, 1834, by P. Dubois, 
and from this time on, thanks to the efforts of Dezeimeris, Lacour, Fer- 
niot, and Lazare See, it was performed and written about constantly, 
until to-day it is the practice of all French accoucheurs. 
While the operation was becoming generalized, its indications were 
widening, and to-day they are almost infinite. The indications, however, 
are subordinated to a certain number of conditions, which Naegele and 
Grenser state as follows: 
1. Exact diagnosis of the shape of the pelvis 
2. Certainty of foetal life. 
3. Determination as far as possible of the date of gestation. 
4. Absence of serious disease which might be aggravated by the opera- 
tion. 
Indications. 
The most frequent indication for the induction of premature labor, the 
one for which it was originally performed, is contraction of the pelvis. 
Authorities, however, are not in accord in regard to the limits of this 
contraction, that is to say, as to where the line is to be drawn which justi- 
fies resort to the procedure. 
Spiegelberg, in 1870, from the study of the results of the operation in 
case of deformity of the pelvis, constructed the table on the following 
page, which sets forth the practice of different authorities. 
Comparing now these results with those obtained in case of the spon- 
taneous induction of premature labor in case of pelvic deformity, and with 
labor, under the same condition, terminated by forceps and version, he 
places the upper limit of justifiability of the operation at 3.12 inches. 
Whenever the maximum contraction does not reach this figure in the true 
conjugate, he rejects premature labor, except where from previous labors 
large children are to be expected with large heads, etc. 
In 1871 Litzmann concluded that Spiegelberg had understated the in- 
dication. He ranges himself, and we think justly, on the side of the 
mother's interest mainly. He divides pelves into three classes: 
1. Pelvis generally and regularly contracted, diameter 3.9 to 3.5 inches; 
Pelvis simply flattened, or generally contracted from 3.7 to 3.19 inches. 
Here premature labor is only justifiable in case of complication. THE INDUCTION OF PREMATURE LABOR. 
165 
Induction of Premature Labor in Case of Contracted Pelvis. 
Operators. 
Number 
of Cases. 
Mothers. 
Children. 
Dead 
after 
Labor. 
Total 
Number 
of 
Deaths. 
Living. 
Dead. 
Living. 
Dead- 
born. 
Michaelis 
6 
4 
2 
1 
3 
2 
5 
Busch 
8 
7 
1 
2 
3 
4 
7 
Spaeth 
15 
10 
5 
1 
5 
9 
14 
Crede 
8 
6 
2 
4 
1 
3 
4 
Germann 
19 
17 
2 
9 
2 
8 
10 
Riedel 
6 
6 
0 
1 
4 
1 
5 
Cohen 
3 
3 
0 
1 
2 
0 
2 
Birnbaum 
6 
5 
1 
3 
1 
2 
3 
Franque 
12 
11 
1 
1 
7 
4 
11 
Grenser 
25 
19 
6 
4 
13 
9 
22 
Hecker 
3 
3 
0 
1 
0 
2 
2 
Schroeder 
6 
5 
1 
2 
0 
4 
4 
Scanzoni 
14 
14 
0 
3 
7 
4 
11 
Martin 
39 
34 
5 
24 
12 
3 
15 
Dohrn 
9 
9 
0 
4 
3 
2 
5 
Isolated Cases 
12 
10 
2 
5 
4 
3 
7 
Lange 
14 
13 
1 
4 
6 
4 
10 
Spiegelberg 
14 
10 
4 
3 
4 
7 
11 
Total 
219 
186 
per cent. 
84.9 
33 
per cent. 
15 
73 
per cent. 
33 
77 
per cent. 
34.8 
71 
per cent. 
32.1 
148 
per cent. 
66.9 
2. Pelvis generally and regularly contracted, 3.5 inches at least. Pel- 
vis simply flattened, or generally contracted and flattened, 3.19 to 2.8 
inches. Operation is indicated, even in primiparee. 
3. Pelvis simply contracted, or generally contracted and flattened, about 
.29 of an inch. The operation is only exceptionally admitted. 
Presentation and Position 
of Foetus. 
Vertex 
Prolapse of cord 
" of limb 
Face 
Pelvic Extremity 
Oblique and Transverse 
Presentations 
Spontaneous Labor in 
contracted Pelvis. 
Induced Labor in 
contracted Pelvis. 
ca co to co o No. of Cases. 
h cj ca ® ® id Proportion to En 
\ • • • • ■ g 3 tire No. of Labors 
4^ Or GC GO O F* 
Children dead 
immediately 
after or 
during Labor. 
Per cent. 
33 or 11.4) 
11 " 55 V 
0 0 
2 or 100 1 
7 " 31.8 
* 
4 " 80 J 
Per 
cent. 
14.1 
40.7 
tn 
<D 
o 
o 
6 
Z 
Per 
cent. 
14 
3 
2 
0 
O' 
6 
q o or go £ S J 1 Proportion to En- 
Cl bo bo U r ~ | tire No. of Labors 
-3 -J 
O 2 IO o Children dead 
ci -3 © o co immediately 
P5 r3 .w g 8 after or during 
© -3 oo c Labor. 
► 
Per 
cent. 
42.1 
73.3 
1 Including one child whose mother died undelivered. 166 
A TREATISE ON OBSTETRICS. 
Next comparing spontaneous premature labor, and induced from the 
side of the child, Litzmann gives the following table: 
Total. 
Dead during or 
immediately 
after Labor. 
Boys. 
Dead during or 
immediately 
after Labor. 
Girls. 
Dead during or 
immediately 
after Labor. 
Per cent. 
Per cent. 
Per cent. 
Premature spontane- 
ous Labor, with large 
Pelvis . 
1181 
9 or 7.6 
50 
6 or 12 
68 
3 or 4.4 
With small Pelvis .... 
16 
5 or 31.2 
10 
4 or 40 
•• 
1 or6.2 
2. Induced premature 
Labor in contracted 
Pelvis 
34 
19 or 55.8 
21 
11 or 54.7 
13 
7 or 53.8 
168 
33 or 19.6 
81 
21 or 25.9 
87 
11 or 12.6 
1 Including nine street deliveries. 
In 1880, Maygrier in turn endeavored to estimate the value of prema- 
ture labor (induced). 
In 37 cases, in pelves 2.73 inchesand below: Mothers saved 23, dead 11, 
mortality about 33.33 per cent. Infants saved 12, dead 22, mortality 
about 64.70 per cent. 
Further, of these 12 living children eight died within the first week. 
From the standpoint of the infant, these figures may be arranged: 
4 labors at 8 months, pelvis 2.73 inches. Infants living, 3 
6 " " 7| " " 2.53 " . " 1 
2 " " 7 " ... " 0 
1 " unknown ..... " 0 
Kunne, at Elberfeld, has induced labor fifteen times. All the mothers 
recovered, two only being sick; of the 15 infants, 12 were born alive and 
lived. 
Berthold, at Ronsdorf, practised the following operations, from 1870 
to 1873: 
Induction of premature labor . 9 Maternal death, 0 
Forceps to head, .... 30 " 1 
Podalic version and extraction, .17 " 1 
Pelvic extremity, ... 3 " 0 
Perforation, .... 3 " ' 0 
Reposition of the cord, . . 1 " 0 
Artificial delivery, ... 6 " 1 
Total 69 3 
Nothing is said about the infants. THE INDUCTION OF PREMATURE LABOR. 
167 
Naegele and Grenser place the limits between 2.73 and 3.7 inches. 
Schroeder gives no upper limit, the inferior limit is 2.63 inches. Jac- 
quemier places it as low as 2.54 inches; Dubois 2.54 inches; Joulin 2.54 
inches; Velpeau 2.63 inches; Cazeaux 2.34 inches; Depaul 2.34 inches; 
Tarnier 2.14 inches. According to the latter, if extraction of a living 
child is impossible, embryotomy offers a better chance, for the very rea- 
son that the foetus is only partially developed. 
Considering now the figures of Rigaud and of Stanesco, we have a total 
of 810 cases of pelvic contraction, where premature labor was induced. 
They may be divided as follows: 
Pelvis. 
Cases. 
Maternal 
deaths. 
Mothers 
living. 
Infants. 
Living. Died. 
3.51 inches 
. 3 
1 
2 
3 0 
3.51 to 3.12 " . 
. 17 
3 
14 
6 8 
3.12 " 2.73 " . 
. 18 
5 
13 
6 12 
2.73 " 2.34 " . 
. 10 
4 
6 
1 9 
2.34 " 1.95 " . 
. 5 
3 
2 
0 5 
53 
16 
37 
16 34 
We see, then, that underneath 2.34 inches premature laboi' has always 
been fatal to the infant. It is apparent that under this figure we must 
reject the operation, although a personal case, which we have already re- 
lated, where the pelvis was 2.14 inches, and the child, at seven months, 
was born alive and lived twenty-four hours, would lead us to place the 
limit at 2.14 inches. Such cases, however, are very exceptional, and we 
may say that below 2.34 to 2.14 inches there remains only the Caesarean 
section, or cephalotripsy with or without traction. Now, considering the 
danger to the mother of both these methods, and considering the almost 
absolute fatality of induced premature labor to the infant in case of such 
pronounced contraction, it is really to induced miscarriage, that is to say, 
before viability, that we should have recourse. 
From the researches of Burns, Salomon, Dubois, Stoltz, Tarnier, Budin, 
etc., it is seen that the bi-parietal diameter of the fcetal head measures: 
At term, 3.7 inches. 
At 9 months, . . . . . . 3.5 " 
At 8| " 3.3 " 
At 8 " 3.1 inches. 
At7j " 2.9 " 
At 7 " 2.7 " 168 
A TREATISE ON OBSTETRICS. 
These figures, be it remembered, are not at all absolute, being only 
means. We have seen that the foetal head was compressible to the extent 
of .39 inches without danger to the life of the child. It is evident, there- 
fore, that below 2.34 inches the head might be delivered by the forceps, 
but at the expense of injury to it and to the mother. Whence the neces- 
sity, in order to obtain a living child, of limiting the induction of prema- 
ture labor' at 2.34 inches; and although we have stated above that the 
limit might be 2.14 inches, it is because the head is at times more readily 
moulded, or the infant less developed, and hence may pass. Of course this 
lesser development means less chance of survival; nevertheless, encour- 
aged by our one success, we would take the chances in analogous cases. 
Further indications for premature labor are complications which 
threaten the life of the mother, whether these complications are deter- 
mined by pregnancy, or aggravated by the presence of this condition. 
Such are: Uncontrollable vomiting, eclampsia (according to certain 
authorities, although we are, as stated under the subject, absolutely op- 
posed to this), hemorrhages, acute or chronic diseases of the respiratory 
and circulatory organs, hydramnios, ascites, goitre (d'Outrepont,) prolap- 
sus uteri, pernicious anaemia of the gravida (Gusserow), abdominal tumors, 
intercurrent or epidemic diseases. (See The Pathology of Pregnancy, 
Vol. II.) Here the question is a delicate one. )Ve must not forget that 
the induction of labor by determining in the woman what Raymond has 
called the great puerperal state may aggravate her condition, and thus we 
may act directly against our aim. The case is somewhat analogous to 
what happens to a wounded man with a compound fracture requiring 
amputation. If this operation be done at once, he dies; if we allow him 
to recover from shock and then operate, his chances of life are greater. 
The state of affairs is about the same in the pregnant woman suffering 
from an acute disease. If in her already depressed condition, we add the 
shock of premature labor, we diminish her chances of recovery. Only 
as a last hope should we, hence, induce labor in this case, and then in 
order to diminish the gravity of the disease from which she is suffering. 
Finally, the induction of labor has been recommended in certain anom- 
alies of pregnancy, such as the habitual death of the foetus without known 
cause. In such a case, if the antecedents or the constitution of the 
woman do not call for special treatment, such as in syphilis, we are justi- 
fied in inducing labor. 169 
THE INDUCTION OF PREMATURE LABOR. 
Certain authorities go further still, and have advocated the induction 
of labor where the foetus has died and remains in the uterus. Here we 
believe the operation to be absolutely contra-indicated, since the presence 
of the foetus cannot harm the mother as long as the ovum is intact. 
Premature labor being indicated, it remains to study the means at oui- 
disposal for induction. 
When the indication is a complication or disease threatening the life of 
the mother, the choice of the time is absolutely subordinated to the 
gravity of the complication and the state of the mother. In these cases, 
there being no obstacle to the birth of the foetus, it runs no more risk 
than in normal labor; we seek simply to put off the time as long as is 
possible, as near to term as is possible, in order to increase the infant's 
chances of survival, remembering chiefly always, however, the interests 
of the mother, since it is for her life that we are going to interfere. Act, 
then, neither too soon nor too late, being guided purely by the nature of 
the complication, and its effect on the mother. 
The question is more difficult of decision in case of pelvic deformity. 
Although we may usually reach a fairly exact idea of the form of the 
pelvis, it is far otherwise as to the period of pregnancy, and the volume 
of the foetus, two conditions of capital importance. 
1. The State of Pregnancy.-We have seen already (yide Pregnancy, 
"Vol. I.), that it is almost impossible to determine the exact date, and that 
we are always liable to great error. Of 50 women studied by P. Dubois, in 
order to find out the possible variations between the supposed date of 
pregnancy and the real, in 17 cases the difference was 8 days; in 17 
others between 8 and 15 days; in 3 between 15 and 20 days; in 13 be- 
tween 20 to 30 days. The supposed date of pregnancy was placed 8 
times before, and 41 times after the real. From these cases, and 100 
others, Dubois states that 15 days' error is ordinarily possible. 
The gravity of such an error is understood, when we are dealing with 
a contracted pelvis requiring premature laboi' between 7 and 7| months. 
The data given by the patients in regard to the last menstruation are 
often very inexact, and the foetus being entirely above the cavity, our 
error would be great if we based an opinion on the development of the 
abdomen. 
2. Volume of the Foetus.-Ahlfeld has endeavored to determine this in 
order, on the one hand, to find out the period of gestation, and, on the 170 
A TREATISE ON OBSTETRICS. 
other, to recognize the disproportion existing between the foetus and the 
possible degrees of pelvic contraction. After having shown that the ra- 
tional history and the main physical signs furnish only illusory data, he 
concludes that the only absolute is given by the volume of the foetus. 
He has endeavored, hence, to measure this, and he has reached the fol- 
lowing conclusions: The foetus being in a state of flexion, it constitutes 
an ovoid, one pole formed by the lowest part of the head, and the other 
by the highest of the breech. By measuring the distance between these 
two poles, that is to say, the intra-uterine longitudinal axis of the foetus, 
Ahlfeld has determined that it represents about one-half of the total 
foetal length. We may thus obtain quite an exact idea of the true length 
by measuring the axis. We may measure this axis by means of the pel- 
vimeter, one blade in the vagina to one pole of the ovoid, the other on 
the abdominal wall over the second pole. Doubling this measurement 
will give us the true length of the foetus, and thence the age of the ges- 
tation. In the following tables Ahlfeld's experiments are resumed: 
Mean Weight and Length of the Foetus by Weeks. 
40th week 
Weight 6.97 lbs. 
Length 19.6 inches. 
39th " 
" 7.30 " 
" 19.73 " 
38th " 
" 6.63 " 
" 19.46 " 
37 th " 
" 6.32 " 
" 18.83 " 
36th " 
" 6.17 " 
" 18.83 " 
35th " 
" 6.05 " 
" 17.44 " 
34th " 
" 5.33 " 
" 17.96 " 
33rd " 
" 4.58 " 
" 17.12 " 
32nd " 
" 4.63 " 
" 16.09 " 
31st " 
4.33 " 
" 17.04 " 
30th " 
" 4.11 " 
" 16.38 " 
29th " 
" 3.46 " 
" 15.4 " 
28th " 
" 3.59 " 
" 15.71 " 
27th " 
" 2.51 " 
" 14.15 " 
Intra-Uterine Volume of Foetus.-Mean. 
Week of 
pregnancy. 
Mean length. 
Number 
of cases. 
Length at 
same period 
of infant 
born. 
Week of 
pregnancy. 
Mean length. 
Number 
of cases. 
Length at 
same period 
of infant 
born. 
40th. 
9.98 in. 
2 
19.6 in. 
31st. 
8.46 in. 
4 
17.04 in. 
39th. 
9.98 " 
9 
19.73 " 
30th. 
8.15 " 
8 
16.38 " 
38th. 
9.71 " 
16 
19.46 ' 
29th. 
7.87 " 
6 
15.4 " 
37th. 
9.39 " 
20 
18.83 " 
28th. 
7.56 " 
4 
15.7 " 
36th. 
9.32 " 
18 
18.83 " 
27th. 
7.37 " 
4 
14.15 " 
35th. 
8.78 " 
20 
18.44 " 
26th. 
6.9 " 
4 
34th. 
8.97 " 
11 
17.96 " 
25th. 
7.1 " 
1 
33d. 
8.66 " 
10 
17.12 " 
24th. 
5.07 " 
1 
32d. 
8.39 " 
13 
16.09 " THE INDUCTION OF PREMATURE LABOR. 
171 
Proportion Between Height of Uterus, and Length of Intra-Uterine Foetal 
Axis, and Length of New-born Infant. 
Week of 
pregnancy. 
Height 
of 
Uterus. 
Length 
foetal axis, 
(intra-ute- 
rine.) 
Length 
new-born 
infant. 
Week of 
pregnancy. 
Height 
of 
Uterus. 
Length 
foetal axis, 
(intra-ute- 
rine.) 
Length 
new-born 
infant. 
40th. 
10.18 in. 
9.98 in. 
19.6 in. 
31st. 
8.42 in. 
8.46 in. 
17.04 in. 
39th. 
10.02 " 
9.98 " 
19.73 " 
30th. 
8.38 " 
8.15 " 
16.38 " 
38th. 
9.7 " 
9.71 " 
19.46 " 
29th. 
7.87 " 
7.87 " 
15.4 " 
37th. 
9.5 " 
9.39 " 
18.83 " 
28th. 
7.91 " 
7.56 " 
15.7 " 
36th. 
9.4 " 
9.32 " 
18.83 " 
27th. 
7.44 " 
7.37 " 
14.15 " 
35th. 
9.16 " 
8.78 " 
18.44 " 
26th. 
7.41 " 
6.9 " 
34th. 
9.12 " 
8.97 " 
17.96 " 
25th. 
6.95 " 
7.1 " 
33d. 
8.7 " 
8.36 " 
17.12 " 
24th. 
5.85 " 
5.07 " 
32d. 
8.5 " 
8.39 " 
16.09 " 
The importance of these researches is at once appreciated. The age of 
gestation and the volume of the foetus being known, there remains simply 
the other element, the dimension and the form of the pelvis. Let us say 
here, once for all, that delivery being always more difficult in the generally 
and regularly contracted pelvis than in the simply flattened or not, it will 
be necessary to interfere in this case earlier. 
1. Pelvis at least 3.5 inches.-There is a difference according as we are 
dealing with a primipara or a multipara. In the latter everything de- 
pends on how the previous labors have passed. If, at term, they have 
been simple, easy, and resulting in living infants, we need not induce 
labor, but can wait; if the forceps has been required, although easy and 
with living infants, we must be more reserved. We must never forget 
what we have already stated, that infants increase in size with the preg- 
nancies, especially boys; and consequently in the fourth and fifth preg- 
nancies we might meet with difficulties which did not exist in the others. 
We are, therefore, justified in inducing labor a little before term. With 
all the more reason, of course, if the woman is in the habit of bearing 
large children, if on palpation and on mensuration we suspect a large 
child, if the anterior labors have necessitated the forceps, resulting in dead 
children, or if the forceps has not sufficed, and the foetus has had to be 
mutilated. 
When the pelvis is at least 3.5 inches, after deduction, and the foetal 
head at term will be 3.7, reducible by .39 of an inch, labor should be in- 
duced at eight months one week to eight and a half months, according to 
the obstacles met with in previous labors, and the supposed volume of 
the foetus. 172 
A TREATISE ON OBSTETRICS. 
If, on the other hand, we are dealing with a primipara, since infants 
are usually smaller, we may wait till term, or at least not induce labor till 
eight or ten days before term. 
2. Pelvis of 3.31 inches.-In this case, whether we are dealing with a 
primipara or a multipara, premature labor is indicated, and at eight 
months to eight and a half. 
3. Pelvis of 3.12 inches.-Premature labor is to be induced between 
eight and eight and a half months at the latest. 
4. Pelvis of 2.9 inches.-Premature labor is to be induced between 
seven and a half and eight months. 
5. Pelvis of 2.73 inches.-Premature labor is to be induced between 
seven months and seven months three weeks. 
6. Pelvis of 2.53 to 2.34 inches.-At seven to seven and a half months 
at the latest. 
Below 2.34 inches, miscarriage should be induced; instances where in 
pelves of 2.14 inches living children have been obtained are very excep- 
tional, and cephalotripsy and embryotomy are too dangerous for the mother. 
Indeed, when we are going to induce premature labor, we must not 
consider this operation alone, for although in pelves of 3.5 to 3.12 inches 
we can usually extract living infants with the forceps, this is far from 
being the case where the contraction is less than 3.12 inches. Here we 
may be able to bring the foetus down to the pelvic floor, but no further, 
and be obliged to mutilate it. The greater the contraction of the pelvis, 
the greater the difficulty of mutilating operations, and hence the less the 
chances for the mother. It is of advantage to her, therefore, to substi- 
tute miscarriage for premature labor. 
We see, then, from the above figures, that it is in the most common 
degrees of deformity, 3.51, 3.31, 3.12, 2.73 inches, that it is, in general, 
of advantage to induce premature labor, and that the time of election 
corresponds to about these same figures, since the foetal head is reducible 
by .39 of an inch. These divisions, however, are not at all absolute, and 
the accoucheur must carefully study the obtainable data in each case be- 
fore resorting to the operation. We must further remember that in rick- 
ets both the foetus and the uterus develop above the brim, since the head 
cannot engage; and that, consequently, the size of the abdomen will 
always indicate a more advanced pregnancy than in reality exists. We 
must always take into account this exaggerated elevation of the fundus, THE INDUCTION OF PREMATURE LABOR. 
173 
particularly in case of contraction between 2.34 and 2.73 inches. Here 
premature labor should be induced between seven and seven and a half 
months at the latest, and since an error of 15 days is possible in our esti- 
mation, we will often induce miscarriage, that is to say, not obtain a via- 
ble child. 
Once having determined on the induction of premature labor, another 
question presents itself-What is the presentation of the foetus? 
Although, prior to the last few years, cephalic presentations were con- 
sidered most favorable in contracted pelves, latterly, the experiments of 
Budin, Champetier, Milne and Goodell, tend to show that the balance is 
in favor of pelvic presentations, certainly before term. We may well ask, 
therefore, if it would not be advantageous to convert head into breech 
by external manipulation? We cannot answer this question at present. 
Facts are not numerous enough, and the future must decide. The good 
results from the forceps lessen as the degree of contraction increases; 
cephalotripsy and embryotomy always sacrifice the foetus, and become the 
more dangerous for the mother with increase in degree of contraction. 
We'are, therefore, justified in trying the method of Milne and Goodell, 
which has yielded them such brilliant results. (See subject of Contracted 
Pelves, Forceps and Version.') 
We give below the results of Winckel at the Dresden Maternity, in 
cases of contracted pelvis. 
Of 10,679 labors, from October, 1872, to the end of March, 1882, Winck- 
el noted 300 cases of contracted pelvis with 356 labors; 129 of these 
women had rickets. 
Weidling (Halle) divides his cases according to the number of labors 
thus: 
1872. 
1873. 
1874. 
1875. 
1876. 
1877. 
1878. 
1879. 
1880. 
1881. 
1882. 
147^- I. P. . 
1 
14 
21 
8 
10 
17 
10 
34 
14 
15 
3 
94- II. P. . 
2 
8 
8 
5 
13 
13 
6 
11 
14 
11 
3 
43- III. P. . 
2 
3 
3 
4 
9 
5 
3 
3 
3 
2 
25- IV. P. . 
5 
4 
6 
2 
5 
1 
2 
18- V. P. . 
1 
1 
1 
1 
5 
1 
4 
2 
1 
1 
13- VI. P. . 
3 
2 
2 
3 
3 
7- VII. P. . 
1 
2 
1 
1 
1 
1 
3-VIII. P. . 
1 
1 
1 
2- IX. P. . 
2 
2- X. P. . 
1 
1 
1- XI. P. . 
1 
1- XII. P. . 
1 
356 
4 
29 
39 
19 
38 
51 
25 
58 
39 
37 
11 174 
A TREATISE ON OBSTETRICS. 
Winckel, comparing his figures with the above, obtains the following 
percentage: 
I. 
P. 
n. 
p. 
III. 
P. 
IV. 
P. 
V. 
p. 
VI. 
P. 
VII. 
p- 
VIII. 
p. 
IX. 
p. 
X. 
p. 
XL 
P. 
XII. 
p. 
Labor with pelvic con- 
tractions, 
44.6 
24.8 
10.5 
6.3 
4.7 
4.1 
1.9 
.6 
.6 
.6 
.3 
.03 
Total number of labors, 
51 
27.6 
10.9 
4. 
2.3 
1.3 
.7 
.6 
.3 
.2 
.1 
.03 
As for the influence of pelvic contraction on the presentation of the 
foetus, Winckel has noted: 
Vertex, anterior parietal, ... 7 times. 
Vertex extended, . . . . . 4 " 
Face, ....... 12 " 
Brow, 3 " 
Pelvic extr. . . . . . . 10 " 
Transverse, . . . . . . 6 " 
Brow with prolapse of limbs, . . 6 " 
Prolapse of cord, 37 " 
Cephalic presentations, . . 27 " 
Winckel 
Vertex. 
Anterior 
parietal. 
Face. 
Pelvic T . 
extremity. irunK- 
Winckel, 
75.8# 
1.9# 
1.8# 
3.2# 10# 
Weidling, 
90.6# 
.2# 
3.4# 
2.6# 1.6# 
Weidling. Winckel. 
Prolapse of limbs, . . . 1# . . 1.7# 
" " cord, . . . 5.9# . . 7.7# 
Twists in cord. 
(Winckel.) 
Simple, ... 67 times or 82.7# 
Double, . . . 9 " " 11.1# 
Triple, . . . 5 " " 6.2# 
Ordinarily the general percentage is 25 per cent., or taken singly: sim- 
ple twists 70.4 per cent.; double 10 per cent.; triple 1.6 per cent. 
Prolapse of the cord was the cause of death in 33 per cent, of infants, 
that is, 1.8 per cent, more than in the other cases. 
Varieties and Degrees of Contraction. {Winckel and Weidling f 
1. Pelvis with conj. vera 3.7 to 3.5 inches, flattened and ricketty, 181 
2. " " 3.12 " " 11 . 87 
3. " " less than 3.12 " " " . 18 
4. ' ' generally contracted, ricketty and not ricketty, generally 
and regularly, generally and irregularly contracted, . 5 THE INDUCTION OF PREMATURE LABOR. 
175 
5. Pelves obliquely contracted, 6 
6. " contracted at inferior strait. Lumbo-sacral kyphosis, . 1 
7. " olisthetic, 2 
8. Pelvis contracted with conj. vera 3.7 to 3.5 in. flattened and 
ricketty, .......... 38 
9. Pelvis contracted with conj. vera 3.4 to 3.5 in. . . . 44 
10. " " " below 3.12 in. ... 9 
11. " " generally, 14 
12. " " obliquely, 1 
Total ..... 406 
In Winckel's cases, twice the conjugate was but 2.73 in., and once 
2.63 inches. 
In Weidling's cases, the greatest degree of contraction was 2.73 inches, 
in two other cases 2.84 inches. 
Of Winckel's cases the method of interference in 300, was: 
1. Reposition of retroverted uterus, contracted pelvis, pregnancy 
went to term, ......... 1 
2. Induced premature labor, (3 children living, 1 mother dead.) 9 
3. Reposition of the cord, (3 children saved.) .... 9 
4. Version, (Ritgen's method.) ....... 5 
5. Forceps, (2 mothers dead, 4%. 14 infants dead, 4 by perfora- 
tion; 5 died during first 8 days; mortality 21.3%. Mater- 
nal mortality 4%.) . . 51 
6. Version and extraction, (1 mother dead, 3.1%; dead children 
6; born alive, died in 11 first days, 3; perforation after- 
coming head 7. 31 
7. Perforation, (out of 357 labors in contracted pelvis.) . . 48 
8. Cephalotripsy, ......... 3 
9. Cranioclasty, (mortality of mothers, 8, reduced to 6, since two 
mothers were already in extremis. That is, of 32 cranio- 
clasties, maternal mortality 18.7%. 36 women were sick 
during the puerperium, of which number: recovered 12, 
died 20.) 32 
Therefore: morbidity 10.6%; mortality 6.8%. 
Maternal Deaths. (Winckel.) 
Uterine rupture at entrance into clinic . . . .2 
<< " " " .... 6 
Puerperal septicaemia, ....... 9 
Other diseases, ........ 3 
Of 100 women with contracted pelvis, 8 died. (Weidling). 176 
A TREATISE ON OBSTETRICS. 
Winckel notes these facts in regard to maternal and infantile mortality: 
P. Muller lost 7# women; Gonner lost 5.9# women and 66.3# infants; 
Michaelis lost 45.5# women and 23# infants; Weidling, infants living 
74.2#, dead 25.7#. 
Winckel, out of 115 dead infants in 357 labors, including one twin 
labor, as follows: 
1. Macerated (including 1 anencephalous), . . .3 
2. Perforation, 48 
3. Dead without mutilation, . . . . . .39 
4. " in first 17 days, . . . . . . .25 
Total, . . . . 115 
Comparing then the infantile mortality, according to primiparity and 
multiparity, the following figures are given: 
Winckel. Weidling. 
I-para, . . . 45:147=30.6# 32.2# 
II-parae, . . . 26:95 =27.7# 27.3# 
Ill-parse, . . . 12:43 =27.5# 23.1# 
IV-parae, . . . 5:22 =22.7# 17.6# 
Multi-parae, • . . . 14:44 =31.8# 26.1# 
Foetal mortality. Maternal mortality. 
Winckel, . . . 29.6# . . .1:72 labors. 
Weidling, . . 25.7# . . . 2:47 " 
Out of 210 spontaneous labors, in contracted pelves: 
Foetal mortality, (Dresden Clinic.) . . . .17.6# 
Maternal 11 11 .... 2.4# 
Out of 308 at the Halle polyclinic: foetal mortality 12#; maternal mor- 
tality 1.3#. 
Winckel concludes that we should only interfere when this is absolutely 
called for, and resuming his practice he gives the following rules, which 
agree with those given by Spiegelberg: 
Wait, as long as the spontaneous passage of the head seems possible 
and without danger. 
Resort to the forceps, even when the head is not engaged, as soon as 
the life of mother or child is in danger; if the forceps does not quickly 
succeed, perforate and extract with the cranioclast. 177 
THE INDUCTION OF PREMATURE LABOR. 
If the head engages badly, or remains movable, resort to version and 
extraction. 
In agreement with Spiegelberg, Winckel holds foetal life cheap compared 
to the mother's, and with him also agrees that any intervention is dan- 
gerous compared to spontaneous labor. 
His clinical results accord absolutely with Spiegelberg's : 
Breslau clinic, maternal mortality 7.9 per cent, foetal 30 per cent. 
Dresden clinic, maternal mortality 6.0 per cent, foetal 29.6 per cent. 
The time for induction having been chosen, it remains to choose one 
from the numerous effective agents. The different agents may be di- 
vided as follows: 
1. Excitation of uterine contractions by the internal administration of 
drugs: 
2. Excitation of the uterus either directly, or by reflex action: 
3. Peripheral irritation of the cervix: 
4. Direct dilatation of the cervix: 
5. Excitants placed between the ovum and the uterine walls. 
6. Separation and perforation of the membranes. 
I. Internal Medicines.-In this series are found all the drugs reputed 
to be abortifacient: Rue and sabine, which act only in toxic doses, and 
should hence be excluded; ergot, used latterly by Bongiovanni, and, al- 
though rarely powerful enough, even in large doses, to awaken uterine 
contractions, acts profoundly on the foetal circulation, often stops it and 
thus acts contrary to the end we have in view, without speaking of the 
accidents it may occasion to the mother at the time of delivery. The 
sulphate of quinine recommended by Sayre. [This drug has absolutely 
no power of awakening uterine contractions, else how may it be given in 
large doses to the gravida suffering from intermittent fever with none but 
good results ? When once contractions are in progress, however, there is 
no question but that a large dose intensifies them.-Ed.] 
Recently pilocarpine has been recommended. It has been studied in 
particular by Muller, Dick, Fehling, Prochownick, Kleinwachter, Bidder, 
Stroynowski, Mossmann, Schauta, Felsenreich, Welponer, Scotti, Ohms,. 
Marmi, Labarraque, and it has been used to induce labor by Sanger, 
Parisi, Hyernaux, John Clay, Ercole Pasquali, Chantreuil, Mari-Autet, 
Kroner. The following are Mari-Autet's conclusions: 1. In a certain 
number of cases pilocarpine subcutaneously has had no effect (Welponer, 
Vol. IV.-12 178 
A TREATISE ON OBSTETRICS. 
Parisi, Hyernaux and Sanger); 2. The same is true of a number of ex- 
periments on animals (Hyernaux, Chantreuil); 3. When, however, the 
woman is in labor, or has reached term, the subcutaneous injection has 
an effect, also in animals; 4. In a certain number of cases, the con- 
tractions observed after injection have determined labor (Massmann, 
Schauta, Kleinwachter, Sanger); 5. Usually the action has been insuffi- 
cient to determine the expulsion of the product of conception; 6. It ap- 
pears legitimate to conclude, that if at term and during labor pilocarpine 
seems to have influence over the contractility of the uterus, before term 
the action is nil as regards the induction of premature labor. 
Autet, however, fails to mention what others have, that pilocarpine 
produces symptoms of poisoning, and only acts in the presence of these 
symptoms, a fact brought out strongly by Sanger, Kroner, and Hyernaux. 
The last gentleman attributes the oxytocic effect of pilocarpine, not to 
a special action of the alkaloid, but to its toxic property. It is an epi phe- 
nomenon of the great disturbance it causes in the organism. He com- 
pares it to the labor which follows on heart disease, profound emotion, or 
nervous shock, the convulsions of epilepsy and hysteria, (Wasseige.) We 
must hence absolutely reject pilocarpine. 
[The binoxide of manganese, which has of late proved of such great 
utility in atonic amenorrhea, would seem to possess marked oxytocic 
properties, certainly in the early months of pregnancy. We are person- 
ally cognizant of three cases, where the drug was administered by others 
during pregnancy, with resulting miscarriage. Possibly in the later 
months of gestation, it will not so act, but it is well to bear in mind the 
fact that it may evoke uterine contractions.-Ed.] 
II. Direct and reflex Excitation of the Uterus.-D'Outrepont advised 
friction and massage of the uterus. Schreiber has used galvanism; Dor- 
rington and Simpson electro-magnetism; Henning farad ism; Gardien hot 
baths frequently repeated; Friedereich blisters to the mammae; Scanzoni, 
Langenreich, Germann, rubber suction bulbs on the nipples. Aside from 
the fact that many of these methods are painful, and even dangerous, they 
are all untrustworthy, and lead but slowly and rarely to the proposed end. 
[The recent contributions of Bayer and Fleischmann, amongst others, 
would lead us to think that in the electric current we possess a most valu- 
able means of inducing premature labor, and safer than many others in 
use, for the reason that all possible chance of infection is avoided. In THE INDUCTION OF PREMATURE LABOR. 
179 
Fleischmann's cases the effect was most marked when the cathode lay in 
the posterior cul-de-sac, and the anode was placed over the lumbar verte- 
brse. He suggests as possible that the contractions are evoked through 
irritation of Frankenhauser's ganglion. Personally, we propose to try 
electricity when occasion offers, and preferably the faradic current, mild 
of course, and with the precaution of not passing the current through the 
poles of the foetal ovoid. Our belief in the action of this current is based 
largely on the results yielded us in two cases of uterine inertia, to which 
we have already referred. Likely enough the interrupted galvanic cur- 
rent would act as well as the faradic.-Ed.] 
Fig. 125.-Braun's Colpeurynter. 
III. Excitation of the Periphery of the Cervix.-Schoellerhas proposed 
the tamponade of the vagina with pieces of charpie, as in case of hemor- 
rhage, and has thus been successful twelve times in twenty. Hitter and 
Busch, instead of using charpie, tampon with a bladder containing an in- 
fusion of ergot, destined to act by exosmosis!!! Braim uses the colpeuryn- 
ter (Fig. 125), and it has succeeded in a number of instances. 
IV. Douches.-Kiwisch has advocated hot douches against the cervix, 
at a temperature of 110° F. continued for twelve to fifteen minutes. 
Scanzoni has proposed the substitution of intravaginal douches of carbonic 
acid. Giordano cauterizes the cervix with the stick of nitrate of silver. 180 
A TREATISE ON OBSTETRICS. 
V. DUatation of the Cervix.-Busch, Mende, and Krause, have used 
metallic dilators. Kluge introduces into the cervix a cone of prepared 
sponge (Fig. 126), and holds it in place by a vaginal tampon. This sponge 
softens, swells, dilates the cervix, and awakens uterine contractions. Van 
Leynseele, and Pigeolet, replace the sponge by laminaria tents. [If a 
tent is to be used, the tupelo should be preferred to the sponge and the 
laminaria. The danger from septic infection is too great from the sponge, 
however carefully prepared, and it should never be used in the gravida 
for this reason. The laminaria wounds the cervix too much, and in this 
way exposes to septic infection. The tupelo is not open to either of these 
objections, dilates evenly and just as thoroughly, and is the tent par ex- 
cellence.-Ed.] 
Snackenberg uses an instrument which he calls the spheno-siphon. 
It is composed of a syringe and canula about two inches long, pierced 
with lateral holes, and covered with prepared skin which will distend to 
the extent of one to two inches. The syringe is filled with liquid, the 
canula inserted into the cervix, the piston pushed down, and the skin blad- 
der distended with fluid. A screw holds the piston in place. On the 
following day more fluid is injected, and similarly on the third day. 
Barnes has devised a method which not only allows him to determine 
labor, but to accelerate it, and to end it, so to speak, at will. His appar- 
atus consists of three rubber bags of different sizes, shaped like a 
violin, and adapted to each there is a long rubber tube fitted with a stop- 
cock. The smallest of these bags is .78 to 1.1 of an inch, the largest 2.34 
to 2.79 inches. Barnes begins by obtaining a certain amount of dilata- 
tion through the douche or by the prepared sponge; then he inserts his 
smallest bag, and distends it with warm water. When dilatation is suffic- 
ient, the bag slips into the vagina, he withdraws it and inserts the next 
size, and later the largest, and, when dilatation is complete, he ruptures 
the membranes, and terminates labor by either forceps or version, gener- 
ally the latter. Barnes has recently modified the procedure. Over 
night he inserts a bougie, 5.8 inches deep, and leaves it there. In the 
morning, dilatation having commenced, he inserts the small bag, rup- 
tures the membranes, continues the dilating process with the second and 
third bag, and ends the labor by version, as soon as the cervix is suffic- 
iently dilated. 
Chassagny has devised a double bag, analogous to Barnes's dilator, ex- THE INDUCTION OF PREMATURE LABOR. 
181 
cept that each bag is provided with an independent tube, so that one or 
both may be inflated indifferently. 
Deviliers used a double current catheter, the end of which was covered 
Fig. 126. Fig. 127. 
Fig. 126.-Kluge's Method. Introduction of Sponge Cone 
.Fig. 127.-Tarnier's Dilator. 
with a species of condom which, when in the cervix, is distended with 
water. 
Mattei has devised a similar instrument. 
Tarnier, finally, has devised his dilator, which he describes as follows 
(Fig.127): il The instrument is composed of two portions-a rubber tube 
and a conductor. The principle of its action is to insert into the uterus, 
above the internal os, a rubber tube of the size of a bird's feather, which 182 
A TREATISE ON OBSTETRICS. 
swells at its uterine extremity into a bladder the size of an egg when it is 
distended. It is left in situ till expelled by the uterine contractions. 
The rubber tube is 11.5 inches long, and closed at one end. The walls 
are thick and resisting, becoming thin at their extremity. When injected, 
the unequal thinness of the walls causes them to distend at this portion. 
To the end of this tube is attached a strong thread, 19.5 inches long. 
The conductor is metallic, tunnelled throughout its length, and curved 
like the hysterometer. It is pierced by three eyelets, two at the end, .39 
inches apart, the third near the handle. To mount the tube on the con- 
ductor, I pass the thread through the eyelet nearest the extremity; it is 
then passed through the next eyelet, and it runs down the gutter to 
emerge out at the eye near the handle. By making traction on the thread 
the tube is held on the conductor. The thread is twisted around the 
screw. 
" To use this instrument I proceed as follows: It is guided by two fin- 
gers into the cervix between the ovum and the uterine walls, at least one' 
inch above the internal os. Fully an ounce of liquid is injected, and the 
tube becomes sufficiently distended. The stop-cock is closed, the thread 
unwound, and the conductor withdrawn. The tube will remain in place, 
and the woman should move around and attend to her household duties. 
Labor pains rapidly set in, in three to four hours the cervix opens, and 
the tube falls into the vagina. This happens in about ten to twelve hours." 
Pajot has modified Tarnier's dilator by replacing the conductor by a 
small hollow tube ending in a bulb. (Fig. 128). 
VI. Excitants placed between the Uterine Walls and the Ovum.-Tar- 
nier's apparatus not only acts as a dilator, but also as an excitant. Krause 
uses a gum-elastic catheter, which he inserts between the membranes 
and the uterus, and leaves it in place until the uterine contractions have 
brought about sufficient dilatation of the cervix. Zuidhoeck used a wax 
bougie. Mampe and Lehmann are satisfied witfl introducing a bougie 
several times between the membranes and the uterus, in different direc- 
tions. 
VII. Separation and Perforation of the Membranes.-Schweighauser 
and Cohen have advised inserting between the membranes and the uterus 
an elastic catheter to which a syringe is fitted. Through this water is 
injected, which separates the membranes and awakens contractions. 
Hamilton recommends simply passing the finger above the internal os, 183 
THE INDUCTION OF PREMATURE LABOR. 
and separating the membranes as high up as possible from the lower 
uterine segment. This method has been partially practised by Copeman 
in case of uncontrollable vomiting. Finally Scheel, Hopkins and Meiss- 
ner, have counselled perforation of the membranes by means of a pointed 
feather trocar, or the uterine sound. Kluge and Ritgen have devised 
Fig. 128 Fig. 129. 
Fig. 128.-Pajot's Instrument for Inducing Labor. A, Rubber tube. B, Metal guide. C, 
Dilatable upper extremity. 
Fig. 129.-Meissner's Trocart. 
instruments, the aim of which is to suck down the membranes into the 
opening of the canula, and there perforate them. The advantage of this 
method is that the liquor amnii escapes by drops. (Fig. 129.) 
Such are the different methods in use to-day. All have not the same 
value, and we proceed to point out the advantages of each, and our own 
preference. 184 
A TREATIES ON OBSTETRICS. 
At the outset, we eliminate internal drugs, since their action is un- 
trustworthy or nil, and when they do act they compromise the mother's 
health and the foetal existence. The same remark holds for frictions and 
massage, the action of which is, at best, but transitory; excitation of the 
mammae, which, aside from the fact that they are very painful, often 
fail; electro-magnetism, galvanism, etc. 
[From what we have said before, we take exception to this exclusion 
of electricity. We believe that this agent will prove the most effective, 
and the least dangerous, seeing that uterine contractions can with abso- 
lute certainty be evoked, and with not the slightest risk of septic infec- 
tion or damage to the cervix or the uterus.-Ed.] 
Amongst the active measures, we mention the tampon. It often suc- 
ceeds, especially in case of hemorrhage, but its application is painful, 
slow, and it must be renewed on account of its odor. 
[That the action of the tampon is slow we grant, but, when inserted, 
as only it should be, in Sims' position and through Sims' speculum, it is 
not at all painful, simply uncomfortable; and, as for its frequent removal, 
if iodoform gauze is used, it may be left in situ for thirty-six hours, in 
case of necessity. A practical point in connection with the tampon, is 
not to fill the lower third of the vagina, and thus avoid pressure on the 
neck of the bladder and the urethra, with the consequent tenesmus.- 
Ed.] 
The measures most frequently resorted to are those of Kluge, Kiwisch, 
Barnes, Tarnier, Krause, Cohen, Scheel and Meissner. 
Kluge's method, that is to say, dilatation of the cervix with prepared 
sponge, or with laminaria, is certainly an excellent one. First proposed 
by Brunninghausen, later by Siebold, it was especially practised by Kluge, 
and is called after him. Dilatation of the cervix is thus accomplished 
slowly and with certainty, and the sponge acts mechanically as well as 
dynamically, without risk for the mother or the child. It leaves the 
membranes intact, and thus the mother and the child remain under nor- 
mal conditions. The introduction of the tent is, however, often very 
difficult. In primiparae, in particular, where the cervix is high up and 
behind, it is difficult to insert and to retain in place. Often, further, the 
tent acts so very slowly that we are obliged to perforate the membranes, 
thus depriving the foetus of a portion of the benefits of the operation. 
In 70 cases collected by Hofmann it was successful 50 times alone; 7 185 
THE INDUCTION OF PREMATURE LABOR. 
times other methods had to be joined to it; 7 times it absolutely failed. 
Let us add, finally, that there is some risk of septic infection following 
its use, and this is truer still of laminaria. Nevertheless, the method is a 
good one, especially in multipart. 
Kiwisch's method, the hot douche, also succeeds well. Used first in 
Germany by Kiwisch, in 1846, it was imported into France in 1852, by 
Campbell, who told P. Dubois about it. The method has become classic 
with us. Dubois used it with an irrigator containing 2| gallons; Depaul 
either with the irrigator or the bulb syringe. Blot directed the stream 
against the os, and even proposed to inject into the canal, when, in the 
hands of Depaul, of Salmon, of Blot, of Tarnier, of Simpson, of Olshausen, 
of Lazatti, and of Van Leynseele, there occurred cases where women died 
during the douche, as the result of the entrance of air into the uterine 
sinuses. Tarnier showed further that with the powerful syringe of Mat- 
tieu the vaginal culs-de-sac might be torn. From this time forth 
Kiwisch's method was abandoned. 
Barnes' method is not simply one for the induction of labor, but is a 
variety of accouchement force, and should be reserved for exceptional 
cases. 
Tarnier's method is to-day the favorite in France; it has decided advan- 
tages over all the others, but it is not, as Tarnier says, proof against ob- 
jection. As Tarnier himself admits, it is often difficult, if not impossible, 
to introduce the dilator, and in primiparae the conductor is too large. The 
rubber tube may break, "and then involuntarily we inject into the 
uterus." In multiparse, especially, we have seen the instrument slip be- 
fore dilatation was completed, and been obliged to reinsert it as often as 
four times. Hence loss of valuable time. Nevertheless, the method is a 
valuable one, not dangerous to mother or child, and usually rapid and 
successful. 
Cohen's method is a good one, but is little used, because, like Kiwisch's, 
it exposes to the entrance of air into the uterine sinuses, and to sudden 
death of the mother. 
There is one method which we prefer over all, and this is Krause's. 
It is simple, efficacious, harmless. It consists in inserting a gum-elastic 
bougie between the membranes and the uterus, and leaving it in situ un- 
til dilatation is sufficient, and contractions regular enough to warrant the 
belief that labor has really set in. We have used the method twelve 186 
A TREATISE ON OBSTETRICS. 
times without a failure. We take a bougie, 17 to 18 french. The 
woman is placed across the bed, and two fingers of the left hand are in- 
troduced into the vagina to the cervix, and placed underneath the ex- 
ternal os. These fingers guide the bougie into the uterus, and it is gen- 
tly pushed inward, being withdrawn a little in case it meets any obstacle, 
and then pushed in again. In general, labor sets in at the end of a few 
hours, and the bougie is left in situ until dilatation is completed. 
This method, we see, is the simplest of all. Mampe, Lehmann, Earle, 
have simplified the method by moving the bougie in different directions, 
and thus separating the membranes, and then withdrawing it. Leh- 
mann has succeeded in a number of instances. Valenta recommends 
pushing the bougie to the left, and behind, because: 1. The placenta is 
rarely on this side; the presentation of the occiput to the left being the 
most frequent of all, the bougie slides readily over the smooth occiput and 
the back, without risking rupture of the membranes; the uterus being 
dextro-verted, catheterism is easier on the left. With Hiiter we believe 
that these rules are purely theoretical. 
The opponents of Krause's method make the following objections: 1. 
The insertion of the bougie is difficult, seeing that it bends and stops be- 
fore penetrating sufficiently into the uterus. Far from finding this an 
objection, we believe it to be a safeguard. It is impossible with«an elastic 
instrument like the bougie to injure the uterus or the foetus, and admit- 
ting that we cannot make it pass to the fundus, we may always, by acting 
gently and slowly, place it in the lower uterine segment, where it will 
bend and produce the desired effect. 2. We may rupture the membranes. 
This objection is not, to us, founded on fact, for the bougie, sliding 
gently between the membranes and the uterus, simply separates them, 
and it is later, under the influence not of the bougie, but of the uterine 
contractions, that the membranes rupture. If the membranes are not 
ruptured by Tarnier's metallic guide, with greater reason will they not 
be by the bougie. 3. The bougie does not only excite the uterus, but 
irritates and inflames it, and further there may adhere to it septic mat- 
ter, or else it may itself alter and give rise to septic products which will 
poison the woman. 
These objections seem to us more theoretical than practical, and, in 
not a single one of the twelve cases in which we have used Krause's 
method, have we seen any accidents. In one case it remained in the 187 
THE INDUCTION OF PREMATURE LABOR. 
uterus twenty-eight hours, and was withdrawn unaltered. Further we 
always take the following precautions: We irrigate the vagina with a 1 to 
100 phenic acid solution, and wash our hands and the bougie in the same 
fluid, and we grease it with carbolized vaseline before introduction. 
Whilst it is in place, the woman injects herself every five to six hours with 
warm carbolized water. 
Certain authorities, nevertheless, with Hegar at theii head, fear septic 
infection so much that they always resort to the next method, that is to 
say, puncture of the membranes. Whether we rupture them at the in- 
ternal os, or higher up, the result is the same, labor is induced, for the 
ovum has been torn. This, it may be said, is the only inevitable means 
of inducing labor. The method, however, has its disadvantages, and it 
should be reserved for cases where the bougie fails, and then we would 
perforate at the internal os, and not higher up. 
We may make the following objections to perforation: 1. It acts slowly, 
the more so the higher up it is done. Indeed la^or may not set in for 
as much as twenty-four to forty-eight hours or longer, when we remember 
what may happen in case of spontaneous rupture of the membranes. 
We have just seen a case where labor only set in forty-four days after* 
spontaneous rupture at the seventh month of gestation, and we might 
mention others. 2. The perforation of the membranes, by evacuating the 
liquor amnii, places the mother, and above all the foetus, in less favor- 
able conditions than all the other measures where the liquid is retained. 
And this is why Meissner and Hopkins advised perforation high up, in 
order that the liquor might escape slowly, and thus preserve as long as 
possible the cavity of the ovum. 
Prognosis.-^-Considered alone, the induction of premature labor being 
an operation practised in the interests of the mother and of the child, is 
inoffensive, and all the more so when performed by an expert. But, in 
studying the different methods, we have seen that several have caused 
the death of the mother, and that therefore the choice of the method is 
not a matter of indifference. The most inoffensive, in our opinion, are 
those of Kluge, of Tarnier, and of Krause, and then follow the method 
of Kiwisch, and the perforation of the membranes, the latter compromis- 
ing especially the life of the foetus. We must further considei* the oper- 
ation from the standpoint of its results for the mother and the child, par- 
ticularly in connection with pelvic deformity. In this case, indeed, the 188 
A TREATISE ON OBSTETRICS. 
induction of labor is purely preparatory to true labor, so to speak, and 
the operation does not always save the child from forceps, perforation, or 
embryotomy, with all the consequences of these operations for the mother 
and for the child. 
Hecker, in giving the results of the labors at the Munich Maternity 
from June, 1859, to March, 1879, tells us that in 17,220 labors with 17,400 
infants, interference was necessary in 1,424 cases, as follows: 
Induction of premature labor, .... 24 
Cephalic version, 6 
Podalic " (1 foot) ...... 202 
Extraction, simple, . . . . . . 210 
" after version, . . . . 189 
" " forceps, ..... 446 
" " perforation, .... 30 
" 11 cephalotripsy and cranioclasty, . 26 
• 
Caesarean sectioif: living women, 2; dead women, 3, 5 
Reposition of the cord, ...... 76 
Artificial third stage, ...... 210 
Of the 17,220 women, 279 died, or 1.6^: 
During or immediately after labor, ... 24 
" the puerperium, ...... 80 
After leaving hospital, . . . . . . 175 
Of the 17,400 infants, 1,715 died, or 9.8^: 
Dead before labor, ...... 407 
" during labor, or born in apparent death and 
not re-animated, ..... 540 
" from congenital weakness, .... 435 
" " disease, ...... 333 
Certainly the induction of premature labor is an immense progress; for 
as Naegele and Greuser say, " the proportion of fatal cases is not great, if 
compared with the operations which would have been required, other 
things equal, by the mother at term. As for the children, the prognosis 
is less favorable, for being born prematurely they are much more diffi- 
cult to rear than at term." 
But we must remember that the induction of premature labor is called for 
precisely because the woman is in unfavorable circumstances, and we may 
say then that the prognosis of the operation is always grave, especially THE INDUCTION OF PREMATURE LABOR. 
189 
since it may be followed by other operations. The operation, then, will 
give results the less favorable the greater the degree of pelvic deformity, 
and the earlier in gestation we are obliged to resort to it. 
Spiegelberg and Litzmann, followed by Berthold and Fritsch, have, in 
particular, endeavored to weigh the results from the induction of prema- 
ture labor. 
"Spiegelberg first establishes the fact that the operation has attained its 
present high reputation, because: 1. The comparative risks of the opera- 
tion have never been stated. 2. Those children have been considered 
definitively saved who were born alive at the end of the operation. He 
then examines the results of his personal experience and of that of others, 
and he finds that at Frieburg, between 1865 and 1869, there were 2,264 
labors, with 307 cases of pelvic deformity, the contraction varying between 
2.34 and 3.75 inches, and including 11 cases of pelves regularly and gene- 
rally contracted, 3 obliquely and 1 transversely contracted. The follow- 
ing are the points of interest in connection with these 307 labors: 
The presentations were divided into: Vertex 257; face 8; brow 1; 
breech 11; shoulder 30. 
There were 165 spontaneous labors, and 142 induced labors, with the 
following results as regards maternal and infantile mortality: 
By expectant treatment:-Mothers saved, 94.5$; infants saved, 64.8$. 
By interference:-Mothers saved, 93.4$; infants saved, 62.8$. 
Next, considering the statistics of different German authors, he obtains 
the following figures: 
a. Result in 1,124 labors in contracted pelves, taken generally: 
Mothers saved, .... 1,143-93.3$ 
" dead, .... 81- 6.6$ 
Infants saved, .... 880-71.2$ 
" dead, .... 355-28.7$ 
b. Results in 271 cases of artificial labor, taken en masse: 
Mothers saved, .... 220-81.1$ 
" dead, .... 41-18.8$ 
Infants saved, .... 94-33.9$ 
" dead, .... 92-33.2$ 
" " after labor, . . 91-32.8$ 190 
A TREATISE ON OBSTETRICS. 
c. Results in 219 cases of induced labor, contracted pelves: 
Mothers saved, .... 186-84.9# 
" dead, . 33-15.0# 
Infants saved, . . . . 73-33.0# 
" dead, .... 77-34.8# 
" " after labor, . . 71-32.1# 
d. Results in 587 cases of spontaneous labor, contracted pelves: 
Mothers saved, .... 549-95.5# 
" dead, .... 38- 6.4# 
Infants saved, .... 383-64.9# 
" dead, .... 207-35.0# 
e. Results in 239 cases of very pronounced contraction (1.17 inches and 
below): 
Mothers saved, .... 205-85.7# 
" dead, .... 34-14.2# 
* Infants saved, . . . . 100-41.4# 
" dead .... 141-58.5# 
Spiegelberg, therefore, pronounces himself in favor of expectancy as 
against induction of premature labor. 
Gierich, in 110 cases collected from different authorities, gives the fol- 
lowing figures: 
In 110 cases of induced premature labor: 
Mothers saved, .... 84-76.3 # 
" dead, .... 26-23.63# 
Infants saved, .... 35-31.8 # 
" dead .... 29-26.36#) 
" " after labor, . . 46-41.81# J 68> 18^ 
The same authority in 793 cases of contraction down to 2| inches, and 
where consequently there was no question of premature labor, noted: 
Mothers saved, .... 746-94.07# 
" dead, .... 47- 5.92# 
Infants saved, .... 402-75.1 # 
" dead, .... 199-24.8 # 
Litzmann, finally, reaches the results found in the subjoined tables: THE INDUCTION OF PREMATURE LABOR. 
191 
Number 
of 
Labors. 
Presentation of Foetus. 
Progress of Labor. 
Mothers. 
Infants. 
Natural. 
0) 
Artificial. 
Saved. 
Dead. 
Born 
Alive. 
Dying 
or Born 
Dead. 
Living. 
1. Labor at term.... 
323 
86.5# 
- 
y 
With Prolapse of Cord .... 
With Prolapse of Limbs... 
Face 
Pelvis 
_ Shoulder 
to 
4^ 00 tO tO GO CO 
II II II II II II 
GO 
i-1 o o w os 
Ct 00 
227 
70.2# 
96 
29.7# 
302 
93.4# 
21 
6.5# 
271 
83.9# 
52 
16.19# 
264 
81.7# 
2. Labor before term 
a. Spontaneous 
16 
4.2# 
- 
"Vertex 
With Prolapse of Cord ... 
With Prolapse of Limbs... 
Pelvis 
Shoulder 
Vc Uc lx 
oio 
O CQ o io O 
1OH CQ 
II II II II II 
10 
62.5# 
6 
37# 
16 
100# 
0 
0.0# 
11 
68.7# 
5 
32. W 
8 
50# 
b. Artificial .... 
34 
9.1# 
- 
' Vertex 
With Prolapse of Cord .... 
With Prolapse of Limbs... 
Pelvis 
Shoulder 
Ci co to cc 
II II II II II 
to rfx 
-Q Ci Cl GO 
Ci 4^ co co 
12 
35.2# 
212 
61.7# 
29 
85.2# 
5 
14.7# 
15 
44.1# 
19 
55.8# 
7 
20.5# 
Total.... 
373 
•< 
Vertex 
With Prolapse of Cord 
With Prolapse of Limbs... 
Face 
Pelvis 
Shoulder 
co 
- cc to © 
H-i to Cl CO I- 
II II II II II II 
co 
COGOO^OiO 
CD CO CT CO I-L C5 
249 
66.7# 
123 
32.9# 
Not termi- 
nated, 
1 
.8# 
347 
93.02# 
26 
6.9# 
279 
74.7# 
76 
20.3# 
297 
79.6# 
1 In this number 
are included, prolapse of cord or limbs, tamponade, episiotomy. 
2 One labor not completed. 
Table I.-Results in 373 Cases of Labor in Contracted Pelves. 
Pelvis regularly and generally contracted, 73, or 19.5$. Pelvis simply flattened, 194, or 52.5$. Pelvis generally contracted 
' and flattened, 104, or 27.8$. 192 
A TREATISE ON OBSTETRICS. 
Table II.-Results in 316 Cases. 
First degree of contraction Pelvis regularly and generally contracted, 3.9 to 3.5 inches=73 or 23.1$. Pelvis simply flattened, 188= 
59.4$ ; Pelvis generally flattened and contracted, 55=55.7$-Conjugate of 3.7 to 3.21 inches. 
Number 
of 
Labors. 
Presentations. 
Progress of Labor. 
Mothers. 
Infants. 
Natural. 
Artificial. 
Saved. 
Dead. 
Born 
alive. 
Dying or 
Dead. 
Saved. 
304 
Vertex 264 
86.8% 
226 
78 
289 
15 
265 
39 
258 
1. Labor at Term... 
96.1 % 
With Prolapse of Cord, 15 
4.9% 
74.3% 
25.6% 
95.06 % 
4.9% 
87.1% 
12.8 % 
84.8 % 
With Prolapse of Limb, 2 
.6% 
Face 2 
.6% 
Pelvic 18 
5.9% 
Shoulder 3 
.9% 
2. Premature Labor 
10 
Vertex 7 
70% 
9 
1 
10 
0 
10 
0 
8 
a.-Spontaneous... 
3.1% 
Prolapse, Cord 1 
10% 
90% 
10% 
100 % 
00% 
100% 
00% 
80% 
" Limb 1 
10% 
Pelvic.. 1 
10% 
b.-Artificially In- 
21 
Pelvic 1 
50% 
1 
1 
1 
1 
1 
0 
duced 
.6% 
Oblique 1 
50% 
50% 
50 % 
50% 
50% 
50% 
00% 
Total 
316 
235 
74.3 % 
80 
25.3% 
300 
94.9% 
16 
5.06% 
276 
87.3% 
40 
12.6% 
266 
84.1 % 
1 Mothers not delivered. 
Dead from entrance of air into veins. THE INDUCTION OF PREMATURE LABOR. 
193 
Table III-Results in Forty-seven Labors. Contraction of Second Degree. 
Pelvis simply flattened, 5, 10.6#. Contraction, 3.19 to 2.9 inches. Pelvis generally contracted-flattened, 42, 89.3#; Dimensions, 
3.51 inches. 
Number 
of 
Cases. 
Presentation. 
Progress. 
Mothers. 
Children. 
Natural. 
Artificial. 
Saved. 
Dead. 
Born 
Alive. 
Dying 
or Dead- 
born. 
Saved. 
1. Labor at Term.... 
2. Premature Labor, 
a. Spontaneous.. 
b. Artificially in- 
duced 
16 
34% 
4 
2.5% 
27 
57.4% 
f Vertex 13=81.2% 
■[ Prolapse of Cord 2=12.5% 
Shoulder 1= 6.2% 
' Vertex 1=25% 
Prolapse of Cord 1=25% 
Shoulder 1=25% 
Pelvic 1=25% 
f Vertex 11=40.7% 
Prolapse of Cord 3= 4.1% 
- Prolapse of Limbs 2= 7.6% 
Pelvic 7=25.9% 
Shoulder 4=14.8% 
1 
6.2% 
1 
25% 
11 
40.7% 
15 
93.7% 
3 
75% 
16 
59.9% 
13 
81.2% 
4 
100% 
25 
92.5% 
3 
18.7% 
10 
2 
7.4% 
4 
25% 
1 
25% 
13 
48. 1% 
12 
75% 
3 
75% 
14 
51.8% 
4 . 
25% 
0 
0.0% 
7 
25.9% 
Total 
13 
27.6% 
34 
72.3% 
42 
89.3% 
5 
10.6% 
18 
38.2% 
29 
61.7% 
11 
23.4% 
Vol. IV.-13 194 
A TREATISE ON OBSTETRICS. 
Number 
of 
Cases. 
Presentation. 
Progress. 
Mothers. 
Infants. 
Artificial. 
Natural. 
Saved. 
Dead. 
Born 
Alive. 
Dying or 
dead-born 
Saved. 
1. Labor at Term.... 
2. Spontaneous Labor 
Total 
1 
50% 
1 
50% 
Vertex 1=100% 
Pelvic u 1 = 100% 
0 
0 
1 
100% 
1 
100% 
0 
1 
100% 
1 
100% 
0 
1 
100% 
0 
0 
1 
100% 
1 
100% 
0 
2 
0 
2 
100% 
1 
1 
50% 
1 
50% 
1 
50^ 
1 
50% 
Number 
of 
Presentation. 
Progress. 
Mothers. 
Infants. 
Cases. 
Natural. 
Artificial, 
Saved. 
Dead. 
Born 
Alive. 
Dying 
or Dead. 
Saved. 
1. Labor at Term.... 
2. Premature Labor. 
a. Spontaneous... 
b. Artificial Labor 
2 
25% 
1 
12.5% 
5 
62.5% 
- 
' Vertex 1= 50% 
Prolapse of Cord 1= 50% 
Pelvic 1=100% 
' Vertex 3= 60% 
Pelvic 1= 20% 
Shoulder 1= 20% 
0 
0 
1 
20% 
2 
100% 
1 
100% 
4 
80% 
0 
1 
100% 
3 
60% 
2 
100% 
0 
2 
40% 
1 
50% 
0 
1 
20% 
1 
50% 
1 
100% 
4 
80% 
1 
50% 
0 
0 
• Total 
8 
1 
12.50% 
7 
87.50% 
4 
50% 
4 
50% 
2 
25% 
6 
75% 
1 
12.50% 
Table IV.-Results in Eight Labors. Third Degree Contraction. 
Simply Contracted, 2, 25$; Generally flattened-Contracted, 6, 75$. Conjugate, 2.84 to 2.14 inches. 
Table V.-Results in Two Labors. Fourth Degree Contraction. 
Generally flattened-Contracted, 2, 100$ ; Dimensions, 2.14 and under. Winckel, from 1846 to 1876, induced labor 25 times; one woman was I- 
para, three II-parse, two Ill-parse. The ages varied between 21 to 45; 
seven from 20 to 30 years, fourteen from 30 to 40 years, four over 40. 
The operation was done: 
2 in the 31st week; 10 in the 32d; 12 in the 33d; 1 in the 34th. 
It was called for: in 12 by contraction to 2d degree; in 12 by contraction 
to 3d degree; and in 1 by contraction to 4th degree. 
There were 3 twin labors; 7 presentations of vertex, 12 of pelvic ex- 
tremity, and 8 of shoulder. 
The interval elapsing between induction and birth varied from 12 to 
168 hours: 
In 3 forceps to before-coming head. 
6 " " after-coming " 
5 external cephalic version. 
6 internal podalic " 
2 placenta praevia. 
3 artificial 3d stage. 
Mothers saved, 25; children born alive, 13; 6 dying in first 15 days. 
Ultimate results: Children saved, 7; children dead, 14. 
Fritsch, comparing the results given by other methods of interference, 
aside from induction of premature labor, noted: 
THE INDUCTION OF PREMATURE LABOR. 
195 
Cases. 
Children 
dead. 
Mothers 
dead. 
Forceps to head high up, 
25 
13 
1 
" " " down, 
256 
11 
3 
Podalic version, . . . . 
144 
45 
11 
Accouchements force, . 
8 
2 
2 
Pelvic extremity : 
Artificial delivery, 
113 
8 
1 
Perforation, . . . . 
14 
14 
1 
Third stage, artificial delivery, . 
52 
3 
It is apparent from this table that out of 551 operations where the aim 
was to save the mother and the infant, 18 mothers or 3.6^ died, and 144 
children, or deducting 44 dead and macerated before labor, 100, (20^.) 
In those cases where the infant was sacrificed, and the interests of th 
mother alone attended to, 66, mortality of 4, 6.4^. 
Wiener, of Breslau, has induced labor 16 times. Comparing the re- 196 
A TREATISE ON OBSTETRICS. 
1862.... 
1863.... 
1864.... 
1865 ... 
1866.... 
1867.... 
1868.... 
1869.... 
1870.... 
1871.... 
o 
i-1 i-1 i-i . >-» to 
Primiparae. 
Application of 
Forceps, 
Head high up. 
CO 
co co to • i-x-1 i-1 
Multiparae. 
63 
to to co xx i_k i_l to • 
Living. 
S' M 
p 
co 
to to xx to • xx jo 60 xx 
Dead. 
62 
4x4xrfx}o,-xxxiC>C04x- 
Living. 
Moth- 
ers. 
Dead. 
S 
CO 
4 
11 
16 
7 
12 
11 
16 
33 
35 
18 
Primiparae. 
Forceps. 
Head Engaged. 
CO 
co 
6 
5 
7 
2 
14 
3 
9 
24 
9 
14 
Multiparae. 
228 
10 
16 
23 
8 
19 
9 
19 
53 
39 
32 
Living. 
In- 
fants. 
00 
• CT rfx 05 CT -5 xx . 
Dead. 
253 
10 
16 
22 
9 
26 
13 
25 
57 
43 
32 
Living. 
Moth- 
ers. 
co 
: - : : xx : : : : 
Dead. 
1-1 
xx xx xx CO • : XX CO xx 
Primiparae. 
Podalic Version. 
co 
co 
M xx X- XX xx xx xx 
oo-^i-xh-iHx ositxtoooao 
Multiparae. 
io 
5 
4 
7 
7 
6 
6 
9 
4 
11 
13 
Living. 
In- 
fants. 
io 
3 
5 
5 
8 
10 
5 
5 
8 
7 
16 
Dead. 
co 
co 
6 
8 
10 
14 
16 
10 
13 
12 
18 
26 
Living. 
Moth- 
ers. 
Ei 
CO 1 1 u xx 1 XJ. to -x to 
Dead. 
£ 
to to CT xx CO to 1 1 to 
Primiparae. 
Labor in Pelvic 
Extremity. 
Artificial Termi- 
nation. 
4 
4 
9 
10 
7 
5 
4 
10 
17 
22 
Multiparae. 
63 ha 
haqdcocoqo<i<350i63^ 
Living. 
In- 
fants. 
io 
05 
CO xx to to KX CO 05 4X to to 
Dead. 
si 
60 HA HA 
^^0lC3OO63O^OI 
Living. 
Moth- 
ers. 
XX 
..... »-a . • • . 
Dead. 
^1 
........... 
Primiparae. 
Accouchement 
Forc6. 
oo 
. 4a. i-L i-k ha ►-a • I 
Multiparae. 
co 
• HA . . . • . . . ! 
Living. 
In- 
fants 
C7I 1 
• 60 • • ha . ha . I-1 
Dead. 
05 
• O0 HA • • HA . H • 
Living. 
Moth- 
ers. 
td 
• 1-1 • • ha • • • • • 
Dead. 
05 
ha • . qt • • • • • • 
Primiparae. 
Operations 
in 
Third Stage 
05 
xx <0 <X xx M 05 • 
Multiparae. 
SO 
6 
6 
1 
1 
7 
12 
2 
12 
2 
Living. 
Moth- 
ers. 
CO 
: : : : xx : : 
Dead. 
to 
: : : xx : : xx : : : 
Primiparae. 
Perforation. 
£ 
to to HX 1 to • XX . to to 
Multiparae. 
co 
to to xx xx to 1 l-x . to to 
Living. 
Moth- 
ers. 
xx::::::: xx :: : 
Dead. 
2 
27 
46 
54 
43 
53 
47 
59 
92 
103 
93 
Operations. 
Total Number 
of 
Operations. 
407 
19 
24 
36 
22 
32 
25 
31 
74 
72 
68 
Living. 
Infants. 
s 
6 
10 
11 
17 
20 
12 
15 
15 
17 
21 
Dead. 
g 
CT 
24 
45 
50 
40 
52 
43 
58 
92 
101 
90 
Living. 
Moth- 
ers. 
to 
to 
co to • HX 4x XX co 4X XX co 
Dead. 
From 1862 to 1871. THE INDUCTION OF PREMATURE LABOR. 
197 
suits for the mothers in these cases with those from spontaneous labor, 
since 1870, in case of pelvic contraction: 
Of 203 labors, in contracted pelvis, there were 10 maternal deaths, 5^; 
and 36 sick women, 17.7^; divided as follows: 
Flattened pelves, 132; of which number: 87 were 1st degree, and 48 
were 2d degree. 
Generally contracted pelves, 67; of which 20 were 1st degree, 46. 2d 
degree, and 1, 3d degree. Funnel-shaped pelves, 3; oblique 1. 
No. of 
Spontaneous Labor. 
Artificial Labor. 
Cases. 
* 
Cases. 
Mortality. Morbidity 
Cases. 
Mortality. 
Morbidity 
Per cent. 
Per cent. 
Per cent. 
Per cent. 
87 
Pelves flattened, 1st de- 
gree, 
75 
1.3 
14.6 
12 
8.2 
16.6 
45 
Pelves flattened, 2d de- 
gree, 
28 
25 
17 
11.8 
29.4 
132 
Flattened pelves, 
103 
1 
17.5 
29 
10.3 
24.1 
20 
Pelves generally con- 
traded, 1st degree, 
16 
4 
50. 
46 
Pelves generally con- 
traded, 2d degree, 
22 
27 
24 
16.6 
20.8 
67 
Pelves generally con- 
tracted, 
38 
16 
29 
20.7 
20.7 
In the contractions to the third degree, labor is always artificial. 
If now these cases be compared with the 16 where labor was induced: 
Spontaneous ter- 
mination, 9. 
Flattened pelves, 2 cases. 
Generally contracted, 6 cases. 
Oblique pelvis, 1 case. 
Labor induced 
16 cases. 
Flattened pelvis, extraction 
by trunk, 1 case. 
Generally contracted, (of 
which 3 extractions by 
trunk, 3 by version and 
extraction), 6 cases. 
Artificial termi- 
nation, 7. 
Three mothers died, 1 after spontaneous labor, 2 after artificial. 
Thus: 16 cases, mortality, 6.25^; morbidity, 25^. 
Of the children: 16 cases, 10 dead, 7 during labor; 3 soon after; 62.5^ 
Of the 6 infants remaining: 2 died 5 weeks after, of marasmus; in 2, 
result not known; 2 still living. 
Wiener's conclusions are as follows: " Artificial labor induced in pelves 
of 3.3 to 2.7 inches compromises the mother more than spontaneous labor. 
The same perhaps does not hold true for the foetus, but the advantage to 198 
A TREATISE ON OBSTETRICS. 
the latter is more apparent than real, since the majority die rapidly after 
delivery. " 
We have already given the results obtained at the Paris Maternite and 
at the Clinic, as deduced from the records by Rigaud and Stanesco. 
The induction of premature labor, then, is most likely to succeed the 
nearer term it is performed-that is to say, the less the pelvis is con- 
tracted, and consequently the less active and necessary secondary inter- 
vention, and, on the other hand, the greater the development of the 
foetus, and ability to exist outside of the uterus. 
As for the prognosis, when the pelvis is normal, and the operation is call- 
ed for by a complication of pregnancy, or a supervening disease, it should 
always be guarded; for, although, at times, we may thus save the mother 
and infant, in other cases it will be impossible to save the infant, endan- 
gered as it is already by the disease from which the mother is suffering; 
and often, by adding to the disease the shock of labor, the operation is 
simply an additional risk, and not only cannot save the mother, but will 
diminish her chances of survival. It should never be resorted to, there- 
fore, except as a last resort, when we are deprived of all other therapeutic 
means. CHAPTER VI. 
THE INDUCTION OF MISCARRIAGE. 
|^J"NDER the term induced miscarriage, we understand the artificial 
expulsion of the ovum at a time when the foetus is not able to ex- 
ist outside of the uterus, is not viable-that is to say, before the twenty- 
eighth week of gestation. 
The induction of artificial labor in case of pelvic deformity naturally 
led to the thought of the induction of miscarriage in cases of extreme 
pelvic contraction. It was also in England, in 1768, that W. Cooper, 
Barlow and Hull counselled miscarriage in place of the Caesarean section. 
From 1774 on, the induction of labor and of miscarriage rapidly spread 
throughout Germany, Holland and Italy. France alone rejected both 
procedures, and although, in 1831, Stoltz practised the induction of pre- 
mature labor, it was not till 1842 that P. Dubois, publicly at the Clinic, 
induced miscarriage in a case of contracted pelvis. The method was ac- 
cepted by Cazeaux, Lenoir, and others, but still was rejected by many, 
and to-day the induction of miscarriage is accepted in principle, although 
its two most decided opponents, Stoltz and Villeneuve, of Marseilles, re- 
ject it in case of contracted pelvis, where they prefer the Csesarean section, 
and authorize it in other instances, such as uncontrollable vomiting. 
To-day the question is definitively settled, and, as Devilliers justly says, 
"although, with us, civil and religious law does not make any distinction 
between criminal and medical miscarriage, yet the magistrates, on weighing 
the facts of an induced miscarriage, cannot, in justice, apply the penalties 
of the law. This is why the physician should never act except under 
the advice of experienced counsel. Still, if at the moment of sacrificing 
the foetus, his hand stops from conscientious motives, he may smother 
these, for both the sacred text and the college at Rome have given an 
affirmative answer to the question." 
As we have stated above, the principle of induced miscarriage is ad- 
mitted to-day, and authorities only differ in regard to the indications, 200 
A TREATISE ON OBSTETRICS. 
some deeming it justifiable when the mother's life is in danger from the 
fact of pregnancy, or of its complications, but excluding carefully pelvic 
deformity where they advise the Caesarean section; others include con- 
tractions of the pelvis. 
As for us, in accord with our teachers, we admit not only that we 
may, but also that we ought to induce miscarriage: 1. Whenever pelvic 
contraction is considerable, that is to say, below 2.34 inches; when the 
infant cannot be delivered by the forceps, and when embryotomy is so 
difficult as to compromise the life of the mother. 2. Whenever during 
pregnancy, either from this fact alone, or from intercurrent disease, the 
life of the mother is in danger, and the interruption of pregnancy would 
seem to deliver her from danger. In a word, between the foetal and the 
maternal existence we would never hesitate. 
Miscarriage should be induced: 1. In case of extreme pelvic deformity, 
under 2.34 inches. 2. Where the pelvis is obstructed by tumors which 
can neither now, nor later, be removed or pushed out of the way. 3. In 
uncontrollable vomiting. 4. In uterine retroversion. 5. In hemor- 
rhages, profuse, and endangering, either immediately or from recurrence, 
the life of the mother. 6. In every case where the life of the mother is 
endangered, (hydramnios, ascites, circulatory or pulmonary affections, 
etc.) We will examine each of these indications separately. 
Extreme Pelvic Deformity.-The opponents of the method, in these in- 
stances, base their views on the results obtained from cephalotripsy and 
the Caesarean section, in particular the latter. It suffices to glance at 
statistics to see how disastrous these operations are for the mother and 
the infant, cephalotripsy necessarily killing the foetus even as does mis- 
carriage, and the Caesarean section giving less satisfactory results than is 
ordinarily supposed. 
As regards cephalotripsy, De Soyre, in his thesis, gives the following 
figures: 
Pelves of less than 2.15 inches: 
Lauth.-16 cases: mothers saved, 9; mothers dead, 7. 
Gueniot.-4 cases: mothers saved, 1; mothers dead, 3. 
Pajot.-7 cases: mothers saved, 5; mothers dead, 2. 
Bi gaud.-2 cases: mothers saved, 1; mothers dead, 1. 
Stanesco.-3 cases: mothers saved, 2; mothers dead, 1. THE INDUCTION OF MISCARRIAGE. 
201 
De Soyre.-20 cases mothers saved, 13; mothers dead, 7. 
That is, of 52 cases: 32 recoveries, 20 deaths, 38.46 per cent. 
From the Caesarean section, the results are scarcely more brilliant: 
Kayser.-338 cases: mothers saved, 128; mothers dead, 210. 
Murphy.-477 cases: mothers saved, 176; mothers dead, 301. 
Baudelocque, 
Michaelis, 
Velpeau, 
Sprengel, 
Simonart, 
Hubert de Louvain, 
1,274 cases. 
Mothers saved, 554. 
Mothers dead, 720. 
Churchill, 
Figueira, 
West, 
Constantin, 
Joulin, 1,785 cases. 
Mothers saved, 844. 
Mothers dead, 941. 
Gueniot cites the following figures, which formally contradict one an- 
other: 77 cases-mothers saved, 47; mothers dead, 30. 69 cases- 
mother saved, 5; mothers dead, 64. 
Finally, as De Soyre says, we must take into account the infantile mor- 
tality after the Caesarean section. From Joulin's table, borrowed from 
Churchill, West, Kayser and Constantin, of 1,050 operations, 352 chil- 
dren were dead, 35.5 per cent. 
Therefore, if miscarriage always sacrifices the infant, it saves the ma- 
jority of women at least, and we do not think there is scope for hesitation. 
Still, we must make a distinction between pelves deformed by rickets 
and by tumors and osteo-malacia. In the latter, indeed, the bones, in 
certain cases, are so flexible and supple, that, as is proven by the facts of 
Pagenstecher, Kilian, Schroeder, and others, even pelves with absolute 
contraction may yield to the pressure of the foetal body, and allow birth 
at term. We might, therefore, here, wait for the induction of prema- 
ture labor. 
Uncontrollable Vomiting.-This is one of the most frequent indications 
after contracted pelvis, and all authorities are in agreement. The inter- 
ruption of pregnancy is the only means of saving the mother, and on one 
condition, that we do not interfere too late. 
From the statistics which Gueniot has collected, it is apparent that 
out of 118 cases 72 women recovered and 46 died. The 72 recoveries 
occurred: 202 
A TREATISE ON OBSTETRICS. 
Without miscarriage, all grave cases and subjected to varied treat- 
ment, 31. After spontaneous miscarriage, equally grave cases, 20. After 
induced miscarriage or labor, desperate cases, 21. 
41 times, then, out of 72, cure resulted from premature labor, or mis- 
carriage, artificial or spontaneous. 
As for the deaths: Without miscarriage, 28. After miscarriage or 
spontaneous premature labors, 7. After induced miscarriage, 11. 
McClintock reported to the Dublin Medical Society 36 observations of 
premature labor in case of uncontrollable vomiting, and of these 27 lived, 
and 9 died. 
Cohnstein makes a distinction between multipara? and nullipara?, and 
does not counsel interference in the former: "after the expulsion of the 
foetus, vomiting ceases in 40# of the cases. But we must distinguish be- 
tween provoked and spontaneous miscarriage, since the former is 25# of 
the 40#, and the latter 15#. The remaining 60# includes the cases where 
vomiting only partially ceased, 26#; those where it persisted, 18#; those 
where it increased, 4#; and those where death occurred at once or shortly 
after miscarriage, 12#. He concludes that it is better to await spontane- 
ous miscarriage." 
We saw in the chapter on uncontrollable vomiting, that the selection of 
the time is of capital importance, and that it should be fixed at the end 
of the second period, without awaiting the third, the chances of recovery 
diminishing with waiting. 
Finally, among the causes which justify miscarriage, we must cite re- 
troversion of the uterus, hydramnios, molar pregnancies, and certain in- 
stances where the life of the woman is seriously endangered, pregnancy 
being complicated by oardiac or pulmonary lesions, or by intercurrent 
diseases. 
Miscarriage once decided upon, it remains to choose the time and the 
method. 
If it be disease which calls for the operation, the time is, of course, sub- 
ordinated to the condition of the patient. We can fix no precise date. 
We must neither act too soon, nor yet too late. The same does not hold 
in case of pelvic deformity. Here the accoucheur, ordinarily, may choose 
his own time, but we must not forget that miscarriage is less grave at 
certain periods than at others. Although during the first two months, 
and generally from the fifth to the sixth month, miscarriage is simple and THE INDUCTION OF MISCARRIAGE. 
203 
without complication, it is far otherwise from two and a half to four and 
a half months. It is usually, at this time, that we meet with serious hem- 
orrhages, and miscarriage in two stages with retention of the secundines, 
and its sequelae. It is of advantage, then, to practise the induction of 
miscarriage in the first two months, or after the fifth. 
We are not, however, always free to choose, because, on the one hand, 
the patients are rarely seen before the third month, and because later we 
must take into account the degree of contraction, the volume of the 
foetus, and the size of its head. De Soyre insists, particularly, on this 
point. The figures in the following table represent the mean dimensions 
of the foetal head before term: 
Months. 
Weight in 
grains. 
Length in 
Inches. 
Occipito- 
frontal 
Diameter. 
Bi-parietal 
Diameter. 
Three Months 
1,500 
6.63 
1.56 
1.37 
Three Months and a half 
1,950 
9.36 
2.34 
1.56 
Four Months 
2,280 
7 99 
1.85 
1.76 
Four Months and a quarter .. 
4,500 
8.58 
1.95 
1.95 
Four Months and a half 
6,300 
10.14 
2.54 
2.34 
Five Months 
8,325 
11.89 
2.73 
2.34 
Five Months and a quarter.. . 
9,000 
12.87 
2.93 
2.54 
Five Months and a half 
9,150 
11.70 
2.63 
2.40 
Six Months 
16,920 
13.84 
3.51 
2.80 
Six Months and a half 
19,950 
15.60 
3.71 
2.93 
Up to this period, then, the foetal head, on account of the flexibility 
of the bones, is much more reducible than at term, a reducibility which 
is increased by the width of the fontanelles and the sutures. It is, there- 
fore, the degree of contraction which should guide us. 
De Soyre divides pelves into two classes: 1. Those having at least 2.34, 
and not under 1.56 inches. 2. Those under 1.561 inches. 
In the first, the pelvis being at least 1.56 and the foetal head at 6| 
months having a bi-parietal diameter of 2.93 inches, reducible by at least 
. 78 of an meh, miscarriage should be induced between 4| and 5^ months, 
that is, we wait as long as is possible. 
In the second category, when the pelvis is 1.56 or less inches, the head 
admitting only .78 inches reduction, premature miscarriage should be 
induced all the more quickly, as the pelvis falls under 1.56 inches. 
We may say then: 
In pelves of 1.56 inches miscarriage need not be induced until 5 
months; of 1.17 inches 4 to 4^ months; of .98 inches 3| to 4 months. 204 
A TREATISE ON OBSTETRICS. 
Under .98 inches, if the patient is not seen till after the third month 
and a half, the Caesarean section is the only recourse. 
As for the operative methods, they are identical with those described 
in the previous chapter. Our preference, seeing that we take no account 
of the foetus, is for rupture of the membranes. The only precaution we 
must take is not to wound the uterus. CHAPTER VII. 
THE CESAREAN SECTION. 
NDER the name, Ccesarean section, sectio Ccesarea, partus Ccesareus, 
hystero-tomotoky, we understand an operation which consists in 
opening the abdomen and the uterus of the gravida, in order to deliver 
thus artificially the f cetus, which cannot be born by the natural passages. 
History and Statistics.-Pliny tells us that this operation owes its name 
to the fact that the first of the Cassars was thus brought into the world, 
but according to others, its name is derived from the operation itself, 
cceso matris utero. It is practised not only on the living, but on women 
dead during pregnancy and labor. 
Made lawful by the royal laws of Numa Pompilius, adopted by the 
Christian church, counselled by the Talmud and the Koran, it was prac- 
tised for the first time in 1500, on the living woman, by Jacques Nufer, 
a swine herdsman, on his own wife, with success; but it was not till 1581 
that the first treatise on the subject was written by Rousset. Opposed by 
Ambroise Pare, Guillemeau, Mauriceau, Viardel, Pen, Dionis, Amand; 
it was again successfully performed by Ruleau. Then appeared the mono- 
graphs of Simon and of Levret. About the middle of the last century 
occurred the celebrated quarrel between the Symphysiotomists and the 
C.aesarianists, but, notwithstanding the intense advocacy of Saccombe and 
his anti-Caesarean school, cases multiplied. Although all the successful 
cases were published, it was far otherwise with the others, and thus it is 
very difficult to give exact figures in regard to frequency and results; 
and it is only since the middle of the last century that we have been able 
to weigh the operation at all from the standpoint of its results for mother 
and for child. 
Harris gives the data of 120 cases in the United States, and one fact is 
striking-the difference in the results obtained in the city and in the 
country: 206 
A TREATISE ON OBSTETRICS. 
In the country, . . 32 cases Recoveries 20-62^ 
In the towns, . . 55 " " 19- 
In the cities, . . 33 " " 11-33^ 
In 1866, Gueniot collected the following figures: 
Cases. 
Recoveries. 
Deaths. 
Percentage. 
Hull 
231 
139 
92 
39.82 
Klein 
116 
90 
26 
22.44 
Michaelis, (1801-30) 
258 
118 
140 
54 26 
Kayser, (1750-1839) 
338 
128 
210 
62.00 
Burns 
24 
2 
22 
91 66 
( (British) 
56 
10 
46 
) 
Murphy -j (U. S.) 
12 
8 
4 
((Europe) 
409 
158 
| 63 00 
' Baudelocque, (1750-1816).. 
73 
31 
42 
57.55 
Michaelis, (1801-1832) 
110 
48 
62 
56.36 
Hubert Velpeau, (1700-1835) 
265 
118 
147 
55.47 
Sprengle, (18th century)... 
116 
61 
45 
42.45 
Simonart 
720 
296 
424 
58 88 
Pihan-Duffeuillay 
88 
50 
38 
43 18 
Kayser 
79 
Hoebecke 
16 
11 
5 
31.24 
Bosch 
5 
4 
1 
20 
Stoltz 
6 
4 
2 
33.33 
Winckel 
15 
7 
8 
53 33 
Kilian 
7 
4 
3 
42 85 
Bili 
8 
3 
5 
62.05 
Bormey 
2 
1 
1 
50 
Jolly 
6 
2 
4 
66.66 
a- 
oi mon 
23 
4 
19 
82.60 
Guillemeau 
5 
5 
100 
Sentin 
14 
14 
100 
P. Dubois 
17 
17 
100 
Depaul 
4 
4 
100 
Danyau 
3 
3 
100 
Kunecke 
6 
6 
100 
Bouchacourt 
5 
1 
4 
80 
Schroeder, in 1874, gives the following more recent statistics, com- 
piled by Mayer: 
Cases. 
Recoveries. 
Deaths. 
Percentage. 
England 
480 
236 
244 
50 
Germany 
712 
332 
380 
53 
France 
344 
153 
191 
55 
Belgium 
11 
4 
7 
63 
Italy 
46 
5 
41 
87 
America. 
29 
8 
21 
33 
1,622 
738 
884 
54 
[From the latest publications of Harris on the Caesarean section in the 
United States, we have collected the following data in regard to the opera- 
tion from 1846 to the end of 1886: THE CAESAREAN SECTION. 
207 
Prior to 1846 there were 21 operations with 13 maternal recoveries and 
10 children saved. 
From 1846 to 1855, 25 operations: women saved 12, lost 13. Children 
delivered alive 13, dead 12. 
From .1856 to 1865, 25 operations: women saved 12, lost 13. Chil- 
dren delivered alive 10, dead 15. 
From 1866 to 1875, 36 operations: women saved 10, lost 26. Chil- 
dren delivered alive 11, dead, 25. 
From 1876 to 1886, 37 operations: women saved 8, lost 29. Children 
delivered alive 16, dead 21. 
Thus out of 144 operations, 55 mothers were saved and 60 children 
were delivered alive. In 42 of these cases, according to the same author- 
ity, uterine sutures were employed. 
From a personal communication from Lungren, of Ohio, we gather 
that in this State alone there have been 13 operations with 9 maternal 
recoveries and 8 children born alive. Lungren has, himself, operated 
three times, twice on the same woman. These women recovered, and the 
one operated on twice is still living with her Caesarean children.-Ed.]. 
The mortality, in general, from the Caesarean section varies from 54^ 
to 60^. It is not, therefore, astonishing to find accoucheurs admitting 
the justifiability of the Caesarean section only exceptionally, and prefer- 
ring, whenever at all possible, cephalotripsy or embryotomy. 
[While this statement was true enough at the time of the author's writ- 
ing, it is no longer so, since the improved Caesarean section has been ad- 
vocated and performed, in particular, by Sanger and Leopold. This im- 
proved Caesarean section depends largely on the method of suturing 
employed for the uterine wound, and the greater success must also, in 
part, be laid to the score of earlier, more timely operation. In Germany 
this improved section is called after Sanger, w'ho claims to have originated 
the method of suturing, which consists essentially in bringing the sur- 
faces of the peritoneum in contact, in other words, the aim is at a seroso- 
serous apposition. While there can be no question that, owing to San- 
ger's writings, this method of suturing has become popularized, it is still 
true that he was by no means the first to use it, and it is further estab- 
lished, that the modified Csesarean section, as performed to-day, is lacking 
in some of the details (excision of the muscularis, for instance) on which 
Sanger laid stress in his earlier writings. Careful study of the literature 208 
A TREATISE ON OBSTETRICS. 
of this operation would lead us to reject giving to it the name of any 
special operator, although to Sanger, more than to any one else, belongs 
the credit of its special advocacy. Harris, of Philadelphia, writes us: 
"lam not in favor of calling operations after the names of men, as the 
title of an operation should be explanatory, if possible. The Caesarean 
operation, with the seroso-serous multiple suturing of Sanger, would be 
proper." Garrigues, after an exhaustive and careful survey of the litera- 
ture of the subject, claims that the improved Caesarean section of to-day 
is the outcome of many improvements which have originated in time, 
and in the hands of different operators. These improvements he classi- 
fies as follows: The antiseptic treatment; early operation; turning out 
the uterus before incision; the insertion of a few sutures at the upper end 
of the incision in the abdominal wall, so as to tie them promptly when 
the uterus is turned out, thus preventing protrusion of intestines and 
entrance of blood into the peritoneal cavity; the pushing of a piece of 
disinfected gutta-percha tissue behind the turned-out uterus, in order 
further to protect the peritoneal cavity; the compression of the cervix 
by means of a rubber tube, in order to avoid or arrest hemorrhage from 
the uterus ; the avoiding of shock by wrapping the uterus in warm cloths; 
the method of uterine suture. 
As for this suture, the essential part of which is the bringing of the 
peritoneal surfaces into contact, it has long been recognized as of great 
advantage. In the United States Lungren, of Ohio, used it in his two 
operations on the same woman (1875, 1880); Baker, of Indiana, in 1880, 
put " four carbolized silk sutures in the uterus, not through the entire 
thickness of the walls, but passed in near the mucous surface and out a 
short distance from the incision through the peritoneal coat, so that when 
they were tied they brought the peritoneal coats together first. " Spencer 
Wells, in 1881, in speaking of the removal by laparotomy of tumors from 
the uterine wall, clearly proved the advantage, not alone of a seroso-serous 
suture, but of deep muscular sutures as well; Garrigues, himself, in 1882, 
used this double method of suturing. In 1882 Sanger's first contribution 
to the subject appeared, in which he advocated the removal of a piece of 
the muscularis from both edges of the uterine wound, resection of the 
peritoneum, but there is no special reference to turning in of the peri- 
toneal surfaces, and their suture in this position. Leopold shortly put 
these recommendations into practice, but has since, with Sanger, Credo, 
and others, dispensed with exsection of the muscularis. THE CAESAREAN SECTION. 
209 
From this sketch of the details which go to form the modified Caesarean 
section, we believe it apparent that to no single operator should belong 
the honor of having it called after him. Sanger is unquestionably entitled 
to much of the credit, and it is through his writings that certain details 
have become popularized, but to call the operation after him is to give 
no credit to the gentlemen who individually contributed to its present 
success by the introduction of certain details and the rejection of others. 
We much prefer, therefore, to call the operation the modified Cesarean 
section, which is a non-committal and yet sufficiently distinctive term. 
For the latest statistics we are again indebted to Robert P. Harris: 
Up to 1886 there have been performed 38 operations, which may be 
classified as follows: 
Countries. 
Cases. 
Maternal 
Recoveries. 
Maternal 
Deaths. 
Children 
Saved. 
Children 
Lost. 
Percentage 
of 
Maternal 
Recoveries. 
Germany 
25 
21 
4 
24 
1 
84 
United States... 
5 
0 
5 
2 
3 
0 
Austria 
4 
2 
2 
1 
0 
50 
Italy 
2 
1 
1 
4 
3 
50 
France 
2 
2 
0 
2 
0 
100 
The percentage of women saved in all countries is 68T8T; and that of 
women saved in Europe is 78. 
Since the above figures of Harris there have been no cases recorded. 
Lusk, within a few weeks, has operated on a case successfully as regards 
both the mother and the child. In this country, as Harris justly puts 
it, we have yet to learn to make the operation one of choice and not of 
compulsion. 
The record of individual operators from the improved Caesarean section 
is of special interest. Credo, in his analysis of 26 cases, notes the follow- 
ing points: 
Recovery of the mother, 76.0^ 
Death, " " ..... 24.0^ 
Children born alive, . . . . . . 88.4^ 
" " dead, 11.6^ 
In three of the fatal maternal cases, septic infection existed before 
labor; twice, in very grave cases, infection occurred during the operation; 
in two cases the patients died of other grave complications. 
Of 23 cases with 4 deaths, operated upon in Germany and in Austria, 
Vol IV.-14 210 
A TREATISE ON OBSTETRICS. 
not a single death is referable to the operation itself, or to the method 
employed. 
Of Leopold's ten cases, one of which was operated upon by Korn: 
Nine recoveries (maternal) ..... 90^ 
One death " ..... 10^ 
Children delivered alive, ..... 100^ 
Of G cases operated upon at Leipsic, 4 by Sanger, and one each by 
Obermann and Donat, there was not a single maternal death, and all the 
children were saved. 
From these groups, then, we obtain a total of 16 cases with 15 maternal 
recoveries (93.7^), and all the children living. 
The great point which stands out clearly from these cases is the neces- 
sity of timely operation.-Ed.] 
Levret and Simon first formulated the indications for the Caesarean 
section, and it is thanks to their efforts that the operation was made jus- 
tifiable. They found ready followers in Smellie, Stein, Baudelocque, 
Stoltz, etc. These indications may, according to Naegele and Grenser, be 
divided into absolute and relative. 
Absolute.-When the pelvic contraction is so pronounced that the foetus 
can be delivered, neither living nor dead, by the genital passages. 
Relative.-When the pelvis is so contracted that the foetus cannot be 
delivered at term without mutilation; that is, when we have to choose 
between cephalotripsy, embryotomy, and the Csesarean section. 
Authorities, however, are not in accord in regard to the limits to be 
assigned to contractions of the pelvis. Thus: Baudelocque places the 
limit at 2.6 inches. The cephalotribe invented by his nephew lowers this 
limit, and P. Dubois, who accepts 2.6 inches when the foetus is living, labor 
begun, membranes intact or recently ruptured, places the limits of ceph- 
alotripsy at 2 inches when the foetus is dead. 
Jacquemier descends to 2 inches, foetus living. 
Cazeaux " " 1.95 " 
Tarnier " " " " 
Depaul descends to 1.56 inches, although he prefers the Csesarean 
section in pelves of 2.34 to 1.56 inches when the foetus is alive. 
Stoltz invariably rejects embryotomy when the foetus is alive, as well as 
induced miscarriage; and far from lowering the limits of the Caesarean 
section, he tends to raise them. Gueniot places the limit at 1.56 inches; THE CJESAREAN SECTION. 
211 
Joulin at 1.56 inches; Michaelis at 1.83 inches; Scanzoni performed 
Caesarean section from 2.65 to 3.12 inches. Naegele and Grenser con- 
sider 2.51 inches as the extreme -limit for embryotomy. They cite, how- 
ever, four cases of Michaelis at 1.83 inches, and Osborne's extraordinary 
case, where the diminished foetus was extracted through a pelvis of .8 
of an inch. Schroeder states no limit, but admits as an indication ex- 
tensive cancer of the soft parts. Spiegelberg admits that we should resort 
to the Caesarean section down to 2 inches, but, in case the pelvis is ob- 
liquely contracted, embryotomy is practicable down to 1.5 inches. Barnes, 
who admits the absolute and relative indications, performs, nevertheless, 
embryotomy in pelves of 1.4, 1.2, and even .98 inches. Playfair resorts 
to the Caesarean section below 1.4 inches; Hyernaux below 1.85 inches. 
Hubert de Louvain, on the other hand, resorts to the Caesarean section if 
the infant is alive in pelves of 2.73. 
In view of the danger from cephalotripsy, and the disastrous results 
under 1.56 inches, we believe we should accept this as the figure under 
which the Caesarean section is called for; nevertheless, the results obtained 
by Pajot through his method of repeated cephalotripsy without traction are 
so satisfactory, that down to 1.17 inches it is allowable to choose between 
the two operations. In reality, however, for the majority of accoucheurs, 
the indication for the Caesarean section is absolute under 1.5 inches. 
As for the relative indication, it depends entirely on the judgment and 
feeling of the individual accoucheur. Although the majority prefer to 
sacrifice the living infant in the hope of increasing the maternal chances, 
a certain number, in France and abroad, do not believe that they have 
the right to kill the foetus, and prefer to perform the Caesarean section 
even in pelves of 2.73 inches. Their reasons are the following: 
1. Embryotomy performed in such a pelvis is as dangerous for the 
mother as the Caesarean section. 
2. Embryotomy always kills the foetus, while the Caesarean section, 
performed at the proper time, should always save the foetus. 
3. We have no right to kill the foetus when we may save it, and, at the 
same time, not seriously compromise the life of the mother. 
These objections, we believe, are not really tenable : 
1. We have seen that the mean mortality rate from the Caesarean section 
may be placed at 54^. If, now, we look at the figures from cephalotripsy, 
we find that in 67 cases of pelvic deformity, from 2.53 to 1.4 inches, there 212 
A TREATISE ON OBSTETRICS. 
were 39 recoveries and 28 deaths, a mortality of 41.79# (Maygrier's thesis, 
1880); and among these cases there were 31 where the pelves measured 2.34 
inches at the highest, with 17 recoveries and 14 deaths, a mortality of 
only 45.16#. The Belgian statistics are still more favorable: In 79 cases 
of contraction to 2.73 inches and below, where the saw-forceps was used, 
there were 86 recoveries and only 10 deaths, that is to say a mortality of 
10.41#: 
56 cases, 2.73 to 2.34 inches contraction, 52 recoveries; 4 deaths, mor- 
tality of 7.14#; 40'cases, below 2.34 inches, 34 recoveries, 6 deaths, mor- 
tality 15#. 
Hubert, the younger, perforates, and in 18 cases, 2.93 to 1.56 inches 
contraction, had 16 recoveries, 2 deaths, mortality of 11.11#. 
The results, hence, are certainly more favorable when the foetus is 
sacrificed. 
Pajot, with cephalotripsy repeated without traction, in 8 cases, in pelves 
from 2.34 inches to 1 inch, had 6 recoveries. 
2. The Csesarean section, the objectors say, should always give a living 
infant. Practically this is not true; for it results from Kayser's figures 
that the infantile mortality is 30#, and in this figure are not included 
those which die in the first days after birth. 
3. The third objection, we think, is also of no value. We do not be- 
lieve we have the right to hesitate between the precarious life of an infant 
and that of an adult woman who, likely enough, may bear other children. 
What should ever guide the accoucheur is the interest of the mother, 
even though this entails the sacrifice of the child; and even as we main- 
tained the right of the accoucheur to induce miscarriage, even so do we 
claim that he has not the right to wilfully expose the woman to the dan- 
gers of the Csesarean section. As Cazeaux justly says, "that which is 
certain in the Csesarean section, is that we sacrifice at once at least one 
half the women; and, further, what the experience of centuries proves, 
supposing all the infants to be extracted alive, not one half will reach the 
age attained by their mothers." 
For us, the section should be an operation of absolute necessity, and 
we do not admit the relative indications; and as long as the instrument, 
cephalotribe, saw-forceps, perforator, etc., can pass, it is to it that we 
give the preference. Repeated cephalotripsy, without traction, is a marked 
progress, since it has enabled Pajot to save 6 women out of 8, where the THE CAESAREAN SECTION. 
213 
pelves were contracted from 2.34 inches down to 1 inch. As to whether 
the Porro operation is as great a progress, we will see presently. 
[As we will note later on, laparo-elytrotomy, as revived by Thomas of 
New York, would seem to offer the best chances to both the mother and 
the child, when performed at the time of election.-Ed.] 
Although Rousset included among the indications for the Caesarean 
section, excessive size of the foetus and mal-presentations, tumors and 
congenital vices in development of the genital canal, etc., Simon and 
Levret reduced these indications to cases of pelvic contraction and cer- 
tain large tumors of the cervix, to which Baudelocque added schirrous, 
broad-based tumors, which were not operable except at greater risk than 
the section offered. To-day, these indications, we have seen, are reduced 
nearly to pelvic deformity; for cases of fibrous tumors, seeming to call for 
the Cesarean section, have been reported where labor has terminated 
spontaneously, even with living children, proving how great are the re- 
sources of Nature, and to what extent we ought to count on her coming 
to our aid. The same is true of carcinoma of the cervix, although here 
we might well hesitate, seeing that the mother is already condemned, as it 
were, to death from the fact of the disease alone. We still, however, 
believe that here, as well, the Caesarean section should be postponed to 
the utmost limit. As regards osteo-malacia, in certain cases a natural 
termination of labor is possible, and therefore we should act with thd 
greatest reserve. 
As for the contra-indications, they depend on the state of the mother 
and on that of the foetus. If the foetus is dead, if the mother is exhausted 
by long labor or by repeated attempts at delivery, anything, we believe, 
is preferable to the Caesarean section, for we would simply diminish her 
chances by an operation which might not save the foetus. Three condi- 
tions, hence, we think, are absolutely indispensable, in order to justify 
the-operation: 1. The necessity must be absolute, that is to say, there is 
no other method of terminating labor. 2. The child must be living and 
viable. 3. The mother must formally consent to the operation. None 
of the risks should be hidden from her. As Naegele and Grenser re- 
mark, " the intellectual state of the mother may render her incapable of 
judgment. In this case it belongs neither to the husband, nor to the 
family, nor to the physician, to decide in favor of the Caesarean section. 
We must then resort to every other method less dangerous to the woman, 
except when the section really affords her better chances." 214 
A TREATISE ON OBSTETRICS. 
Once having determined on the operation, what is the time of election ? 
AH authorities are in agreement here. It is just before, or just after, 
rupture of the membranes-that is to say, "when dilatation has proceeded 
to a degree, and the uterine contractions are intense and regular. Graefe 
is the only one who counsels waiting later. 
Without being possibly of very great importance, the length of the labor 
is an element in prognosis: Kayser, in 164 cases where the duration of 
labor was noted, found: 
Mothers. 
Infants. 
Recovered. 
Died. 
Recovered. 
Died. 
After 24 hours duration, 
20 
40 
42 
16 
" 24 to 72 hours " 
34 
41 
48 
24 
Over 72 " " 
8 
21 
11 
17 
1 
- 
- 
- 
- 
62 
102 
101 
57 
lie thinks, then, that only after 72 hours does duration have a bad 
effect. 
Harris, however, proves that after 24 hours the influence is bad: 
Before 24 hours, . . 7 operations 7 recoveries 
" 34 " . . 7 4 
After 34 " . .10 " 1 recovery. 
Of 100 cases collected by Radford: 
Before 24 hours, . . 24 operations 7 recoveries 
After " " . . 76 " 9 " 
Harris, in 17 personal cases, and where the operation was undertaken at 
the end of the first day of labor: 
In 7 cases before 34 hours, ... 4 recoveries 
" 10 " after "..... 1 recovery 
In 16 cases where peritonitis occurred after operation, 13 times the 
operation was performed 30 hours after the beginning of labor. 
Radford, in 100 cases: 
24 before 24 hours, 7 recoveries 
76 " " " 9 
and he places the mortality at 70 to 88^. THE CAESAREAN SECTION. 
215 
A curious fact is that the operation seems to lose gravity when practised 
for the second time on the same woman. Lungren, in this connection, 
gives the following figures: 
Of 48 women subjected altogether to 119 sections, 8 died, and 40 re- 
covered. 
Operation. 
Preliminary Precautions.-These are absolutely the same as for ova- 
riotomy: An isolated, room, temperature of 80° to 90° F., filled with car- 
bolic spray. All instruments and sponges (new) should be soaked in a 
carbolized solution, having previously been for twenty-four hours in 
alcohol. Operate on a table. Four assistants, at least, are needed: one 
to anaesthetize, another to hold the uterus through the abdominal walls, 
One to hand the instruments and to watch the spray, one, a nurse, to 
receive the infant. The necessary instruments, etc., are: a convex and a 
blunt-pointed bistouri, a director, ligatures, artery forceps, tenacula, 
scissors, silver wire, needles, and six to eight lengths of diachylon plaster 
to go around the body once and a half, cotton, napkins, etc. The rectum 
and bladder should be emptied. 
The lateral incisions of Levret, the transverse of Lauverjat, the oblique 
or diagonal of Stein, the younger, Osiander's method, are to-day abandon- 
ed in favor of Deleurye's method, incision in the linea alba. (Fig. 130.) 
The uterus must be brought to the mid-line, and held there by an as- 
sistant, and by percussion we must assure ourselves that there is no in- 
testine between the organ and our line of incision. 
Gastro-elytrotomy.-1This is an operation which consists in opening into 
the vagina, through an incision made in the abdomen, so as to avoid the 
peritoneum. It was proposed by Joerg, modified by Ritgen and the 
younger Baudelocque, and then was forgotten till in the last few years it 
was resuscitated by Thomas, Skene, Edis, Garrigues. Notwithstanding 
the favorable results obtained in America, the operation has not been 
accepted in France, where the classic Caesarean section is in high favor. 
[Notwithstanding the fact that laparo-elytrotomy, as modernized by 
Thomas, of New York, has not been received with favor in France or 
Germany, or, with two exceptions, in England, this essentially American 
operation should have the preference over all others, where the operator 216 
A TREATISE ON OBSTETRICS. 
can elect the time,*seeing that, uniformly, under such conditions it has 
given the best results both for mother and child. 
The preliminary precautions, as regards cleanliness and the preparation 
of the woman, are similar to what should hold for any major abdominal 
operation. The incision should be made on the right side, about 1 inch 
above Poupart's ligament, and extending from an inch above the anterior 
superior iliac spine to within about 1| inches of the spine of the pubes. 
The muscles and the fascia are to be divided carefully on a director down 
Fig. 130.-Different Incisions.-a, Levret's, b, Stein's, c, In linea alba, d, Lauverjat's. e, 
Osiander's. f, Ritgen's. 
to the peritoneum, always remembering the danger of wounding the 
peritoneum. When this has been exposed, it is to be separated from the 
fascia iliaca and pushed above. The lateral vaginal wall is thus reached. 
At this point the ureter is to be carefully sought for, isolated, and lifted 
out of the way. The vaginal wall should be pushed upward into the 
wound by a sound in the vagina, and then nicked with the scissors, or 
burnt through with the Paquelin cautery, when it is to be torn as far as 
is necessary by the fingers. The cervix is then to be brought into the 217 
THE CAESAREAN SECTION. 
wound, and the child extracted, manually, or by the forceps, carefully 
watching lest the ureter be injured. 
Such is the operation of laparo- or gastro-elytrotomy. It is extra- 
peritoneal; the uterus is not wounded; the peritoneum should not be; 
the ureter and bladder are the only organs likely to be injured. To 
determine this, it is advisable to inject warm water or milk into the blad- 
der, before suturing the incision. The after-treatment is similar to that 
after any abdominal incision. 
The time of election, and indeed the necessary precautions for its full 
success, are: By preference, head above the brim, or just engaged, mem- 
branes unruptured or just ruptured, cervix dilated or dilatable, and 
lastly, timely resort to operation, before exhaustion has at all set in. 
This is the key-note to success. 
By the operation of laparo-elytrotomy, shock and danger of septicaemia 
are far less than in the classic Caesarean section; secondary hemorrhage 
is hardly a factor, and yet, even after the improved Caesarean section, 
there is still danger of internal hemorrhage from tearing of the sutures 
or relaxation of the uterus. In case the bladder is torn or cut, sew it up 
at once. 
The operation has now, January, 1877, been performed 12 times, so 
far as they have been recorded, with six maternal deaths and five in- 
fantile: 
♦ 
Mother. 
Infant. 
1. T. G. Thomas,U.S., 
2. Skene, " 
3. Skene, " 
4. Skene, " 
5. Thomas, " 
6. Hime, England, 
7. Edis, 
8. Gillete, U.S., 
9. Dandridge, U.S. 
10. Jewett, " 
11. Skene, " 
12. Jewett, " 
7thm'th, 
At term, (C.V. 2| in.) 
" (C.V. 2j in.) 
" (C.V. If in.) 
" (C.V. 2J in.) 
" (21 in.) 
" (If in.) 
" (2f in.) 
66 
" (less than 2 in.) 
" (41 in.) 
Died. 
Died in 7 hrs. 
Recovered. 
Recovered. 
Recovered. 
Died in 2 hrs. 
Died in 40 hrs. 
Recovered. 
Died in 40 hrs. 
Died in 72 hrs. 
Recovered. 
Recovered. 
Lived one hour. 
Dead. 
Recovered. 
Lived 18 days. 
Saved. 
Saved. 
Saved. 
Putrid. 
Dead. 
Dead before delivery 
Saved. 
Saved. 
Of these twelve operations, all the mothers that were lost were in an 
exhausted condition, and, in a number, previous attempts at delivery, 
forceps, version, craniotomy, had been made. The operation, then, in 
/ . . 
these cases, was not done in time, and judging from the cases which 
recovered, had laparo-elytrotomy been resorted to at once, instead of pre- 218 
A TREATISE ON OBSTETRICS. 
cious time having been lost, all might have recovered. It is further to 
be noted, that of the six successful cases, three were done in hospital. 
As for the child, in three instances it was dead before operation, in one 
it died during extraction. 
From these data, we believe the assertion justifiable that laparo-elytro- 
tomy, resorted to early, offers the best chance of all operations which aim 
at saving the Qhild, as well as the mother. It is questionable, indeed, if, 
in the near future, it is not destined to supersede, where the child is 
alive and the time is opportune, not only the Caesarean section (classic and 
modified), and Porro's operation, but also to relegate to their proper 
sphere, where the child is dead, in particular, the mutilating methods, 
craniotomy, cephalotripsy, embryotomy.-Ed.] 
In the performance of the classic Caesarean section, we may distinguish 
foui' stages: 1. Opening the abdominal cavity. 2. Opening the uterus 
and extraction of the foetus. 3. Removal of the placenta, arrest of hem- 
orrhage, toilette of the peritoneal cavity. 4. Suture of the abdominal 
wound, and dressing. 
Incision into the Abdominal Cavity.-The operator stands on the right 
of the patient, and with the convex bistouri makes an incision five and 
a half inches long, down to one inch above the pubes. The incision should 
be in the linea alba. It is carefully prolonged to the peritoneum, cutting 
layer by layer on the director. Each bleeding vessel should be ligated, 
or seized with forceps, and then the peritoneum should be opened to the 
same extent as the incision in the parietes. 
Opening of the Uterus, and Extraction of the Fcetus.-The assistant 
opposite the operator should compress the uterus at the level of the inci- 
sion, and keep the omentum and intestines from issuing. The uterus is 
to be incised, layer by layer, but rapidly to prevent loss of much blood, 
and by preference the incision into the uterus should be prolonged up- 
wards. If the membranes are intact, we must keep them so as long as 
possible. The incision into the cavity is to be made with a blunt-pointed 
bistouri along the guiding finger, in order not to injure the foetus. As 
soon as the membranes have been ruptured, the foetus is to be grasped by 
the portion which presents, and it is slowly extracted, so as not to wound 
the uterine walls. The cord is tied, cut, and Kthe fcetus given to the 
nurse. (Fig. 131.) 
Whenever possible, it is advisable to grasp the infant by the head, since, 219 
THE CESAREAN SECTION. 
as the uterus is emptied, the uterine wound contracts, and, therefore, 
when we extract by the feet, we may find some difficulty in removing the 
larger head. During the entire period of extraction, the assistant must 
carefully press the abdominal parietes against the uterus, to prevent 
entrance of blood into the abdominal cavity. 
Extraction of the Placenta.-The placenta and the membranes are care- 
fully peeled off and removed entire. All clots are then removed, and 
uterine contractions are excited by friction, by massage, by the hypoder- 
matic injection of Yvon's ergo tine. The complications which may be 
Fig. 131.-Cesarean Section^ Extraction of the Fcetus. 
met with are: 1. The placenta may lie under the line of incision. 2. 
The uterine wound may contract around, and delay the head. 3. Hem- 
orrhage. 4. Adhesions of the placenta. 5. Prolapse of the intestines 
through the abdominal wound. 6. Escape of liquoi' amnii, or of blood, 
into the peritoneal cavity. 
It is at times possible to recognize the placental site through the uterine 
walls, and then our incision should be made outside of it. When we 
meet the placenta the operation must be finished as quickly as possible, 
the placenta removed first, and the foetus extracted afterwards. This 
complication is one of the most serious. 
The head may be grasped by the uterine or abdominal edges, and, 220 
A TREATISE ON OBSTETRICS. 
in the first instance, the gravity is great, for the uterus cannot contract, 
and the blood wells out of the open uterine sinuses. The incision must 
at once be enlarged sufficiently to allow extraction of the head. 
It is ordinarily after extraction of the foetus that hemorrhage is profuse, 
especially if contractions are not energetic. This is the gravest of all the 
complications. The uterus must be made to contract. We must use 
friction, cold water, ice, alcohol applications; if these do not suffice, Ritgen 
advises bringing the uterus outside the incision in the abdominal wall, 
and not returning it to the peritoneal cavity till all hemorrhage has 
ceased. Indeed, Ritgen advocates bringing the uterus externally before 
extracting the foetus. 
When the placenta is adherent, its removal is difficult, but should be 
attempted carefully, although quickly, and in the aim of leaving nothing 
in the uterine cavity. We reject the advice of Wigand, Joerg, Stein, 
Planchon, and Maygrier, to terminate the third stage through the natu- 
ral passages. We never know, till we seek to remove it, that the placenta 
is adherent, and we can the more certainly break up the adhesions by 
working through the wound than through the vagina and the cervix. 
The intestines and omentum usually protrude at the upper angle of the 
abdominal incision. This may be avoided by causing the assistant to 
compress the abdominal walls against the uterus. 
Before closing the abdominal incision, we must, even as in ovariotomy, 
carefully cleanse the peritoneal cavity. 
When all hemorrhage has been checked, and the uterus well-contracted, 
and the peritoneal cavity thoroughly cleansed, we must unite the abdomb 
nal wound. If necessary, we must wait an hour or two before doing this. 
And now the question arises, must we suture the uterus, or leave this to 
Nature ? 
[Before stating Charpentier's deductions in regard to this point, we would 
recapitulate the essential modifications in the operative technique, which 
have been introduced of late years. 
1. Before incising the uterus, turn it out, compress the abdominal in- 
cision below it, place an antiseptic dressing, gauze, sublimated or carbo- 
lized towel, gutta-percha, under the organ. The object is to prevent exit 
of intestines, and to prevent entrance of extraneous matters into the peri- 
toneal cavity. 
2. Pass a rubber cord around the uterus, at the supra-vaginal junction, 221 
THE CAESAREAN SECTION. 
and twist it in order to limit hemorrhage from the uterus when it is 
incised. 
3. After the emptying of the uterus and the disinfection of its cavity, 
deep suture of the muscularis, and sero-serous suture of the perito- 
neum.-Ed.] 
The uterine suture was first used by Lebas, was rejected by Levret, 
Smellie, Baudelocque, Gardien, Velpeau, Jacquemier, and is to-day ad- 
mitted in certain cases by Stoltz, Schroeder, Naegele and Grenser, and 
has been used by Harris, Wiesel, Godefroy, Malgaigne, Tarnier, Spenser 
Wells, Grandeso Silvestri, Martin, father and son, Veit, Birnbaum, Routh, 
Tauffer, Breisky, Oswald, Laroyenne, Barnes, Spiegelberg, etc. The 
results obtained by these gentlemen are very contradictory; yet the uter- 
ine suture would seem rather harmful than useful. 
[In the light of the experiences of the past few years, this statement 
is the reverse of the fact. For the reasons we gave when speaking of the 
improved Caesarean section, it is apparent that the uterine suture, properly 
applied, is one of the greatest of all the advances made in the technique 
of the Caesarean section in modern times, and that to it is largely due the 
excellent results which are being obtained in Europe by Sanger, Leopold, 
etc.-Ed.] 
Dusart and Tarnier have gone further still, and, not content with sutur- 
ing the uterus, they unite it as well to the abdominal incision, the viscero- 
parietal suture. In a case where we saw Tarnier use it, the patient died. 
In this case the lower angle of the uterine wound was left open, and in 
communication with that of the abdominal wound, and through these 
openings Tarnier passed a long piece of cloth, which was carried through 
the cervix into the vagina. The patient died on the third day. 
Stoltz thus describes his procedure: " He rejects on principle the uterine 
suture, for the incision into the uterus, when the organ has thoroughly 
contracted, is so narrow that there is no necessity of bringing the edges 
together. Where, however, the incision has necessarily been very exten- 
sive, or the organ does not contract well, then the suture might be of 
utility. Separate sutures of metallic wire might be of great value. As 
for the abdominal incision, its union is absolutely necessary, but authori- 
ties differ in regard to the manner. Many consider a simple bandage, of 
linen, or of plaster, sufficient; others are in favor of the suture. Lauver- 
jat condemned the suture; Peleurye considered it useless; but Baudeloc- 222 
A TREATISE ON OBSTETRICS. 
que praised it. Most of the advocates of the suture prefer the running, 
others the separate. Successes by either method are about equal. Over 
these, however, long slips of plaster, encircling the body, should be placed. 
Latterly metallic sutures have replaced those of catgut and silk. There 
are two sets, the one deep and the other superficial. For the deep, sil- 
ver oi' platinum wire is preferable. The first suture should be inserted at 
the upper angle, and the rest about 1| inches apart. They should be 
Fig. 132.-Suture of the Abdominal Wall.-a, Deep quill suture, b, Twisted superficial su- 
ture. Cotton around each suture, d, Cotton or linen drain at inferior angle. 
inserted about H inches from the margins of the wound, and include the 
peritoneum. Each suture end is twisted around a quill. Care should be 
taken not to include intestine or omentum in the line of suture. (Fig. 
132.) Superficial sutures of silk are placed between each deep suture to 
prevent gaping, and to keep the borders in exact apposition. Then plas- 
ter strips are passed around the body to make compression and to keep 
the edges in contact." 
Stoltz, Reich, Hilmann and Barnes are opposed to the drain at the in- THE CEES ARE AN SECTION. 
223 
ferior angle, as also, strongly, to the method of Cazeaux, and of Tarnier, 
of passing the drain through the cervix into the vagina. Barnes says that 
the capital point is to close the wound. 
The dressing of the incision is similar to that after ovariotomy. 
After-Treatment. 
Stoltz divides this into surgical and medical. 
Surgical Treatment.-Contrary to Barnes, who favors the entire closure 
of the wound, Stoltz believes in leaving the lower angle open to allow the 
escape of whatever liquid may collect in the peritoneal cavity. The first 
dressing should not be changed till the third or the fourth day, except in 
case of symptoms of hernia, of intestinal strangulation, of purulent col- 
lection. If union occurs by first intention, the superficial sutures are 
removed on the fourth day, the deep on the fifth or sixth day. The 
lower .angle should be left open as long as there is drainage. 
Medical Treatment.-The first complications are hiccough, vomiting, 
tympanites. Stoltz recommends cold applications, antispasmodics, the 
ether douche, opium, injections of morphia, and of the sulphate of qui- 
nine. Metz (Berlin, 1852), who had 7 recoveries in 8 operations, gives 
the following directions: " As soon as the patient has been put in her 
bed, cold applications are to be placed on the abdomen, and ice given by 
the mouth, these measures to be kept up as long as the patient feels well." 
(Naegele and Grenser.) 
For peritonitis Stoltz recommends leeches, frequently applied, and the 
sulphate of quinine; Naegele and Grenser, oil purgatives. 
The lochia should be carefully watched and good drainage kept up. 
Convalescence is ordinarily slow, and recovery is rarely assured before the 
sixth week. During this period, the diet should be carefully attended to, 
as any error may be fatal. The patient should wear an abdominal binder 
for months afterwards. 
[The after-treatment should m all respects be similar to that of any 
abdominal operation. Where the uterine and abdominal sutures are used, 
and the peritoneal toilette has been carefully attended to, we question the 
advisability of using the drainage tube. We are further opposed to the 
use of opium in any form, except when absolutely demanded by pain, dur- 
ing convalescence, for the reason that it paralyzes the peristalsis of the 
intestines, and locks up the secretions at a time when all the emuncteric 224 
A TREATISE ON OBSTETRICS. 
organs should be kept active, to carry off the products of retrograde 
metamorphosis. In case of tympanites, large enemata of turpentine, one 
drachm to the pint, are often of great service, administered by preference 
through a long rectal tube. These failing, we should not hesitate to 
puncture the intestines through the abdominal wall. A weak faradic 
current over the intestines, by awakening peristalsis, may assist in the ex- 
pulsion of flatus. 
In case of symptoms of peritonitis, following the example set by Law- 
son Tait, we believe it advisable to give a full saline purgative, before 
bringing the patient well under the influence of opium. When the in- 
flammatory trouble is marked and the temperature is at or above 102° F., 
the ice-coil should be placed on the abdomen and maintained for days, if 
necessary, taking the precaution to insert between it and the abdomen a 
napkin or fold of cotton, to prevent refrigeration of the skin. For the 
temperature, antipyrin, given preferably by rectal suppository, in thirty 
grain doses repeated every four hours till the temperature falls to 101°, 
should be our mainstay, never forgetting, however, when administering 
this drug, its depressing effect on the heart, and protecting it, therefore, 
by alcohol, digitalis, according to indication. Such are additional means 
of after-treatment, which, if faithfully followed, may save even a forlorn 
hope.-Ed.] 
Prognosis. 
The statistical data which we gave at the outset, make clear the gravity 
of the operation, and show why certain authorities absolutely reject the 
Caesarean section, except in case of stringent necessity. But, curiously 
enough, the repetition of the operation on the same woman does not 
entail unfavorable results; it seems, even, as though the mortality were 
less, for, in 17 cases collected by Kayser, the mortality was only 29^, and 
Lungren, who has collected 119 operations practised on 49 women, found 
only 8 deaths, or 6.73^. 
The large majority die in the three first days. After the first week, 
according to Michaelis, only one in nine. Michaelis and Oetler have each 
operated four times on each of their patients. Barnes explains these re- 
sults by the fact that the uterus in healing contracts parietal adhesions, 
and, therefore, in case of a second hysterotomy, the incision lies in these 
adhesions, the peritoneal'cavity being shut off, and this is why he advo- 
cates the viscero-parietal suture. Such cases, however, seem rather to THE CAESAREAN SECTION. 
225 
indicate individual tolerance than to give statistical proof of the innocu- 
ousness of the operation. Frerichs has reported a case where he per- 
formed the section for pelvic deformity, and the mother and the child 
recovered. The same woman again conceived, and premature labor was 
induced at about eight months. The uterus ruptured: gastrotomy was 
resorted to, to deliver the child. The intestines escaped from the incision, 
and to replace them it was necessary to make repeated punctures, not- 
withstanding which, they had to be incised to allow of escape of faecal 
matter. The woman recovered perfectly, and Barnes asks, how many 
women are thus tolerant ? 
As for the children, all those who are in good condition at the beginning of 
the operation should be born alive, provided it be performed before, or a 
little after rupture of the membranes, and the child be extracted rapidly. 
The longer we wait before operating after the onset of labor, and espe- 
cially after the escape of the liquor amnii, the greater risk for the infant. 
Kayser places the infantile mortality at 39^. Scanzoni, who investigated 
the lot of 81 children delivered by 120 Caesarean sections between 1841 
and 1853, found that 53 lived, or 60^. During the past few years Porro 
has proposed such a radical modification of the section, that it calls for 
special study, although, as we will see, its results have not been as good 
as was expected, and that, therefore, modern authors tend to return to 
the classic section, and to improve its methods. Thus Halbertsma, be- 
lieving that the greatest risk is from hemorrhage through wound of the 
placental site, endeavors to avoid this by making a preliminary puncture 
to determine the placental site, and then carrying his incision, outside of 
this region. Contrary to the practice of Muller, who pulls the uterus 
out of the abdominal cavity, throws an elastic ligature, or Esmarch's, 
bandage, around the cervix, and then cuts into the uterus, Halbertsma. 
makes his incision, with the uterus in situ, on the anterior surface. 
Hence he cannot well avoid the placenta, seeing that, in the majority of 
instances, it is inserted on the anterior uterine wall, and his exploratory 
punctures are useless. 
Cohnstein advocates drainage of the uterine wound. He pulls the 
uterus to the surface, and makes his incision on the posterior surface, in 
order to drain Douglas's cul-de-sac as well, and he rejects the uterine 
suture. Muller objects to this method, and says that drainage under these 
conditions is very difficult, and has little chance of success. 
Vol. IV.-15 226 
A TREATISE ON OBSTETRICS. 
Frank similarly rejects the uterine suture, and he seeks to close the 
abdominal incision, as hermetically as possible, through the ancient utero- 
abdominal suture (the viscero-parietal of Dusart), which he has essentially 
modified. His suture is very complicated, and aims to closely unite the 
anterior surface of the uterus to the abdominal wall, and also to make a 
large connection between the uterine cavity and the exterior. His 
method, however, is generally rejected. 
Sanger rejects the viscero-parietal suture, returns to the uterine, but 
makes a double suture. Uniting, at the outset, the muscular tissue, he 
then brings together the peritoneal edges which have been peeled off the 
uterus. He seemfe however, as Muller remarks, not to be very confident 
in his method, for he recommends, in addition, massage and faradization 
of the sutured uterus as a safeguard against hemorrhage. Finally, he 
believes in drainage of the peritoneal cavity. 
Finally, Kehrer has added another modification. He believes the suc- 
cess of the operation depends on the following three conditions: 1. Strict 
Listerism; drainage of the peritoneal cavity; drainage and irrigation of 
the genital canal. 2. Double uterine suture (after Sanger). 3. Trans- 
verse incision on the anterior surface, at the level of the internal os. This 
latter incision, according to Muller, will determine anteflexion of the 
uterus, and thus oppose gaping of the edges of the incision, which occurs 
so frequently from perversion of contractions, and uterine inertia. 
We believe that the modifications should be in the direction of anti- 
sepsis. The results obtained by surgeons in ovariotomy through antisep- 
sis, would seem to point out the way for the obstetricians, although we 
do not forget that ovariotomy and the Caasarean section are not compara- 
ble. In the one instance we remove a diseased organ from out of the 
body; in the other, we open and extract a foetus from an organ in a state 
of full physiological evolution. However vascular the pedicle of an ova- 
rian cyst, it can never compare to the proportions of the gravid uterus. 
There is also a further phenomenon, which, it seems to us, has received 
too little attention; we refer to uterine involution, the puerperal state, 
a fact which, we think, aside from the immediate complications of the 
operation, plays the important role, and in which resides the real danger 
threatening the life of the patients, and rendering the section so grave, 
and, unhappily, so disastrous. CHAPTER VIII. 
PORRO'S OPERATION. 
r | 1HE unfavorable results from the Cesarean section necessarily led. to 
modifications of the operation, and according to Muller, of Berne, 
Cavallini, in 1769, removed the gravid uterus from animals, and seeing 
them survive, deemed a similar operation possible in case of woman. 
Geser, in 1862, Fogliata, in 1874, Rein, in 1876, performed operations 
similar to those of Cavallini, and reached the same conclusion. Michaelis, 
and the younger Stein, were also advocates of the operation, whilst Kilian, 
in 1850, and other operators, were opposed to it. 
In 186^, Storer, of Boston, performed the first utero-ovarian amputa- 
tion in woman. He was doing gastrotromy for the removal of a fibroid 
tumor from a gravida. At the outset of the operation, the hemorrhage 
being considerable, he determined on opening the uterus, and extracting 
the foetus. The hemorrhage still persisting, he pulled the uterus and its 
annexa outside of the abdominal cavity, threw a ligature around the cer- 
vix at the supra-vaginal junction, and amputated the uterus, the ovaries, 
and the tubes. Three days thereafter the woman died, and this was for 
a time fatal to the method. Storer's operation, however, was a matter of 
necessity, and it is really Porro, who, in face of the difficulties and com- 
plications of the classic Caesarean section, concluded in favor of the utero- 
ovarian amputation under the carbolic spray, and performed it the twenty- 
first of May, 1876. The mother and child were saved, and this too at 
the maternity in Pavia, where, at the time, puerperal septicaemia was 
raging. This success encouraged others, and the operation was per- 
formed in Italy, Germany, Austria, Russia, etc. In France, Fochier, of 
Lyons, first performed it in 1879, he was followed by Lucas-Championniere 
and by Tarnier, and since, especially in Italy, this operation tends towards 
displacing the classic section. Thus: 228 
A TREATISE ON OBSTETRICS. 
Imbert de la Touche, . . in 1878 mentions 6 cases 
Castro-Soffia, . 1879 " 32 " 
Pinard, . 1880 " 38 " 
Harris (Philadelphia), . . " 1880 " 50 " 
Levis (Copenhagen), . . " " " 51 " 
Maygrier, . . . . " " " 51 " 
Zweifel, . 1881 " 74 " 
H. Simpson, . . . " " " 76 " 
Petit, " 1882 " 78 " 
Charpentier, . . . " " " 99 " 
In the 99 cases which we have collected are included cases of cancer, 
of tubo-ovarian pregnancy, of uterine rupture, etc., for in all of these 
the operation was the utero-ovarian amputation, or that of Porro. We 
have left out cases of Freund's operation, because they do not belong in 
this category. 
These 99 cases occurred in the following countries: 
Italy, ... 38 England, ... 4 
Austria, . . . 21 Russia, ... 2 
Germany, . . 11 Switzerland, . . 1 
France, . . . 10 Holland ... 1 
America, . . 5 Sweden, ... 1 
Belgium, . . 4 Turkey, ... 1 
The following were the results: Mothers living 43; dead 56. Infants 
living 70; dead 26. In the infantile deaths are included four where the re- 
sult has not been stated. 
The mortality figures differ a little from that obtained by other au- 
thors : 
Mortality. Mortality. 
Pinard, 1880, . 45.4 Zweifel, 1881, . 59.4 # 
Petit, 1882, . 55.10^ Championniere, 1882, 67. # 
Maygrier, 1880, . 58.49^ Charpentier, 1882, 56.56^ 
Simpson, 1881 . 58.3 # 
To the above cases must be added 5 additional, where both the mother 
and child were saved, performed since 1880. 
The total percentage of recoveries and deaths, therefore, is: 
Maternal mortality, 56 out of 105, 53.33 per cent.; recovery, 40 in 105, 
46.66 per cent. Foetal mortality, 25 out of 105, 23.80 per cent.; recovery 
76 in 105, 76.20 per cent. PORRO'S OPERATION. 
229 
As for the indications in these 99 operations: 
Rickets, . .54 cases Osteosarcoma, . . 1 case. 
Osteomalacia, . 12 " Infantile pelvis, . 1 " 
Fibromata, . . 5 " Kyphosis, . . 1 " 
Uterus septus, . 4 " Generally cont. pelvis, 1 " 
Uterine rupture, . 3 " Dyspnoea, . . 1 " 
Cancer, . . 2 " Not noted . . 14 cases. 
Comparing now the mortality rate from Porro's operation with that 
from the Caesarean section we obtain: 
Porro's operation 53.33 per cent, to 56.56 per cent. Caesarean opera- 
tion 54 per cent, to 60 per cent. 
We see, hence, that the results obtained from Porro's operation are 
scarcely better than those from the Caesarean section. We are not now 
speaking of the children, since, in theory, they should always be saved by 
either. 
Among the causes of death, peritonitis heads the list with 22 cases; 
shock 3 cases; septicaemia 2 cases; hemorrhage 3 cases; embolism 1 case. 
In a certain number of cases, the condition of the women was such that 
only death could be expected. 
If now we compare the results from Porro's operation, and from others: 
Mortality. 
Induced premature labor, . Pinard, . . . 32.35^ 
Caesarean section, . . Mayer, . . . 54. % 
Harris, . . . 70 to 88^ 
" ... Zweifel, . . . 54 to 60^ 
Porro operation, . . . Pinard, . . . 45.4 
" Petit, . . . 55.10# 
Charpentier, 56.56 or 53.53# 
Simpson, . . . 58.2 # 
Zweifel, . . . 59.4 # 
Maygrier, . . 58.49# 
" L. Championniere, . 67. % 
Cephalotripsy and embryotomy, Maygrier, . . 41.79# 
" Charpentier, . . 28.68# 
It is not possible to form an exact opinion from these figures, for if all 
the cases of Porro's operation have been published, such is not the case 
with the Caesarean section, and the other operations. What is clearly 
evident, however, is that, like the Caesarean section, Porro's operation 
should be, not one of choice, but of absolute necessity, and that the 230 
A TREATISE ON OBSTETRICS. 
chances of success are the greater if done within twenty-four hours of the 
onset of contractions. 
Pinard thus lays down the indications for the Porro operation: 
1. The pelvis does not allow of embryotomy. Here the indication is 
absolute, and we agree perfectly with our colleague. Preference should 
be given to the Porro over the Caesarean section. 
2. The pelvis allows embryotomy, but measures less than 2.7 inches. 
If the foetus is dead, then perform embryotomy, except in case of osteo- 
malacia. If the infant is alive, the proper operation is a subject for dis- 
cussion. We wrould not agree with Pinard, but would say that, the foetus 
alive or dead, embryotomy should be the choice. 
3. The pelvis measures over 2.7 inches. Porro's operation should be 
absolutely rejected. 
4. Finally, with Alessandrini, of Milan, Pinard advocates the Porro 
operation in case of rupture of the uterus. The cases cited by Halbert- 
sma, and the results given by Jolly in his thesis, seem to justify this 
opinion. 
As for the indication from the presence of fibrous and cancerous 
tumors, we have discussed it elsewhere. 
To resume, then: Porro's operation, like the Caesarean, should be one 
of absolute necessity, and whenever we have the choice between it and 
another, it is to the other that the preference should be given. 
[The results obtained of late years through the improved Caesarean sec- 
tion, have led most authorities to practically reject the Porro operation, 
except in case of rupture of the uterus, which makes the Porro an opera- 
tion of necessity, where it is not possible to use the uterine suture. 
We are again indebted to the labors of Dr. Robert P. Harris for the 
more recent statistics of this operation, and its modifications, which we 
append below. 
Maternal 
Mortality. 
Maternal 
Recoveries. 
Children 
Saved. 
Children 
Still-born. 
Children 
Dying 
during 
Extraction. 
Pure Porro, 
90 Cases.... 
49 
41 
71 
17 
3 
Porro- Muller, 
36 Cases.... 
17 
19 
28 
7 
2 
Porro-Veit, 
13 Cases.... 
10 
3 
10 
3 
0 
In many of the cases in this table the maternal death was due to the 
fact that the operation was deferred too long, and since the compilation PORRO's OPERATION. 
231 
of the table the total number of operations has been increased to 164. 
" Deducting from this number 3 moribund cases, and 14 in which the 
stump was dropped and proved fatal in 10, we have remaining 147 cases 
with 44 per cent, maternal recoveries." (Harris.) 
In regard to the various methods in vogue for the delivery of the child 
per abdominem, Harris sums up the question so tersely and justly, that 
we append his remarks: " The Caesarean section and the Porro are largely 
dependent for success upon the condition of the patient at the time it is 
performed. If then a timely, elective, and pre-arranged Caesarean operation 
must have an unfavorable prognosis because of the physical condition and 
poverty of the subject, can much more be anticipated from the Porro im- 
provement under the same disadvantages ? Laparo-elytrotomy may prove 
less fatal than either, because it neither wounds the uterus nor opens the 
peritoneal cavity." 
To sum up this question in the light of to-day's knowledge, we would 
say: Perform laparo-elytrotomy if the conditions essential to its perform- 
ance are present; it* not, perform the modified Caesarean section with 
deep muscular and sero-serous superficial sutures; reject the Porro or its 
modifications except in the presence of rupture of the uterus where the 
uterine suture cannot be used; above all, operate in time, before exhaus- 
tion has set in, and pay strict attention to scrupulous cleanliness.-Ed.] 
Description of the Operation. 
Preliminary Precautions.-These are identical with those applicable 
to ovariotomy or the Caesarean section. 
The operation is divided into four stages: 
1. Incision of the abdominal wall. 
2. Incision of the uterus, and extraction of the foetus. 
3. Amputation of the uterus and ovaries, and formation of the pedicle. 
4. Dressing of the abdomen. 
Incision of the Abdomen.-The incision should extend from 1^ to two 
inches above the pubes to one to two inches above the umbilicus, to one 
side of which it passes. The peritoneum is divided on a director. 
Incision of the Uterus and Extraction of the Foetus.-The uterus is 
brought close to the abdominal wall, and is incised layer by layer. The 
membranes are ruptured, and the foetus extracted. 
Muller brings the uterus externally, and applies an elastic ligature 232 
A TREATISE ON OBSTETRICS. 
around the cervix at the level of the internal os, and then only does he 
open the uterus and extract the foetus. This is the method which Rein 
followed in his experiments on animals. 
Instead of the ligature, Litzmann and Fehling use Esmarch's bandage. 
Resorted to by Litzmann, Breisky, G. Braun, Tarnier, Tibone, C. 
Braun, Chiara, and others, Muller's modification has given good results 
only in the hands of Breisky. It can be only used in easy cases, for it 
may result in tears or injury of the peritoneum, and hence in peritonitis. 
Amputation of the Uterus and Ovaries, Formation of the Pedicle.- 
Porro incises the uterus in position, and it is only after extraction of the 
foetus that he draws it out by means of long ovarian forceps. He then 
passes a trocar through the uterus, at the junction of the body and the 
cervix, and through this two metallic wires, which are twisted the one to 
the right and the other to the left. He then amputates. 
Tarnier and Championniere pass a steel needle through the uterus at 
the same junction, and a second, at a slightly higher level, perpendicu- 
larly to the first. A wire loop is passed around the cervix, underneath 
these needles and including the ovaries and tubes, and this is twisted, and 
the uterus is amputated about | inch above the wire. The peritoneal 
cavity is then cleansed, and the pedicle is fixed in the lower angle of the 
incision in the abdominal wall. The abdominal incision is united by metal- 
lic sutures. The dressing is the same as after ovariotomy. 
Schlemmer (Stuttgart, 1881) objects to the Porro operation, on the 
ground that it is immoral, since it removes all possibility of further con- 
ception, and therefore might be abused. 
Muller, whose thesis is simply an eloquent plea in favor of the Porro 
operation, is compelled to admit the bad results of this operation, and that 
they are not much more satisfactory than those from the classic section. 
He ends his conclusions in the following words: " The day when a large 
number of cases prove to me that, by means of modifications of the classic 
section, we have obtained as sure a guarantee against hemorrhage and 
sepsis as is offered by the utero-ovarian amputation, then I will be the 
first to declare against the Porro operation. Until then I will remain a 
partisan in its favor, seeing that I have personally tested its advantages." 
Notwithstanding these words of Muller, the tendency to-day is to re- 
turn to the classic section, and the search is always in the direction of im- 
proving the technique of this operation. CHAPTER IX. 
THE POST-MORTEM CAESAREAN SECTION. 
T first sight it would, seem as though there could, be no doubt as to 
the necessity of practising this operation, whenever, after the 
twenty-eighth week of pregnancy, the mother dies, and the living child 
cannot be extracted by the natural passages, or only after delay which 
would compromise its life. There are, however, two circumstances which 
modify this law, so natural and obligatory, leaving out of question the re- 
ligious point of view. 1. We possess, at present, no absolute timely sign 
on which we may rely as pointing to the maternal death, and as Naegele 
and Grenser put it, " aside from the cases where death results from pro- 
longed disease, typhoid, phthisis, etc., where we are in no doubt as to 
the cessation of life, it will never perhaps be possible to obtain certainty 
of death at a time when the section should be made in order to save the 
foetus." There are further a number of cases recorded where the opera- 
tion has been performed on women in a state of apparent death, such as 
those of Peu, Trinchinetti, Reinhardt, Bodin, d'Outrepont, etc. 
2. We do not know exactly the time which may elapse after the mother 
expires before the foetus dies. 
The results of the operation are not very satisfactory. According to 
Heymann and Lange, in 331 operations, only 6 to 7 children were saved, 
and 13 lived but a few hours; according to Schwartz, in 107 operations, 
performed in the electorate of Hesse, not one child was saved. 
Breslau, on the other hand, who has made experiments on animals, 
deduces the following conclusions: 
1. There can be no doubt but that the foetus, human as well as animal, 
survives the mother when death has been sudden, as in hemorrhage, as- 
phyxia, apoplexy, etc. 
2. The human foetus survives the sudden maternal death longer than 
the animal foetus. t 
3. The section is not likely to save the child if performed beyond fif- 234 
A TREATISE ON OBSTETRICS. 
teen to twenty minutes after the maternal death. The best known cases 
are those of Pingler, the infant extracted alive, fifteen minutes after the 
maternal death, and lived 32 minutes; infant extracted 23 minutes after, 
and survived; Breslau, extraction 15 minutes after, and lived a few 
hours; Brotheston, 23 minutes, infant lived; Hoscheck, a few minutes, 
infant lived; Campbell, 10 minutes, infant lived 14 years. 
4. If the mother dies of an essential fever, we cannot hope to save the 
infant, because its life-supplies have not been cut off suddenly, but little 
by little. The same holds true of poisoning by substances which deter- 
mine rapid decomposition of the blood, such as prussic acid. Death 
from chloroform seems to be an exception, because it does not seem to 
penetrate into the circulation of the infant. 
Breslau adds, ''the duty of every physician is always, as soon as the 
mother's death is established, to resort to the Caesarean section, unless, 
indeed, the foetus be dead before the mother, or where we can extract it 
more readily by the natural passages." (Naegele and Grenser.) 
[There is a natural repugnance in the mind of every one towards allow- 
ing the mother's body to act as the infant's coffin. Even, therefore, 
where the death of the foetus antedates that of the mother, it is more ap- 
propriate to extract the foetus by section, except, of course, where this is 
possible per vias naturales.-Ed.] 
Extraction by the natural passages has been advocated by Naegele and 
Grenser, and by Thevenot, and we pass briefly to the study of the ques- 
tion. CHAPTER X. 
ARTIFICIAL DELIVERY THROUGH THE NATURAL PAS- 
SAGES AS A SUBSTITUTE FOR THE POST-MORTEM 
CAESAREAN SECTION. 
"yy^E may have to face two very different conditions, which we will ex- 
amine in succession. The choice of operative method will de- 
pend upon which of these conditions is present. 
1. Labor has begun; the Cervix is dilated or dilatable.- Although 
delivery by the natural passages, as a substitute for the post-mortem 
Caesarean section, was advocated for the first time by Schenck, in 1665, 
it was Rigaudeaux who first resorted to it, in 1745, in a woman who was 
believed to be dead, but was only in a state of apparent death. Delivery 
by version was successful, and thereafter, Baudelocque, 1796, Capuron 
1811, Gardien, 1824, Velpeau, 1835, pronounced themselves in favor of 
it. In 1832 Heymann, and in 1833 Rizzoli, even went so far as to advise 
the accouchement force in case the cervix was not dilated or dilatable, but 
in France and in Germany, Siebold, Naegele, Velpeau, Chailly, Cazeaux, 
opposed this and pronounced in favor of the Caesarean section. Du- 
parcque, Devilliers and Otterburg, nevertheless, agreed with Rizzoli, and 
in 1861, Depaul counselled delivery by the natural passages, no matter 
what the condition of the cervix. One thing, however, is indispensable, 
and this is a normal pelvis, since success will depend on the ease and 
rapidity of the operation. For lack of attention to this prerequisite, 
Beluzzi, in 1863, after vainly attempting delivery by the natural passages, 
resorted to the Caesarean section too late to save the child. 
The pelvis being normal, either, 1, the head presents and is deeply en- 
gaged, or, 2, it presents but is movable above the superior strait, or, 3, 
another portion of the foetus presents. 
In the first instance we should, of course, deliver at once by the forceps. 
Reinhard reports five cases, one successful (Jackson), and Devilliers one 236 
A TREATISE ON OBSTETRICS. 
case, child dead-that is 6 cases, with 5 dead infants. Under the second 
condition there are no cases on record; under the third, version is indi- 
cated, and Thevenot cites 5 observations: Verhoff, 1819, child saved; Tali- 
nucci, 1854, child dead; Bataille, 1861, child lived seven hours; Franchini, 
1861, child saved; Gueniot, 1863, child dead. In all these instances 
delivery was easy, except in Gueniot's, where the extraction of the after- 
coming head required incision of the cervix and the forceps. Success, it 
is apparent, will depend on the little time which elapses between the 
death of the mother and resort to operation; for although Villeneuve 
cites cases where living children were obtained by the Caesarean section 
from two and a half to four hours after maternal death, these cases are not 
authentic, and fifteen minutes must be stated as the extreme limit at 
which it is possible to obtain a living child. 
2 Labor has not begun, or has just begun.-In this case, Duparcque, 
Heymann and Rizzoli, also counsel delivery per vias natrirales, and state 
that the procedure is not of much greater risk to the infant than under 
the previous condition. Thevenot reports a number of instances, cases 
of Rizzoli, Golinelli, Capari, Beluzzi, Hyernaux, Rivani, Talinucci, etc., 
and in five of the cases the mothers were only in a state of apparent death, 
the children being delivered alive. It is on account of the fact that we 
cannot always be sure of the mother's death that Thevenot, and we agree 
with him, counsels delivery per vias nat urates in preference to the Caesa- 
rean section. Ordinarily the hand suffices for dilatation, although, where 
necessary, the cervix may be incised, and delivery accomplished by the 
forceps or by version. 
In 1827, Costat claimed that it was incumbent on the accoucheur to 
terminate labor in every instance where pregnancy was complicated by a 
disease threatening the mother's life, whenever the foetus was viable. Of 
the instances where this advice was followed we cite: Duparcque, 1840, 
eonsumptive woman in extremis; Guiseppe, 1844, in a case of apoplectic 
coma; Esterle, 1861, reports 4 cases, infants all living; Beluzzi, 1877, 
3 cases. Thevenot collects, altogether, 15 instances of accouchement force, 
in extremis, with 13 living children, 6 surviving, and 5 mothers saved, 3 
relieved. These cases are certainly encouraging, although we cannot 
quite share Thevenot's opinion: " Delivery should be resorted to in the 
interest of the mother as well as of the child, and furthermore the ac- 
couchement force, in extremis, is without danger." It is the opinion of all obstetricians that accouchement force in the living woman is a disas- 
trous operation, and should only be resorted to as an ultimum refugium, 
and yet it is advocated on a dying woman, where the least shock may 
be the last drop which causes the goblet to overflow! The logic is false, 
and, as one of the observations proves, it is rather for the spiritual than 
for the temporal interest of the child that the practice has been advo- 
cated, to baptize, in other words, the infant. The fact is that no one 
is in a position to say positively that the woman is dying, and therefore 
we would reject absolutely accouchement force under these conditions, 
and we would formulate our practice as follows: 
1. Labor has commenced, cervix is dilated or dilatable; rapid extraction 
by forceps, or by version. 
2. Labor has not begun. 
a. The woman is dead, or in a state of apparent death; delivery 
vias naturales, by incision of cervix, if necessary, and forceps or version. 
b. The woman is in extremis: Respect her condition, and do not hasten 
her end by manoeuvres which may posssibly not save the child. Once 
the mother dead, however, act quickly in the interests of the child. 
ARTIFICIAL DELIVERY. 
237 CHAPTER XI. 
SYMPHYSEOTOMY. 
rjMIIS operation was proposed by Sigault, in 1768, and after having 
been the cause of considerable discussion, has to-day almost fallen 
into neglect, except in Italy. Morisani, of Naples, read a paper on the 
subject before the London International Medical Congress, 1881. To 
quote from this paper: Symphyseotomy has been practised fifty times 
at Naples, twice on the same woman, with the folio wing results: 40 women 
saved, 10 dead, 20 per cent; 41 infants saved, 9 dead, 18 per cent. 
Kilian, in 68 cases, found a maternal mortality of 32 per cent., and a 
foetal of 63 per cent. 
In 45 instances the vertex presented with 4 deaths; in 3 the pelvic ex- 
tremity, with 3 deaths; in 2 the trunk, with 2 deaths. In 50 cases the 
conjugate measured: 
In 12, 3.3 inches; in 16, 2.9 inches; in 7, 2.7 inches; in 13, 2.6 inches; 
in 2, 2.4 inches. 
Where the measurement was over 3 inches expectation was the rule, 
and even the forceps was used before resorting to symphyseotomy. The 
lowest limit of the operation is placed at 2.6 inches. Unfavorable results 
are often obtained because this lowest limit is disregarded. 
Comparing the statistics of embryotomy in Italy by Tibone and Chiara, 
and those from the Porro operation, Morisani makes the following state- 
ments: 
Embryotomy, Tibone, . Mat. mort. 21^ 
" Chiara, . " " 24^ 
Symphyseotomy, Morisani, 11 " 50^ (41 living infants.) 
Porro operation, 13 out of 27 mothers, and 24 out of 27 infants saved. 
[By reference to the results obtained from the modified Caesarean sec- 
tion, in particular, it is at once apparent that symphyseotomy has nothing SYMPHYSEOTOMY. 
239 
in its favor. Of the last 18 operations, Harris points out that 8 mothers 
were lost, and 5 children.-Ed. J 
Morisani uses a blunt-pointed curved bistoury, with the cutting edge 
on its concave surface. " We make an incision about 2 inches above the 
symphysis down to the articulation. The bistoury cuts through the in- 
terosseous cartilage from below upwards. We then wait for spontaneous 
delivery, unless the pains are feeble, or the head does not engage, in 
which event we extract with the forceps." 
Whatever the results obtained by Morisani, we do not believe that 
many obstetricians are prepared to return to symphyseotomy. CHAPTER XII. 
EMBRYOTOMY: PERFORATION.-CRANIOTOMY.-CEPHALO- 
TRIPSY. -CRANIOCL AST Y. -EVISCERATION. 
"J^ROADLY, embryotomy is an operation by which the volume of the 
foetus is diminished in order to render delivery easier, or even pos- 
sible. It is known under the various names which head this chapter. It 
has been practised from the earliest times where the infant is dead, but 
to-day it is still rejected by certain accoucheurs, notably Stoltz, where the 
infant is alive. Stoltz, however, is about the only one who absolutely 
rejects the operation where the infant is living, for the most pronounced 
advocates of the Caesarean section resort to embryotomy where the mother 
refuses the section. For our part, we believe that the accoucheur should 
never forget that the life of the child is not at all comparable to that of 
the mother, and that, therefore, he ought never to hesitate to sacrifice the 
former in order to increase the chances of the latter. We must never for- 
get, furthermore, that embryotomy will give the most favorable results the 
earlier it is resorted to, and the less the previous efforts to obtain a living 
child. Once then we are satisfied that Nature cannot accomplish her 
task, and we have tried by reasonable means to save the life of both child 
and mother, we are of the opinion that we should absolutely neglect the 
child and turn our whole attention to saving the mother. 
The statistical results vary considerably according to the country and 
operator. Sickel gives us the following figures in regard to frequency of 
employment of various operations: 
Sickel in 470,975 labors, 400 times. 
Oldham ' " 22,681 " 81 " 
Johnston and Sinclair " 13,933 " 130 " 
In Germany " 434,371 , " 189 " 
Perforation 
Cephalotripsy " 12,273 " 21 " 
Embryotomy " 304,150 " 22 '' 
Caasarean section " 422,686 " 97 " 
Premature labor " 465,908 " 48 " 241 
EMBRYOTOMY. 
In a table constructed by Ploss, giving the statistics of perforation and 
cephalotripsy in the German maternities, there are 540 out of 291,618 
labors. 
Pawlick, recapitulating the cases reported of decapitation by Braun's 
hook, gives a mortality of 24 per cent.; Spaeth gives the recoveries as 77 
per cent.; Muller in 17 perforations had only 2 deaths; in 26 premature 
labors 3 deaths of the mother, and 12 of the children. 
At the Clinique, Paris, from 1852 to 1880 (the year 1853 lacking): 
Cephalotripsy, 202 cases.-Mothers living 145; mothers dead 57. Em- 
bryotomy, 56 cases.-Mothers living 39; mothers dead 17. Maternal 
mortality 28.68 per cent. 
The statistics of Rigaud and of Stanesco give a mortality of 38.52 per 
cent, in 122 cephalotripsies. 
Once having determined on embryotomy the choice of the method re- 
mains. In one operation the head of the foetus is alone involved, at 
other times the trunk. We will consider these methods under the follow- 
ing headings: 
1. Perforation of the skull. 
2. Cephalotripsy. 
3. Cranioclasty. 
4. Sawing of the head. 
5. Sape sphenoidienne of Gueniot, intra-cranial cephalotripsy of Guyon, 
transforation of Hubert. 
6. Decapitation, decollation, detruncation. 
7. Evisceration, brachiotomy, spondylotomy. 
I. Perforation. 
This is the most ancient of all methods for reducing the size of the 
head, and it consists in the artificial opening of the vault of the skull, in 
order to give exit to the brain, in addition, exceptionally, to the removal 
of pieces of the bone. Innumerable instruments have been devised for 
the purpose. Sadler and Levy have given a succinct description of all. 
We will note here simply the most important. 
a. Cutting Perforators.-Those devised by Hippocrates, Albucasis, 
Pare, Guillemeau, Mauriceau, Roederer, Stark, Wigand, Waller, and 
others. These are to-day practically all rejected. 
Vol. IV.-16 242 
A TREATISE ON OBSTETRICS. 
b. Scissor Perforators. -Those of Bing, Wallbaum, Smellie (Figs. 133 
and 134.) Naegele (Fig. 135), Levret, Stein, Denman, Brunninghausen, 
Siebold, Busch, Simpson, Oldham, Greenhalg, Blot (Figs. 137 and 138), 
etc. The last is decidedly the best, particularly since it is absolutely 
harmless to the mother and the accoucheur. 
c. Trephine Perforators.-Those of Joerg, Mende, Ritgen, Kilian, 
Leissnig (Fig. 136), Braun, Martin, etc. 
As we have said, the best instrument is Blot's. It is composed of two 
Figs. 133 and 134.-Smellie's Scissors. (Modified.) 
Fig. 135.-Naegele's Scissors. 
blades. When closed the dull edge of each covers the sharp edge of its 
fellow. By pressure at 1) the blades open like Smellie's scissors. 
The indications for resort to perforation, are: 
1. The Foetus is dead.-Perforation is indicated whenever the dispro- 
portion between the head and the pelvis renders spontaneous delivery 
difficult, in particular where, if the forceps is used, damage to the ma- 
ternal parts might result. 
2. The Foetus is living.-Whenever the capacity of the pelvis justifies, 
the forceps should first be tried, always, however, taking care not to dam- 
age the mother. If, after three to four attempts, the forceps does not 243 
EMBRYOTOMY. 
bring down the head, we believe it disadvantageous to the mother, and of 
no advantage to the child, to persist longer. We should perforate, and 
then resort to craniotomy or not according to the case. 
One of the great advantages of perforation is that it may be resorted to 
before complete dilatation of the cervix. The cervix need only be dilated 
Fig. 136. Fig. 137 and 138. 
Fig. 136.-Leissnig's Trephine Perforator, Modified by Kiwisch.-g, Upper portion, and, g', 
lower portion of the canula. b, Steel screw holding the two portions together, t, Blade. B, Crown 
of the trephine. P. Point of trephine, v, Screw blade which works in aa. 
Figs. 137 and 138.-Blot's Perforator, Closed and Open. -A, Separated blades. B, Lock. C, 
Spring which keeps the blades closed. D, Handle, pressure on which opens the blades. 
sufficiently to allow of the passage of the instrument. Under the influ- 
ence of the contractions of the uterus, the skull empties itself of its con- 
tents, the bones collapse, and we have frequently seen labor terminate 
spontaneously where instrumental extraction would have been called for 
had the head remained intact. Usually, however, perforation is in- 
sufficient, and cephalotripsy must follow it. 244 
A TREATISE ON OBSTETRICS. 
In Holland and in Belgium, the perforated head is extracted by means 
of the lever. Tarnier prefers the forceps, particularly where the contrac- 
tion is not great. We resort, in such instances, to Bailly's cephalotribe, 
which we will shortly describe. 
We have stated that before perforating a few attempts should be made 
to deliver by the forceps. If this fails, it is advantageous to still hold 
the head in the forceps blades, and perforate between them, for thus we 
may fix the head by directing an assistant to make gentle traction on the 
handles; and further, by compressing the handles we assist in the expres- 
sion of the cerebral matter and in causing the bones to collapse. Often 
thus we may complete extraction with the forceps, and thus do away with 
the necessity of inserting the blades of the cephalotribe. We cannot insist 
too strongly on perforating before using the cephalotribe, else we may 
deliver the mutilated foetus and to our horror see it live for some 
minutes. 
Operative Method.-We must consider this successively where the 
before-coming head, or the face, or the after-coming head, presents. We 
always use Blot's perforator. 
1. Presentations of the Vertex.-The preliminary precautions and the 
position are the same as in any obstetrical operation. Since the opera- 
tion itself is not painful, chloroform is only requisite when, in addition to 
perforation, immediate extraction or cephalotripsy is requisite, and then 
narcosis should be induced to the surgical degree. The rectum and blad- 
der should always be first emptied. An assistant should steady the head 
firmly through the abdominal walls at the superior strait. The operator 
introduces the index and middle finger of the left hand into the vagina, 
and inserts them into the cervical canal against the head. The perforator 
is then guided by these fingers, and its point applied perpendicularly 
against the foetal head. It is not essential to perforate through a suture 
or fontanelle, but the point of the instrument is pushed boldly down to 
the bone, and then the instrument is rotated from right to left, and from 
left to right, in order to facilitate the passage through the bone. As soon 
as the instrument has penetrated the cranial cavity, by pressure on the 
handle the blades are opened, and the instrument is moved in every di- 
rection in order to thoroughly break up the brain. Pressure on the 
handle is then relaxed, the blades close, and the instrument is withdrawn. 
In these manoeuvres the maternal parts are exposed to absolutely no risk. EMBRYOTOMY. 
245 
On the withdrawal of the instrument blood and cerebral matter gener- 
ally issue from the vulva. (Fig. 139.) 
2. Presentation of the Face.-Perforation, in this instance, is a trifle 
more difficult. The instrument may be made to penetrate eithei* through 
the orbit, the frontal bone, or the palatine arch, the last offering the 
greatest difficulties. We prefer the frontal bone, although we do not 
agree with Naegele and Grenser in believing it indispensable to perforate 
through the frontal suture. 
Fig. 139.-Craniotomy with the Scissor Perforator. 
3. The after-coming Head.--Here manipulation is still more difficult, 
since the body of the child is in the way and the occipital bone is so thick. 
We must, therefore, perforate either under the chin, or else, as is pre- 
ferable, through one of the posterior lateral fontanelles. (Fig. 140.) 
Chailly prefers perforating through the palatine vault for the reason that 
he believes the point of the instrument is less likely to slip. lie recom- 
mends the insertion of two fingers into the mouth, forcible depression of 
the inferior maxilla, and penetration with Smellie's scissors through the 
palate into the skull. 
Perforation alone rarely suffices. Cephalotripsy must ordinarily be 246 
A TREATISE OX OBSTETRICS. 
superadded. For extraction of the head, blunt and sharp hooks have 
been recommended (Figs. 141 and 142), but we absolutely condemn them 
on account of the risks which they entail. Bone forceps have also been 
devised (Fig. 143), and the simplest of all is that of Danavia, described 
Fig. 140.-Perforation of the After-coming Head. 
by Baudelocque, and recommended by Pajot. This instrument, however, 
is often not effective, owing to the yielding of the bones, and either the 
forceps or the cephalotribe is better. 
II. Cepiialotripsy. 
This is an operation which consists in crushing the head of the foetus, 
in order to diminish both its volume and its resistance. The operation 
was in reality first placed on a scientific basis by Baudelocque, the 
nephew, in 1829. It was not, however, till 1834, that he gave to the in- 
strument its present shape. EMBRYOTOMY. 
247 
Fig. 141.-Extraction of the Head by means of the Blunt Hook. 
Fig. 142.-Sharp Hook. 
Fig. 143.-Bone Forceps. 248 
A TREATISE ON OBSTETRICS. 
Baudelocque's cephalotribe (Fig. 144) is composed of two strong blades, 
21 inches long, weighing about pounds, with no fenestrae. The maxi- 
mum breadth is about 1| inches. The lock is similar to that of Brun- 
ninghausen's forceps. The distance between the blades is about 1 inch, 
Fig. 144. Fig. 145. 
Fig. 144.-Baudelocque's Cephalotribe. 
Fig. 145.-Depaul's Cephalotribe. a, Screw working the chain b, c. d, Groove for passage of 
chain, c, Lock, f, Blades. 
and these are slightly convex externally, and concave within. The pel- 
vic curve is about 4 inches. The blades are approximated by a screw rod. 
Since the time of Baudelocque the cephalotribe has been modified as 
extensively as the forceps. (For a detailed description of each form, see 
Lauth's thesis, 1863.) The best known instruments are those of Busch, 
Cazeaux, Ritgen, Langenreith, Martin, Dubois, Kilian, Depaul (Fig. 145), EMBRYOTOMY. 
249 
Kiwisch, Chailly (Fig. 146), Scanzoni (Fig. 147 and 148), Braun, Brei- 
sky, Bailly, Tarnier, Blot. 
We will describe simply the three last. 
Blot's cephalotribe (Fig. 149) is composed of two blades; like the for- 
ceps, each blade is fenestrated. The blades are a trifle more curved than 
is the case in Baudelocque's instrument. They are convex on one surface 
Fig. 146.-Chailly's Cephalo- 
TRIBE. 
Fig. 147.-Scanzoni's Cephalo- 
tribe. (Closed.) 
Fig. 148.-Scanzoni's Cephalo- 
tribe. (Disarticulated.) 
and concave on the other. Their extremities touch. The instrument 
is constructed of steel, and the handles are roughened for firm grasp. 
The left blade holds the pivot on which the compressing bar articulates; 
the right blade is bifurcated at its extremity to allow of the passage of 
the same bar. The lock is Brunninghausen's. The blades having been 
applied, even as with the forceps, the compressor bar is articulated and 
passed through the bifurcated extremity of the right blade, and then, to 250 
A TREATISE ON OBSTETRICS. 
crush the head, it is only necessary to turn the screw, and the blades are 
approximated. 
Bailly's cephalotribe (Fig. 150) is thus described by the inventor: 11 My 
idea in devising this instrument was to possess one which, while strong 
enough to crush, would seize the head better than the ordinary cephalo- 
tribe My instrument has the form of the forceps and its large and con- 
Fig. 149.-Blot's Cephalotribe. 
Fig. 150.-Bailly's Cephalotribe. 
cave blades and, in addition, the power of the cephalotribe. The inter- 
nal surface of the fenestras is studded with points, which dig into the head 
and hold it firmly as compression is made. Antero-posteriorly the breadth 
of the blades is 2.2 inches. When their extremities are in contact the 
greatest width between them is 2.1 inches. My cephalotribe, therefore, 
may be used in contractions of the pelvis between 2£ and 3.7 inches. 
In contractions below 24 inches it is not applicable. The compressing 
mechanism is similar to Blot's." EMBRYOTOMY. 
251 
For our part, we can affirm that between these limits Bailly's cephalo- 
tribe is an excellent instrument. We have used it in twenty-three in- 
stances: 17 times in vertex presentations, 5 times in face (once with co- 
incident prolapse of a limb), and once where a large fibroma obstructed 
delivery. The instrument has never slipped, and we have always been 
able to extract the head. The only possible objection to it, indeed, is the 
Fig. 151. Fig. 152. 
Figs. 151 and 152.-Tarnier's Cephalotribes. 
fact that its utility is limited, to the lesser degrees of contraction. 
Tarnier's Cephalotribe.-Tarnier has invented a number of cephalo- 
tribes. (Figs. 151-153.) One of his modifications is furnished with a 
number of transverse projections to grasp and. firmly hold, the head.; in 
another he has addeS. a perineal curve; in his last model he has modified. 
Blot's lock, so as to render it easier to adjust the compressing bar. 
[Lusk has devised an excellent and effective instrument, which presents 252 
A TREATISE ON OBSTETRICS. 
certain advantages over Blot's. It has a cephalic curve of 2| inches. The 
pelvic curve is a trifle beyond 3 inches in length. The blades are fenes- 
trated, and are grooved on the inner surface. With this instrument it is 
possible to grasp the head above the pelvic brim, and since, after the head 
has been crushed, " the points approach each other closely, the instrument 
Fig. 153. Fig. 154. Fig. 155. 
Figs. 153, 154 and 155.-Tarnier's Cephalotribes with Perineal Curve. 
becomes a perfect tractor, holding the head as securely as an ordinary 
forceps. Its construction is, however, the abandonment of two favorite 
but chimerical ideas regarding the capacity and mode of action of the 
cephalotribe, viz., that it is capable of flattening the head so that the 
latter can be drawn through a pelvis measuring but two inches in the con- 
jugate diameter, and that this can be accomplished by rotating the in- 253 
EMBRYOTOMY. 
strument, so as to make the flattened head correspond to the shortened 
diameter of the pelvis." (Lusk.) Lusk's instrument, further, is less 
bulky than any, actually so efficient, as yet devised.-Ed.] 
Indications.-Cephalotripsy is indicated whenever delivery is impossi- 
ble, without mutilation of the foetus. Benoit in his thesis, 1881, divides 
the indications into the following categories: 1. Those from the side of 
the mother. 2. Those from the side of the child. 3. Those dependent 
on both. Before studying the indications, we wish to emphasize our 
previous statement, that before resorting to cephalotripsy we ought, when- 
ever the pelvis allows, to make one to two attempts at delivery with for- 
ceps, always within the limits of prudence, and that only when we have 
thus assured ourselves of the impossibility of delivery without mutilation 
are we justified in first perforating and then crushing the head. In 
many instances, we would also add, it is advantageous to allow a number 
of hours to elapse after perforation, before using the cephalotribe. 
1. Indications from the Side of the Mother.-Pelvic Deformity. 
a. Pelves of 3.9 to 3 inches.-The operation is only exceptionally called 
for, since forceps and version ordinarily suffice for delivery. In case the 
infant is dead, however, it is preferable to resort to the cephalotribe, 
since thus the mother is spared the risk of energetic tractions. 
b. Pelves of 3.3 to 2.7 inches.-First try the forceps, then the perforator 
and Bailly's cephalotribe. 
In this instance the cephalotribe gives fairly satisfactory results. 
Lauth in 50 cases, . . . Mortality 32^ 
Rigaud " 22 " . . . " 50^ 
Stanesco " 33 " . . . " 24^ 
Benoit " 14 " . . , . I( 14.28^ 
c. Pelves of 2.3± to 1.93 inches.-The forceps has little chance of suc- 
cess. With the cephalotribe Stanesco, in 18 cases, had a mortality of 
22.22 per cent. 
d. Pelves of at least 2.5 inches.-Authorities differ as to the choice of 
methods. It is our opinion that the cephalotribe should be used as long 
as it will pass. Stanesco gives the following figures: Pelves from 2.5 to 
2.15 inches, mortality 41.17 per cent.; pelves of 2.15 inches, 3 cases with 
3 recoveries. Maygrier gives the following figures: 254 
A TREATISE ON OBSTETRICS. 
Pelvic measurement, 2.54 in. Cases 32 Mortality 40.62^ 
" 2.45 in. " 1 
" 2.42 in. " 1 
" 2.38 in. " 2 " 50. £ 
" 2.34 in. " 20 " 50. # 
" 2.3 in. " 1 
" 2.22 in. " 1 " 100 # 
" 2.15 in. " 4 " 25 
" 2.1 in. " 1 
" 1.9 in. " 3 " 33.33# 
" 1.4 in. " 1 " 100 # 
As was to be expected, the mortality rate increases with the degree of 
contraction, as also the difficulty of the operation. To obviate this Pajot 
proposed repeated cephalotripsy without traction. In reference to this 
operation, he says: " Struck by the numerous failures of cephalotripsy in 
exaggerated pelvic contractions, remembering the deplorable consequences 
for the women of the use of excessive force, and objecting to the Csesarean 
section pract'sed from choice and not from necessity, I have proposed a 
new method under the name of ' repeated cephalotripsy without traction.' 
After the skull has been perforated, the first application of the cephalo- 
tribe should be made as early as possible, with the usual precautions. 
After crushing the head, I endeavor to turn it by means of the instrument, 
so as to place the diminished diameter in the contracted portion of the 
pelvis. If this rotation cannot be made with ease I abstain, for experience 
has taught me that the uterus itself will usually mold the diminished 
head and rotate it, with less risk of injury than by artificial rotation. The 
instrument is to be withdrawn without making any attempt at traction 
whatsoever; it is reapplied a second and a third time, the head again 
crushed, and after each crushing the instrument is withdrawn, always 
without traction. The woman is placed in bed, and according to her 
general condition and the uterine contractions, I repeat these multiple 
crushings every two, three, or four hours. When the head has been com- 
pletely crushed, the trunk ordinarily presents obstacles which necessitate 
one to two crushings. By this method I have had six successes in eight 
cases, in the presence of extreme pelvic deformity, where many accoucheurs 
would have resorted to the Csesarean section. " 
e. Pelves contracted at the Inferior Strait or in the Excavation, by 
Tumors, Exostoses, Spondylizema, Spondylolisthesis.-It is impossible EMBRYOTOMY. 
255 
to fix exact limits. Everything depends on the degree of contraction. 
The same holds true of fibrous tumors, osteo-sarcomata, etc. 
2. Indications f rom the Side of the Foetus. 
Such are excess of volume of the head, advanced ossification of the 
skull, complicated or irregular presentations, in particular those of the 
face, foetal monstrosities, the death of the foetus, etc. 
As for the contra-indications to cephalotripsy, we know of but one, and 
this is the opposition of the mother. In such an instance we must either 
let the woman die undelivered, or else resort to the Caesarean section. 
The operation is performed in four stages: 1. Insertion of the blades. 
2. Locking of the blades. 3. Crushing of the head. 4. Extraction, 
where PajoVs method is not followed. 
Introduction of the Blades.-The woman having been anaesthetized and 
placed in the obstetrical position, the head, perforated or not, (it is our 
practice always to precede cephalotripsy by perforation), is to be steadied 
at the superior strait by an assistant. The blades are to be inserted so 
as to grasp the head firmly by its base, in order to crush it at its most 
resisting part. The blades, hence, are usually applied at the sides of the 
pelvis, and usually, indeed, this is' the only way the cephalotribe may be 
employed, since the pelvic contraction is ordinarily in the antero-posterior 
diameter of the superior strait, and the greatest space exists at the extremi- 
ties of the transverse diameter of the pelvis. The rule in a nut-shell, 
however, is to grasp the head how and where we can, remembering always 
that the cephalotribe is a thicker and more massive instrument than the 
forceps, and that the space in which it must work is very limited. Patience 
and gentleness, therefore, must characterize the insertion of the blades. 
Down to 2.34 inches Bailly's cephalotribe may be used, and this instru- 
ment being scarcely at all different from a strong forceps with narrow 
blades, the insertion is very much simplified; but below 2.34 inches we 
are obliged to use Depaul's instrument, or that of Blot or Tarnier, where 
the blades are narrow, and therefore it is not so easy to grasp the head. 
Whatever instrument is used, it must be inserted deeply, so as to seize the 
base of the skull well, and often the lock will be in the vagina. 
The general rules for application are identical to those of the forceps, 
the difficulty, of course, being greater, and frequently the entire hand 
must be inserted into the vagina. 256 
A TREATISE OX OBSTETRICS. 
Locking.-The same rules apply to this procedure as to the forceps, 
although greater care, if possible, is necessary, for the cephalotribe being 
more massive than the forceps, the risk of injury to the maternal parts is 
greater. 
Crushing.-As Pajot well says the responsibility of the assistant who 
steadies the head is here great, for the classic cephalotribe being very nar- 
row, the head tends to slip and the operation may on this account fail. 
Further still, the assistant is able to appreciate how the head has been 
grasped. 
Fig. 156.-Application of the Cephalotribe. 
The process of crushing should be slow and intermittent, and should be 
kept up until the handles of the instrument have been brought into con- 
tact. As the head collapses and the cerebral matter escapes, compression 
must be more energetic, or else the instrument will slip at the first trac- 
tion. 
Extraction.-After an interval of a few minutes, the cephalotribe should 
be seized in both hands, and rotated so as to bring the lesser curve of the 
instrument towards one or another thigh of the mother. (Fig. 156.) 
This movement aims at bringing the crushed diameter of the head into 
the conjugate-that is to say, the most contracted diameter of the pelvis. EMBRYOTOMY. 
257 
The head having been crushed in one direction, elongates in the other, 
and this elongation is in the conjugate of the pelvis. Tractions are then 
made, and these must be slow, sustained, combined with lateral move- 
ments. Ordinarily, the instrument rotates itself as the head engages, 
and we must favor this spontaneous rotation. The head once in the cav- 
ity, rotation in the inverse direction is made, and thus the lesser curve of 
the instrument is brought under the symphysis. Traction, even as with 
the forceps, should always be made in the pelvic axis, ajid during delivery 
the perineum should be as carefully watched. The head once delivered, 
the body follows quickly, except in case of great contraction. "We may 
then," says Pajot, "apply the cephalotribe on the thorax, or else, by traction 
on the body and rotation of a shoulder under the symphysis, we may be 
able to hook a finger in the axilla, bring down an arm, and thus deliver." 
Each of these periods may offer difficulties which render cephalotripsy 
one of the most delicate operations in obstetrics. It is often extremely 
difficult to place the blades, and it may be necessary to attempt the pas- 
sage several times before our efforts meet with success. The irregularity 
of the pelvis and the narrowness increase the difficulty, whence the neces- 
sity of proceeding slowly, pushing the blades in deeply, making sure that 
the head is well grasped. A capital point to be remembered is, as Pajot 
points out, the necessity of carrying the handles as far backwards as is 
possible, in order to assure grasping and crushing of the base of the skull. 
Bailly's instrument is, we think, the one which best enables us to ac- 
complish our aim, owing to the breadth of the blades and the greater 
concavity. The head is thus grasped the better, and cannot so readily 
escape from the instrument. Where the pelvis is greatly contracted, 
however, if the blades are not carried sufficiently backwards, their ex- 
tremities touch the posterior pelvic wall, and the projecting sacro-verte- 
bral angle. Here it is that repeated attempts at application of the blades 
are necessary, and however gently these are made, the risk of injury to 
the maternal parts is greatly enhanced. The danger from cephalotripsy, 
therefore, increases greatly in direct proportion to the degree of pelvic 
deformity. 
Generally, with Bailly's cephalotribe, locking is not difficult, but the 
same does not hold true of the classic instrument, on account of the nar- 
rowness of the blades. 
During crushing, slipping of the head is more likely as it is badly 
Vol. IV.-17 258 
A TREATISE ON OBSTETRICS. 
grasped and movable. The chief difficulty, however, is to crush the base 
of the skull. With Bailly's instrument, whenever it can be used, we are 
able to obtain most readily complete destruction of the base. During ex- 
traction, the chief thing to guard against is slipping, which may cause 
such injury to the maternal parts. It is to avoid this risk that Tarnier 
and Bertin have proposed, after a few attempts at extraction, if the head 
does not engage, to resort to podalic version. The objection we would 
make to this proposal, is that the uterus is often retracted on the foetus, 
and that version is hence impossible without running great risk of rup- 
turing the uterus. Further still, version is far from being practicable 
in every pelvis. 
Prognosis.-One of the risks resulting.from cephalotripsy and perfora- 
tion is from the spicuke of bone which project, and may injure the mater- 
nal parts. These must, hence, be removed with care before exerting 
traction. Otherwise the lesions which may follow cephalotripsy are the 
same as those likely to be caused by the forceps, and the more readily 
since it is a bulkiei' instrument, and the field of manipulation is more 
limited. 
The prognosis, indeed, is very grave. Rigaud places the mortality at 
50 per cent.; Stanesco at 33.72 per cent.; at the Clinic, during thirty 
years, we find the average to be 28.21 per cent.; Maygrier puts it down 
as 41.79 per cent.; Sickel as 22.75 per cent.; English authors as low as 
12.5 per cent., but certain among them never use the forceps, but resort 
at once to the cephalotribe as soon as delivery does not occur spontane- 
ously. [The author gives no authority for this statement. Certainly no 
English-speaking obstetrician of the present day would practise or seek 
to justify such unwarrantable destruction of the foetus.-Ed.] 
In 1881 Castelain (Lille) proposed to perform cephalotripsy not on the 
before-coming, but on the after-coming head-that is to say, first to try 
the forceps; if this fails, version, followed by cephalotripsy. He divided 
pelves into the following categories, from the standpoint of this advice: 
1. Pelves of at least 3.3 inches; forceps or version, cephalotripsy only 
exceptionally. 
2. Pelves from 3.3 to 2.7 inches; the forceps, this failing version fol- 
lowed by cephalotripsy. 
3. Pelves from 2.7 to 2 inches; the same procedures. 
4. Pelves below 2 inches; Ca?sarean section. EMBRYOTOMY. 
259 
The chief utility of the method he advocates consists in the fact that 
thus it is possible to grasp the skull by its base. In four cases where it 
was tried at the Lille Maternity, there were four recoveries. 
Although we admit, in a measure, the value of version in the lesser de- 
grees of contraction, since we may thus hope to obtain a living child, and 
still be able to resort to cephalotripsy if need be, below 2.7 inches we re- 
ject it, for, as Castelain himself observes, the head can certainly not pass 
by the contraction. The only way, in these instances, to obtain a living 
child is by the Caesarean section, and to this operation, as we have stated, 
we prefer cephalotripsy. [The time has not as yet arrived for positive 
statement, but we believe that the drift of opinion is towards the Caesa- 
rean section or Japaro-elytrotomy in every case where the infant is living, 
in place of cephalotripsy or other operation which of necessity sacrifices 
the foetus. It only remains to be shown that the risk to the mother is 
not thereby enhanced, and obstetricians have only to learn the advisa- 
bility of not waiting too long before resort to one or another of the opera- 
tions which take account of the child's life as well, and then both cephal- 
otripsy and cranioclasty and embryotomy will be relegated to what we 
believe is their proper sphere, cases where the foetus is dead. Such will 
be the verdict in the near future.-Ed.] 
We reject absolutely, however, version as a preparatory step to cephalo- 
tripsy. Version practised in deformed pelvis is an extremely difficult 
operation, and one which by itself alone exposes the mother to great risks. 
To resort to it before cephalotripsy, is simply to expose the woman to two 
risks instead of to one, which by itself is grave enough. It is true that in 
Castelam's three cases the women recovered, but three cases are not suffi- 
cient to warrant the justifiability of a new method. As to the advantages 
which result from the ability of crushing the base of the skull, they are 
incontestable, but we believe that by pushing the blades in deeply enough, 
the before-coming head may be grasped sufficiently to enable us to crush 
it thoroughly. In very contracted pelves, it is to Pajot's method of re- 
peated cephalotripsy to which we should have recourse, remembering the 
point on which Pajot insists, that after each act the head should be placed 
in a different position, so that the instrument may grasp it differently. 
To add version to these repeated cephalotripsies in pelves measuring 
from 2.7 to 2 inches, seems to us to act directly contrary to our aim, the 
succor of the mother. 260 
A TREATISE ON OBSTETRICS. 
III. Cranioclasty. 
Devised by Simpson in 1860, the cranioclast is in reality a bone-forceps. 
[The name craniotractor, suggested by Munde, is peculiarly appropriate, 
since it describes the action of the instrument exactly.-Ed.] 
The instrument is composed of two blades, (Fig. 157), the one smooth 
Fig. 157.-Simpson's Cranioclast. 
Fig. 158.-C. Braun's Cranioclast. 
and fenestrated, the other solid and roughened, fitting into the first. 
When closed, the blades, slightly curved, resemble, as Gueniot says, the 
bill of a duck. 261 
EMBRYOTOMY. 
The use of the instrument is preceded by perforation, and then the solid 
blade is applied within the skull, the fenestrated externally, and through 
their approximation, the bones are crushed. The instrument may then 
be withdrawn and the expulsion of the head be left to Nature, or else it 
may be used as a tractor, and delivery thus completed. 
The objections to Simpson's instrument are that it is too short, and 
therefore can scarcely be used above the superior strait, and further its 
lack of curve. Braiin has lengthened and curved it, and has added a 
compression screw. (Fig. 158.) [These modifications make Braun's in- 
Fig. 159.-The Bones of the Vault have been Removed, and the Base of the Skull is 
Grasped by the Instrument. The Head, Face first, is being drawn through the Contracted 
Strait. 
strument not only an efficient tractor, but also an efficient compressor. 
Being lighter and less bulky than the cephalotribe, and accomplishing the 
same end, we personally prefer it, especially since it may be used in cases 
of deformity where the cephalotribe, on account of its bulk, cannot.-Ed.] 
Wasseige thus states the advantages of the cranioclast: 1. It is a smaller 
instrument than the cephalotribe. 2. We may make traction with it as 
readily as by the body of the foetus. 3. The instrument rarely produces 
any lesions of the maternal parts. 4. It never slips, and if perforation 
has been effective, it always delivers. 5. Braun's instrument may be used 262 
A TREATISE ON OBSTETRICS. 
in cases where the contraction at the superior strait is as low as 1.5 inches. 
6. It may be used in case of all presentations. 7. It may be applied on 
hemicephalic and acephalic foetuses. 
Barnes, who is a great advocate of the cranioclast, recommends, before 
traction, the removal of portions of the vault. Burnes, contrary to the 
assertions of Hull, has shown that the removal of the vault reduces the 
base of the skull, and that if the head be brought down even as in case 
of face presentation, only the diameter between the orbits and the chin 
Fig. 160.-The Cranial Vault has been Removed, the Remainder is being drawn through 
the Strait. A, Promontory. C, Coccyx. 
presents at the strait, and this diameter is scarcely one inch. If then the 
conjugate is 1.5 inches, and the transverse 3 inches, cranioclasty is suffi- 
cient for delivery. Below this the Caesarean section is requisite. 
Although the inventor of the cranioclast, Simpson much prefers ver- 
sion, and he bases this preference on the following figures: Cranioclasty 
251 cases, mortality 1 in 5; version 169 cases, mortality 1 in 15. Further, 
he states that, ceteris paribus, version is resorted to earlier than cranio- 
tomy, and, therefore, will offer greater chance of success, the maternal 
mortality increasing always with the duration of labor. 263 
EMBRYOTOMY. 
Since 1862, the cranioclast tends in Germany to replace the cephalo- 
tribe, and Braun uses it exclusively. Rokitansky, up to 1871, had used 
it 52 times in Braun's Clinic: before-coming head 47 times; after-coming 
head 5 times. 
Braun, from 1871 to 1878, used it 82 times: Before-coming head 63 
times; after-coming head 19 times. Mothers recovered 59; mothers died 
23. Of the 23 deaths, 6 were in good condition before operation, and 17 
in bad condition. 
The causes of death were: Eclampsia 1; peritonitis 6; physometra 2; 
spontaneous rupture of uterus before operation 14. 
Bidder, from 1873 to 1875, has used the instrument 32 times success- 
fully. 
Fritsch has used it 41 times, with 7 deaths. Braun always perforates 
with the trephine. 
[The trephine best subserves the purpose of perforation of the before- 
coming head, and Naegele's scissors of the after-coming. After perfora- 
tion with either, a sound or similar blunt-pointed instrument should be 
inserted into the skull, and the brain thoroughly broken up, especially 
the medulla, lest a gasping, still-living infant, be brought into the world 
to the horror of the attendants.-Ed.] 
Wiener, of Breslau, comparing the results obtained from cranioclasty 
and cephalotripsy at the Clinic, from 1865 to 1876, gives the following 
figures: 
Perforations, 101: Before-coming head, 92; after-coming head, 9. 
Primiparge, 41; biparge, 25; triparae, 18. 
Presentations, 92: vertex, 1st position, 50; 2d position, 34; face, 1st 
position, 3; brow, 1st position, 2; brow, 2d position, 3. 
Head above superior strait, 47: occiput, 24; sinciput, 20; posterior 
parietal, 3. 
Head at the superior strait, 13: Occiput, 5; sinciput, 4; posterior parie- 
tal, 4. 
Head deeply engaged, 26: Occiput, 15; sinciput, 9; posterior parietal, 
1; brow, 1. 
Head in excavation, 10: Occiput, 8; brow, 1; face, 1. 
Operation was performed: After the death of foetus, 36 times; mother 
in critical state, 39; prolonged labor, 23; putrefaction of foetus, 10; sep- 
tic peritonitis, 1; eclampsia, 1; chorea, with affection of heart, 1. 264 
A TREATISE ON OBSTETRICS. 
In twenty instances many attempts at delivery with forceps had been 
made before perforation, the head above the brim. The results were: 
Died, 2; vesico-vaginal fistula, 1; vesico-uterine fistula, 1. 
Version had been attempted in 4: Died, 2; recovered, 2. 
Degree of pelvic deformity: 1st degree, simple flattened, 12; 2d degree, 
simple flattened, 14; 1st degree generally contracted, 17; 2d degree gen- 
erally contracted, 39; 3d degree generally contracted, 4; funnel-shaped, 
9; oblique-oval, 1; transversely contracted, 1. 
Except in 9 cases where, after perforation, labor was allowed to termi- 
nate spontaneously, extraction was always resorted to. Until 1871 the 
blunt hook or the cephalotribe was used for extraction. Since then the 
cranioclast has been used. 
Extraction with blunt hook, 20; extraction with cephalotribe, 17; ex- 
traction with cranioclast, 39; extraction with forceps 6. 
While extraction with the cephalotribe succeeded 17 times and failed 
11, the cranioclast succeeded 33 times and failed in only 7 instances. The 
cases in which the cranioclast was used are thus decomposed: Head 
above the brim, 19; head movable at the brim, 3; head fixed at the brim, 
8; head in cavity, 8. 
Where the cranioclast failed, labor was terminated by: Version and 
extraction, 3; cephalotribe, 2; forceps, 1; Caesarean section, 1. 
Where the cephalotribe failed, termination by: Blunt hook, 1; version 
and extraction, 2; cranioclast, 5; forceps, 2; post-mortem section, 1. 
The characteristics of the puerperium were: 
After cephalotripsy: Normal, 2; diphtheritic ulcers, 2; endometritis, 3; 
phlebitis, 1; vesico-vaginal fistulas, 1; left parametritis, 1. 
After cranioclasty: Normal, 15; intestinal catarrh, 1; abscess of left arm, 
1; endometritis, 1; septicaemia, left pleurisy, 1; fever, 2; vesico-vaginal 
fistulas, 4. 
After blunt hook: Peritonitis, 4; endometritis, 5. 
The total maternal mortality was 25.7 per cent, thus: Of 26 maternal 
deaths after: Cephalotripsy, 7; cranioclasty, 7; forceps, 3; blunt hook, 3; 
version, 3; traction on perforated head, 1; during extraction, 1; un- 
known, 1. 
Wiener draws the following conclusions: 
1. As soon as the necessity of perforation is evident, every other method 
of delivery, in particular the forceps, should be rejected. 265 
EMBRYOTOMY. 
2. Extraction should always follow perforation. 
3. The objections to the cephalotribe are: 
a. Risk of slipping. 6. Augmentation of the diameter of the head in 
one direction, and decrease in the opposite, c. Frequent injuries of the 
maternal parts, d. Grave troubles more frequently follow its use than 
that of the cranioclast. 
4. The advantages of the cranioclast are: a. It never slips if the inter- 
nal blade be carried high towards the base of the skull, and the external 
blade grasps the head over the ear and maxilla, b. It may be used in a 
smaller space and the operator may place it where he pleases, c. It in- 
jures the mother less frequently than the cephalotribe. d. It diminishes 
the base of the skull. 
Credo, without detracting from the value of the cranioclast, prefers the 
cephalotribe, because he has been enabled by it to end labor where the 
cranioclast had been tried in vain. In Italy, Fabri and Cuzzi, from a series 
of experiments with Braun's cranioclast, limit the utility of the instrument 
to instances where the sacro-pubic-diameter is not below 2.3 inches, and 
Cuzzi adds that if Rokitansky was able to succeed in greater degrees of 
contraction, it was because the foetuses had been dead for some time, and 
the bones and the sutures were, therefore, very movable. 
Narich proposes the following procedure: Extend the head by intro- 
ducing the fenestrated blade between the pelvic walls and the foetal face, 
and using it as a lever. Then perforate about | inch above the root of 
the nose. Make tractions downwards, accompanied by rotation, which 
will bring the bi-malar diameter towards one or another side of the sacral 
excavation. We may thus use the cranioclast in cases where the conjugate 
is diminished even down to 1^ inches. 
If the objections to the cephalotribe are true when applied to the clas- 
sic instrument, they are not at all applicable to Bailly's instrument, ex- 
cept, unfortunately, that it cannot be used in pelves diminished below 
2.5 inches. We have used it fully fifteen times, and it has never slipped, 
has always extracted the head, has always crushed the base of the skull 
when the blades were inserted deeply enough. We have lost but two 
women, and in these repeated attempts at delivery had been made before 
they were seen by us. It should be remembered that Narich's experi- 
ments were made on a bronze pelvis, and surely the conditions in the 
living woman are very different. Whatever the results obtained in 266 
A TREATISE ON OBSTETRICS. 
Germany, the cranioclast, we think, should remain an instrument of excep- 
tional utility. Above 2.5 inches we would recommend Bailly's cephalo- 
tribe, and below 2.5 inches the cranioclast. 
[We have not often, we are very thankful to say, been obliged to muti- 
late the living foetus, and, therefore, we cannot dogmatize in regard to 
the superiority of the cranioclast over the cephalotribe, and vice versa, 
although we prefer the former instrument. Our general practice is, where 
the case is seen in time (before or just after rupture of the membranes, 
and before engagement), to perform bi-polar version and endeavor to 
extract where the conjugate is not diminished below 2f to 3 inches at the 
brim. Thus we may possibly obtain a living child, and if we cannot ex- 
tract we can still perforate. Below 2$ inches the cranioclast is just as 
effective an instrument as the cephalotribe, and being less bulky is far less 
likely to injure the maternal parts. Why then ever use the cephalotribe ? 
Thorough perforation and evacuation of the cerebral matter, followed by 
careful insertion of Braun's cranioclast and crushing by means of it, will 
certainly accomplish all that the cephalotribe can, and not do what the 
cephalotribe may, damage the mother. 
Such we believe to be sound practice, for the present. We repeat, 
however, that we look forward to the approach of the day when custom 
will sanction resort to an operation in case of the living infant which will. 
give it a chance and yet not increase the maternal risk.-Ed.] 
IV. Sawing of the Head, or Cepiialotomy. 
In 1842, struck by tlie risk of damage resulting from the projection of 
spiculse of bone after perforation and cephalotripsy, Van Huevel devised 
a saw-forceps which permits of sawing into the head without splintering 
it. His instrument (Fig. 161) has been repeatedly used by himself, and 
Hyernaux, who advocates the instrument strongly, says: "It is now 
twenty-four years since Van Huevel devised his instrument, and we can 
vouch for its frequent success in cases where there was contraction even 
down to 1.5 inches, its limit of application." 
Didot (Liege) has modified Van Huevel's saw-forceps, and has devised 
what he calls a diatrypteur, an instrument resembling a glove stretcher. 
It has never been used on the living. 
Tarnier has caused the construction of two models of a saw-forceps, EMBRYOTOMY. 
267 
with parallel blades. The one (Fig. 162) has a single chain saw and is 
similar to Van Huevel's instruments; the other (Fig. 163) has two chains 
which move at the same time and cross one another, so that after the 
Fig. 161. Fig. 162. 
Fig. 161.-Van Huevel's Saw-Forceps. Fig. 162.-Saw-Forceps with single chain 
of Tarnier. 1, A, Holes through which the chain passes. B, Key. C, Opening for passage of 
conductor. D, Lock. E, Chain saw. FF, Handle of saw. IK, Flexible conductor. 2, Insertion of 
chain saw through openings. 
sawing the section of bone is loose and may be at once extracted. The 
removed portion has the shape of a cone, with a base a trifle over inch 
in thickness. In his experiments, Tarnier was able to extract, from a 268 
A TREATISE ON OBSTETRICS. 
wooden box through an opening inches long by £ inch broad, the 
cadaver of a foetus after three successive applications of his saw-forceps, 
a result not practicable with any other instrument. 
The saw-forceps is open to a number of objections: it is difficult to 
Fig. 163.-Double Chain Saw-Forceps of Tarnier. A, Key. B, Screw bringing together the 
blades. CD, Chain saw. EF, Ends of chain. GG, Ends of conducting rods. HI. Chain saw passing 
through openings. 
handle; where the pelvis is much contracted, a long time is requisite for 
completion of the operation; it is not an instrument for extraction; it is 
very expensive. 
In case of extreme contraction, Barnes uses a serre-noeud and a metal- 
lic cord, and has operated by means of these in a rachitic pelvis measuring 269 
EMBRYOTOMY. 
not quite an meh in the sacro-pubic diameter. He thus describes his 
method: "Even as in cephalotripsy, it is useful first to perforate. It 
further facilitates the operation to twist off a portion of the parietal 
bones by the cranioclast. The wire loop thus buries itself more deeply, 
and it cuts its way through more readily. If the sphericity of the head 
Fig. 164.-Barnes' Operation of Lamination by the Fcraseur. 
is not first destroyed, the wire loop is apt to glide off the head, seizing 
only the scalp when the screw is worked. The crotchet is next passed 
into the hole made by the perforator and held by an assistant, so as to 
steady the head. (Fig. 164.) A loop of strong steel wire is then formed 
large enough to encircle the head. The loop is guided over the crotchet 
to the side of the uterus where the face lies. The compression being 270 
A TREATISE ON OBSTETRICS. 
removed, the loop springs open to form its original ring. This is guided 
over the anterior part of the head (See Fig. B). The screw is then tight- 
ened and the wire is buried in the scalp. The whole force of the man- 
oeuvres is expended on the foetus; there is no outward pressure on the 
Fig. 165.-Hubert's Perfora- 
tor (Terebellum.) 
Fig. 166.-Protecting 
Blade. 
Fig. 167.-Hubert's Transforator. 
(Complete.) 
maternal parts, as is inevitable with the cephalotribe or Van Huevel's 
saw-forceps. A steady working of the screw cuts through the head in a 
few minutes. The loose segment is then removed by the cranioclast. In 
minor degrees of contraction the removal of one segment is enough to 271 
EMBRYOTOMY. 
enable the rest of the head to be extracted by the cranioclast. But in 
cases of extreme distortion it is desirable to still further reduce the head 
by taking off another section. This is best done by re-applying the loop 
over the occipital end of the head (See Fig. A). It thus accomplishes 
what the cephalotribe does not, it breaks up the base of the skull. The 
small part of the skull still remaining offers no obstacle. It serves as a 
hold for traction. The cranioclast seizes it firmly and the delivery of the 
trunk is proceeded with. If the child be well developed, this task will 
require considerable skill and patience." 
This method appears to us a very difficult one in practice, as much so 
as the saw-forceps, although theoretically it seems simpler. 
We recall, finally, as matters of curiosity, Ritgen's labitome, Finizzio's 
sego-cefalotomo, Joulin's diinseur-cephalique. The latter was used once 
on the living; the conductor perforated the uterus, and the woman died 
in a few hours. 
It remains for us to describe the transforation of Hubert, and the in- 
tracranial cephalotripsy of Guyon, which methods are included by Gueniot 
under the term sape-sqjhenoidienne. 
Hubert's transforator (Fig. 167) is composed of a terebellum, a steel rod 
at the end of which is a pear-shaped, sharply pointed screw, and a pro- 
tecting blade about 1 inch thick, the extremity of which is perforated for 
the passage of the terebellum. 
By means of this instrument numerous holes may be drilled into the 
skull, and then either expulsion be left to Nature, or else delivery by 
traction may be resorted to. With the transforator E. Hubert states the 
maternal mortality to be only 11.62 per cent., against 22 per cent, with 
the saw-forceps, and 18 per cent, the lowest obtained by cephalotripsy. 
Hubert gives the following comparative tables, which show at a glance 
the results obtained by these three methods. 
Cranictomy in General. 
Cephalo tribe, 
235 cases. 
Saw-Forceps, 
130 cases. 
Transfonator, 
43 cases. 
Deaths 
34.46% 
22.36% 
11.62% 
Puerperal accidents 
20.42% 
26.15% 
16.62% 
Normal puerperium 
45.12% 
o 1. 
76.42% 272 
A TREATISE ON OBSTETRICS. 
Craniotomy in Cases where the Pelvic Measurements are Noted. 
Cephalotribe, 
127 cases. 
Saw-Forceps 
91 cases. 
Transforator, 
43 cases. 
Deaths 
38.58% 
23.07% 
11 62% 
Puerperal accidents 
18.89% 
29.78% 
11.62% 
Normal puerperium 
24.52% 
47.25% 
76.42% 
Craniotomy in Contractions from 2.5 to 3.1 Inches. 
Cephalotribe, 
46 cases. 
Saw-Forceps, 
50 cases. 
Transforator, 
29 cases. 
Deaths 
26.08# 
22# 
10 34# 
Puerperal accidents 
21 73# 
30# 
10.34# 
Normal puerperium 
5.17# 
48# 
79.31# 
Craniotomy in Extreme Contractions, at least 1.8 Inches. 
Cephalotribe 
24 cases. 
Saw-Forceps, 
33 cases. 
Transforator, 
14 cases. 
Deaths 
54.16% 
18.18% 
14 28% 
Puerperal accidents 
8.33% 
33.33% 
14.18% 
Normal puerperium 
37.51% 
48.48% 
71.42% 
This method, with the transforator, deserves the serious thought of 
accoucheurs in view of the most excellent results it yielded in the hands 
of the late Professor Hubert, of Louvain. 
Intra-cranial cephalotripsy of Guyon is thus described by Kalindero: 
" The apparatus consists of two long trepans, and of one small forceps. 
The instrument is used as follows: The index of the left hand seeks the 
point of the skull where it is desired to perforate, and the trephine rod 
(Fig. 168) is guided to this point, and screwed down and into the bone. 
The large trephine is then adjusted to the rod, and by working it, a 
round piece of bone is removed. Through the resulting hole the smaller 
trephine is inserted, carried to the sphenoid bone, the basilar apophysis, 
and destroys it. The aim of the trephines then is to break up the base of 
the skull, and this once accomplished, the small forceps is applied in the 
ordinary manner, and compression of the handles by the hand suffices EMBRYOTOMY. 
273 
to crush the head. Before making traction the instrument is rotated to 
bring the greatest diameter of the head into that of the pelvis, and then 
extraction is easy. 
The instrument has been used six times, in three successfully; in the 
remaining three, two were already in extremis, and the third died at the 
Necker hospital of sepsis, during the prevalence of an epidemic. The 
procedure is certainly as harmless as it is ingenious, and the intra-cranial 
Fig. 168.-Screw Rod. Fig. 169.-Forceps. Fig. 170.-Trephines. 
touch allows us to readily trephine the sphenoid bone, but as Gueniot 
justly remarks " the difficulty is increased in case of obliquity of the head." 
The capital point of the method is that intra-cranial touch allows us to 
guide the trephine io the portion of the skull, which we desire to attack. 
V. Embryotomy. 
Embryotomy, properly so-called, is an operation which consists in cut- 
ting off the neck or the body of the foetus, when delivery is not possible, 
Vol. IV.-18 274 
A TREATISE ON OBSTETRICS 
either by the forceps, version, or cephalotribe. It is, hence, an operation 
which is only exceptionally called for. The indications may be summed 
up under the following heads: 
1. In presentation of the shoulder, where version is not practicable, ow- 
ing to contraction of the uterus, or deep engagement and immobilization 
of the presenting part. 
2. In pelvic contraction where the foetus cannot be extracted without 
risk to the mother. 
3. In case of monstrosities, where there is excess in size of the foetus. 
Of these indications it is unquestionably the first which is the most 
frequent. 
The study of embryotomy has been pursued most completely by Pinard, 
in 1875, and by Thomas, in 1879. Pinard resumes the contra-indications 
of version as follows: 
A. Non-dilation of the Cervix.-The contra-indication is temporary, or 
else, in certain instances of cancer and fibrous tumors, it is absolute. 
B. Deep Engagement of the Foetus.-The contra-indication is absolute. 
C. Tetanic Retraction of the Uterus.-The contra-indication is similarly 
absolute. 
D. Extreme pelvic Contraction.-Version contra-indicated in all pelves 
measuring less than 2.73 inches, if the infant is living; version is allowa- 
ble whenever the hand can be introduced, if the infant is dead; below 2 
inches version is not possible. The same rule applies in case of any osse- 
ous tumor obstructing the parturient canal. 
We cannot accept in its entirety this classification, and although we 
share Pinard's opinion in regard to the three first indications for embry- 
otomy, where version is impossible, we are absolutely at variance with 
him in case the infant is dead. In presence of the difficulty of version 
in contracted pelves, in presence of the death of the foetus, it is not to 
version we would resort, but to embryotomy, in particular to decapitation. 
When carefully performed, decapitation is without risk to the mother; 
in 7 cases where we have resorted to it, in slight degrees, of pelvic defor- 
mity, it is true, we have had 7 recoveries. Evisceration, eventration, on the 
contrary, is much more grave, and in the three cases where we have per- 
formed it, we have had but a single recovery. To attempt version, how- 
ever, where the infant is dead, and where there is marked pelvic contrac- 
tion, seems to us just as grave a procedure as eventration. EMBRYOTOMY. 
275 
The operations which may be performed on the fcetus in presentation 
of tlie shoulder are : 
1. Decapitation, detruncation. 
2. Section through the entire body. 
3. Evisceration. 
4. Section of the vertebral column, or spondylotomy. 
5. Section of the upper extremities, or brachiotomy. 
Detruncation is certainly the simplest of all these operations, but un- 
fortunately it is not always possible to reach the neck. 
Although embryotomy has been practised from the earliest times, since 
it may be found mentioned by Hippocrates, it is only since the beginning 
of the present century that precise rules for its performance have been 
formulated, so that we are in a position to state definitively the aim of 
each one of the possible procedures. Pinard ranges these aims in the 
following categories: 
1. Evisceration or exenteration, preceded or not by brachiotomy, aim- 
ing at forced version. 
2. Evisceration or exenteration, without brachiotomy, but occasionally 
With spondylotomy, aiming at forced evolution. 
3. Spondylotomy at the neck or the centre of the body, aiming at the 
successive extraction of the foetus in portions. 
1. Method which aims at forced Version. A. Robert Lee's Procedure. 
-This consists in performing brachiotomy, then perforating the thorax, 
and by means of a hook inserted into the pelvis or the lower part of the 
vertebral column, to make traction on the foetus, and deliver without 
damage to the maternal parts. 
Rejected by Chailly and Cazeaux, brachiotomy has been practised by 
Dubois as a means to assist in decapitation. Stoltz, Pajot, Depaul, Blot, 
admit that it is useful, and in certain instances indispensable. By bra- 
chiotomy we mean, of course, disarticulation of the shoulder. 
B. Guiseppe Portas's Procedure.-It consists of two stages: The first 
is to pass a filet over the arm, and make traction so as to engage the 
shoulder and the axilla deeply, when perforation is performed by means 
of a bistoury into the thorax, and thence the abdominal and thoracic vis- 
cera are removed; the second is to seek the feet and deliver' by podalic 
version. 
2. Method which aims at forced Evolution.-There are five procedures. 276 
A TREATISE ON OBSTETRICS. 
A. Veit's Procedure.-The foetus is eviscerated, without brachiotomy, 
traction is made on the arm and the breech simultaneously, and the infant 
extracted doubled on itself. 
B. Michaelis's Procedure.-Evisceration, followed by spondylotomy 
and forced evolution of the foetus. 
C. Macdonald's Procedure.-Spondylotomy without evisceration, ex- 
traction of the foetus by the feet-in other words, delivery by forced ver- 
sion. 
D. Boens's Procedure.-Removal of procident portions, that is to say, 
brachiotomy, thoracic and abdominal evisceration, crushing of the thorax 
by the fingers. Finally, section of the foetus in two, followed by separate 
extraction. 
E. Championniere's Procedure.-Evisceration; spondylotomy by a 
screw rod; at times brachiotomy; removal of the foetus in two portions. 
Results; 3 operations with two deaths. 
3. Method which aims at successive Extraction of Portions of the Fcetus. 
-Section of the foetus may be practised on the neck or on the trunk. 
In the first instance we are dealing with decapitation, method of Celsus. 
The instruments with which decollation may be performed are ranged 
as follows by Thomas: a. Knife embryotomes., b. Scissor embryotomes. 
c. Saw embryotomes, d. Embryotomes which act by pressure and lacer- 
ation. 
a. Knife Embryotomes.-In this category belong the bistouries of Steinen 
and of Busch, the knives of Albucasis, Pare, Rizzoli, Mauriceau, Rams- 
Fig. 171.-Dubois' Scissors for Decollation 
botham, Jacquemier, the crochet of Simpson, the decapitator of Scan- 
zoni, etc. In general, these instruments are defective, and by no means 
as valuable as the scissors. 
b. Scissor Embryotomes.-The best instrument is that of Dubois. It 
consists of long handles, very strong, short blades slightly curved on the 
flat, with blunt ends. (Fig. 171.) In using them, having carefully de- 277 
EMBRYOTOMY. 
termined, the presentation, Dubois inserts the left hand into the vagina, 
and guides along the fingers a blunt hook which he endeavors to pass 
around the foetal neck. When successful, he withdraws the hand, and 
grasping the handle of the hook he makes strong traction to bring down 
the foetal neck. He then hands the hook to an assistant, inserts his hand 
again into the vagina, and places the end of his finger at the point where 
he intends to cut the neck. He passes the scissors along this finger up 
to the foetus, and cuts the integuments little by little, separating the 
blades only slightly, in ordei' not to damage the maternal parts. During 
this procedure the finger which surrounds the neck must never leave it, 
but must take account of the progress of the section. 
Mattei uses strong scissors which he calls endotomes; Lazarewitch uses 
an instrument which is at once a sector and a tractor. Tarnier contends 
that the scissors attack with difficulty the soft parts, and all the more the 
bone. Never, however, have we seen the operation last longer than ten 
minutes when performed by Depaul, and never, except in one case, has 
it required longer in our personal experience. The difficulty is not in the 
cutting, but in the passage of the hook around the neck. Where the 
neck is accessible, we believe the method to be the best. Where the neck 
is not accessible, we must eviscerate. 
c. Saw Embryotomes.-Here belong Jacquemier's embryotome (Fig. 
172,) Van der Ecken's crochet (Fig. 174), the crochets of Kilian, Mathieu, 
Heyerdahl, Kierulf, Hohl, Wasseige (Fig. 173), Stanesco (Fig. 175), 
Tarnier (Fig. 176), etc. All these crochets are intended to carry behind 
the neck or behind the trunk of the foetus, a saw or ecraseur, in order 
thus to break up the infant. 
Of all these instruments the simplest is that of Pajot. With a stout 
piece of silk or twine the foetus may be sectioned in a minute, the twine 
being worked backward and forward, and without risk to the mother. 
The twine may usually be passed around the foetus by means of a blunt 
hook, and I have had a hole drilled in the blunt crochet of the forceps 
which receives the twine, and to the twine maybe attached a small leaden 
weight, which assists the accoucheur in reaching the end which has 
been passed around. Tarnier has suggested Belloc's sound for the passage 
of the twine. [A gum-elastic catheter, the uterine sound, instruments 
which are apt to be in every accoucheur's bag, are as serviceable as any- 
thing else.-Ed.] When the twine has been passed, the hook is with- 278 
A TREATISE ON OBSTETRICS. 
drawn, the ends of the twine brought out through a cylindrical speculum, 
which is inserted to protect the vagina, and then by to-and-fro movements 
the operator may readily saw the neck, or the trunk. This method was 
Fig 172.-Jacquemier's Embryotome. Fig. 173.-Wasseige's Crochet. 
first advocated by Boyer, and has been successfully used by Pajot, Tarnier, 
Rey, and others. EMBRYOTOMY. 
279 
The crochets of Kidd, of Tarnier, of Hubert, of Wasseige, of Stanesco, 
are certain ones articulated, and others not. 
d. Embryotomes which act by pressure or laceration.-The simplest of 
all is Braun's blunt hook. It is composed of a steel bar bent at an acute 
angle in the shape of a crook. (Fig. 1'77.) The foetal arm is pulled down 
Fig. 174-Van der Ecken's Crochet 
for Decapitation. 
Fig. 175.-Stanesco's 
Crochet. 
Fig. 176.-Tarnier's 
Crochet. 
as much as possible in order to make the neck accessible. The left hand 
is introduced into the vagina and one or two fingers are passed around 
the neck. The hook is then passed flat along the hand and behind the 
foetal neck, guided by the fingers. The handle of the instrument is then 
lifted up, and vigorous traction made horizontally until the ligaments of 
the vertebral column are heard to rupture. The hook is then turned 280 
A TREATISE ON OBSTETRICS. 
around several times, traction being simultaneously made. The vertebral 
column and the tissues are thus torn. The fingers should not be with- 
drawn during this manoeuvre, since they are there to protect the mater- 
nal parts against injury. The foetal trunk is readily extracted by pulling 
on the arm, and the head may be removed either by the hand, the for- 
ceps or the cephalotribe. (Fig. 178.) 
Fig. 177.-Braun's Blunt Hook. 
Fig. 178.-Decapitation after Braun. 
Pierre Thomas has devised an apparatus which consists in: 1. Braun's 
hook. 2. A chain-saw. 3. A vaginal protector. 
Braun's hook is perforated for the passage of the chain-saw, and is used 
for passing the chain around the foetal neck. This accomplished, the 
hook is withdrawn, and the two ends of the chain passed through the 
tubes of the vaginal protector (Fig. 179, B), and the neck is sectioned by 
working the chain. Thomas says of his method: " We believe that it 
has the following advantages over Braun's: 1. The maternal parts cannot EMBRYOTOMY. 
281 
be injured either by the hook or the chain. 2. The operation is less 
painful, and is more certain and rapid." We have already stated that 
Barnes carries an ecraseur wire by means of Ramsbotham's hook, in order 
to perform brachiotomy. 
The two most recent embryotomes are that of Tarnier and that of 
Thomas, which is simply a modification of Tarnier's. 
Fig. 179.-Pierre Thomas' Instruments for Decapitation. 
Tarnier's embryotome is composed of two blades, two conducting rods, 
a chain-saw. One blade is called the posterior and the other the anterior. 
These blades are grooved. The posterior blade is curved to fit into the 
concavity of the sacrum. The anterior blade is slightly curved for inser- 
tion between the foetus and the pubes. The blades are applied around 
the foetus, and are locked and screwed down until the handles are close 
together. The chain is then pushed through the groove in the blades by 282 
A TREATISE ON OBSTETRICS. 
means of the conducting rods, and worked along as well by the screw key. 
The foetus is divided from below upwards. The entire thickness of the 
body may be cut through in five seconds, according to Tarnier. 
Thomas's latest embryotome consists of two blades, two stylets, a special 
saw. (Fig. 181.) The instrument is used as follows: The posterior 
blade is inserted behind the neck or the trunk of the foetus, and the an- 
terior blade in front. The blades are locked and brought in apposition. 
The chain-saw is then carried by the stylets through the blades. The 
instrument is steadied by an assistant, and by rapid to-and-fro movements 
of the chain the foetus is sectioned from below downward. The mater- 
nal parts run no risk of being damaged by the saw, being protected by 
the blades of the instrument. 
Fig. 180.-Tarnier's Embryotome. EMBRYOTOMY. 
283 
We see then that it is not instruments which are lacking. The real 
difficulty in embryotomy is the contraction of the uterus. Where then 
the blunt hook cannot pass, the same will hold true of other instruments. 
The simplest method is that of Braun, but it requires gn amount of force 
which may be dangerous to the mother. The same does not hold true 
of Dubois's scissors. We should then prefer them, resorting to Pa jot's 
Fig. 181.-Pierre Thomas' Embryotome.-A, Posterior blade. The exaggerated curve of the 
uterine portion is shown, also the groove for the passage of the chain saw. B, The anterior blade is 
slightly curved at its uterine part. C, D, Stylets. E, Instrument articulated. The conducting 
stylet is inserted. F, Chain saw. 
device if they failed. In every case where we have been called upon to 
detruncate or eviscerate, Dubois's scissors have answered us well. We 
have had six successes in seven cases. 
After decapitation the body of the foetus readily follows on traction on 
the arm. The head may give us trouble. In case it resists our gentle 
efforts with the hand, forceps or cephalotribe, we may try a blunt hook 
inserted into the mouth. 284 
A TREATISE ON OBSTETRICS. 
Embryotomy is always a grave operation. The mortality rate is, there- 
fore, high, even where practised with the greatest possible care and ex- 
pertness. 
Such are the operations which may be practised on the foetus. May 
they be compared one with another, from the standpoint of the results 
Fig. 182.-Embryotome around the Neck of the Fcetus, held by an Assistant. 
which they give for the mother and the infant? We do not think so; the 
conditions vary too markedly according to the case, the mode of interven- 
tion and the necessity. The statistics which we have given, it should be 
remembered, have been copied and recopied, and they vary much accord- 
ing to each author. There is further the element of expertness, which 
we must take into account, and which explains fully the success of some 
where others have failed. PART VIII. 
The Pathology of the Puer- 
periiim. CHAPTER I. 
THE PATHOGENY OF PUERPERAL FEVER. 
LTHOUGH under the term pathology of the puerperium, we might 
include all the morbid manifestations which may occur during, and 
disturb the course of the physiological puerperal state, a detailed study 
of these manifestations would carry us far beyond the limits of this work, 
and require volumes. We will limit ourselves, therefore, to a sketch of 
what was formerly called puerperal fever, but what tends more and more 
daily, to be known as puerperal septicaemia. Although, however, we think 
that puerperal fever, as an essential morbid entity, should be rejected, we 
believe that Luys and Siredey have gone too far in wishing to banish it 
altogether. Among the diseases which may affect the puerperal woman, 
there are some which are purely inflammatory, and there are others, un- 
fortunately the vast majority, which depend on a true poisoning, which 
are due, in other words, to the absorption by the puerpera of septic 
germs, products of decomposition, the name matters not, and these we 
may range under the term puerperal fever, puerperal septicaemia. Such 
are the accidents to which the older writers gave the name puerperal 
fever, and to entirely reject this term is to enter the road which leads 
directly to the localization of puerperal affections. Certainly all women 
affected with puerperal fever do not present the same lesions. At times 
we have a phlebitis, and again a lymphangitis, or a peritonitis, or even a 
pleurisy, as the principal lesion, but each of these is simply a peculiar 
manifestation of a general state, and it is this general state which consti- 
tuted for the ancient writers puerperal fever, and which is to-day known 
under the name qf puerperal septicsemia. In a word, there is infection of 
the patient. One or the other term, hence, is with us interchangeable. 
Puerperal fever, puerperal septicemia, may be endemic or epidemic. 
Even as the symptoms of the affection may vary infinitely, however, so 
too may the epidemics in their severity. Since the first epidemic at the 
Hotel-Dieu, recorded by Mauriceau and Lamotte, 1664, scarcely a year 288 
A TREATISE ON OBSTETRICS. 
has passed, without our being able to refer to an epidemic at one or another 
place in the different parts of the world. 
While all authorities agree in regard to the application of the term 
puerperal fever, the theories of its origin have been innumerable, and 
even to-day there are questions concerning it which it remains for the 
future to decide. 
The earliest theory was based on the idea of retention of the lochia, 
and decomposition of remnants of the placenta. This theory originated 
with Hippocrates, and was defended by Galen, Avicenne (1000), Rhodion 
(1532), Mercatus (1570), Victor Trincavellus (1597), Roderic de Castro 
(1603), Michaelis (1615), Boerhaave (1629), Sennert (1631), Sydenham 
(1682), Stahl (1690), Hitter (1711), Mauriceau (1712), Burton (1751), 
Smellie (1752), Astruc, Johnston (1769), Tissot (1795), and many others. 
The lochia being checked by inflammation, or by spasm of the vessels, 
septic materials were retained in the blood. The uterus and other organs 
became diseased, and there finally resulted putrid fever. 
To this theory succeeded that of the metastasis of the milk, which was 
first promulgated by Mercurialis and Willis, in 1662, and was advocated, 
in particular, by Puzos, (1743), and latei* by Lieutaud (1750), Sauvages 
(1640), Levret (1766), Van Swieten, Deleurye (1777), Baldinger, Leroy, 
Plenck, Henkel, Boer, Fischer, Hecker, Wenzel, E. Martin, Broussais, etc. 
At the beginning of this century, Autenreith formulated his physiological 
theory, which is purely a combination of the preceding. During preg- 
nancy excretions flow specially towards the uterus, but after labor they 
are eliminated by the sweat glands, the lochia and the milk. If these 
peripheral functions are interfered with, the course of these excretions is 
turned towards the head, the thorax, and above all the abdomen. This 
theory was accepted and sustained by Schmidtmuller, Carus, Joerg, 
d'Outrepont, etc. 
Then arose the gastro-bilious theory of Trincavellus, which was advo- 
cated in particular in England by Manning, Cooper, Denman, and others. 
The fifth theory is the phlogistic; according to which inflammation is 
the cause of puerperal fever. According to the site of the inflammatory 
process, we may have three varieties: 
1. A metritis, the opinion of Plater, 1602, Denman, Tissot, Naegele, 
and others, and this metritis may be associated with a phlebitis or a lym- 
phangitis. THE PATHOGENY OF PUERPERAL FEVER. 
289 
2. An enteritis and a peritonitis. ' 
3. Peritonitis, pure, the view held by Johnston, Hunter, Siebold, 
Capuron, Baudelocque, and others. 
Then followed the erysipelatous theory, which was advocated in par- 
ticular by Eisenmann, and accepted by Delaroche, Bayrhoffer, Gordon, 
Ingleby, Lee, many American and English authorities. This theory con- 
siders puerperal fever an internal erysipelas. 
The discussion on puerperal fever at the Academic de Medicine, in 1858, 
resulted in a division of authorities into two categories, the localists and 
the essentialists. 
The localists, represented by Boullaud, Cruveilhier, Cazeaux, Jacque- 
mier, Velpeau, Piorry, Beau, claimed that the local lesion constituted the 
disease, and they eventually all, with the exception of Beau, finished, 
under the influence of Trousseau, by claiming that puerperal fever had 
its origin in lesions of the genital tract, which were complicated by gene- 
ral secondary lesions, the outcome of purulent infection. 
The essentialists, under the leadership of Paul Dubois and Depaul, 
claimed that ' ' puerperal fever was due to a primitive external influence, 
at first acting on the blood and then attacking the organism at points of 
predisposition, such as the genital system, the peritoneum, but essentially 
leading to general poisoning by morbid reaction on the blood, and the 
organs in general. The contagious nature of the disease was granted in 
full by them. " (Doleris.) 
The idea, hence, of a miasm, of a poison, of a transmissible virus, was 
thus definitively established, and was later advocated by Hervieux. This 
idea had already been broached by Why te, in 1770, who, from the fact that 
puerperal affections showed themselves in particular in maternity hospi- 
tals, claimed that septic matters either developed spontaneously in the or- 
ganism or were introduced through the atmosphere tainted by putrid ele- 
ments. Walsh, in 1788, reported the case of a puerpera poisoned by 
putrid fever; Douglas described an epidemic or contagious form; Cru- 
veilhier accepted the doctrine of hospital miasm, and the poisoning of the 
puerpera through the uterine wound, and he was followed by Eisenmann 
and Helm, who declared that the uterine wound might be contaminated 
by miasmatic influences acting directly, or else penetrating into the circu- 
lation by the respiratory tract, and finding in the irritated and the 
wounded uterus a point of receptivity. Finally, Kiwisch, Litzmann, 
Vol. IV.-19 290 
A TREATISE OX OBSTETRICS. 
Scanzoni, Bamberger, Veit, claimed that the poison acted directly on the 
blood, and this is the theory of Dubois and of Depaul. 
Scanzoni and Ferguson endeavored to detect the nature of the blood 
change, and found, successively, hyperinosis, pyemia, dissolution of the 
blood. In 1847 to 1861, Semmelweiss promulgated the following theory: 
Puerperal fever must always be considered as a fever due to the absorp- 
tion of a decomposed animal organic matter, and this absorption may re- 
sult from auto-infection (the product of decomposition coming from the 
individual itself), or from hetero-infection (the product of decomposition 
coming from without). Consequently, not only the cadavers of every age, 
and of every sex, when they are in a state of decomposition, but also 
the sick of every age, and of every sex, whose disease is accompanied by 
decomposition of organic animal matter, and furthermore every animal 
organic tissue, which presents a certain degree of decomposition, every 
one of these may be the starting-point of puerperal fever. 
Puerperal fever is not, therefore, a peculiar and exclusive disease of 
the puerpera. An identical affection, even as has been proved by Trous- 
seau, Schee, Helm, Buhl, Simpson, Tarnier, may be met with in virgins, 
in the new-born, in wounded of either sex. The point of origin of the dis- 
ease is found as well in the uterine wound, and in slight superficial wounds 
of the genital organs, as in lesions of the peri-uterine cellular tissue, or 
in the vagina. The primitive local disease becomes general through the 
carrying of the morbid process to the cellular tissue, thus gaining in ex- 
tent, or else it is transported by the lymph or the blood to all the other 
organs; or else foreign bodies are carried by the circulation, deposited in 
different organs, and there become the source of the disease. The causes 
of isolated cases, that is to say, of those developing aside from all epidemic 
influences, are: 1. Lesions and wounds of the genital organs. 2. Reten- 
tion followed by alteration of portions of the placenta or of the membranes. 
3. Primitive inflammations of the vagina and of the womb, such as those 
caused by gonorrhoea. 4. Finally, infection of wounds of the genital 
organs by cadaveric emanations, purulent or gangrenous secretions, etc. 
Schroeder, who is a resolute advocate of the theory of Semmelweiss, 
thus expresses himself: " In order to understand distinctly the manner 
after which infection occurs in the puerpera, it must be compared with 
one of the frequent varieties of infection which occurs in other parts of 
the body. THE PATHOGENY OF PUERPERAL FEVER. 
291 
When, at an autopsy, infectious materials from the cadaver come in 
contact with a slight abrasion on the finger, we witness, according to the 
amount absorbed, and especially according to the individual predisposi- 
tion, different phenomena. Either the point of contact alone is affected, 
so that there results suppuration of long duration; or else the inflamma- 
tion extends to neighboring parts, and there result inflammatory affections 
of the lymphatic vessels of the arm, and an abscess in the subcutaneous cel- 
lular tissue, as well as in that between the muscles. The entire system 
is not otherwise affected than it is in case of other local inflammatory 
affections-that is to say, the individual has only a moderate fever. 
Similarly, in a puerpera, as the result of infection of an' abrasion on the 
vulva, there may arise an ulceration which heals quickly, or else an in- 
flammation, which, following the course of the lymphatic vessels and the 
cellular tissue, may extend much further and eventuate in a suppurative 
lymphangitis and an exudation around the uterus and the vagina. The 
entire organism is not much more affected than in case of other local in- 
flammatory diseases, and the fever is identical with that which accompa- 
nies such affections. If,' however, the infection of the finger by the 
cadaveric poison is more intense, then, at the end of twenty-four or of 
thirty-six hours, we see serious general phenomena develop. These are 
characterized above all by elevation of temperature entirely out of pro- 
portion to the local affection, a fever which imperils to a high degree the 
functions of 'the entire organism. Death may occur with lightning-like 
rapidity, and post-mortem, aside from slight alterations in the blood, we 
may find no changes visible to the naked eye. The individual has suc- 
cumbed to septiccemia. 
In other instances we find acute degeneration of the large abdominal 
glands and of certain portions of the voluntary muscles, or else pleuro- 
pneumonia, peritonitis, arthritis. The individual has succumbed to 
ichoremia. 
In other instances, finally, there are thrombi in the veins near the wound. 
These thrombi are decomposed, and small portions are carried by the 
vessels and deposited usually in the lungs, and then give rise to infarctions 
and to abscesses. The individual has succumbed to pyemia. 
In an exactly similar way, when infection occurs in the puerpera, are 
the local affections thrown into the background. At the end of thirty- 
six hours, the temperature rises to a high degree, with or without a chill. 292 
A TREATISE ON OBSTETRICS. 
and the same fever affects her as we have seen may affect the individual 
suffering from cadaveric poison. The parallel need be carried no further, 
since the same phenomena occur here step by step, even as we have just 
described them. 
Further still, even in case of simple wounds, the entire system may be 
touched, and this is what is called traumatic fever. But although the 
ordinary traumatic fever is evidently the result of decomposition of the 
inflammatory products within the tissues, products which are carried in 
the circulation, and which consequently give rise to what may be termed 
a fever from absorption; and although this fever scarcely presents what 
may be termed specific characters, by which it may be distinguished from 
that due to infection, the essential characteristic of non-infected wounds 
is precisely their local nature, that is to say, the inflammatory process does 
not extend beyond the tissues which limit it; it remains circumscribed, 
and the fever, even though it presents differences in intensity according 
to the individual, never exceeds the degree which it usually attains in 
local inflammatory affections. If, on the other hand, the wounded sur- 
face is infected, either by auto-infection or by hetero-infection, the in- 
flammatory process may still remain local, since the infectious materials 
are isolated from the remainder of the organism, owing to the transforma- 
tion of the wound into an abscess incapable of resorption; but if this salu- 
tary abscess, so to speak, does not form, or not in time, the inflammation 
may spread to the neighboring tissues. If it extends superficially along 
the skin or the mucous membrane, it manifests itself as an erysipelas. 
In other instances it penetrates more deeply, by following the connective 
tissue, and we may have an abscess. The entire organism may, in these 
cases, present nearly identical phenomena to those which accompany local 
inflammatory processes, but very frequently the temperature rises higher, 
the pulse becomes much more frequent than one would expect in case of 
a purely local affair, and this is proof that the excretions from the infected 
site have reached the blood. Again, when the fever is moderate, we may 
always doubt if the entire organism is not affected by septicaemia, or 
ichorremia, as the result of the nutritive inflammatory troubles which are 
present in all the organs. 
What, therefore, we must consider as peculiarly characteristic and dan- 
gerous in infected wounds, is the great tendency of the inflammation to 
extend by continuity to other parts. In the puerpera, the state of the THE PATHOGENY OF PUERPERAL FEVER. 
293 
cellular tissue around the uterus is an indication as to whether the in- 
flammation of the vulva or cervix is local or progressive. Exudation in 
this tissue, in our experience, always depends on infection of the puerpera, 
or the non-puerpera. If, during delivery, there occurs a tear of the 
upper part of the vagina, when there is no infection, it is always the parts 
immediately in contact with the borders of the wound which inflame. 
The sides of the uterus are neither tumefied nor sensitive, while, even in 
case of simple erosion of the vaginal mucous membrane, if there be in- 
fection, we may usually determine the fact that the inflammatory process 
has spread into the cellular tissue which exists to the sides of the uterus." 
If we have thus detailed Schroeder's views, it is because they represent 
absolutely our own, and because with him we grant in puerperal diseases 
only two varieties. Every labor, however normal, is necessarily accom- 
panied by erosions, wounds, fissures, of the vulvo-vaginal mucous mem- 
brane and of that of the uterus, possibly deep lesions to the side of the 
cervix and the uterus. Finally, the placental site, with its thrombosed 
vessels, represents itself a vast wound. If these wounds remain simple, 
there arise no symptoms, or else these remain purely local; but if the 
wounds are infected, there result poisoning of the woman, and that en- 
tire series of phenomena to which the name of puerperal fever has been 
and is still given. 
We would, however, go still further than Schroeder, and maintain that 
even these wounds and abrasions are not indispensable for infection. Do 
we not indeed often see true phenomena of poisoning appear in physicians 
who are frequently brought in contact with cadavers, or are busied with 
the preparation of anatomical specimens? Here the infection unques- 
tionably occurs through the respiratory and digestive tracts. There is 
true septicgemia, and the same holds true, we believe, during the puer- 
perium. The wound is not necessary, but only the presence of the in- 
fecting agent. We will see shortly what the nature of this agent is. 
Doleris thus expresses himself: " To-day all authorities are in accord in 
considering puerperal fever as a species of poisoning. The most resolute 
localists have long since renounced the view that the disease resides in 
the lesion itself. This lesion is, according to them, purely a necessary 
phenomenon, necessary when it is primitive, as the uterine wound, and 
gives access to the poison or furnishes a site for its development; necessary, 
again, when it is secondary even as are organic metastases, which are only 294 
A TREATISE ON OBSTETRICS. 
a result of the introduction of the poison into the economy; necessary, 
further still, when it is intermediate, so to speak, as is phlebitis, lym- 
phangitis, which are only the traces of the passage of the toxic element, 
the septic element, whatever it be, and which serve as entrance-gates into 
the organism. The question, therefore, for them is limited to the infec- 
tion of the wound. The sine qua non condition of toxemia is a raw sur- 
face, a surgical wound. JVo wound, no infection. Both phlebitis and 
lymphangitis, in surgery as well as in obstetrics, exist from the same 
causes. Lesions of the uterine lymphatics are in intimate connection 
with lesions of the neighboring serous membrane and the glands, even 
as the septic wound, however slight it be, is in absolute connection with 
the lymphangitis, the erysipelas, the diffuse phlegmon, which are often 
the consequences. Phlebitis introduces into the blood morbid elements, 
which carry further on the germs of what are known as metastatic affec- 
tions, and which, customarily, are found in the viscera. Such is the case 
both in puerperal metritis and in the surgical wound." 
The recent investigations of Lucas Championniere, Siredey, Quinquaud, 
Fiouppe, Despine, Bode, plead in favor of the absolute similarity of 
puerperal and of surgical infection. This is the doctrine uniformly ad- 
mitted in France, and the one stated by Winckel in 1878. It is the doc- 
trine admitted almost uniformly throughout the world. 
[In the United States, the belief of almost all accoucheurs is certainly 
in accord with the statements made by Charpentier. Puerperal fever is 
septicasmia, differing only from surgical septicaemia in that, superadded 
to infection, is the puerperal state. The most distinguished exception is 
Fordyce Barker. He still clings tenaciously to the views promulgated by 
him years ago, and with an ardor which, if it does not carry complete con- 
viction, certainly tends to make every thoughtful man hesitate a trifle in 
propounding the absolute statement that puerperal fever is always sim- 
ply puerperal septicaemia. In the memorable discussion before the New 
York Academy of Medicine, in 1884, when Thomas, with all his elo- 
quence, plead for the entire identity of this fever with septicaemia, Barker 
alone protested against such a broad view, and stated that " his creed to- 
day is fully avowed in his book on the Puerperal Diseases, and unless in 
the future he learned new facts and new arguments to change his faith, 
he should die impenitent." In- reference to Thomas's argument, he stated 
that its pathological doctrines were misleading and dangerous, because THE PATHOGENY OF PUERPERAL FEVER. 
295 
they were "supersaturated with septic infection." Barker's creed to-day, 
even as yesterday, is that there does exist an epidemic disease differing in 
all characteristic points from what is known as septicaemia; differing in 
its origin, its modes of attack, its symptoms, its anatomical lesions. 
These symptoms are frequently manifested a day or two before, or even 
during labor, even when the child is subsequently born alive. In septi- 
CEemia, the symptoms are never observed before or during labor, except 
when the foetus is putrid. The former disease, puerperal fever, originates 
from epidemic causes, and from contagion and infection; the latter from 
nosocomial malaria, from autogenetic infection, and from direct inocula- 
tion. Barker's conviction, therefore, is still that there is such a disease 
as puerperal fever sui generis, and that outside of hospitals less than two 
per cent, of the puerperal diseases, and not half of one per cent, of the 
deaths after child-birth, are due to septicaemia. 
Such then is Barker's standpoint to-day, and he holds this position 
firmly in face of the almost uniform belief of obstetricians throughout the 
world that, as Lusk expresses it, surgical fever and puerperal fever are 
not only analogous, but are essentially one and the same process. Of all 
those who discussed Thomas's paper, Lusk, Chamberlain, Hanks and 
others, only one, Munde, was inclined to agree in a measure with Barker. 
Mundt's views are best expressed in a quotation from his recently pub- 
lished appendix to Cazeaux and Tarnier's Treatise on Obstetrics: " I be- 
lieve the majority of cases of so-called puerperal fever to be, in reality, 
cases of puerperal septicaemia, the septic infection coming usually from 
without, carried generally by the fingers, instruments, dressing, etc., and 
no doubt at times in the clothing or on the person of the attendant, but 
in exceptional cases transmitted through the medium of the atmosphere. 
I am impelled to the last admission by the fact that I have seen appar- 
ently spontaneous cases of puerperal fever, in which all possibility of in- 
fection by contact could be absolutely excluded. I have been unable to 
explain the occurrence of such cases except by transmission through the 
air by a so-called status epidemicus (I refer, of course, to cases in private 
practice), unless I join the small minority of obstetricians, at the head of 
whom, in this country, stands Fordyce Barker, who still firmly believe 
in the occurrence of puerperal fever as a zymotic disease sui generis, 
that is, a disease produced by a specific poison of its own. I must confess 
that I have not been able to entirely divest myself of the belief that such 296 
A TREATISE ON OBSTETRICS. 
a disease may exist, though I also believe that it is one of the rarest of 
exceptions." 
For our part, we are unwilling to commit ourselves to the absolute 
statement that we are ever dealing with septicaemia, pure and simple, ex- 
actly like unto surgical septicaemia. Every age has its craze, and this is 
essentially the age of microbes and of sepsis. The question, judicially 
considered, must still be left open. We have certainly seen cases where 
there was absolute certainty, as far as this can exist at all, of the absence 
of any and all possible causes of infection, and yet the patients have 
suffered from puerperal fever, a fever zymotic, essential. The future, we 
think, will testify to the truth of Barker's views in very exceptional in- 
stances, that is to say, while septicamiia will be the disease in nine hun- 
dred and ninety-nine cases, in the thousandth the disease will be of 
zymotic origin. The one, in the future, will be absolutely preventable, 
the other no more so than are the other so-called essential fevms.-Ed.] 
Max Boer, in his report at Berlin, 1877, declares in the name of the 
appointed committee, that puerperal accidents are due to the absorption 
by the lymphatics, and by the blood-vessels of septic materials engen- 
dered in the uterus by putrid decomposition, and Boer's conclusions are 
accepted by Schroeder, Fasbender, Martin, Lohlein, Winckel and Spiegel- 
berg. 
In America, in Belgium, in Italy, Denmark, Switzerland, England, 
the same unanimity exists, and Johnston, Atthill, MacClintock, Macau. 
Priestley, admit that puerperal fever is only septicaemia the result of 
ichorremia. According to Playfair there exists identity between puer- 
peral septicaemia and surgical septicaemia, and there may be either auto- 
or hetero-infection; auto-infection resulting from any condition which 
causes decomposition, whether of the maternal organs themselves, or of 
debris retained in the uterus or the vagina, or of putrefied portions of a 
dead foetus; hetero-infection, resulting from cadaveric poison, erysipelas, 
zymotic diseases, puerperal contagion through physician, nurse, or others. 
[Robert Barnes, in discussing the question as to the absolute identity 
of puerperal fever and so-called surgical fever thus expresses himself: 
" That there are many points of analogy is undoubted; but there are also 
points of difference which forbid us to accept the doctrine of identity. 
The subject of an amputation, and a woman after labor, both present 
wounds. Both may be considered as susceptible to invasion by poisons. 297 
THE PATHOGENY OF PUERPERAL FEVER. 
In both the poison may affect a lodgment on the wounds. But it is easy 
to carry the comparison too far. Amputation is presumably performed 
on account of disease. The condition of the patient is pathological to start 
with. There is no special provision in the system made for the express 
purpose of healing the wound. The wounds in the puerpera are phy- 
siological. There is a distinct provision ad hoc for restoration to the 
ordinary state. It is in this provision, marked by extraordinary activity of 
absorption and excretion, that lies the peculiarity of the puerperal state. 
This condition has no parallel in the ordinary surgical patient. If we are 
asked, What is puerperal fever? may it not be asked in return, What is 
surgical fever? Is surgical fever one uniform, definite, pathological 
entity ? In neither case is the fever one constant thing. There are vari- 
eties of surgical fevers, even as there are varieties of puerperal fevers. If 
it be contended that by surgical fever is meant septicsemia, and nothing 
else, this is simply begging the question; we must still ask, What is septi- 
caemia? And again, if surgeons are prepared to give a precise definition 
of septicaemia in surgical patients, are they also prepared to show that 
septicaemia of the same character is produced in lying-in women ? Sep- 
ticaemia is a compound term. There is the sepsis, the poison; there is 
the blood which receives the poison. Now, if it be possible to show that 
the sepsis in the two subjects is identical, it would still be necessary to 
show identity or near similarity in the recipient blood. The first term 
of the proposition is certainly not proved; the second is certainly not 
true. This theory, then, like that of the microbists, is too absolute and 
exclusive. It may account for a large number, perhaps the greater num- 
ber, of cases in lying-in hospitals; but it does not account for cases begin- 
ning before there is a wound, nor for the propagation to non-]$uerperal 
women." Barnes, further, is inclined to grant that a fever may attack the 
puerpera of zymotic origin, to which the specific term puerperal fever 
may be applied. These words, from one of the leading accoucheurs of 
the world, may well be pondered by those who, carried away by the 
prevalent doctrines of sepsis and of microbes, can see nothing outside of 
them. 
Alfred Galabin, in his recent work on obstetrics, resumes the question 
of puerperal septicaemia and of puerperal fever, sui generis, as follows: 
The chief arguments showing that puerperal fever is not a specific zymo- 
tic disease are: 1. The symptoms and anatomical lesions of the disease 298 
A TREATISE ON OBSTETRICS. 
have not a special and definite character like those of a specific zymotic 
disease, but are rather analogous to those of septicaemia or of pyemia fol- 
lowing surgical wounds. 2. A definite local cause, such as decomposition 
of retained placenta, may give rise to a disease undistinguishable from 
puerperal fever due to conveyed contagion, and having the same anatomi- 
cal lesions. 3. Puerperal fever may be originated not merely by conta- 
gion conveyed from other puerperal women, but by various kinds of septic 
material. 
The same gentleman thus resumes the evidence for the belief that a 
disease in a puerperal woman, not having the characteristic symptoms of 
a zymotic disease, but resembling puerperal septicaemia, may really be of 
zymotic origin: 1. Even apart from the puerperal state, cases of zymotic 
disease occur in which the rash or other characteristic signs are not de- 
veloped. 2. In undoubted cases both of puerperal scarlatina and puer- 
peral erysipelas, symptoms of inflammation of the peritoneum and in the 
pelvis are common. 3. Undoubted scarlet fever is so modified in puer- 
peral women, that while the mortality is very high, the sore throat is 
almost always slight. 4. Cases of puerperal pyrexia occur, often severe 
or fatal, in which sore throat is absent or very slight, and the rash so 
little defined that it is difficult to decide as to whether the disease should 
be reckoned as scarlatina or not. In these cases symptoms of inflamma- 
tion of the peritoneum and in the pelvis are often marked. " There is 
strong evidence that a disease ■which cannot be distinguished from other 
forms of puerperal fever, may be originated by the conveyance of conta- 
gion from certain zymotic diseases, especially erysipelas and scarlet fever. 
Accordingly the view is accepted by many, probably the majority of ac- 
coucheuBs in this country (England) that these diseases may give rise to 
puerperal fever." 
Gallabin, thus, must be ranked with those who claim that, although 
rare, a puerperal fever, sui generis, may exist.-Ed.] 
As we have seen, almost all authorities admit the necessity of a wound, 
and Hervieux and Depaul are about alone in the claim that there is some- 
thing else than a septicaemia of local origin in puerperal affections, thus 
championing the doctrine of essentiality. 
We think that there is exaggeration in both these beliefs. Certainly, 
in the vast majority of cases, there is a wound, and by wound we under- 
stand not only the uterine, but fissures, vulvar and vaginal erosions, tears 299 
THE PATHOGENY OF PUERPERAL FEVER. 
of the cervix caused by the foetal head; and here it is that, ordinarily, in- 
fection occurs. But this wound, these fissures, are not for us indispensa- 
ble, and from this standpoint we agree with Hervieux and Depaul. 
Puerperal fever is the result of infection; it is contagious to the highest 
degree, but, according to our belief, no wound is necessary, and we claim 
that infection, aside from any local lesion, may take place through the 
respiratory tract, or the digestive, the patient thus infected being able to 
transmit the contagion to other puerpera. This contagion of puerperal 
fever is to-day no longer contested, and it has been proved by numerous 
researches both in France and abroad. It remains only to find the septic 
agent, the miasm, the poison, the infectious germ, the indispensable 
agent. What is it? Whence does it come? Such are the questions 
which it remains to study, and which have been answered by Pasteur, 
whose researches have been faithfully sta-ted in Dolcris's thesis. 
According to Pasteur, this agent is a proto-organism, and this proto- 
organism is not single, but multiple in variety, giving rise thus to those 
multiple affections which may be observed in puerperse. 
Mayerhofer first determined, in 1865, that the lochia of infected women 
were in character putrid, and discovered motile vibrios, which, according 
to him, were the cause of the putridity. Recklinghausen, and Waldeyer, 
continuing his researches, proved the presence of these vibrios not only 
in the lochia, but on the surface of puerperal wounds, in the uterine 
lymphatics, in the exudations in the cellular tissue, in the serous cavities, 
and proved also that the fine grain-like masses described by Virchow and 
Hohl were purely microscopical organisms, moniliform bacteria. Despine 
and Quinquaud, by injecting putrid lochia into animals, produced lesions 
similar to those of septicaemia. 
Orth, in 1873, rejected cylindrical bacteria, which, he claimed, came 
from the interior, and stated that the puerperal fever germ was a micro- 
coccus, sometimes in isolated globular points, sometimes'joined infinitely 
together so as to form chaplets. Heiberg, 1873, Birsch-Hirschfeld, 1874, 
Spillmann (Nancy), 1876, Kohrer, 1876, believed both in the vibrios and 
the bacteria, and Hausmann, (Berlin) 1876, caused septic phenomena by 
injecting septic material into the vagina and uterus of rabbits, pregnant 
and not pregnant. In the latter instance, however, infection only oc- 
curred in case there existed a lesion of the vagina. 
In 1878, Hugh Miller, of Edinburgh, from a series of researches, 300 
A TREATISE ON OBSTETRICS. 
claimed the presence of bacteria, micrococci and vibrios. Billroth, on 
the other hand, did not believe in the bacteria. " The etiological connec- 
tion, he says, between bacteria and septic disease, or putrjdity of the 
blood, has not been proved. In the living organism, certain forms of 
acute inflammation bring to the pus, from the surrounding tissues, 
materials which modify its chemical composition in such a manner that 
the microscopical spores may develop in an exuberant way. In addition 
to the wounds, there must exist certain determinate forms of inflamma- 
tion of the connective tissue, erysipelas, abscess, pseudo-erysipelas, diph- 
theria, or else traumatic inflammation must be transformed into these 
inflammatory affections, in order that the pus may, in turn, alter a little, 
and the microbe may develop in abundance. It has been indeed deter- 
mined that the pus corpuscles may change without the presence of any 
organism, and, on the other hand, these organisms may be carried in 
bandages, on instruments, the fingers of the accoucheur, and transplanted 
on the wound. The water with which this wound is washed is of itself 
sufficient. " 
It is to Pasteur, 1879 to 1880, that we owe the most valuable researches. 
Doleris has resumed the experiments of this distinguished teacher, and it 
is from his monograph that we borrow the following pages: 
"Puerperal infection is an infection which borrows nothing at all 
peculiar from the puerperal state, otherwise than that it is more or less 
linked with the weakened condition, the result of parturition, thus finding 
in diminished ability to resist the action of morbid agents a condition 
favorable for its development. 
"Puerperal women are wounded women, and in addition they have been 
subjected to hemorrhage, shock, weakness following on prolonged labor, 
and their blood and tissues generally have been peculiarly modified. Here 
then are a certain number of predisposing causes. Further still, the 
nature of the wound, its situation, the presence of materials in a state of 
disintegration or of decomposition, the retention of decidual or placental 
debris, the presence of external wounds, on the vulva, in the vagina, in 
a position peculiarly favorable for the entrance of germs even before de- 
livery. Such, among others, are additional predisposing causes. We 
would not thus imply that always, and in every situation, infection pro- 
ceeds from local lesions of the wound, for this would be to ignore the 
simplest undoubted pathological principles; but, unquestionably, the THE PATHOGENY OF PUERPERAL FEVER. 
301 
cases of infection from the uterus, are the most frequently observed. It 
is only exceptionally that infection occurs by other routes. The infection 
is not always of the same nature. Its varieties depend on many condi- 
tions, the principal of which are: The degree of resistance of the subject, 
the care which is taken, therapeutically, to increase the resistance of the 
subject, and, above all, the nature of the morbid germ. As Pasteur has 
said, guided by the light of his experiments, the disease is complex, even 
as are the causes which give it life. 
" The one grand fact resulting from all these experiments is the presence 
and the action of inferior organisms. In accord with all other workers 
in this line of research, I can affirm that the morbid germ of the disease, 
ever present in the diseased puerpera, is always absent from the healthy 
puerpera. This germ is a living organism, susceptible of reproduction 
under well-established conditions, and capable of reproducing nearly 
identical lesions. The morbid germs differ according to the different 
forms of the disease, and, more exactly, according to the lesions presented 
by the patient." 
As early as 1863, Chalvet and Reveil, Lemaire, 1867, de Ranse, 1868- 
1869> Quinquaud, 1872, Perrin, 1876-1877, had proved that the air in 
hospital wards, in particular lying-in and surgical wards, contained an 
infinite number of vibrios, bacteria, and micrococci of all sorts, and Pasteur 
and Bernheim have proved that certain of these germs are anaerobic, and 
others aerobic, and it is well established that, where decomposition is 
most abundant, where the germs find the greatest amount of material for 
development, there they will exist in greatest numbers, and that, as has 
been conclusively proved by Pasteur, the aerobic micobes prepare the 
soil for the anaerobic. 
" Now," says Doleris, " we know what an excellent culture medium the 
blood is for certain germs, with what facility it decomposes under their 
influence, and acquires those septic properties on which the greater num- 
ber of data in regard to septicaemia are founded. There is one point 
which appears to me fully established, and this is that if we do not always 
meet with microbes in the circulation, it is not always so where there has 
occurred rupture of a vessel, and consecutive apoplexy into the surround- 
ing tissue, or into an organ. The germs then develop with extraordinary 
rapidity. It is likely that the active motion of the blood in the vessels 
during life is the true cause opposed to the development of germs, when 302 
A TREATISE ON OBSTETRICS. 
they are in moderate quantities, and when they do not possess certain 
adhesive properties so well-described by Koch, which allows them to 
group together, to unite the corpuscles, and to obliterate certain capil- 
laries where they may develop at will. 
It is allowable to think that each drop of blood, of pus, of milk, of 
urine, of any fluid, in short, coming from the uterus, a wound, a secre- 
tion, etc., may become a veritable nest of vibrios. These conditions are 
present to the highest degree in surgical wards. 
On the other hand, it has been amply proved that the wounds of the 
genitals following on labor-and we repeat these wounds are inevitable 
almost during delivery-are the more exposed to the entrance of germs 
the more they are external. They each furnish plastic fluid, blood, 
lymph, morphological elements in which the organisms may develop, and 
they will develop the more rapidly the greater the alkalinity of the fluids. 
Now alkalinity is the rule during the few days following delivery, and if 
douches are sufficient to destroy the few germs which may have gained 
access by the vulva, the same is not true if the douches arc not thorough 
or only practised at long intervals. The germs then may gain access to 
the uterus, and there multiply at their ease. Indeed, the aneerobic 
germs, finding themselves then not exposed to the air, are among condi- 
tions most favorable for development. At the same time, the other or- 
ganisms, which result from putrefaction, and which can live as well in as 
out of the air, may also develop in the vagino-uterine passage. Whence 
the multiplicity of the germs which are found in this canal. But all are 
not of the same importance, nor do they portend the same danger. Many 
exist normally in the utero-vaginal secretions, aside from pregnancy and 
labor. It results, indeed, from the experiments of Hausmann, Miller, 
Hottenier, that the Termo, the common bacteria, the doubly-pointed 
micrococcus, which Pasteur considers the cause of putrefaction, is almost 
always found there. The same holds true, however, of this organism as 
of the others-it is the number which constitutes the danger. Of course 
the quality has some effect, but we may more readily get rid of very 
harmful microbes in small quantity than of less harmful in great quan- 
tity. Now it is exceptional that the lochia even of healthy women do not 
contain microbes, but they are of different varieties: 
1. One is almost constant, the pyogenic, which Pasteur believes to be 
a form peculiar to pus. It is composed of two points well distinct, but THE PATHOGENY OF PUERPERAL FEVER. 
303 
united to form couples. It appears in particular about the third or 
fourth day, and is distinguished by the fact that it is composed of protean 
granulations, is flat and is automatic in movement. It is displaced in- 
versely to the current of fluid. (Fig- 183.) This is the diploccocus of 
many writers, who reserve the term monococcus for the isolated living 
grains. Others call it the micrococcus. 
2. The second microbe differs only from the first in volume, being 
three to four times larger, and also more brilliant. It unites in pairs, in 
triplets, and does not constitute true chaplets. Doleris believes that it 
belongs to a very deadly variety. The more abundant it is, the greater 
the danger of septicaemia. (Fig. 183.) 
3. In the first portion of the vaginal canai is found, sometimes from 
the sixth to the seventh day, a little aerobic vibrio. It .is of little im- 
portance from a pathological standpoint. (Fig. 184.) 
4. Finally, in true septicaemia, the kind which prostrates from the 
very beginning, there are found no living organisms in the blood until 
just before death or even after. The variety of organism is multiple, 
and is formed of long, thin, cylindrical elements, which are movable and 
burrow into the tissues, the lymphatics, the peritoneum. Only at a late 
stage do they reach the blood. These bacteria .may assume many shapes. 
(Fig. 185.) The blood containing them is thick, at times black when 
death has supervened quickly. The blood globules are much altered, 
deformed, deprived of haemoglobulin, but the leucocytes are not particu- 
larly increased. (Fig. 186.) 
In a milder form of septicaemia the blood always contains microbes, 
and this is in the common suppurative form. The micrococcus in chains 
is the active organism. (Fig. 186.) But in the phlebitic form, with 
thrombi, these micrococci in chains are not common. The nature of the 
organism differs with the case. When the lymphatic lesion coexists and 
developes progressively, cultivation of the micrococcus of the blood gives 
rise almost constantly to long chaplets of grains similar to those con- 
tained in the lymphatics, and sometimes cylindrical. When the hematic 
lesion alone exists, culture gives rise only to colonies of micrococci in 
irregulai' groups or in couples, but these are never sufficiently organized 
to form chains. 
When the hematic lesion is accompanied by phlebitis and thrombus, 
the almost constant form is the point in couples. Culture produces it 304 
A TREATISE ON OBSTETRICS. 
Fig. 183.-Microbes in the lochia of three septic puerperae. (Doleris.) The numbers, 1,2, 3, etc., represent the day after delivery. 
Fig. 184.-Microbes often met with in small quantities in the lochia of healthy puerperae. (Doleris.) THE PATHOGENY OF PUERPERAL FEVER. 
305 
Fig. 185.- A, Septic vibrio from the blood. (V. Repens.) B, Septic bacteria of different shapes; 
(2) Zooglea; (3) Chains of micrococci developed in pus contained in a lymphatic vessel. C, Chaplets 
obtained from culture of the blood. (Doleris.) 
Vol. IV.-20 306 
A TREATISE ON OBSTETRICS. 
Fig. 186.-A, Microbes from pus and blood, 24 hours after culture. B, Larger microbes (case of cerebro-spinal meningitis) 12 hours after culture. B', The same 70 
hours after. C, Deformed globules. D, Appearance of the microbes in the lochia. E, Clot in the crural vein. The black points are groups of endothelial microbes. 
(Doler is.) THE PATHOGENY OF PUERPERAL FEVER. 
307 
at once in large numbers, to such a degree, that it seems as though we 
had made artificial pus. 
After delivery, everything favors rapid absorption by the lymphatics. 
When the uterus contracts, the intra-parietal branches, true enough, are 
closed, but those in the sub-peritoneal layer are widely open. In the 
sub-serous reticulum the organisms collect and develop, and they spread 
rapidly to distant parts. No law presides over the distribution of the 
microbes, whence the varied resulting lesions, abscesses, peritonitis, 
pleurisy, meningitis, arthritis. Infection by the lymphatics is always the 
first in order. The blood is only reached secondarily through the thora- 
cic duct, and from a clinical standpoint cases may be divided as follows: 
1. Those rare but actual cases of rapid septicaemia characterized by the 
early introduction into the blood of the long septic bacteria, isolated or 
united with the micrococcus. 
2. Those more common cases of puerperal infection, characterized in 
particular by the presence of the micrococcus in the lymphatics, the ten- 
dency to suppuration, and the occurrence of true septicaemia ultimately, 
that is to say, the invasion by the septic bacteria, which are sometimes 
found in the lymph or the blood just before the agony. This is the sup- 
purative lymphatic, serous, purulent form. 
3. Cases of pyemia with phlebitis and thrombosis, answering to surgical 
purulent infection. 
4. Finally, the slow, progressive pyemic forms, of long duration, fre- 
quently characterized by the presence of puerperal pernicious anemia, 
or of abscess, or of chronic metritis. 
To resume then: While we might confound all the varieties of puer- 
peral infection under the name septicaemia, with variable forms and vari- 
able pathological products, still I believe myself authorized, following 
Pasteur exactly, and considering the organism from the standpoint of 
specialization of its product and not from that of its probable origin, in 
separating morbid infectious germs into two great categories 
1. Cylindrical septic bacteria (rapid septicaemia.) 
। 2. Micrococci in chains (attenuated septicaemia); under the shape of 
couplets; under the shape of dots or points. 
I admit, therefore, that the micrococcus is always characterized by an 
attenuation of the septic nature of the products, and that the double dot 
or point is the true pyogenic element." (Doleris.) A TREATISE ON OBSTETRICS. 
308 
These researches of Pasteur, then, seem to throw great light on the 
nature and the method of the production of puerperal affections. Ray- 
mond has resumed the question as follows: " When the lochia of a healthy 
puerpera are examined under the microscope, either none at all or else a 
few micro-organisms are found. If, on the other hand, the lochia of a 
woman on the point of having some puerperal affection be examined, we 
are struck by the large number of organisms present; and if she dies, in 
the pus of the peritoneum, in the uterine lymphatics, in the exudations 
of the pleurae, in the metastatic abscesses, etc., the same organisms exist 
as were found before death in the lochia. By means of those valuable 
and delicate culture processes which were devised by Pasteur, he has 
been able to demonstrate in the blood before death microscopic organ- 
isms, touching, as it were, with the finger, the cause of the poisoning. 
Further still, Pasteur, in the services of Hervieuxand of Championniere, 
has been able, by the simple microscopic examination of the lochia, to 
predict the appearance of affections before the clinician even suspected 
them. During the discussion before the Academy of Medicine, Pasteur 
showed an organism in chaplets of many grains which he had frequently 
found in the lochia of women dying from infection, and he has seen them 
in myriads. He has found this little organism, under such circumstances, 
everywhere in the body. Is this the only organism met with in the 
course of puerperal fever? Must we attribute the disease to it? Pasteur 
thinks not. Puerperal fever has not its special microbe, but there are 
many which may affect the puerpera in one or in another way, accord- 
ing to its number. Indeed the micro-organism which kills the woman 
may even not have any infectious property. Injected subcutaneously it 
may produce no symptom. It is thence to the special conditions of the 
uterine wounded surface that the puerperal accidents are due. The 
organism developes rapidly and in abundance in the lochia within the 
uterine cavity. It penetrates readily to the neighboring peritoneum, and 
there, by the fact of rapid multiplication, produces peritonitis with pus 
full of the micro-organisms, which Pasteur has shown us. In case the 
peritoneal cavity does not afford conditions favorable for development the 
affection will be more limited, and instead of intense general peritonitis, 
we will have localized pelvic peritonitis, which is less acute. It is equally 
easy to understand the development of cases of phlebitis and of pelvic 
peritonitis. It is the situation of the wound, the connections *of the THE PATHOGENY OF PUERPERAL FEVER. 
309 
uterus, which increase the danger, and this is what is peculiar to the 
puerpera. If the infectious microbe reaches her by any one of the many 
open routes, then infectious and rapid septicaemia develop, and those sud- 
den deaths may occur which have so frequently swept out maternity hos- 
pitals. The blood then offers the characteristics of the typhoidal diseases, 
a fact on which the essentialists lay great stress in behalf of their theory. 
When we remember the protean aspects of puerperal fever, it is diffi- 
cult to grant that always one single infectious agent, one single micro- 
organism, is the cause, all the more so when we bear in mind the infinite 
variety of organisms in the lochia of the diseased puerpera, fresh legions 
of which are constantly being introduced into the uterus. Each invasion 
causes chill, and new elevation of temperature, and in those cases where 
the battle is prolonged, death results only after many days of suffering, 
with alternations of betterment and of aggravation. In these instances, 
if the uterine lymphatics are the route by which the microbe enters, we 
will witness the development of lymphangitides, purulent pleurisies, 
metastatic abscesses, etc., and the case must be a rapid one indeed where 
we will not find visceral lesions, peritonitis, or suppuration. The woman 
dies septic, even as may a man after an amputation. 
Such is Pasteur's theory, but it is not as yet accepted by all authorities, 
and the following are the objections made to it: If these germs are every- 
where around us, if we inspire them by hundreds, if they infect every 
object near us, why is it that they only exert their noxious influence on 
puerpera? in lying-in wards, while in our private practice they are inno- 
cent of harm? Has not the puerpera in the country an open uterine 
wound, even as has the puerpera in a hospital ? The germs reach the 
one as well as the other, and yet the one almost always recovers, while 
the other frequently dies. What do the germs do in the intervals of 
puerperal fever epidemics ? To-day our wards are perfectly healthy, the 
puerperium is unclouded; but let the number of lying-in women increase, 
and the disease breaks out and the mortality is fearful. 
Finally, how have the germs gained access in those most frightful of 
all cases, where death supervenes in a few hours? The uterus, perfectly 
contracted, has left no open-mouthed vessel, the lochia have not been at 
all foetid, there exists neither phlebitis, nor lymphangitis, nor phlegmasia 
of any kind. How then have the germs entered in order to invade, not 
the puerpera, but the gravida and the infant she is carrying, and the 310 
A TREATISE ON OBSTETRICS. 
nurses as well, not pregnant, but living in the midst of puerperal women ? 
For even these latter may become affected, and present the peritonitis 
which is so characteristic of puerperal infection ? 
Pasteur replies that the atmosphere contains but few germs, that they 
are particularly spread over solid objects, where they adhere and where they 
accumulate, and that it is especially by the accoucheur's hand that 
they are brought to the puerpera, as well as by the towels, etc., in hospi- 
tal wards. 
All the above objections, however, are not refuted by this explanation, 
and further still, we might state others, as for instance, how explain by 
the germ theory peritonitis observed by Lorain in foetuses still within the 
uterine cavity? We must admit that the germs have penetrated the 
multiple epithelial layers which, at the placental site, separate the mater- 
nal from the foetal organism. But experience up to the present teaches 
us that no organic matter passes from the maternal into the foetal blood. 
If the germ theory is true, we must grant either that the peritonitis ob- 
served by Lorain was not of septic origin, or else that these proto- 
organisms penetrated into the foetus by effraction." (Raymond.) 
It is apparent then that many a point is still to be elucidated, and that 
we are far from having reached a definite solution. There is, however, 
one fact on which every one agrees, and this is that puerperal fever is 
eminently infectious, and that epidemics of puerperal fever are the im- 
mediate result of this contagion. The idea of the transmissibility of 
puerperal fever is to-day unanimously accepted. But what is the manner 
of infection? Here still, the vast majority of accoucheurs admit that, 
whether infection be due to auto- or hetero- cause, it occurs through 
the wound, whatever the conveyance of the infectious agent. If we are 
dealing with auto-infection, this is created at the wound-site itself, by the 
decomposition of putrid placental debris, or lochia, or blood clots. If, 
on the other hand, we are dealing with hetero-infection, it is conveyed 
by a direct cause, whether accoucheur, nurse, clothing, etc. 
Doleris, on the contrary, who grants but a single cause, the microbe, 
does not admit auto-infection properly so-called. The morbid germ, 
the microbe, must be introduced into the economy, and for him, hence, 
it is always hetero-infection. But, and here we agree with him perfectly, 
if infection by the wound is the most frequent, this is not the only route 
of access, there are others to which we proceed to refer. THE PATHOGENY OF PUERPERAL FEVER. 
311 
1. Contagion by the Wound.-a. In certain instances there exist viru- 
lent vaginal discharges before labor; certain infusoria, which are after- 
wards found in the lochia, may pre-exist in the genital passages-in a word, 
the vagina contains before labor infectious germs introduced by chance. 
b. Contagion may occur through the linen, towels, syringes, the injected 
fluid even, which are often filled with inferior organisms of all sorts, c. 
It may occur through dirty, improperly cleansed instruments, d. 
Through septic uterine debris in the curtains, the sheets, the bed-pans. 
e. Through an infant contaminated by ecthyma, abscess, erysipelas, pur- 
ulent ophthalmia, peri-umbilical lymphangitis, etc. f. Through the nurse, 
the physician, etc. g. Finally, through propinquity to a surgical service 
where there exists lymphangitis, erysipelas, etc. 
The above instances of contagion have been observed over and over 
again, both in private and in hospital practice. We would cite simply 
the epidemics observed by Danyau, Trousseau, Dubois, Wells, Atthill, 
Boardman, Hecker, Holmes, Braxton-Hicks, Thierry, and others. 
Having thus established the fact of contagion, we need not be astonished 
to see the disease develop simultaneously, rapidly, and successively, in a 
large number of puerperal women, when they are crowded together. Epi- 
demics, indeed, are purely the result of a wider dissemination of the con- 
tagion, the cause and the mechanism remaining the same. In order that 
an epidemic may exist, we need the infectious spark in the shape of the 
germ, and the diffusion of this germ. Now one single circumstance brings 
together these conditions, and this is, says Doleris, overcrowding. 
2. Overcrowdir<g as a Cause of Epidemics.-1. The morbid germs are 
thus multiplied. 2. The points of contact are thus increased. 3. There 
is insufficient aeration, oxygenation. 4. The resistance to disease of the 
woman is thus lessened. Now where are these injurious conditions better 
found than in the lying-in wards of maternities, where the same nurse 
cares for the well and the sick puerperas, where isolation wards do not 
always exist, where instruction is given, and where, it must be said, dis- 
infection is not practised as vigorously as it should be. Is it surprising 
then to find such fearful mortality, often, compared to that in private 
practice ? 
Besides these facts of contagion by the vaginal or uterine wound, it 
seems to us impossible not to admit contagion by other routes. How 
otherwise explain those cases noted by Depaul, Tarnier, Hervieux and 312 
A TREATISE ON OBSTETRICS. 
others, where women were infected before labor, and therefore before the 
existence of any wound ? And how explain those instances where young 
nurses have been poisoned by the simple fact of sojourn among puerperae 
during an epidemic ? Tarnier says: " It is probable that by the lungs, 
offering as they do conditions favorable for absorption, infection often, if 
not always, occurs." Others grant absorption by the intestines: " When- 
ever some cause or other destroys the integrity of the mucous membrane 
or augments the proportion of the germs, whether absolutely by the direct 
introduction of septic substances by the digestive tract, or relatively by 
an arrest of the faecal current, then the fight becomes unequal, and sep- 
ticaemia results." (Doleris.) 
The experiments of Schweninger, 1866, of Hemmer, Coze, Peltz, 1869, 
Meyer, Legros, Humbert, 1870-73, Doleris, 1879, have conclusively proved 
the possibility of infection by the intestine. 
We would resume then as follows: Although we may no longer consider 
puerperal fever from the standpoint of the older writers, we cannot deny 
but that there exists an ensemble of phenomena, of puerperal accidents, 
which are the result of puerperal septicaemia, and which we may collect 
under the generic classic name of puerperal fever. These affections are 
the result of infection, and they are consequently infectious to the highest 
degree. Rare endemically, they are met with in particular in Maternities, 
where they assume the epidemic form. The most recent researches point 
to their origination from the penetration into the economy (by the veins 
or lymphatics, often by both simultaneously) of a septic agent (cadaveric 
poison, product of decomposition according to some, proto-organism ac- 
cording to Pasteur), a septic agent which may gain access to the economy 
either, and this is the rule, by the vagina and the vaginal and uterine 
wounds, or else, exceptionally, by the lungs and intestines. According 
to the different entrance points, and according to the varied conditions of 
development in the economy, this agent will determine different affec- 
tions and phenomena, which will impress on each epidemic its special 
characteristics. 
[Among the recent contributions to the subject of the relationship exist- 
ing between micro-organisms and puerperal fever, we would note the 
article published by Lomer, of Berlin, in the Am. Journal of Obstetrics, 
July, 1884. The aim. of the writer was to collect the facts which have 
been offered as such regarding this relationship, and we here insert his 313 
THE PATHOGENY OF PUERPERAL FEVER. 
conclusions as being representative of the most recent views on this sub- 
ject. After an impartial statement of the knowledge derivable from pa- 
thological anatomy, and from culture experiments, Lomer studies the 
relation of scarlet fever, diphtheria, erysipelas, pyemia, etc., to puerperal 
fever, and then draws the following conclusions: 1. Of all organisms 
found in puerperal fever, the chain-like micrococci seem to be those to 
which we should especially direct our attention, and which are the most 
important. 2. When in any case of puerperal fever their presence has 
been detected in the exudations, they have also been found in the deeper 
organs. 3. They have been found in erysipelas, scarlet fever, diphtheria, 
and puerperal fever, and in each possess the same form, and show the 
same disposition towards fertilizing fluids and coloring matters. 4. Al- 
though it is very probable that different varieties do exist among these 
diseases, we as yet have no positive evidence of the fact. 5. A differen- 
tiation according to size is an extremely difficult, perhaps hopeless task, 
but according to manner of growth, it maybe possible. 6. Vaccinations, 
with cultivations of these micrococci from different diseases, have proved 
fatal to animals, but have given no typical or characteristic results. 7. 
Chain-like micrococci have also been found in infected wounds, and in 
the blood of pyemic patients. 8. The pathologico-anatomical investiga- 
tions thus show that these clinically related diseases (puerperal fever, ery- 
sipelas, diphtheria, scarlet fever, and pyemia) possess similar micro-organ- 
isms. 9. Besides the chain-like form, other micro-organisms may be 
present in puerperal fever (i.e., mixed infection.) 10. The presence of 
these latter in the cadaver does not always prove that they existed in the 
living body; on the contrary, they are often the result of post-mortem 
decomposition. 11. It is probable that the processes of decomposition 
are sometimes present before death actually takes place; different varieties 
of micro-organisms therefore found, for instance, during the death strug- 
gle, may have nothing to do with the cause of the disease. 12. It is as 
yet impossible to classify puerperal fever, as regards course and prognosis, 
according to the varieties of micro-organisms found (Doleris), or according 
to their mode of invasion (Fraenckel.) 13. In some cases no micro-organ- 
isms have been found, but this does not prove that they did not exist. 
Such may be considered a fair statement of the views held to-day in 
Germany, and largely in this country, in regard to the relationship existing 
between germs and puerperal fever. 314 
A TREATISE ON OBSTETRICS. 
Robert Barnes, in his system of obstetric medicine and surgery, thus 
summarizes his views in regard to puerperal fever: " By the term puer- 
peral fever, we must understand fever in a puerpera. As fevers of vari- 
ous kinds may assail non-puerperal persons, so they may assail puerperae. 
We must, therefore, abandon the vain attempt to find one definite puerperal 
fever, and we must recognize the clinical truth that there are puerperal 
fevers. There is, however, one constant underlying condition of all the 
puerperal fevers, that is, the puerperal constitution. This puerperal 
constitution is the soil in which all the disturbing influences work, in 
which noxious matters, from whatever source, germinate; and which, 
without always destroying the individual properties of the foreign poisons, 
imparts to all some common features. It is also highly probable that, 
under the mutual reactions of ingested poisons, and the puerperal consti- 
tution, new innominate poisons may be engendered. The puerperal 
fevers may be classified under the two great divisions of autogenetic and 
heterogenetic. The autogenetic fevers are: 1. The simple excretory puer- 
peral fever, the result of endosepsis, or the arrest of the excretion of waste 
stuff of involution. This form complicates all other fevers. It is in 
itself the only true puerperal fever. 2. The fever resulting from the ab- 
sorption of foul stuff from the parturient canal, either from unbroken 
mucous surface, or by the open mouths of vessels, or from traumatic 
surfaces, this is autoseptic. This form also is likely to complicate other 
fevers. 3. This, the proper septicemic puerperal fever, is revealed 
under the forms of metritis, peritonitis, pelvic cellulitis, thrombosis and 
general toxemia. 
The heterogenetic fevers are due to the reception of a poison from with- 
out. These may be divided into: 1. The cadaveric poison, the septic stuff 
from other puerpere, animal poisons of obscure origin. 2. The known 
zymotic poisons, as smallpox, scarlatina, typhoid, diphtheria, erysipelas. 
All the various modes of infection recognized as acting in non-puerperal 
subjects act in the puerpera. But she is especially open to invasion by 
direct inoculation of the parturient tract; and empoisonment by the ordi- 
nary routes is enormously favored by the peculiar activity of the absorptive 
function of the puerpera. Pathological anatomy fails to differentiate the 
fevers. In cases of various origin the anatomical changes may exhibit 
close similarity. The constancy of pathological effects illustrates the 
proposition that all the fevers acquire some common character from the THE PATHOGENY OF PUERPERAL FEVER. 
315 
underlying puerperal constitution. The symptoms at the onset of puer- 
peral fever rarely indicate with precision the source or nature of the 
fever. Most are ushered in by the common signs of toxemia. Differen- 
tiation, or the identification of the particular poison at work, is established 
sometimes by watching the clinical evolution of the disease, by the ante- 
cedent history, by search into the surrounding influences, and not seldom 
the problem baffles solution. We must then be content with the general 
fact that we are dealing with a puerperal fever." 
In the Am. Journ. of Obstetrics for May, 1886, Dr. Emil Noeggerath 
described a species of puerperal fever dependent on a microbe which he 
cultivated and is represented on the annexed plate. The special features 
of this variety of puerperal fever, as deduced from study of a reported 
case, are that: 611. There is an invasion of a septic element, notwithstand- 
ing the most complete aseptic management of the confinement. 2. Long 
duration and obstinacy of a moderate amount of fever against early, per- 
sistent, and energetic local and internal treatment. 3. Its remittent, 
almost intermittent character. 4. The inflammatory action of the poison 
upon the tissue of the uterus. 5. The absence of deposits in remote 
organs, notwithstanding the length of time the patient was under the in- 
fluence of the fever germs." The special microbe on which this variety 
of puerperal fever depended belonged to the bacteria called saprogenes, 
and Noeggerath thus describes it: " Its length, although varying in size 
according to the medium on which it is raised, is between a large coccus 
and a bacillus. It is a short rod, separated in the middle by a slight 
constriction just visible with a very high power, which gives it the appear- 
ance of two oblong cocci joined closely together. Sometimes two or three 
rods are joined in one. Fig. 1 (vide plate) represents, near a, their charac- 
teristic appearance. It is about one-quarter larger than bacterium termo. " 
Fig. 4 shows this microbe growing in meat-peptone, when it acquires 
the shape of a cone, point downwards, and it resembles very much a 
comet with a large nucleus. As it grows, it developes a very intense odor 
of putrefaction. Fig. 3 represents the ordinary puerperal strepto-coccus, 
for purposes of comparison. li The life history of this parasite, enables 
us to classify it among the saprophytes, and we must call the fever de- 
scribed, not as symptomatic of septicaemia, but of sapremia. This dis- 
tinction is now fully established as existing in fevers occurring during 
the puerperal state, especially through the researches of Duncan and 316 
A TREATISE ON OBSTETRICS. 
Ogston. Sapremia is simple putrid infection, not a poisoning from an 
organism which goes on developing in the blood, but a reception into 
the circulation of decomposed lymph and gases. The organisms which 
produce sepsis and pyemia have probably nothing to do with putrefaction 
at all." The very practical conclusion which Noeggerath draws from his 
study, a conclusion worth emphasis, is: " A so-called good plumbing, 
from an engineering point of view, is no guarantee of a sanitary condition 
of a dwelling." 
Parvin, in his recent work on obstetrics, thus summarizes his own 
views in regard to puerperal fever: " From what is known of so-called 
puerperal fever, it should not be regarded as a specific disease, and, strictly 
speaking, there is no puerperal fever, that which is so denominated being 
a febrile affection caused by the entrance into the system of a poison from 
without, the nature of which we do not know, the entrance taking place 
through a wound of the uterus, or of some part of the vulvo-vaginal canal." 
From the above extracts it is evident that there is still ample diversity 
of opinion in regard to the cause or causes of puerperal fever or fevers, 
to use Barnes's expression, except in the minds of those convinced be- 
lievers in the influence of microbes. For them " no microbe, no fever " is 
the cry. For us, we are content to leave the matter in the doubt forced 
upon us by the present state of our knowledge. To dogmatize, as yet, we 
do not believe is scientific. The wise course is to accept the doctrine of 
septicaemia as applicable to the vast majority of cases. Fortunately for 
the woman, our treatment of the disease is to-day more certain than our 
theory as to its origin, and if in the future a better explanation of the 
cause is offered than that at present acceptable to the majority of ac- 
coucheurs, we do not hope for much change in the generally accepted 
treatment, which is outlined further on.-Ed.] EXPLANATION OF PLATE VIL 
Fig. 1.-Noeggerath's saprocyte. 
Fig. 2.-a, Slender bacillus, like that of tuberculosis; b, large dip- 
lococcus; c, coccus in chains;, d, rod bacteria. 
Fig. 3.-Common puerperal streptococcus. 
Fig. 4.-Noeggerath's saprocyte in the culture fluid. irpen tier 
PLATE VII. 
NOEGGERATH-A PUERPERAL FEVER MICROBE. 
H. BENCH E, LITH. N Y CHAPTER II. 
FORMS OF THE DISEASE. 
^QTNDER what forms now do we meet with puerperal affections ? They 
are as numerous as they are varied, as is apparent from consulting 
the descriptions of different epidemics of puerperal fever. Whence the 
divisions into metritis, metro-peritonitis, peritonitis, phlebitis, lymphan- 
gitis, purulent infection, pleurisies, endocartitis, etc. Whence also those 
numerous diseases described by Hervieux in his work, and which, from 
our standpoint, are only manifestations of general infection, of puerperal 
septicaemia. We propose here simply to study the clinical side of puer- 
peral affections without entering into elaborate detail. We will mention 
purely the most marked forms of what was formerly called puerperal 
fever, and to-day is known as puerperal septicaemia. 
At the outset, as has been so well shown by Pajot, there is a vast differ- 
ence between the lesser puerperal state, that is to say, the modifications 
in the organism during pregnancy and lactation, and the greater puer- 
peral state, that is to say, the modifications which occur in the puerpera. 
" Let us examine, ' ' says Pajot, "the organs on trial, and in no respect do 
the physiology and the pathology of the puerperal state resemble the 
physiology and pathology of pregnancy. All tends to hypertrophy during 
pregnancy; after delivery, it is atrophy which is the predominating factor. 
The nosological line of demarcation is just as striking." And Raymond, 
after having quoted the above words of Pajot, adds with justice: " If we 
consider the general modifications impressed on the economy by preg- 
nancy and the puerperium, we find marked differences. In the first state, 
the equilibrium is with difficulty preserved, seeing that it is disturbed 
day by day; the mother must look after her own nourishment, and that 
of her child; the co-efficient of distribution varies each hour so to speak. 
In the puerperal state the inverse obtains: the alimentary decline pro- 
duced by lactation is lowered after a certain time; if it increases occa- 320 
A TREATISE ON OBSTETRICS. 
sionally, it is never with the same regularity and the same continuity as 
during pregnancy. In the gravida, the alteration of the fluids of the 
body is qualitative; there are never foreign elements in the economy. In 
the puerpera it is very different. Nutrition tends to become normal, and 
per contra, the blood may contain septic products. There exists then a 
difference between the physiological and the pathological processes, which 
precede and follow delivery." 
During the puerperal state, indeed, what changes in the circulation, 
the temperature, what variations in the secretions and the excretions; 
what modifications and transformations in the genital organs, and, in 
consequence, what transitory or persistent accidents, what diverse and 
multiple diseases 1 
Leaving aside all theory, and basing ourselves purely on clinical data, 
we may divide puerperal accidents into two great classes: 1. Those which 
are almost always recovered from. 2. Those which almost certainly kill. 
The first are frankly inflammatory, with a tendency towards localization, 
and retaining the characters of a simple inflammation; the others are 
strikingly infectious in character, reacting on the entire economy, and 
accompanied by diverse manifestations in organs more or less remote from 
the starting-point of the infection. 
A. Accidents which are almost always recovered from.-Such are me- 
tritis, peri-metritis, pelvic peritonitis, abscesses in the broad ligaments, 
etc. These remain, as it were, local, and are dangerous purely from the 
fact of their presence. Being essentially inflammatory in nature, they 
follow the ordinary course of an acute inflammation, lasting in the acute 
state for a few days, to terminate in suppuration, or, as is the rule, 
in resolution, convalescence being tardy. These forms, however, may 
really be due to infection, and then we see them in the shape of gangrene, 
diphtheria, croup, of the Germans. They become then exceptionally 
grave, and instead of cure, it is death which is the rule, death occurring 
quickly, the disease approaching in type what Peter calls the " typhus of 
the puerperium. " 
The most grave expression of these semi-inflammatory and semi-infec- 
tious forms, and which may be considered the connecting link between 
the purely inflammatory and the deadly forms, is peritonitis, puerperal 
metro-peritonitis, and this is ordinarily the result of true infection. 
Sometimes primitive, and again secondary, that is to say, complicating 321 
FORMS OF THE DISEASE. 
metritis, its progress is rapid, sometimes lightning-like, it is accompanied 
by serous and sero-purulent exudations, and it usually ends in death. 
B. Accidents almost always fatal. -The first variety under this heading, 
is usually the result of putrid infection from decomposition of placental 
debris, shreds of membranes, clots retained in the uterus, gangrenous 
eschars in the vagina or the uterus. Infection of this nature is usually 
seen after incomplete miscarriage, or when a dead putrid fcetus is in the 
uterus. Its progress is slower, and when the foreign body is removed, it 
may terminate in recovery, and it is possibly the morbid form where our 
therapeutics avail the most. But, unhappily, this removal of the infec- 
tious mass is not always possible, or does not occui' spontaneously, and 
the patients, poisoned by the detritus, die at the end of a variable time, 
usually after a somewhat prolonged interval. [See Vol. II., under Mis- 
carriage, for remarks bearing on this point.-Ed.] 
The second variety is purulent infection, identical to that in case of 
major wounds, beginning, in general, more slowly than the preceding, 
and accompanied by the same local and general phenomena as m case of 
purulent surgical infection, and also with metastatic abscesses, internal or 
external, emboli, etc. Cure is absolutely exceptional. 
The third variety constitutes what we call puerperal septicaemia. Here 
there is no proper localization, but all the organs of the economy may be 
invaded simultaneously or successively, and thus the patients present, 
alternately, morbid phenomena from the side of the abdomen, pleura, 
heart, brain, lungs, joints, skin, etc., without our being able to say what 
in reality was the cause of death. It is in these instances that the special 
alterations of the blood are found on which Depaul, Dubois and Hervieux, 
based the theory of essentiality. 
Such are the chief varieties of affections which dominate, we may say, 
the pathology of the puerperal state. We must add two more which 
belong to the puerperal period, although they differ notably from the pre- 
ceding. The one is puerperal mania, which we studied in connection 
with the psychical disorders of pregnancy; the other is a late accident of 
the puerperium, since it rarely appears before the tenth to the twelfth 
day, often later, and this is iMegmasia alba dolens. 
Finally, we would mention the worst accident of all, sudden death, 
which occurs unfortunately too frequently without any premonitory 
symptoms. 
Vol. IV.-21 322 
A TREATISE ON OBSTETRICS. 
It will be noticed that we do not use the terms phlebitis, lymphangitis, 
adeno-Iymphitis, and that we make no attempt to differentiate them. 
Whether the poison, the germ, the infectious microbe, enters the econo- 
my by the veins or the lymphatics, the effects at the bedside are such as 
to enable us to classify the case under one or another of the varieties 
mentioned. The diagnosis of lymphangitis or phlebitis can only be con- 
firmed at the post-mortem, and such a diagnosis made at the bedside is 
entirely too subtile, and devoid of practical interest. Such a distinction 
is certainly of importance theoretically, but in practice it is not. We will 
describe clinically only the following varieties: 
1. Inflammatory affections localized in the uterus or its adnexa. 
2. Puerperal peritonitis. 
3. Putrid infection. 
4. Purulent infection. 
5. True puerperal septicaemia. 
6. Phlegmasia alba dolens. 
7. Sudden death in the puerperal state. 
Before entering upon a description of these different forms, we would 
mention that when puerperal fever becomes epidemic: 
1. The same affections occur in all the diseased puerpera, peritonitis, 
pleurisy, phlebitis, lymphangitis, and the same lesions are found in all the 
women. 
2. Epidemics are always preceded in Maternities by diseases of the 
children, enteritis, ophthalmitis, etc. 
3. The surgical wards are the seat of erysipelas, purulent infection, 
hospital gangrene, etc. 
I. Puerperal Metritis.-Inflammatory Affections localized in 
the Uterus, its Adnexa, and neighboring Organs. 
Inflammatory processes may affect each of the organs in the pelvis 
'separately, or else spread from one to another. Thus the uterus alone 
may be affected, and we have a metritis with its varieties: endometritis, 
when the mucous membrane is alone diseased, and this may be simple, or 
gangrenous, diphtheritic, or ulcerative; or else the metritis itself may be 
accompanied by inflammation of the serous covering of the uterus, and 
there may also exist peri- and parametritis, abscess, oophoritis, salpingi- 
tis, etc. Each of these affections are characterized by peculiar symptoms, FORMS OF THE DISEASE. 
323 
it is true, but they are generally insufficient to allow of precise clinical 
differential diagnosis. These affections, indeed, are masked under the 
symptoms emanating from the accompanying pelvic peritonitis. Metri- 
tis is the initial phenomenon, and the other lesions are the result of ex- 
tension. 
We must here draw a sharp distinction between primiparae and multi- 
parae. While it is not rare in the latter to witness these inflammatory pro- 
cesses succeed the after-pains, which occur as a rule in them, and which 
are then peculiarly intense and persistent, the same does not hold true 
of the former, where the disease usually developes abruptly without pre- 
monition. In primiparae, indeed, after-pains are exceptional, and the 
disease breaks out while the woman is in nearly perfect health. In the 
multipara, on the contrary, after-pains are nearly the rule, but while 
these gradually diminish, to disappear entirely at the end of about thirty- 
six hours, or else only to reappear when the child nurses, when they are 
about to be followed by inflammatory symptoms, they not rarely resist all 
treatment, and persist with a notable intensity and frequency, until the in- 
flammatory process sets in. Usually, in these instances, there is a sensa- 
tion of weight in the abdomen, which persists between the after-pains, 
and is accompanied by a hardness of the uterus, which is in marked con- 
trast with the softness it customarily presents during the first few days 
of the puerperium. 
It is rarely before the third or fourth day, sometimes, however, as early 
as the second, that the initial symptoms appear. Up to this time the 
general and local state is satisfactory, there is no fever, when, of a sudden^ 
appear simultaneously, as it were, three symptoms, two of which are ab- 
solutely constant, and the third nearly the rule. These three symptoms 
are: 1. Pain; 2. fever; 3. chill. 
1. Pain.-At times insidious, dull, continuous, and again sudden, very 
acute, pain is characterized by the fact that it is always spontaneous and 
always increased by pressure. Further, there is always one spot where 
on pressure it has a maximum intensity. Although, indeed, the entire 
uterus is sensitive to pressure, it is in particular in the lateral regions that 
pain is most intense, and in those instances where it is least marked spon- 
taneously, and where it shows itself simply by a sensation of weight, and 
tension in the loins and abdomen, it suffices to press with the finger to 
the right or left of the uterus in order to excite the pain more acutely. 324 
A TREATISE ON OBSTETRICS. 
Usually this tenderness on pressure is on both sides, but it is not rare for 
it to be unilateral and more pronounced on one side than on the other. 
The uterus, checked in involution, is harder, tenser, more resisting. At 
times, indeed, it seems to be more voluminous. If the abdomen is pal- 
pated beyond the region of the uterus, it is painless-in a word, the pain 
is localized over the uterus, the abdomen is either not tympanitic, or else 
only to a degree, in the hypogastrium. The striking point then is that 
the pain is localized purely over the uterus. 
2. Coincidently with the pain, there is rise of temperature, which, 
while moderate in general, is very marked. The pulse is rapid, although 
usually not above 100 to 110; ordinarily, indeed, it remains at 88 to 104. 
The temperature rises from 101° to 103°, rarely reaching 104°. The 
skin is hot, bathed in perspiration, but the facies is calm, not altered, and 
the general state is fairly satisfactory. The patients, nevertheless, com- 
plain of a feeling of malaise in addition to the pain. 
3. Usually, when pain and fever appear, the patients have a chill, fairly 
violent, lasting from a few minutes to one quarter of an hour or more, 
and this is frequently at the beginning of the febrile period. Often, how- 
ever, in multipara?, this chill is lacking. While in them the disease de- 
velopes insidiously, so to speak, while the metritis, the inflammation of 
the uterus, follows progressively on the after-pains, in primiparae the onset 
is almost always more sudden, and to the well-being of the day before 
there succeeds chill, fever, pain, these three phenomena appearing sim- 
ultaneously and more or less acutely. 
At the same time the lochia are in part suppressed, diminishing notably, 
becoming reddish and foetid, occasionally excessively foetid. If the dis- 
ease breaks out before the establishment of lactation, this doesnot appear, 
or only incompletely. Constipation is the rule. Another phenomenon 
appearing simultaneously is arrest of involution. The uterus, instead of 
undergoing the retrograde changes which are usual during the early days 
of the normal puerperium, remains large, heavy, and at the same time is 
painful. Not uncommonly it increases in size, and on palpation it is 
found five to six finger breadths above the pubes - sometimes almost 
reaching the umbilicus, and feeling resistant, instead of having the char- 
acteristic resiliency. On vaginal examination, this canal is hot, painful, 
and touching the uterus evokes the same painful sensations as external 
palpation. The uterus is less movable. The pain evoked bi-manually is FORMS OF THE DISEASE. 
325 
ordinarily more acute on one side than on the other, and not infre- 
quently within the first few days, there exists bogginess in one or another 
of the culs-de-sac, which is an indication of the extension of the inflam- 
matory process to the neighboring parts. There exists in addition to 
metritis, a para- and a peri-metritis. 
The above state persists for a few days, and then either the disease 
tends towards cure, or else it is complicated by inflammatory processes in 
the organs adjoining the uterus. If the case remains uncomplicated, 
and the metritis tends towards cure, the pain gradually diminishes, the 
fever persists only towards evening, and is characterized purely by a gen- 
tle elevation of the pulse and of the temperature. The pulse, which in the 
morning was 100, rises in the evening to 104 or 108, and the temperature, 
about 101° in the morning, rises to about 103° in the evening. The 
uterus begins to involute, very slowly however, and at the end of five to 
six weeks the patients may be pronounced cured. This is the case where 
the disease has remained local in the uterus. 
Far otherwise is it the case usually, however, for then the inflammatory 
process spreads to the neighboring organs, the annexes of the uterus, the 
broad ligaments-in a word, we witness the development of peri- and para- 
metritis, abscesses, etc. Then the scene changes a trifle, according as 
the process is localized at one or finbther point of the pelvis. But that 
which dominates still, and what indicates propagation, is the reappearance 
of the three signs, chill, fever, pain. The chill returns with the fever, 
but the pain is in some respects peculiar, its maximum being no longer 
just laterally of the uterus, but, according to the case, around this organ, 
in the iliac fossae, ifi the hypogastrium, invading the entire abdomen below 
the umbilicus. At the same time palpation gives very different sensations. 
While when the uterus alone is affected, this organ only is hard, the rest 
of the abdomen being soft; when peri- or parametritis, abscess, etc. exist, 
the entire region invaded by the inflammatory process is tense, owing to 
the deposition of plastic material, very appreciable to the touch, painful 
at the outset, and filling one or another of the hypogastric regions accord- 
ing to the site of invasion. At first this plastic mass is readily isolated, 
but later the uterus is surrounded by it, and m a few days the bi-manual 
simply reveals density all around the organ. This mass is rarely smooth 
and uniform, but presents here and there projecting points, harder in 
places, and exquisitely sensitive on pressure. The vaginal culs-de-sac 326 
A TREATISE ONT OBSTETRICS. 
bulge out, the uterus is deviated from the mid-line, and immobilized. 
Whatever the name given to this process, whether peri- uterine phlegmon, 
peri- or parametritis, pelvic peritonitis certainly exists, and the disease 
may follow two different courses. In the one, happily the most common, 
this indurated mass, after having increased for a few days, begins to resolve 
very slowly without suppuration, requiring a number of months, the 
general health improving as the mass disappears entirely. But, on the 
other hand, this mass, so hard at the outset, softens in places, ends by 
suppurating, and finally breaks, usually into the vagina or the rectum. 
The tumor then diminishes rapidly, and often recovery is speedy; usually, 
however, at the end of a few days, cnill and fever reappear, the temper- 
ature rising to 104° or over, and the tumor increases in size, the abscess 
having reformed, and thus many times we may witness the partial re- 
filling and evacuation of the tumor, until it empties itself definitely, and 
recovery ensues. In other instances, again, the fever remains constant, 
and the patients, worn out by prolonged suppuration, succumb eventu- 
ally to hectic fever. 
Such is the ordinary clinical picture of the progress of puerperal metri- 
tis, when it is present in its most striking form. In certain cases, how- 
ever, the progress of the accompanying pelvic peritonitis is still more in- 
sidious. The general phenomena ffre scarcely pronounced, the febrile 
reaction insignificant, the abdominal tenderness not marked, the tume- 
faction and bogginess scarcely apparent, and it is only the touch which 
will reveal the existence of the process. Cure, in these instances, is the 
rule. Unfortunately, by the side of this relatively benign form, there are 
two others far more grave, for they are rarely recovered from, and these 
are the suppurative and the gangrenous forms of metritis. 
In case of suppurative metritis, whether the process invades only the 
tissue of the uterus itself, which is exceptional, or the veins or lymphatics, 
which is the rule, the general phenomena are much more severe; if the 
pain is not more intense, the fever is and the pulse often exceeds 120 
pulsations, the chills are more violent and more frequently repeated with 
notable irregularity. The temperature rises to 105° and even 106°, the 
facies alters, the patients are in a state of more or less pronounced stupor 
and prostration, the tongue is dry, sometimes there is vomiting of bile, 
but, curiously enough, the process does not tend so much to extend be- 
yond the uterus. The abdomen is less sensitive, the same hard tumor is FORMS OF THE DISEASE. 
327 
not found in the hypogastric or iliac regions, the uterus itself is less pain- 
ful on pressure, but the general condition is far more serious, and in a 
few days, the general phenomena become more intense. The fever goes on 
increasing, and then appear delirium, coma, frequent, painful respiration. 
Foetid diarrhoea succeeds to constipation, followed by involuntary dejec- 
tions and death, which is the rule in these instances. The lochia are ordi- 
narily suppressed, and where they persist a trifle the odor is more intense. 
In gangrenous metritis the striking characteristic is foetor of the lochia, 
so intense that it simply poisons the entire ward, and the color is black- 
ish, the contents being often gangrenous shreds. Gangrene is rarely 
limited to the uterus alone, but spreads to the vagina and the vulva. 
Prostration is extreme, the facies greatly altered, the pulse small, worth- 
less, very frequent. There is a general tendency to refrigeration. The 
face is pale, dusky in spots, the lips are blue, the eyes dimmed, the 
patients are in a constant state of semi-delirium, the abdomen is more or 
less tympanitic, and not very sensitive, and the patients again usually die. 
We would add, further, that gangrenous metritis, usually the result of 
trauma during operations, breaks out more quickly than simple or sup- 
purative metritis, usually on the day following delivery, increasing pro- 
gressively and ending in death within foui- to five days. 
II. Puerperal Metro-Peritonitis. 
Puerperal metro-peritonitis is characterized by symptoms which prevent 
its being confounded with any other puerperal process, although at times 
it complicates metritis, and while it may have a prodromic period, usu- 
ally its onset is abrupt, sudden, and within the three days following de- 
livery. 
The first symptom is a chill, usually a single one, lasting for one half 
to three quarters of an hour, violent enough to shake the bed on which 
the woman lies. This- chill is accompanied by a sensation of extreme 
cold, so much so that it is with difficulty the patient can be made to feel 
warm, and this sensation may persist for a number of hours. The chill 
is rarely lacking, and is followed by an intense fever. 
Coincidently with the chill, or immediately following it, there occurs 
pain, which is acute, spontaneous, extending over the entire abdomen, 
although localized in places at the outset. Beginning in the sub-umbi- 328 
A TREATISE ON OBSTETRICS 
lical region, the maximum point of the pain is in the latero-inferior 
regions of the uterus, at the site of insertion of the broad ligaments, and 
thence it spreads rapidly until eventually the entire abdomen is sensitive. 
This pain is spontaneous; the patientscan scarcely bear the weight of the 
bed-clothing; it is increased by pressure, by movements; it has periods 
of exacerbation, when the women shriek out from its intensity. At the 
end of two to three days this pain ordinarily disappears, but we must be 
careful not to thence draw a favorable prognosis, for this insensibility of 
the abdomen is on the contrary, in the majority of cases, a sign of aggra- 
vation in the general condition. Under the effect of this pain the facies 
alters, becomes drawn, pale, and the vital forces diminish. 
The abdomen swells, as it becomes painful, from paralysis of the intes- 
tines, and consequent distension with gas. At the outset, indeed, the coils 
of intestine are outlined under the skin. The percussion note is tympan- 
itic all over the abdomen, when the distension is extreme. In general, 
pain is in inverse proportion to tympanites; the more the abdomen is dis- 
tended, the less the pain and vice versa; so that when the distension has 
attained its maximum, the abdomen is absolutely painless. 
Concurrently with the chill, pain, and ballooning of the belly, appears 
fever, and here we must consider separately the pulse rate and the tem- 
perature rise. 
The pulse rate in puerperal peritonitis is always very frequent, and this 
frequency is directly connected with the intensity of the disease. In 
general, at the beginning, it ranges between 110 and 120 pulsations, 
although it may rise above 120. It never, however, falls below 100. At 
first strong, full, resisting, it diminishes later in force as it increases in 
frequency, until it becomes very small and compressible as the disease 
approaches its height, and in the period of decline the pulse becomes so 
small and frequent that we cannot count it. At the same time, the skin 
becomes cold and covered with clammy sweat. Ordinarily the pulse is 
accelerated towards evening, diminishing towards the morning, but 
always remaining above 100. This is a point on which we lay great stress. 
Like the pulse, the temperature presents variations, and like it a high 
figure is constant. While in simple metritis it rarely exceeds 103.4° to 
104°, it is the rule in peritonitis to see it rise above 104° to 105° and 
over, and further the rise of temperature is not in proportion to the pulse 
rate. The elevation is most marked in the evening up to the end of the FORMS OF THE DISEASE. 
329 
disease, when the temperature falls notably, at times becoming even sub- 
normal. As Wunderlich says: 11 Sub-normal temperatures are especially 
seen in peritonitis, and they should always awaken our suspicions. 
Death often occurs during this sub-normal stage." 
Digestive disturbances are constant accompaniments of peritonitis, such 
as vomiting, diarrhoea alternating with constipation. Vomiting is only 
exceptionally absent, and appears usually as soon as the disease is well 
established, but after the occurrence of chill, fever, pain, and tympanites, 
usually at the expiration of ten to twelve hours. Often preceded by 
nausea and hiccough, it again frequently developes suddenly. In any 
event it has characteristic features. Constituted, at the outset, by water 
and mucosities, it soon becomes bilious and then spinachy. At first with 
effort, the vomiting gradually merges into pure regurgitation, becomes 
incessant, and in surprising amount. Vomiting of this nature usually 
persists throughout the course of the disease, although at times it ceases 
'spontaneously at the end of twenty-four to forty-eight hours. The prog- 
nosis is no more favorable, however, unless the fever and the tympanites 
diminish concomitantly 
At the outset, constipation is generally present, but to it succeeds a 
profuse diarrhoea, on the appearance of which the vomiting frequently 
ceases. The stools are at first solid, then glairy and involuntary, and 
finally are composed of bile mingled with bloody mucus. There is always 
marked foetor to the stools. At the same time the tongue, which has 
been moist, thick, white, cleanses and becomes red, pointed, although 
still moist, only becoming dry at the height of the disease or before death. 
Then it is dry and blackish; the gums, the teeth, the inside of the lips 
being covered with blackish material streaked here and there with red. 
The speech becomes thick and difficult; the thirst excessive, in a word, 
the typhoid state is very marked. Commonly the patients are slightly 
jaundiced, particularly when the peritonitis is generalized. 
As Hervieux has remarked, the appetite is often retained, but this is 
simply the result of " a perversion, not only of the functions of the 
stomach, but also of the brain. " . It makes no difference, however, for 
whatever is ingested is at once rejected. 
These digestive disturbances are, we have seen, preceded by tympanites. 
This, indeed, is an early phenomenon, at times the initial. Curiously 
enough, however, the pain disappears as the tympanites and distension 330 
A TREATISE ON OBSTETRICS. 
of the abdominal walls increase, to cease entirely when the meteorism has 
attained its maximum. Then even deep pressure fails to evoke sensation 
from this extraordinarily distended abdomen. While at the outset the 
pressure of a sheet caused the patient to cry out bitterly, now any pres- 
sure is borne without complaint, and this is one of the most unfavorable 
prognostic signs. 
This excessive abdominal distension, by pressure on the diaphragm, 
induces respiratory troubles, and interferes with the action of the heart 
and the circulation in the great vessels. The respirations become short 
and frequent. It is not unusual to see them rise to 40, 50, 60 a minute, 
and thence arises the sensation of dyspnoea, of oppression, of which the 
patients complain, and the more or less cyanosed tint they present, like 
that of cholera patients in the algid stage. These respiratory troubles, 
however, are not purely mechanical. It is the rule, indeed, that women 
with peritonitis have also pleural and pulmonary complications, as well 
as cardiac affections. These complications, of course, aggravate the 
mechanical disturbances caused by the meteorism. 
Remarkably enough the sensory disturbances are not at all proportionate 
to the grave state of the patients. Although at the beginning they com- 
plain of cephalalgia, this ordinarily disappears promptly, and the intellect 
remains up to the end. The appearance of delirium is an unfavorable 
sign, and this usually is the case twelve to forty-eight hours before death. 
It is rather, in the majority of instances, a low muttering delirium than 
an active one. 
Side by side with these striking symptoms of puerperal peritonitis, we 
must note the alterations in the face. At the outset expressive above all 
of pain, the facies soon becomes thin, wrinkled, and assumes the hip- 
pocratic aspect. Later, prostration and coma deprive the face of all ex- 
pression. Coma gradually deepens, all the faculties fade, the surface of 
the body becomes cold, livid. 
As for the physiological phenomena of the puerperium, they are deeply 
disturbed The function of lactation does not become established, or 
else is abruptly checked if the peritonitis supervenes after its onset. 
Sometimes the lochia are suppressed after having been foetid. The uterus 
does not involute. The patient is often covered with abundant, cold, 
clammy perspiration, and often there appear on the thighs, genitals, and 
buttocks, miliary vesicles, pustules, bulhe, at times petechise. Where the 
disease is prolonged, we may see bed-sores and gangrene of the genitals. FORMS OF THE DISEASE. 
331 
Course, Duration, Termination of Puerperal Peritonitis.-Only excep- 
tionally does the inflammatory process invade at the outset the entire 
serous coat. Usually the hypogastric region is first affected, and only later 
does it reach the sub-umbilical region. At times, however, the course of 
the disease is very rapid, and in a few hours the process is generalized. 
The patients may die in three to four days. Again, the disease breaks 
out violently; then, either spontaneously or as the result of treatment, 
there occurs a remission, to be followed by a new outburst which contin- 
ues to the end. Again, the disease follows a more regular course, and 
then it may terminate in death or in recovery. If it is to be death, the 
course of the phenomena is somewhat as follows: A violent chill followed 
by intense fever with great pain and tympanites. At first limited to the 
hypogastrium, this pain quickly invades the entire abdomen, and persists 
for twenty-four to forty-eight hours, sometimes longer. Then appear 
vomiting and diarrhoea. At the end of three to four days, at the furthest, 
the pain ceases, but the abdomen remains greatly distended, the pulse very 
frequent, the temperature very high, the general condition passes from 
bad to worse, the traits alter, the face becomes thin and drawn, the res- 
piration more and more painful, the vomiting ceases entirely, or else re- 
turns but at infrequent intervals, but the diarrhoea persists, the stools 
become involuntary, delirium sets in, followed by coma and death. But 
few days are requisite for the enactment of this scene, the disease rarely 
extending beyond the seventh or eighth day. 
In more exceptional instances, the disease develops rapidly with grave 
symptoms, and then in about forty-eight hours the. patient seems better, 
when on the morrow, perhaps, the disease again resumes its acute course 
and persists till death. 
Happily such is not always the case, and in rare instances, it is true, 
but they are often met with in private practice, recovery ensues. Some- 
times the peritonitis is apparently aborted, but ordinarily the course of 
events is as follows: After an acute stage, the symptoms decrease in vio- 
lence, the tympanites diminishes, and an indurated mass forms in the 
abdomen, filling it more or less, a mass constituted by the uterus and 
intestines agglutinated by false membrane, and which is felt through the 
cul-de-sac, even as in localized peritonitis. This mass will pass through 
the staged which we described under pelvic peritonitis. Sometimes, and 
this is the rule, it gradually is absorbed to disappear completely in from 332 
A TREATISE ON OBSTETRICS. 
three to five months; again, abscesses form which open through the ab- 
domen, or into the rectum, bladder, or vagina. 
In still rarer instances, the disease seems to transform or to merge into 
another, and we witness the disappearance of the abdominal symptoms, 
and the infection still manifests its action by the onset of suppurative 
arthritis, erysipelas, pleurisy, etc. 
Recovery, it is seen, is always very slow, and it is not very rare to see 
the patients resist the first peritoneal phenomena and succumb later, 
worn out, as it were, by the morbid struggle they have made for so long. 
Such a termination is especially to be feared in cases where there is sup- 
puration with opening into the viscera, the patients gradually yielding to 
hectic fever. 
The differential diagnosis of metritis from peritonitis is thus usually a 
simple matter, and we resume the points as follows: 
Metritis. 
Chill not constant, in general mod- 
erate. 
Fever moderate, except in grave 
cases; the pulse rarely exceeds 100, ex- 
cept momentarily. 
Temperature between 101° and 103°; 
sometimes exceeds this figure and rises 
to 104°, to fall quickly to 103° and lower. 
Pain constant, localized over the uter- 
us, with its maximum sites laterally, 
whence it spreads to the broad liga- 
ments. Spontaneous pain disappears 
quickly, but provoked pain lasts a long 
time. The pain is dull, with weight in 
the loins. The elective site is about one 
inch above the fold of the groin. 
The general state improves as the 
pain lessens. 
The respiration is not altered, but on- 
ly slightly accelerated during the fever. 
Tympanites slight, and limited to the 
hypogastric region. 
Digestive disturbances but slight. 
The tongue lightly coated and moist. 
Peritonitis. 
Chill always violent and prolonged, 
and renewed. 
Fever intense, continuous, with accel- 
eration of the pulse up to death. The 
pulse ranging from 116 to 120. 
Temperature very high, 103° at the 
lowest; often reaches 105° to 106°; pre- 
sents no oscillations. 
Pain constant, acute, spontaneous; 
invading progressively the abdomen 
from the hypogastrium. It lasts only 
a short time. Disappearance of pain 
does not mean amelioration in the con- 
dition. 
The general state may grow worse as 
the pain disappears. 
Respiration anxious, difficult, fre- 
quent; dyspnoea; thoracic complications. 
Tympanites excessive, general. 
Great disturbance of the digestive 
tract, nausea, hiccough, incessant and 
profuse vomiting, persisting at times to 
death. Diarrhoea following on consti- 
pation. Tongue at first moist, then dry. 
Sordes. FORMS OF THE DISEASE. 
333 
Metritis. 
Intellectual disorders nil, except in 
suppurative or gangrenous metritis, 
and then ultimate delirium. 
Facies scarcely changed except in 
grave cases. Icterus never present. 
Lochia fetid, not entirely suppressed. 
Lactation incomplete. Arrest of invo- 
lution. 
To the touch, the uterus is large, pain- 
ful, more or less immobilized. 
Recovery the rule. Complicated by 
peri- and parametritis. Lateral tumor 
ending in suppuration or absorption. 
Death only in rare cases, such as in 
the suppurative or gangrenous forms. 
Peritonitis. 
Intellectual disturbances generally nil 
up to 24 hours before death; then de- 
lirium, coma, profound depression. 
Profound change in facies, cyanosis; 
frequently jaundice. 
Lochia usually suppressed. No lacta- 
tion, arrest of involution. 
Same characters, but more pronounc- 
ed. Later, absolute immobility of 
uterus. 
Death the rule. In case of recovery, 
enormous mass filling abdomen, resolv- 
ing ordinarily in three to five months. 
Sometimes suppuration and death from 
hectic. i 
Metastatic abscesses, arthritis, hepa- 
tic, pulmonary, cardiac complications, 
bed-sores, erysipelas, eruptions, &c. 
III. Putrid Infection. 
We have stated that the puerperal affections, from a pathogenetic stand- 
point, may be due either to auto- or to hetero-infection. To the descrip- 
tion of the former we now pass. 
Putrid infection manifestsitself nearly always under special conditions, 
that is to say, after miscarriages, incomplete third stage of labor, trau- 
matism-in a word, where there has occurred putrid decomposition of any 
thing which has become foreign to and yet is retained in the genital pas- 
sages. Here the general condition predominates over the local manifesta- 
tions. These latter, indeed, are very insignificant. We are dealing with 
a true poisoning from resorption of putrid material. It matters little 
clinically whether this absorption takes place from the uterine wound, or 
by the lymphatics or the veins. The gravity of the case is dependent less 
on the nature than on the fact of poisoning. This poisoning does not 
always take place under the same conditions. At times it is slow, pro- 
gressive, by small doses, so to speak, and again rapid and in large dose. 
At times we are certain of the presence of an infecting body in the geni- 
tal canal. Again this body may be wanting, yet the patient present iden- 
tical symptoms of putrid infection, without our being able to discover 
the cause of the poisoning. Whence, then, certain differences in the 334 
A TREATISE ON OBSTETRICS. 
symptoms and in the course of the disease. The varieties are, however, 
always typical of the disease. 
The first phenomenon is the great alteration in the character of the 
lochial discharge. For several days the lochia remain normal and nothing 
foretells the disease. The discharge then is partially suppressed; it be- 
comes brownish-black, filled with membranous debris, and the odor is 
more or less foetid. Occasionally the patients have profuse, persistent, 
hemorrhages composed of foul clots and portions of the placenta and 
membranes. Again, nothing is found in the lochia. They are simply 
horribly foetid. This foetor may be so intense that not alone the bed, but 
also the room, the entire ward, or house is infected. It is particularly 
in cases where remnants of the placenta or membranes have been left in 
the uterus, that the foetor is so pronounced. The odor is characteristic 
and peculiar, and the accoucheur who has smelt it once will recognize it 
ever afterwards when he approaches the bed of the diseased puerpera. 
Disappearing at times for a few hours, after injections, it soon returns 
and thus persists until the foreign body has been expelled, or removed in 
toto. 
In the above instances there is no room for error, but there are others 
where the diagnosis is very difficult. Here we find no tangible cause of 
infection. The third stage of labor was thoroughly completed; the labor 
itself was natural; there has been no hemorrhage; there exists no visible 
tear of perineum or of vagina. Yet, towards the fourth or the fifth day, 
the patient's condition becomes less satisfactory, the lochia are foetid, 
although not intensely so, and the phenomena which characterize putrid 
infection set in. The abdomen, lungs, heart, give no explanation of the 
phenomena which seriously compromise the patient's life. 
The next phenomena are chill and fever. 
The chill varies in character, sometimes being intense and of long dura- 
tion, and again there are a number of slight, frequently repeated chills, 
varying from simple coldness, to the true chill. There is often marked 
intermittency in these chills. They usually occur towards six or seven 
in the evening, either daily or every other day, and are always followed 
by an acceleration of the pulse, and of the temperature. 
The temperature rise varies with the pulse rate, usually oscillating be- 
tween 101° and 103°, but there is a constant evening rise. The fever in- 
deed is continuous, but remittent. The pulse ranges between 96 and 120 FORMS OF THE DISEASE. 
335 
a minute, and ordinarily does not exceed the latter figure, except just 
after the chill, when the temperature also may rise above 104°. There is 
never complete apyrexia, even when the patients feel better. 
From the side of the abdomen and the genital organs there is nothing 
specially noteworthy. The uterus only exceptionally is slightly sensitive 
on pressure, but its involution, although retarded, is not arrested, and we 
may follow its gradual decrease in size, until it has sunk into the pelvis. 
To the touch there is nothing peculiar. The uterus is scarcely at all 
sensitive, the vaginal culs-de-sac are free, the cervix is often patulous, es- 
pecially when the uterus contains a foreign body in a state of decomposi- 
tion. Then the uterus is large, and a reddish foetid discharge flows from 
the os. At times the discharge is profuse, containing dark clots, and the 
finger introduced into the cervix withdraws black stinking debris. 
Where the retained body is large and the discharge profuse, the internal 
os is open and the finger may reach this body. 
If the uterus contains nothing, the cervix is shut, the organ involutes, 
and there exists simply a more or less bloody discharge slightly foetid. 
[It is well to bear in mind that flexion of the uterus may cause partial 
or total retention of the lochia, and thence putrid infection. On exami- 
nation the os may be closed, the organ not specially sensitive, and yet the 
lochial discharge is foetid, although not from retained placenta or secun- 
dines. The patient may none the less be infected, however, and on 
straightening out the flexion bi-manually, the cause of the infection will 
be evident when more or less stinking lochia escape.-Ed.] 
To this continued fever, foetid lochia, and repeated chills, are joined a 
peculiar general condition, and a facies markedly characteristic. 
The face has not that appearance of suffering which it presents in grave 
metritis, and in peritonitis, but it has a tired worn-out look. The skin 
has a dirty green tinge, it is moist, although the perspiration is not pro- 
fuse; the patients complain of feeling tired, and of vague aches and pains; 
they object to the injections and the odors around them; they are thirsty, 
lose their appetite; the tongue is roughened and a trifle dry. Rarely 
vomiting, usually only slight nausea is present. There exists persistent 
and foetid diarrhoea. The abdomen is neither sensitive nor tympanitic. 
What predominates, as we have said, is the general state without . special 
local manifestation. Each recurrence in rise of temperature is accom- 
panied by more or less perspiration 336 
A TREATISE ON OBSTETRICS. 
If the patient resists the infection, and progresses towards recovery, 
either, the foreign body having been expelled en masse, the natural 
order of things returns, and in a few days she is convalescing; or else, 
the foreign body passing away in shreds, the lochia little by little lose 
their odor, the pulse lowers, the temperature diminishes, and recovery 
ensues more slowly. 
Where, on the other hand, the woman is deeply infected and is going 
to die, she grows weaker and weaker. The diarrhoea cannot be checked, 
the perspiration becomes abundant, the temperature rises, the pulse ex- 
ceeds 120, the face becomes pale and ashy, and in the final twenty-four 
hours, there is slight delirium, the coma passing insensibly, without much 
suffering, into death. 
Although exceptionally putrid infection progresses rapidly, even as in 
gangrenous metritis, ordinarily the phenomena last from fifteen to thirty 
days and over. In a personal case of miscarriage at 3£ months the rem- 
nant of placenta was only expelled spontaneously at the end of thirty- 
seven days. 
IV. Purulent Infection.-Pyemia. 
Puerperal purulent infection is due to absolutely the same causes as 
surgical purulent infection, and the clinical phenomena and the patho- 
logical lesions are the same in the one as in the other. 
In general, pyemia developes late in the course of the puerperium, 
towards the eighth or tenth day, sometimes later still. The instances 
where the disease has appeared earlier are exceptional. We have seen a 
case beginning on the third day after delivery. Ordinarily, the early 
days of the puerperium are normal and regular, the health of the puer- 
pera being perfect, and there being apparent no lesion of the genital 
organs, or else a cicatrizing wound of the perineum. Of a sudden, with- 
out apparent cause, the woman has an intense chill, which may last from 
one half hour to a number of hours. Wunderlich has at times noted, 
immediately before the onset of the pyemic symptoms, a more or less 
great fall in temperature, and again he has seen slight rise of tempera- 
ture. The chill, however, is followed by high temperature. The pulse 
rises to 130 and more pulsations in a few hours, and the temperature to 
106° and even 107.5°. The temperature just as rapidly falls down even 337 
FORMS OF THE DISEASE. 
to 100°, and. exceptionally below the normal. This chill and fever are 
followed by profuse perspiration, so that the bed-clothes are wringing 
wet, and this lasts until the temperature rises again. Sometimes a day or 
even two pass by with the woman in a fairly satisfactory condition, except 
that the pulse is rather rapid and the temperature slightly above the nor- 
mal. Then suddenly the woman is seized with another violent chill, fol- 
lowed by the same rise in temperature and acceleration of the pulse. 
Similar attacks may follow for a number of days, and then the disease is 
pursuing its regular course. 
Wunderlich thus describes the course of this disease: 
1. Rapid rise of temperature, repeated without special regularity, even 
twice or thrice in the same day, the acme reached being nearly that of 
the first attack. Rapid fall of temperature immediately after each attack. 
Very seldom does the fever last for more than half the day at its maxi- 
mum. The decline is to the normal or below, and exceptionally only to 
102°. 
2. Periods of apyrexia, lasting for twelve or even for twenty-four hours. 
3. Usually, in the intervals of the febrile attacks, or else towards the 
end of the disease, there are periods of one or two days, where the tem- 
perature is continuous or remittent, with a tendency upwards, or else with 
no definite tendency at all. 
After the attacks have thus occurred for a number of times in more or 
less rapid succession, the fever becomes continuous with evening exacer- 
bations, and we witness the unfolding of the following series of phe- 
nomena. 
The woman's skin becomes tinged yellow, which deepens shortly into 
the true jaundice hue; the uterus diminishes little by little in size; there 
is neither metritis, nor general nor circumscribed peritonitis; the lochial 
discharge is slightly suppressed, but at no time foetid; and next appear 
the phenomena which are called metastatic. 
Usually these metastases first affect the articulations. A vague, dull, 
and finally acute pain affects one or more joints. These swell, and run 
through the course of a purulent synovitis. At times the inflammatory 
process leaves one joint to affect another and definitively lodge there. Then 
abscesses are formed in the liver, the lungs, spleen, kidneys, rarely in the 
brain. At times the purulent collections are in the serous cavities, the 
pleura, the pericardium, the peritoneum. Endocarditis may occur. 
Vol. IV -22 338 
A TREATISE ON OBSTETRICS. 
The patients grow weaker, and die sooner or later from what may be 
termed a true purulent diathesis. 
Here again the local affection seems insignificant. The uterine or peri- 
uterine lesions are masked by the general phenomena. Yet, post-mortem, 
in the great majority of instances, the veins and the lymphatics are found 
filled with pus, at the insertion site of the tubes and the broad ligaments. 
There has existed, then,phlebitis and lymphangitis, and these are the prime 
causes of the pyemia. 
It is apparent, of course, how serious an affection of this nature is, and 
how rare recovery. 
V. Puerperal Septicemia. 
In this affection there is nothing fixed or precise. Sometimes purely 
inflammatory accidents open the scene, and it looks as though we were 
dealing with one of the classic forms. The woman has a metritis, or a 
peritonitis, or is under purulent infection, and these affections apparently 
follow their ordinary course. Again, on the other hand, general phe- 
nomena predominate, the local troubles being relatively benign. But 
what characterizes this variety of puerperal infection, is particularly the 
peculiar mobility, so to speak, the variety and the multiplicity of the 
local manifestations. Sometimes the abdomen seems most affected, then 
the lungs, then the heart, then the brain, etc. Sometimes there will be 
no special,local manfestation,and these organs in succession will be affected, 
and the morbid phenomena will predominate more in one or in another, 
when, of a sudden, the disease will seem to affect still another organ 
hitherto untouched. In a word, it looks as though morbid raids were 
being made on all the organs without particular localization on any one. 
Elevation of temperature, however, is constant, and is proof that these 
local manifestations are not at all illusory, and that the entire body is 
profoundly affected. In case of septicaemia, indeed, we are no longer 
dealing with the particular forms we have passed in review. The evil is 
much greater if possible. Here the infection has attained its climax. 
Alteration in the blood is the capital phenomenon, and the various mani- 
festations are purely outward signs of this true poisoning of the puerpera. 
The patients nearly always die, without our being able to say which of 
the morbid local manifestations was the cause of death. 
[In his description of the different varieties of puerperal fever, Char- FORMS OF THE DISEASE. 
339 
pentier follows the example of nearly all ancient and modern writers, in 
making no reference to puerperal diphtheria as a special variety. The 
majority of clinical observers have indeed never seen a case of what they 
could term diphtheria of the genital passages of the puerpera, and we 
must rank ourselves with this great majority. Garrigues, of New York, 
however, is a firm believer in the existence of this special variety, and, 
having been fortunate enough to witness twenty-seven cases, he has given 
us a thorough description of the disease. He claims that there exists a 
variety of puerperal fever " distinctly limited by the appearance of a 
diphtheritic infiltration somewhere in the genital canal of puerperal 
women, seriously threatening the patient's life, tolerably well marked by 
other symptoms, and calling for the most energetic special treatment." 
The peculiar infiltration is thus described by him: " Of a light pearl-grey 
color, more exceptionally milk-white or sulphur-yellow, it makes its first 
appearance as discrete spots not larger than a millet-seed, but soon these 
spots extend in all directions and melt together, so as to form one or more 
large thick plates firmly adherent to, imbedded in, and, as it were, dove- 
tailed with the subjacent tissue. The patches have commonly round 
contours, measure from one-eighth to one inch in diameter, and about 
one-eighth of an inch in thickness. All torn and abraded surfaces be- 
come more easily a prey to the diphtheritic infiltration, but I have re- 
peatedly seen entirely healthy parts of the mucous membrane of the 
vagina, yet covered with epidermis and separated by intervening tissue 
from all tears and abrasions, become the seat of the affection. The parts 
surrounding the patches are more or less swollen, dark red, brown, or 
dirty green." 
The symptomatology is not specially peculiar, but the signs of infection 
of the system precede the appearance of the infiltration for several days. 
In one of Garrigues's cases where there existed "an unusual length of 
the period of formation of new patches, the same affection appeared sim- 
ultaneously on the tongue." This he takes as strong corroboration of his 
opinion, that "this disease is identical with diphtheria as occurring on 
non-puerperal wounds, or as a primary disease without any wound, and 
most commonly localized in the throat, but found on all other mucous 
membranes." 
Such is Garrigues's statement in regard to puerperal diphtheria. Com- 
ing as it does from such an eminently conscientious observer it is to be 340 
A TREATISE OX OBSTETRICS. 
hoped that obstetricians generally will watch their cases, in order to cor- 
roborate what at the present day is still scarcely admitted as a justifiable 
addition to the varieties of puerperal fever. Lusk states the prevalent 
opinion as follows: "Whether these so-called diphtheritic patches are 
identical with those which appear in the throat is an open question. 
Morphologically they are so, but in hospitals, epidemics of puerperal diph- 
theritis are not associated with throat diphtheritis. Diphtheritic patches 
indicate an unwholesome atmospheric condition, and are somewhat rare 
outside of public institutions. Orth and Heiberg noticed the same gen- 
eral post-mortem changes in those cases in which the patches were absent 
as in those in which they were present. My own observations show that 
they are rarely developed in the early stages of a hospital epidemic of 
puerperal fever, nor are they to be found in all cases when such an epi- 
demic is at its height." 
It is noteworthy that all of Garrigues's cases occurred in a hospital, and 
in all of them the symptomatology was no different from that which we 
are accustomed to find in other varieties of puerperal fever. It is the 
local lesion, the patch, which constitutes the differential factor, and we 
do not think that either he or other observers have proved the identity 
of this patch with that which is found in the pharynx of patients suffer- 
ing from diphtheria. 
As to whether then there exists a variety of puerperal fever to which 
the distinctive name puerperal diphtheria may be applied, must still re- 
main an open question.-Ed.] 
VI. Phlegmasia Alba Dolens. 
This affection has been variously considered as due to a milk metastasis, 
as a disease of the lymphatic system, a rheumatic, or renal manifestation, 
a phlebitis, and by Virchow as the result of a physiological thrombosis. 
To-day it is believed to be a phlebitis, but of a peculiar kind. In the vast 
majority of cases it is followed by recovery. 
It is a late accident of the puerperium, and rarely appears before the 
twelfth to the fourteenth day, often later, and although at times it appar- 
ently follows on pelvic or abdominal affections, most frequently it is pri- 
mary, overtaking the woman at a time when she believes herself out of 
all possible danger. We have seen three cases where it did not appeal* 
till the twenty-first to the twenty-fifth day. 341 
FORMS OF THE DISEASE. 
Hervieux mentions a sort of prodromic period, characterized by re- 
peated chills, general malaise, more or less intense fever, anorexia, dis- 
quietude. We have never noted it, and in our experience the affection 
always developes suddenly. 
The first symptom is pain, either at the outset faint and heavy and 
slowly becoming acute, or else acute from the start. Sometimes this pain 
first appears in the popliteal region, sometimes in the groin, often at the 
ankle, and then progressively invades the entire limb, either ascending 
or descending. By following the line of the pain it is found to corre- 
spond to the deep vessels of the limb, and frequently a hard cord is to be 
felt, even at the outset, corresponding to the inflamed vein. The in- 
flammation of the vein is all the more pronounced to the touch the less 
in degree the swelling, which shortly sets in. The vein, in any event, 
can always be felt either in the popliteal space, or in the groin. The pain 
is aggravated by motion. 
The edematous swelling of the limb is either slight or enormous. The 
limb may double in size, and it pits on pressure. The skin is tense, 
shiny as though transparent, and often looks as if it were the seat of a 
true reticular lymphangitis. At the same time slight fever appears, usu- 
ally not preceded by a chill, but only by chilly sensations. 
Ordinarily, the edema stops at the root of the leg, but it may extend 
to the hypogastrium. We have seen an example in a case of double 
phlegmasia. It is not rare to find the phlegmasia invading both the 
lower limbs. Usually the second limb is seized when the process is on 
the point of disappearing from the first, although not infrequently both 
limbs may be affected at the same time, in the one limb the process 
being a trifle in advance of that in the other. In one of our serious cases 
the edema extended successively from below upward to the groin of the 
left leg, thence to the hypogastrium, thence to the groin of the right leg 
and down it. In this case then the edema followed an ascending course 
in the left leg, and a descending in the right, and for five to six days 
there was present in addition great depression and high fever, which made 
us anxious lest grave complications were going to set in. The patient, 
however, made a slow recovery. She has since been confined twice; in 
her second labor she had a slight phlebitis in one leg; in her third the 
phlegmasia reappeared on the twenty-third day, invaded both limbs, and 
disappeared only at the end of many months. 342 
A TREATISE ON OBSTETRICS. 
Recurrence, indeed, is very frequent at succeeding confinements, but 
in general, the phlebitis becomes more benign each time. The duration 
of the affection is very variable. Ordinarily the fever lasts only twelve 
to fifteen days, in mild cases, and the pain persists to a greater or less 
degree during the entire febrile state. As the latter disappears so does 
the pain. It is exceptional for the edema to vanish before the third 
week. Often it lasts for a long time, even for months or years, thus in- 
terfering considerably with walking. In one of our patients it was only 
after the lapse of two years that the limb regained its integrity. 
In the vast majority of instances the disease ends in cure, although a 
number of cases of death have been recorded. Death, when it occurs, 
results either from suppuration of the vein and consecutive purulent in- 
fection, or else a clot is detached and the patient dies of embolism. The 
end is slow in the first instance, and very sudden, or nearly so, in the 
second. 
Finally, in certain cases phlebitis is complicated by periphlebitis, a 
true phlegmonous inflammation of the leg and the thigh. We recently 
saw an instance after miscarriage at four months. 
VII. Sudden Death in the Puerperal State. 
Although puerperal affections ordinarily manifest themselves under one 
or another of the forms which we have described, it is not always so, and 
it suffices to refer to the descriptions given of puerperal fever by the older 
writers, and to the history of different epidemics, to see what diverse 
forms puerperal accidents may assume. Here it is phlebitis, there it is 
lymphangitis, here pleurisy, there scarlatina, which dominates the patho- 
logical scene, and Hervieux's work contains the enumeration of all the dis- 
eases which may affect the puerpera. But all these diseases, in order 
to lead, to death, require a certain interval, pass through certain stages, 
give the accoucheur, in a word, a chance to fight, to test his drugs, in 
order to release the woman, if he can, from the danger threatening, and 
in many instances he is successful. There is, however, a further accident 
which threatens the puerperal woman and against which the physician is 
impotent, for it comes like a thief in the night in the majority of in- 
stances, and it carries off the woman with a rapidity which is appalling. 
This is sudden death. FORMS OF THE DISEASE. 
343 
Mentioned for the first time by Dionis, in 1718, by Delamotte, 1766, 
and later by Ramsbotham, 1814, McClintock, 1853, and studied with 
care by Mordet and Moynier in 1858, sudden death of the puerpera has 
since been the subject of numerous monographs, and each author, while 
admitting the occurrence, has given a different explanation, and each, 
basing his deductions on the cases he has seen, has interpreted it after a 
different manner, some attributing death to a lesion of the circulatory 
system, others to a lesion of the nervous system, of the respiratory system, 
others still to syncope, to puerperal poisoning, and finally, like Coste, 
almost exclusively to myocarditis. 
We cannot discuss all the known cases, but we desire at the outset to 
mention the following conclusions: 
1. Death is rarely sudden in the exact sense of the word. Usually it 
occurs after the lapse of a few hours. That is to say, we are not dealing 
generally with lightning-like death, such as follows rupture of the heart 
for instance; and it is possible from a careful examination of the predomi- 
nating symptoms, to determine that the cause resides in one of the three 
organs, which Bichat has called the vital tripod, the heart, the lungs, 
the brain. 
2. As Hervieux remarks, it is ordinarily during deadly puerperal epi- 
demics that sudden death is met with, and, therefore, he was led to seek 
in puerperal poisoning the most active and frequent cause of sudden 
death, and he makes a distinction between cases where death is prompt, 
and those where it is sudden in reality. "It is especially in case of 
prompt death that autopsy has revealed an appreciable lesion; under the 
term sudden death are to be classed all those cases where, post-mortem, no 
alteration competent to explain the fatal issue has been found." 
Coste, from a study of the majority of the reported cases, has reached 
the following conclusion: " Sudden death after delivery is due: either to 
hemorrhage, either to a thrombus in the pulmonary artery, or to myo- 
carditis. Since hemorrhage results in more or less rapid death, and since, 
on the other hand, pulmonary thrombosis appears to be due to a degen- 
eration of the myocardium, we may conclude that sudden death is always 
due, after labor, to a myocarditis." 
This conclusion seems to us at least premature, for, as is seen, Coste 
admits that the death may be more or less rapid, and he enters into the 
field of speculation when he says: " Myocarditis arising during gestation 344 
A TREATISE ON OBSTETRICS. 
may cause sudden death in the first week following delivery, while from 
the form which occurs in the course of puerperal fever, death only results 
in the second week or even during convalescence." 
Every case of sudden death is not, in truth, preceded by affections oc- 
curring during pregnancy or the puerperium, and although in many in- 
stances we may find the cause after death, in many others there have been 
no disturbances of any kind during pregnancy or the puerperal state, 
and yet death occurs with absolute suddenness, without any premonition 
whatsoever. These instances are exceptional, and we are here in the 
presence of an as yet unknown factor which the future may reveal, but 
which, in the present, calls for prudent reserve in expression of opinion. 
Theories aside, we must to-day accept the classic division, and say that 
in the vast majority of cases death results under the following conditions: 
1. Lesions of the circulatory system: a. Lesions of the heart or of its 
envelopes; alteration in the valves; myocarditis; hydatid cysts of the 
septum of the heart; pericarditis ; rupture of the heart. In this sub- 
division belong the cases of P. Dubois, MacCorvan, Corvisart, Hervieux, 
Depaul, McClintock, McNichol, Spiegelberg, Simpson, Despeaux, Ader, 
Peleyo, Danyau, Coste, etc. 
b. Hemorrhages.-The cases of Elsasser, Lachapelle, Dubois, Quesnel, 
Johnson, Matice, Zenker, Besniers, Ollivier d'Angers, Hervieux. In all 
these cases death has been rapid, but not sudden, in the true sense of the 
word. 
c. Thrombosis of the Pulmonary Artery. Cases of Dionis, McClintock, 
Hervieux, Gosselin, Prestat, Hawer, Charcot and Ball, Hoogeweg, Simp- 
son, Pajot, Jacquemet, Playfair, Peter. 
d. Presence of Air in the Heart and the large Vessels.-Lachapelle, 
Baudelocque, Lionnet, Bessens, Olshausen, Litzmann, Depaul, Berry, 
Leven, Smith, Walford, Schroeder, Hervieux, etc. 
2. Lesions of the Respiratory System (congestion, pulmonary apoplexy, 
pleurisy, pleuro-pneumonia).-Cases of Mordret, Moynier, Charpentier, 
Delamotte, Campbell, Devilhers, Verrier, Ollivier d'Angers. 
3. Lesions of the Nervous Centres (hemorrhage, traumatic shock, moral 
emotions).-Cases of Meniere, Schedel, Lachapelle, Moynier, Mordret, 
Villeneuve (Marseilles), Meritan, Blum, Playfair, Burdel, Travers, Mor- 
gagne, Robert, McClintock. F0KM8 OF THE DISEASE. 
345 
4. Puerperal Poisoning, Septiccemia.-Hervieux, Lachapelle, Dubois, 
Keith, Challier, Schroeder, Larrey, Meritan, Charpentier (two cases.) 
5. Acute Myocarditis.-Coste. 
Such are the usual causes of sudden death in the puerperium. In 
many instances, it is apparent, there existed a lesion which predisposed 
to this sudden end, and from this standpoint phlegmasia alba dolens, by 
causing the formation of a thrombus in the crural vein, should hold the 
first place. Happily this fatal sudden termination is rare, and must be 
considered exceptional. 
As for the belief that the property of the blood of puerperal women of 
coagulating spontaneously plays a part, for our part we would reject it 
absolutely, for since this property exists in all puerperal women, we 
should be astonished not at the accident, but at the infrequency with 
which it occurs. CHAPTER III. 
PATHOLOGICAL ANATOMY. 
CRINGE it is granted to-day that puerperal accidents are the result of the 
penetration into the organism of an infectious germ, in other words 
that they are due to a true sepsis, it is not necessary any longer to de- 
scribe in detail the different lesions which may be met with post-mortem. 
Such lesions always exist, are so to speak innumerable, and there is not a 
single one which may not be met with. Although cases have been re- 
ported where no lesion whatsoever was found, these instances daily be- 
come more and more exceptional, and, as Playfair well says: " In such 
cases even the olden-time rough methods of examination will reveal some 
alteration in the blood, and ecchymoses in the lungs, the spleen, the kid- 
neys, etc. Recently it has been shown that, besides beginning inflam- 
mation in most of the tissues, such as cloudy swelling, there exists granu- 
lar infiltration and disorganization of the cellular elements. This is 
proof that the blood, impregnated strongly with septic material, has car- 
ried everywhere the morbid germ, which had not the time to develop 
before the patient's death." 
This morbid germ, we have seen, has been demonstrated by Mayrhofer, 
Waldeyer, Recklinghausen, Heiberg, Orth, Birsch-Hirschfeld, Spillmann, 
Kehrer, Miller, Hausmann, Quinquaud, Despine, etc., but to Pasteur 
and his pupils belongs the honor of isolating this germ, of cultivating it, 
of reproducing it, according to the manner of culture, in determinate 
forms; of establishing, in a word, in puerperal septicaemia, germ-varieties 
and shapes corresponding to the degree of development of the germ. 
According to Pasteur and Doleris, two sorts of organisms preside over 
infection: 
1. The cylindrical septic bacteria, which induces rapid septicaemia. 
2. The micrococcus which begins as a point and then is harmless; later 
forms in couples and determines suppuration; later still assumes the form 
of chapelet de grain, and causes the attenuated variety of septicaemia. PATHOLOGICAL ANATOMY. 
347 
Ono capital point, according to them, dominates the entire pathologi- 
cal anatomy of puerperal fever: " This is the constant presence of microbes 
with a determinate pathological transformation." 
The microbe exists, a number of routes are open by which it may pene- 
trate into the organism, and once it has gained access, we witness the 
development of the most varied and complex pathological manifestations. 
All the necessary conditions for the production of puerperal accidents are 
present: vulvar, perineal, vaginal lesions, uterine wound, on the surface 
of which open the lymphatics and veins in great number, each forming a 
route by which the infectious germ may reach the organism and thence 
be spread by the blood and the lymph to produce the varied secondary 
lesions which are observed in these patients. 
We must hence study in succession, even as do Doleris and Raymond: 
1. The lesions which may be met within the utero-vagino-vulvar canal. 
2. The lesions in the veins, lymphatics, cellular tissue, the channels of 
diffusion. 
3. The resultant secondary lesions. 
4. The vehicles of the poison (blood and lymph.) 
1. Almost all authorities seek the source of infection in the uterine 
wound (placental site.) We believe with Schroeder, Spiegelberg, and 
others, that the wounds of the vulva, of the vagina, and especially those 
of the cervix, are at least as often the starting-point of infection, and this 
explains the unquestionable greater frequency of puerperal septicaemia in 
primiparae over multiparae. 
The wounds, in case of puerperal infection, usually have an unhealthy 
look, and are often transformed, especially at the introitus vaginae, into 
a species of ulceration which the Germans call puerperal ulceration. The 
margins are tumefied, the base covered with a dirty yellow deposit, which 
separates only at the end of a number of days. In certain instances these 
ulcerations have a tendency to spread, at times having a true gangrenous 
appearance, and they are associated with much edematous infiltration of 
the neighboring tissues. When they are extensive, the labia majora are 
livid-red, tumefied, edematous, and it is not rare to witness true gan- 
grene of the vulva and vagina, extending to the cervix, and even within 
the uterus. Virchow has given these appearances the name of malignant 
internal puerperal erysipelas, but we are not dealing with a true erysipelas, 
there being simply inflammation of the neighboring cellular tissue. In 348 
A TREATISE ON OBSTETRICS. 
other instances, the wound looks diphtheritic, or at least it has the same 
appearance as that seen in surgical diphtheritis. When the lesion invades 
the vagina, we have puerperal vaginitis; higher still, and we have puer- 
peral metritis. Occasionally, only the mucous membrane is affected, and 
then there exists an endometritis, the organ being soft, slightly infiltrated, 
sub-involuted, although its muscularis remains sound. The inflamma- 
tion may thence extend to the tubes and give rise to a salpingitis, which 
in turn may set up puerperal peritonitis. But this form, as we will see, 
is more frequently determined by another process. 
Fig. 187.-Puerperal Uterine Lymphangitis.-aa, Purulent lymphatics projecting through 
the peritoneum, bb, Open lymphatics, peritoneum removed, ccc, Inflamed lymphatics with 
thrombi, ci, Intact, open vein, f, Section of left tube filled with pus. gg, Ovary enlarged, and 
covered with purulent exudation. 
Again, the lesions may be more accentuated and deeper, and we have 
no longer a simple endometritis. The mucous membrane, altered, trans- 
formed into a species of reddish slough covering the internal surface of 
the uterus, presents, here and there, especially at the placental site, 
gangrenous vegetations, diphtheritic patches; whence the names gangre- 
nous, diphtheritic endometritis. In such instances, the parenchyma of 
the uterus appears to participate in the lesion, and in places seems to 
have suffered gangrene, but, as Raymond and Spiegelberg have shown, 
this interpretation is not the correct one. What has been described under PATHOLOGICAL ANATOMY. 
349 
the name putrescence of the uterus, is simply phlebitis and lymphangitis 
of the net-work. (Fig. 187.) The uterine tissue is soft, full of serum, 
its vessels are empty or nearly so, a few of the larger veins alone contain 
clots. The muscularis itself is only exceptionally affected. It is in the 
connective tissue that the inflammatory changes are found. The ab- 
scesses of the uterine tissue, described by certain authors, are simply 
ectasic veins or lymphatics filled with pus. The affection is a metro-lym- 
phangitis or a metro-phlebitis. When sections of the uterus are made, 
the sero-purulent infiltration of the connective tissue is found to occupy 
points of election, so to speak, in particular the borders of the uterus 
where the broad ligaments are attached, and where the blood and lym- 
phatic vessels enter and emerge. Often, at these points, the peritoneum 
is lifted up by vessels distended with pus, vessels projecting greatly like 
a bird's feather, and which are due to ectases of these vessels, in particu- 
lar the lymphatics. The pus is most certainly found at the superior angles 
of the uterus where the tubes insert, and thence these lymphatics, filled 
with pus, extend into the plexuses of the broad ligaments, and this ex- 
plains the frequency with which peri- and parametritis complicate me- 
tritis. 
In other instances the veins are more particularly affected. There ex- 
ists a metro-phlebitis, and then it is especially at the placental site that 
the lesions are found. The thrombosed veins are filled with pus, and 
projecting, simulate abscesses of the uterine tissue, thus misleading the 
superficial observer. 
2. The blood-vessels and the lymphatics are the channels by which the 
infectious germ are carried; and long before the direct presence of the 
micrococcus had been determined in them, authorities had laid stress on 
the capital role which these vessels played in the puerperal drama. The 
twro theories of phlebitis and of lymphangitis have for long divided ac- 
coucheurs, and it will suffice to recall the works of Dance, of Behier, 
of Hervieux, on phlebitis; those of Tonnele, Cruveilhier, Championniere, 
Siredey, Auge, etc., on lymphangitis. From the writings of the three 
last, in particular, it is apparent that, although phlebitis does exist, it is 
infinitely rarer than lymphangitis, and Leopold's researches on the uterine 
mucosa and the lymphatics of the uterus explain readily the rapidity and 
intensity of the propagation of the morbid process. The uterus represents 
indeed a vast lymphatic gland, the mucous membrane being perforated, 350 
A TREATISE ON OBSTETRICS. 
riddled, by lymph sinuses, whence the lymph vessels arise. The lesions, 
finally, are about the same, whether it is the veins or the lymph vessels 
which are affected: 
" The first phenomenon which occurs in the veins of the uterus after 
delivery is coagulation of the blood, thrombosis, which, according to the 
investigations of Leopold, begins even before the third stage of labor, a 
thrombosis which normally is limited to the uterine sinuses, but which may 
extend further, pass out of the uterus to the utero-ovarian plexus, the 
large venous trunks and even the limbs. If this coagulated blood contains 
infectious germs, inflammation of the walls of the vein sets in, the throm- 
bus degenerates and the micrococcus appears in the shape of fine grains, 
like sand, infiltrating the vascular wall, lifting it upward, and sowing 
little miliary and sub-miliary nodules. (Doleris.) But, according to 
Fig. 188.-Diseased Ovary in Puerperal Fever. 
Doleris, the suppuration, or rather the cause of the suppuration of the clot, 
is in the blood, and not in the wound. What happens, in fact? Pus is 
rarely found in the veins of the uterus, but the first traces are met with 
in the utero-ovarian plexus, in the veins in the neighborhood of the ovary, 
those which dip into the medullary layer. We may even find a large open 
trunk, closed by a clot, and spreading out in a putrid cavity, the remnant 
of the stroma of the ovary. (Fig. 188.) 
" The centre of the clot is always in a state of suppuration, which makes 
me think that these successive purulent layers in the coagulum are due 
to equally successive depositions of micrococci coming from the blood. 
Their presence in considerable quantity causes inflammation above the 
stopping-place of the pre-existing phlebitis, and at a variable height. 
Next, the deposition of fibrin for a time interferes with the development 
of the micrococcus, seeing that it is shut up, as it were, in the fibrinous 
masses. Later, the embolus is detached; then follows the infarctus with PATHOLOGICAL ANATOMY. 
351 
its varieties, suppurative if the embolus is purely pyogenic, and putrid if 
the embolus is septic. 
11 These lesions of the veins may, however, occur after another fashion, 
secondarily, so to speak, to a lymphangitis. When the latter exists in 
the large vessels, the micrococcus within them travels slowly, and, being 
in contact with the venous trunks, determines periphlebitis and periphle- 
bitic abscesses. The vein, the artery, the lymphatic vessels are then en- 
veloped in a more or less dense mass, in which are found small foci of 
suppuration, either around a veinlet or within it. We have thus suc- 
cessively a lymphangitis, periphlebitis, phlebitis, and later pyemia, puru- 
lent infection. 
" If the main lesions are rather in the lymphatics, they are caused, 
similarly, by the penetration of the infectious germ. This invades at the 
same time the lymphatics of the uterus, and those below the peritoneum. 
These vessels inflame, and the angioleucitis spreading by continuity of 
the serous membranes and the cellular tissue, we witness the production 
of what may be called the secondary lesions, pelvic peritonitis, adenitis, 
pelvic cellulitis, pleurisy, meningitis, arthritis of the pelvis, and finally 
every one of the distant metastatic lymphangitides. We may thus follow 
step by step, so to speak, the progress of the disease. 
" It seems, then, to result from a study of these facts that, as Doleris 
says, the inflammation of the lymphatics is the first factor; that the in- 
flammatory process then spreads to the blood-vessels by way of the thoracic 
duct oftener than by other peripheral channels, by reason of the obstacle 
offered by the ganglia, and that finally, it may appear at distant points, 
owing to the connection of the serous net-work with the capillaries." 
Whether it be desired to make septiceemia and ichoremia different 
varieties of puerperal infection, matters not; the capital, essential point 
is the hematic lesion, and this is constant, although not always identical, 
and hence differences in the views held by a number of authorities. 
While Hersent, Vogel, Laurent de Fresnel, claim that there is slight 
diminution in the fibrin and in the albumin, with increase in the water 
and decrease in the globules, Gautier insists on the almost constant de- 
formity of these globules. The blood, further, contains an excess of urea 
and of carbonic dioxide, and even of glucose and of free hydrogen. The 
albumin is diminished, and often lactic acid is present. Fouassier grants 
the diminution of the red globules and the increase in the white. Finally, 352 
A TREATISE ON OBSTETRICS. 
Colz and Feltz, Spillmann and Heiberg, Pasteur and Doleris, note in the 
blood a considerable quantity of microbes. Doleris goes even further and 
tries, with Pasteur, to class these microbes. 
"Are we dealing with true, lightning-like septicaemia? Then the 
blood, heavy, semi-coagulated, in appearance like badly cooked gooseberry- 
jelly, sometimes blackish, presents an extreme alteration of the corpuscles. 
They are deprived largely of their hemoglobulin, which is much below 
the normal. There is no special increase in leucocytes. The microbe 
does not appear in the blood till late in the disease, sometimes only after 
death. It is made up of elongated elements, thin, cylindrical, moving 
in the tissues and penetrating into the lymphatics, and to the peritoneum. 
" These are the septic bacteria. 
" In order that this form may appear, the septic bacterium of Pasteur, 
the microbe in rods, must find an appropriate medium. There must 
exist anoxemia, lack of oxygen, since these bacteria cannot develop in 
oxygen. There must exist a generative focus outside the blood, and this 
is supplied by the lymphatic system. But in order that the lesion may 
assume the suppurative form, there must be added to the bacterium a 
special microbe, the mocrococcus in double points. 
"Are we dealing with attenuated septicamria? The alteration in the 
blood there takes place more slowly, and it occurs, according to Doleris, 
from the presence of a special organism, which may be fairly called specific. 
It is the micrococcus in chaplets. It passes from the lymphatics into the 
blood continuously, without determining any lesion other than a more or 
less profound change in the corpuscles. Under the influence of the coccus 
the corpuscles become decolorized, crenated, segmented, and the hematin 
almost entirely disappears. 
" The nature of the organism, then, differs in the two instances. 
"When the lymphatic lesion coexists and developes progressively,culture 
of the micrococcus of the blocd gives rise almost constantly to long 
chaplets, sometimes to cylindrical bacteria. 
"When the blood lesion exists alone, culture only gives rise to micro- 
cocci in colonies, in irregular groups or in couples, which never arrive 
at the advanced stage of chaplets, possibly owing to their sojourn in the 
blood. 
" When the hematic lesion is accompanied by phlebitis, infarctus, the 
almost constant form is the single point in couples. Culture reproduces PATHOLOGICAL ANATOMY. 
353 
it in enormous quantities, to such a degree, indeed, that it Iooks as 
though we had made an artificial pus." 
3. Secondary Lesions.-To pass now rapidly in review the alterations 
found in different organs in the body, we find the following modifications: 
In peritonitis, the peritoneum is greatly injected, and the abdominal 
organs are bound together by false membranes to form depressions in 
which accumulates thick serum or pus, usually in considerable amount. 
In the pleura the same inflammatory signs are found, and either effusion 
in or adhesion of the pericardium. The endocardium is injected, with 
ecchymoses, ulcerations, vegetations, and there are even changes in the 
tissue of the heart itself. 
In the lungs are found congestion, oedema, embolic infarcti, abscess, 
lobar and lobular pneumonia, sometimes gangrene. 
In the brain, alterations to a greater or less degree of the meninges, 
suppuration, exudation. 
In the joints, collections of fluid varying from serous to purulent. 
The spleen is enlarged, soft, the color of chocolate, and is filled with 
abscesses. The liver contains abscesses, every stage of acute yellow 
atrophy, fatty degeneration more or less accentuated. The kidneys offer 
degenerative changes, sometimes limited to the cortex, extending even to 
the destruction of the epithelium of the canaliculi, or of the canaliculi 
themselves, emboli, abscesses, etc. The pancreas, parotids, mammae, the 
thyroid, may be affected and riddled with abscesses the result of emboli. 
The ganglia, the cellular tissue, the muscles, may be the seat of greater 
or less suppuration. The intestinal canal, the bladder, the rectum may 
be inflamed, ulcerated or not. Finally, the skin may be the seat of erup- 
tions, pustules, gangrene, etc. In a word, we may meet every possible 
lesion, these varying according to the different forms of the disease. 
Finally, together with phlebitis and lymphangitis, Simpson has de- 
scribed an arteritis and arterial obstructions which are the consequences. 
(Fig. 189.) 
In case the inflammatory form predominates, it is in the uterus and its 
annexa, and in the peritoneum, that the most accentuated lesions are 
found. 
In case the purulent form is in the foreground, phlebitis, with metas- 
tatic abscesses, is the marked lesion. 
In case septicaemia, pure or attenuated, is present, lymphangitis is the 
Vol. IV.-23 354 
A TREATISE ON OBSTETRICS. 
chief vascular lesion, associated with lesions of one or another organ, 
without any special characterisation of the disease. 
According, in a word, to the degree of infection and the resisting power 
of the individual, the effects of infection will tell to a greater or less 
Fig. 189.-Vegetation Obstructing the Inferior Extremity of the Aorta, and Extending 
into the Primitive IlAc Arteries. (Simpson.) 
degree on the economy; and while in one case only metritis or peritonitis 
will be found, in another almost all the organs will be to a greater or less 
degree affected, and the morbid process may, so to speak, be followed 
step by step. CHAPTER IV. 
PROGNOSIS. 
the puerperium is regular and physiological, the patients, we 
have seen, have no fever, not even on the establishment of lacta- 
tion, but possess, on the contrary, a slower pulse, and a temperature 
which does not exceed 100° or at most 101°. Whenever then we find rise 
of temperature in a puerpera, we ought to be anxious lest some grave 
complication is going to develop, and give a guarded prognosis. Al- 
though, indeed, the purely inflammatory affections almost always termi- 
nate in recovery, the same does not hold true of those which are depend- 
ent on infection, and although putrid infection often ends favorably, it 
is far otherwise with peritonitis, the purulent and gangrenous metritides, 
purulent infection and septicaemia, in which death is almost constantly 
the rule. We must, however, here draw a wide distinction between the 
cases which occur in private practice, and those which arise in maternity 
hospitals. As long ago as 1858 Tarnier showed that the mortality at the 
Paris Maternity was 1 in 19, while in the twelfth ward of the same city 
it was only 1 in 322. In 1861, Husson reported that the mortality in Paris 
was 1 in 172 outside of hospitals, while in them, taken collectively, it 
was 1 in 10. In 1866, Lefort, comparing the mortality rate in general 
of maternities and of cities, gave the following figures: 
Maternities and hospitals, 888,312 confinements, with 30,594 deaths; 
cities, 934,781 confinements, with 4,405 deaths, that is to say, in mater- 
nities and hospitals 1 woman died in 29; in cities 1 in 212. Lefort was, 
therefore, justified in drawing the following conclusion: The mortality 
of women delivered in hospitals and maternities is out of all proportion 
to that of those delivered in cities. To explain these facts, the following 
influences have been stated as being effective: the influence of the hos- 356 
A TREATISE ON OBSTETRICS. 
pital, the social state and the morals of the women confined there, and the 
afflux into the hospital of the grave cases which can not be terminated in 
town. These are not the true causes, but rather the overcrowding in 
hospitals, and above all contagion-a contagion the more likely to dissemi- 
nate the greater the crowding, and which may even result in an epidemic. 
Latterly, happily, these views in regard to contagion have become 
classic, and the means taken by accoucheurs in charge of maternity ser- 
vices have considerably reduced the mortality rates. We content our- 
selves with citing the figures given by Beurmann, from the statistics of 
the Lariboisiere and Cochin hospital. 
At the Lariboisiere hospital, Siredey takes two chief precautionary meas- 
ures: The one aims at purifying the surroundings of the lying-in woman; 
the other aims at cleansing from morbid germ those who are in attend- 
ance on the puerpera. 
A study of the following tables shows the proportionate decrease in 
the mortality rate: 
1858 
1859 
1860 
1861 
1862 
1863 
1864 
1865 
1866 
1867 
1868 
1869 
1870 
1871 
1872 
1873 
1874 
1875 
1876 
1877 
1878 
1854 
1855 
1856 
1857 
Years. 
593 
776 
652 
732 
716 
876 
919 
960 
813 
959 
1,091 • 
1,034 
944 
723 
896 
947 
848 
897 
899 
893 
890 
46 
467 
522 
708 
Total 
number of 
labors. 
44 
64 
49 
47 
24 
24 
46 
22 
19 
15 
20 
21 
24 
27 
31 
34 
18 
18 
25 
25 
17 
GO CC 
C© C© Ql H 
Total 
number of 
deaths. 
General mortal- 
ity calculated 
on a basis of 10 
deaths to 100 
deliveries. 
a ,-A t-a |_A CC £3 H-* l-A H-*. 1-1 
CO CO 
-Q CO C© 
Number of 
deaths from 
puerperal 
causes. 
CD Cl O O W W m QO Ol <v (O Cl CC GC m Q 4^ 
Puerperal mor- 
tality, on basis 
of 10 deaths to 
100. 
25 
17 
9 
8 
13 
6 
5 
Number of deaths 
following sim- 
ple labor. 
A-l ^A 
Gn -7 Or C© GO C© 
Mortality after 
similar labors, 
on basis of 10 
to 100. PROGNOSIS. 
357 
Deaths of Women Delivered outside and brought into the Hospital after 
Several Days. 
Years. 
Total 
number of 
deaths. 
Deaths from 
accidental 
causes. 
Years. 
Total 
number of 
deaths. 
Deaths from 
accidental 
causes. 
1854 
6 
1 
1867 
3 
1 
1855 
3 
1 
1868 
13 
1 
1856 
6 
1869 
6 
1857 
11 
1870 
17 
2 
1858 
5 
1871 
11 
1859 
9 
1 
1872 
12 
1860 
20 
1873 
13 
1861 
23 
1874. ..' 
17 
2 
1862 
26 
2 
1875 
10 
1863 
19 
1876 
15 
1864 
23 
1877 
9 
1865 
4 
1878 
4 
1866 
4 
1 
On the other hand, Polaillon, who is a resolute partisan of the antiseptic 
method, and has used it at the Cochin hospital, has obtained the following 
figures: 
Years. 
Number 
of 
deliveries. 
Total 
deaths. 
Proportionate 
mortality. 
Puerperal 
deaths. 
Puerperal 
proportionate 
mortality. 
Deaths 
after sim- 
ple labors. 
Mortality pro- 
portion after 
simple labor. 
1873 
713 
4 
1 in 178.2 
4 
1 in 178.2 
2 
1 in 355.5 
1874 
609 
11 
1 in 63.5 
9 
1 in 77.5 
7 
1 in 99.3 
1875 
739 
5 
1 in 147.8 
3 
1 in 245.7 
2 
1 in 369. 
1876 
738 
9 
1 in 82. 
6 
1 in 125.5 
5 
1 in 146.8 
1877 
808 
5 
1 in 171.6 
1 
1 in 807. 
To resume: In five years at the Cochin hospital there were 3,697 labors 
with 34 deaths, of which 23 were from puerperal causes after simple or 
complicated labors, or 1 in 160.3, and 16 after simple labors, or 1 in 229.9. 
Multiparas 1 death in 97 labors; primiparse 1 death in 119 labors. 
Finally, in 1878, Championniere, at the same hospital, had 770 con- 
finements, with 5 deaths, 2 of which were from puerperal causes, and 3 
from accidental causes (phthisis, acute pericarditis, eclampsia), a puer- 
peral mortality of .232 per cent. 
In 1879, there were 685 confinements with 11 deaths. Of these 11, 
3 were brought to the hospital with rupture of the uterus, 1 dying of 
eclampsia, 1 tubercular; in reality then, 6 deaths from the fact of labor, 
or .85 per cent., a figure which he claims may be reduced to .41 per cent. 358 
[Statistics from other institutions might be added, all going to prove 
that year by year the mortality rate from puerperal causes is being lowered. 
C. Braun has recently published the statistics of his lying-in wards 
during the past twenty-nine years. From 1863 to 1880 the mortality 
percentage was 13 per 1000, and from 1881 to 1885 only 4 per thousand. 
Lusk, of New York, and Richardson, of Boston, report equally favora- 
ble results in the institutions with which they are connected. The 
former, in 1885, recorded his belief that "a woman is safer who comes 
into our Emergency Hospital than her more fortunate sisters in the 
elegant parts of our city." Garrigues gives the following data from the 
records of the New York Maternity hospital: 
A TREATISE ON OBSTETRICS. 
Years. 
No. of 
Deliveries. 
Deaths. 
Per cent. 
1875, . 
570 
15 
2.63 
1876, .... 
536 
20 
3.73 
1877, .... 
480 
32 
6.67 
1878, .... 
255 
7 
2.75 
1879, .... 
254 
11 
4.33 
1880, .... 
149 
8 
5.37 
1881, .... 
382 
9 
2.36 
1882, .... 
431 
14 
3.25 
1883, .... 
447 
30 
6.71 
1884 to October, 1886, . 
1430 
141 
.98* 
Hirst, of Philadelphia, states that the total number of women delivered 
in institutions in the United States, during 1880-1885, was 19,902, with 
516 deaths, or 2.59 per cent. 
Parvin is authority for the statement that at Munich, Winckel has 
reduced his mortality rate to about .5 per cent. Fritsch states that in 
Berlin the mortality has been reduced (in Gusserow's service) to .9 per 
cent.; at Strasburg to .27 per cent. In Breisky's clinic 527 women have 
been delivered with but one death, and Fritsch has recorded 300 deliver- 
ies with no deaths. 
Further statistics which we might collate would simply bear out the 
broad truth which we desire to emphasise, which is that each year gives 
promise of better results in the future, so that we are justified in looking 
forward to the day when no woman will perform the physiological func- 
1 In only 6 was death due to septic causes, that is .42 percent. PROGNOSIS. 
359 
tion of labor with any more risk than she performs other physiological 
functions. Mortality from puerperal causes can be lowered to nil, for 
such mortality is to-day absolutely preventable, except in those very rare 
instances where as yet our prophylaxis and our therapeutics are powerless. 
The means of attaining the end we all have in view are outlined in the 
next chapter.-Ed.] CHAPTER V. 
THE TREATMENT OF PUERPERAL DISEASES. 
j^INCE it is an admitted fact to-day that puerperal fever is the result 
of infection, and that it is eminently contagious, the first indication 
is, by means of rigid prophylaxis, to fight against, to suppress, to prevent, 
in a word, the production of this infection. The second indication is, 
in the presence of infection, to meet it by an energetic treatment, which, 
of course, will vary according to the varieties of the disease. We, there- 
fore, will consider in turn the following three subjects: 
I. Prophylactic treatment. 
II. Curative treatment. 
III. Treatment of the special varieties. 
I. Prophylactic Treatment. 
It would appear to result from experience, that those women who have 
resided in maternities a certain length of time before delivery, are less 
likely to contract puerperal affections than those who enter in labor, or a 
few days before. The difference is that the first are, so to speak, accli- 
matized. It would thus be advantageous if all women who are going to 
be confined in a hospital should enter within the first fortnight preceding 
the expected labor. There they will be under better hygienic surround- 
ings than is possible at home, and many of them might find there moral 
quietude, a condition which is lacking in many women confined in mater- 
nities. 
When the expected time for labor arrives, three conditions should be 
fulfilled: 
1. The woman in labor, and the puerpera, should be so situated that 
every possible cause of infection may be kept at a distance; 
2. Wounds and traumatism should be avoided as far as may be; 361 
THE TREATMENT OF PUERPERAL DISEASES. 
3. Cleanliness of the most minute kind should be scrupulously attended 
to. 
If, notwithstanding prophylaxis, infection occurs, we must without 
waste of time institute an energetic curative treatment, the safety of the 
woman being dependent on thoroughness and rapidity in its application. 
We must have no fear in such cases of over-action, for, as we have seen, 
an affection at first local may become general. 
Is it possible to obtain the first of these three conditions in a maternity 
hospital ? Although the mortality statistics from maternities in recent 
years are far better than those of former years, it is still true that the fig- 
ures are far higher than those obtained in private practice. 
In 1877, Griinewaldt, comparing the mortality rates in the large 
maternities and the small lying-in homes at St. Petersburg, gave the fol- 
lowing figures: 
Maternity of Grand-duchess Marie, . 1,951 labors with 2.04^ deaths 
School for midwives, .... 6,046 " " 2. 6^ " 
Foundling asylum, . . . . 12,266 " " 4. % " 
Small lying-in homes, . . . 7,907 " " 1. 1^ " 
Winckel, in 1875, gave the following statistics: Lying-in homes, 
361,055 labors with 5.5 deaths per 1000; maternities, 701,322 labors with 
34 deaths per 1000. 
Finally, Peter, in 1879, thus expresses himself: " As for the prophy- 
laxis of puerperal fever, it is a simple matter. It means delenda est Car- 
thago; away with maternity hospitals I Since crowding is the cause of 
the gravity of puerperal accidents, the more the overcrowding the greater 
the infection." 
But it is not possible to suppress maternity hospitals. Happily the 
results obtained by surgeons by means of the antiseptic method, have cast 
light on the pathway of obstetricians, and the results obtained by Siredey 
at the Lariboisiere, by Tarnier at the Maternite, and by Polaillon and 
Championniere at the Cochin, prove that there may be a notable diminu- 
tion of the dangers which surround the women who are forced to resort 
to maternities to be delivered, and that the mortality rate may be greatly 
reduced. 
While at the Lariboisiere in 1854, the year of the opening of the hos- 
pital, the total mortality rate was 1 in 10.4, and the puerperal rate was 1 
in 11.8, from the moment when the antiseptic system was introduced by 362 
A TREATISE ON OBSTETRICS. 
Siredey, the mortality rate fell successively to 1 in 35 in 1872, 1 in 145 
in 1877, and 1 in 199 in 1878. 
At the Cochin hospital, Polaillon has obtained a total rate of 1 in 108.7, 
and a puerperal rate of 1 in 160.3, for complicated labors, and 1 in 299.9, 
for simple labors. 
Finally, Championniere, a still more exact observer of the minutiee of 
the antiseptic system, has reached the wonderful figure of 6 deaths in 
1455 labors, that is to say, about .41 per cent. 
How now are we to gain as favorable results? Without speaking here 
of the proper way of building maternities, we may resume the answer in 
the words, attend strictly to antisepsis, before, during, and after delivery. 
Avoid, in a word, all the causes which may favor infection. 
If now we carefully examine the experiments of Pasteur and of Doleris, 
an to-infection, strictly speaking, does not exist. It is always a question 
of hetero-infection. The infectious germ, the microbe, is always brought 
from without, and the whole question is reduced to preventing the intro- 
duction of germs, to paralyzing their action, to shutting the door into the 
economy, that is to say, the lymphatics and the veins. Treatment, then, 
should begin during the last days of pregnancy and the first hours of 
labor, to be continued without interruption till the seventh or eighth day, 
that is, until danger of infection is about over. 
1. Before Labor.-The majority of pregnant women have an abundant 
leucorrhoea, and this discharge increases notably, in general, during the 
few days which precede labor. They often, in consequence, suffer from 
erythema, intertrigo, pruritus, and, as the result of scratching, from 
superficial erosions, frequently very painful. In such instances it is ad- 
vantageous to order not only baths and lotions, but even injections of 
carbolic solution, morning and evening. Doleris advises solutions of 1 
to 60 or even 40, but we prefer 1 to 100. Strong injections are often pain- 
ful, and they defeat the end we have in view, by determining irritation 
around the genitals and of the meatus. When used in the strength of 
1 to 100, the solution has no such disadvantage, but on the contrary is 
very comforting. The only precaution to be taken is, that the point of 
the syringe should not be inserted too deeply, and the water should flow 
slowly, and really bathe the vagina and the vulva without penetrating in 
jets. Such injections may be taken during the eighth to tenth day pre- 
ceding delivery. THE TREATMENT OF PUERPERAL DISEASES. 
363 
2. During Labor.-It is here that the active work of the accoucheur 
begins, and this is, therefore, the place to insist on the precautionary 
measures which should be taken. 
At the outset, everything should be absolutely clean. Everybody who 
is going to have anything whatsoever to do with the woman in labor, 
physician, midwife, student-in a word, whoever is going to conduct the 
delivery-should have his hands scrupulously clean, his nails short, and 
each time before examining the woman, in particular before the vaginal 
touch, he should bathe his bands in a carbolic solution (1-100), and not 
rest satisfied with simply washing them with soap, but use the nail-brush 
thoroughly. The physician should never go direct to the woman in 
labor from a hospital ward, or after visiting patients with eruptive or sep- 
tic fevers. In short, the accoucheur should only be accoucheur, a pure 
specialist in obstetrics. All the more should he avoid confinement cases 
where his duties or studies bring him into contact with cadavers or ana- 
tomical specimens. [This advice, while true in the abstract, is, we believe, 
both unnecessary and impracticable. We grant that a pathologist had 
best never attend confinement cases, and we also grant that those physi- 
cians in whose practice, for the time being, there are many contagious 
diseases or a single case of puerperal fever, will choose the wise part if 
they do not attend labor cases; but to attempt to make the accoucheur 
a specialist is leaning towards antisepticism much too far. The general 
practitioner, with us at least, obtains a large proportion of the confine- 
ment cases, and he may with perfect impunity accept them, and attend 
the patients with absolutely no risk to them, provided he takes the proper 
and self-suggestive precautions in regard to not carrying infection, pro- 
vided he keeps himself clean, insists on the cleanliness of the nurse and 
the patient and her surroundings, and provided he conducts the labor in 
accordance with those principles, on which ample stress has been laid, 
which ensure the patient against putrid infection-that is to say, provided 
he leaves her with thoroughly emptied and contracted uterus, and with 
immediate suture of the perineum in case of its laceration.-Ed.] 
Vaginal examinations should only be made in case of absolute necessity, 
and the examining finger should be dipped in oil, cerate, or, better, car- 
bolized vaseline. We should, in particular, avoid pressure, irritation, or 
attempt at dilatation of the cervix. The diagnosis once established, 
presentation, position, amount of dilatation, the patient need only be 364 
A TREATISE OX OBSTETRICS. 
examined every two hours until dilatation is complete, or the membranes 
have ruptured. Once the position assured by the touch, this becomes 
useless except to certify to the occurrence of rotation. In certain in- 
stances, as we have seen, it may be necessary to sustain, to push up the 
anterior lip of the cervix, and this little act should be performed with the 
greatest possible gentleness. 
Lucas Championniere and Bailly advise keeping on the genitals, during 
labor, a compress dipped in a phenic acid solution. Tarnier places over 
the head, as soon as it appears at the vulva, a cloth dipped in carbolic oil, 
and then the head as it moves up and down in the vagina, keeps the parts 
moistened with the oil. We prefer, for our part, once the head has reached 
the pelvic floor, to pour a teaspoonful of oil into the vagina. 
In case delivery calls for the application of instruments, these should 
first be dipped into a 1-20 phenic acid solution, and then rubbed with 
carbolized oil or vaseline. Interference with instruments, be it well 
understood, is only justifiable when absolutely called for. If labor is 
prolonged, if the membranes have ruptured prematurely, if the infant is 
dead, or the liquor amnii tinged with meconium, it is good practice to 
administer one or two injections of weak carbolized water, with the same 
precautions as those taken before labor. 
The napkins, cloths, etc., should be frequently changed, and if the 
bowels move the fmcal matter should at once be removed, and the genitals 
washed carefully with carbolized water. Sponges, if they are used, should 
first be soaked for several days in carbolic, 1-20, and should be employed 
but once. Tarnier rejects sponges and uses cotton dipped in carbolic. 
It goes without saying, that in maternities entrance to the lying-in wards 
should be absolutely forbidden any student serving in the surgical wards, 
or in the autopsy room. The nurses should be required to take the same 
precautions as the accoucheur. 
The woman once delivered, the toilette should be attended to with 
scrupulous care. The genitals should be washed with new carbolized 
sponges or with carbolized cotton. The 1 to 100 carbolized solution 
should be employed for cleansing her, it should be lukewarm, and it is 
prudent to administer a vaginal douche in case the woman has lost much 
blood, or the labor has been prolonged, or repeated examinations have 
been made, or the hand or instruments have been inserted into the vagina, 
or the infant is dead, or there are lesions of the fourchette or perineum, THE TREATMENT OF PUERPERAL DISEASES. 
365 
especially in primiparae, where fissures and abrasions of the mucous mem- 
brane commonly occur. This precaution is all the more urgent in case 
it has been necessary to artificially extract the placenta, or in case the 
hand has been inserted into the uterus, for any purpose whatsoever, [in 
such instances a vaginal douche is not sufficient, but an intra-uterine 
should be administered by the physician.-Ed.] Next, a carbolized 
compress is applied over the vulva and the patient is placed in a clean 
bed. In case the night dress is the least soiled, it should be changed 
before the patient is placed in her bed. 
These precautions we believe are sufficient, and we do not think it 
necessary to deliver, as is recommended by Fehling and Schucking, under 
the carbolic spray. 
[It will be noted that in the views above expressed, in regard to the pre- 
cautionary measures necessary for the well-being of the patient, reference 
is purely made to phenic acid and none whatever to corrosive sublimate. 
This is because, at the time of writing, the latter antiseptic had not re- 
placed the former. To-day, however, sublimate has replaced carbolic to 
a large extent, even as possibly something else may replace sublimate in 
the not distant future, for such is the history of antisepticism. What is 
found inimical to germs to-day, is found far inferior to something else to- 
morrow. There can be no question, however, but that corrosive subli- 
mate is superior in mild dilution to carbolic in fairly strong as an anti- 
microbic agent, and further it is devoid of odor. It should be remembered, 
however, that corrosive sublimate is much more toxic in its effects than 
phenic acid, and therefore, where frequent irrigation is necessary, the 
latter had better be used in 3 percent, solution. As for sublimate it has 
been amply proved that the strength of 1 to 4000 is strong enough for 
routine purposes. 
The precautionary measures advocated by Charpentier, are eminently 
judicious as applicable to maternity hospitals. In somewhat the same 
direction are the views expressed by Garrigues, of New York, by means 
of whose teaching and writing it has been unquestionably demonstrated 
how puerperal infection may be kept out of maternity hospitals. Although 
not as extreme an antisepticist as he pronounces himself to be, we are 
prepared to accept much of his teaching, and can testify that the excel- 
lent results obtained in the New York. Maternity Hospital are largely due 
to the system of prevention which he introduced there, and which his 366 
A TREATISE ON OBSTETRICS. 
colleagues in its essentials practise with him. In a recently published 
pamphlet on antiseptic midwifery, Garrigues thus summarizes the pre- 
ventive measures against puerperal infection: "If possible the patient 
should take a full warm bath at the beginning of labor. Give an enema 
of a quart of soap-suds. Have half an ounce of bichloride of mercury 
divided into sixteen powders. Pour one powder into a quart bottle, add 
a little hot water, shake, add alternately hot and cold water till the bottle 
is full; shake well. This is the standard solution of 1:1000. Scrub your 
hands, and for operative interference, your arms with soap and water, 
using a stiff nail-brush, and then scrub again with the above solution. 
Cleanse your nails with a pocket-knife. Place beside the patient's bed a 
basin with solution (1:2000), in which you hold your hand, and every- 
thing that comes in contact with her genitals, for at least one minute 
immediately before touching her. Wash the patient's abdomen, but- 
tocks, thighs, and genitals with solution (1:2000), and if she is not clean, 
scrub the parts first with soap and water. Inject a quart of the same so- 
lution into the vagina. Use no lubricant, except when the whole hand 
has to be introduced. Then use carbolized glycerine, three per cent. 
Examine rarely, and do not introduce your finger inside the os in com- 
mon cases. When the presenting part begins to open the vulva, cover 
it with a compress wrung out in solution (1:2000). Likewise, after the 
child is born, express the placenta by Credo's method. If after delivery 
it has been necessary to introduce your fingers into the vagina, or if dur- 
ing delivery manipulations have been performed in this duct, inject from 
a pint to a quart of lukewarm solution (1:2000). If fingers, hands, or 
instruments, have been introduced into the cavity of the womb, or if the 
child is macerated, give an intra-uterine injection of two to three pints 
of hot solution (1:2000). Wash the patient with solution (1:2000). Put 
on a belly binder and antiseptic occlusion bandage. Change the dressing 
every six hours in hospital practice, or three times daily in private prac- 
tice. Let the patient at the time of dressing use the bed-pan, and after 
that run a stream of lukewarm solution over her genitals and neighboring 
parts. No vaginal injections in normal cases. Disinfect instruments 
with a solution of carbolic acid, 5 per cent. If any lubricant is called 
for, smear tliem with carbolized glycerine (3 per cent.)" 
Such are the rules in regard to antisepsis which have unquestionably 
had great influence in rendering the New York Maternity Hospital what 367 
THE TREATMENT OF PUERPERAL DISEASES. 
it to-day approximates, an almost absolute safety refuge for the poor 
women confined there. Of course other factors have aided, such as a 
separate house-staff and nurses, and absolute prohibition of entrance into 
the wards of all who might in one way or another be the .carriers of con- 
tagion. We reproduce these rules in order that any of our readers in 
charge of maternity services desirous of testing a rigid antiseptic system 
may have one at their disposal, which has certainly borne marvellous fruit. 
In private practice we do not deem any special set of rules necessary, 
provided we aim at scrupulous cleanliness and conduct the labor in accord- 
ance with the principles elsewhere emphasized in this book.-Ed.] 
3. After Delivery.-Now begins the true puerperal period, and here 
it is that the antiseptic method should be used with scrupulous care. 
At the outset we are met by the question of vaginal and intra-uterine 
injections after labor. 
It would seem as though the proposal to give vaginal injections to every 
patient, to make the toilette internally as well as externally, should be ac- 
cepted without discussion by every accoucheur. This is far from being 
the case, however, and curiously enough many obstetricians who reject 
them in normal cases (Tarnier and Bailly among others), resort to them 
in complicated cases, and lay stress on their utility. For our part, we 
attach the highest possible importance to these vaginal and intra-uterine 
injections. All our patients, indifferently, whether labor has been nor- 
mal or complicated, receive injections by the vagina even the day after 
delivery. We do not use intra-uterine injections as frequently, not that 
we are afraid of them, but because they require more disturbance and 
manipulation of the patient, at a time when she should be kept as quiet 
as possible. But, if the lochia are foetid, even slightly, and if vaginal 
injections do not suffice to overcome the foetor at the first or second 
injection, we resort at once to intra-uterine injections. We reserve, then, 
these injections strictly for those cases where the woman is in danger of 
putrid infection. 
Let us examine successively this question of vaginal and intra-uterine 
injections. 
In 1873, Rendu studied this question in detail, and he shows that it 
was really Recolin who first, in 1757, advocated the therapeutic measure 
of administering intra-uterine injections. But Recolin and those who 
followed him, Levret, Baudelocque, Mojon, Legras, Deubel, Lachapelle, 368 
A TREATISE ON OBSTETRICS. 
Dubois, Barbe, Liegard, only resorted to them in case of miscarriage, or 
to expedite the exit of the placenta, or debris of placenta and of mem- 
branes. On the other hand, Pasta, Doudement, de Lignerolles, Dupierris, 
Wray, Labalbary, Roper, Barnes, Pajot, Norris, Draper, and others, 
practised such injections in case of hemorrhage, and the solutions used 
were cold water, or dilute iodine, or dilute perchloride of iron. Not 
one of these, gentlemen, however, resorted to them as a prophylactic 
measure against or in the treatment of puerperal infection, and still to- 
day, in France,- a certain number of accoucheurs, and eminent ones, are 
afraid of intra-uterine injections, and look upon them as more harmful 
than useful. Although we find in the writings of Chomel, and of Jac- 
quemier, certain vague indications for resort to these injections as a pos- 
sible means of utility in case of putrid infection, or where there exists 
puerperal metritis or retention of clots, these indications are laid down 
in a cautious spirit, and it is Gensoul who first formally advocated them, 
and Lize, in 18G0, first actually demonstrated their advantages. Since 
used and advocated by Piorry, 1866, Stoltz, 1869, Hervieux, 1870, Guyot, 
1868, and others, intra-uterine injections have slowly gained their way 
into French obstetrical practice, until the happy results from their use 
have been incontestably proved. Abroad, intra-uterine injections met 
with no such opposition as in France. From 1840 to 1850, Griinewaldt 
was using them at the St. Petersburg Maternity, in the shape of chlorine 
water, one teaspoonful to three quarts of water. lie resorted to the in- 
jections within the first hours after delivery, in case the temperature rose, 
and he proved that since the adoption of this practice, the number of 
serious puerperal cases had notably diminished, and that such injections 
were not only advantageous, but so inoffensive that he did not fear to use 
them in case of every and any puerpera within a few hours after her con- 
finement. 
In 1878, Winckel, after having employed them in cases of puerperal 
endometritis, hemorrhage, retention of placental debris, etc., and after 
having successively used a solution of sulphate of copper (2 or 5 to 200), 
of tannic acid (2 or 5 to 200), of carbonate of soda (5 to 100), of subsul- 
phate of iron (50 to 100), of permanganate of potass (10 to 200), he set- 
tled upon the following practice: 
In case of any labor which has been terminated artificially, administer 
a vaginal and a uterine injection of a solution of phenic acid (5 to 100) 369 
THE TREATMENT OF PUERPERAL DISEASES. 
immediately after the delivery of the placenta, and repeat every three 
hours in the strength of 1:50. In case the lochia become foetid, in case 
there exists a sloughing surface of the genitals, in case of retention of the 
lochia, in addition to intra-uterine injections, uterine drainage as ad- 
vocated by Fritsch and Schede should be resorted to. 
Eisenmenger, in 1853, made successfully intra-uterine injections of 
water containing pulverized carbon; Bischoff, 1877, used vaginal injec- 
tions of phenic acid (1:50) from the onset of labor; after delivery he re- 
sorted to vaginal and uterine injections with a solution of 1:10, and in- 
serted into the vagina a cotton tampon saturated in the same solution. 
In case of hemorrhage, the solution for intra-uterine use was of the strength 
of 2 or 3 to 100, used twice or three times daily during the first twelve 
days, and, in addition, every two hours a vaginal douche was administered. 
Haase, Bemlich, use the solutions of phenic acid of 1 and 2 per cent.; 
Egermann, 3 to 5 per cent.; as also Weber, Riegel, Radecke, Spiegelberg, 
Fasbender; Spiegelberg, however, only recommending them in case of 
puerperal complication. The vaginal secretions coming from wounds of 
this tract are in his opinion inoffensive, and he hence rejects intra-uterine 
injections unless they are strictly indicated and then he strongly advo- 
cates them. This is the practice endorsed by Schroeder, Weisl, Duncan, 
Hausmann, ourselves, and many others. Fehling has successively used 
creosote, permanganate of potass, phenic acid, and finally recommends 
salycilic acid (1:300); during labor washing of the hands with the same 
solution; after delivery insufflations of powdered salycilic acid, and the 
use of salycilized cotton. The insufflations should be practised once or 
twice daily in primiparae. In case of fever, intra-uterine injections at once 
should be administered, and especially vaginal six or eight times daily, 
with salycilized solutions (1:600 to 1:1000.) Filatoff, Horder, Kolbe, 
Meissner, Crede, Leopold, Ahlfeld, Fiirst, Henning, also use solutions of 
salycilic acid for intra-uterine injections. 
Fritsch advocates lavage of the vagina after every delivery. He reserves 
intra-uterine injections for those cases where there has been instrumental 
or manual interference, dead, macerated or putrefied child, foetid lochia, 
fever. They must also be used in case of grave and advanced septicaemia. 
Munster, Richter, are partisans of intra-uterine injections, and after 
naving tested phenic acid solutions, express preference for salycilic. They 
state that phenic acid produces burning sensations, and eczema of the 
Vol. IV.-24 370 
A TREATISE ON OBSTETRICS. 
genital organs, and that in certain instances toxic symptoms have been 
produced. 
Chamberlain, Schultz, Schulein recommend intra-uterine injections. 
The latter advocates, before and during delivery, disinfection of the 
hands and arms of the accoucheur and of the nurses with a carbolic 
solution of j per cent. The examining finger should be washed in a 10 
per cent, solution. After delivery he washes out the vagina and uterine 
cavity with a quart of carbolized water (3 per cent.) At first he limited 
his practice to vaginal injections in every labor, but latterly he has used 
intra-uterine as well. In grave cases, or where the hand has been intro- 
duced into the uterus, or where there is fcetor or hemorrhage, he washes 
out the uterus with a 5 per cent, solution of phenic acid. During the 
puerperium he resorts simply to vaginal injections in case of normal con- 
ditions, reserving intra-uterine injections for cases where there is suspi- 
cion of infection-that is to say, whenever the uterus is tender, or there is 
peri- or parametritis, or foetid lochia, and finally whenever the tempera- 
ture rises above 101° or, remaining normal, the pulse rate increases in 
frequency. He uses a glass tube, and the ordinary strength of the solution 
is 40 or 50 per cent. In 26 cases where there existed puerperal infection, 
he used but one injection and had 26 recoveries; and in 29 women seri- 
ously infected, where the injections were administered a number of times 
daily, all recovered. Schulein concludes that carefully administered intra- 
uterine injections are harmless, that they diminish notably the number of 
cases of puerperal infection, that they take off the edge, so to speak, of 
infection when it occurs, and that after them the temperature is lowered 
in a few hours. 
Schede, Langenbeck, go to greater extremes still, and counsel drainage 
of the uterus, and Schucking has proposed continuous irrigation of the 
organ. 
Langenbeck proceeds as follows: He inserts two rubber, disinfected, 
tubes, 4-| inches long, with lateral openings, so that they project about | 
an inch from the vagina. At first the uterus contracts and endeavors to 
expel the tubes, but soon the contractions cease. He then injects for 
three minutes a 3 per cent, solution of phenic acid through one of the 
tubes. He leaves the tubes in situ during twelve hours, then removes, 
disinfects, and re-inserts them. The same manoeuvres are performed for 
two days, and on the third he withdraws one tube, and the other on 
the fourth day. 371 
THE TREATMENT OF PUERPERAL DISEASES. 
Drainage of the uterus does not irritate it, but, on the contrary, quiets 
and abates tlie inflammatory process. It facilitates greatly the evacuation 
of putrid matter, and thus gets rid of the main obstacle in the way of 
cure. This drainage further assists greatly intra-uterine irrigation. 
Schucking proceeds as follows: A large metallic catheter is cut at its 
end and bound to a metallic drain tube, pierced by numerous openings 
and covered with Lister gauze. The gauze lies in the vagina as a thick 
wad; the drain is at the internal os, and subserves the purpose of allow- 
ing the escape of the secretions. The gauze aims at keeping the disinfect- 
ant solutions in contact with the uterine and the vaginal walls. Immedi- 
ately after labor the apparatus thus prepared is introduced to the fundus. 
The uterus is first washed out with a 5 per cent, solution, and then 
the irrigating fluid is allowed to flow in for a number of hours. This 
fluid is composed of 10 per cent, sulphate of soda and 5 per cent, of gly- 
cerin. The catheter is withdrawn every twelve hours, disinfected in 5 
per cent, carbolic, and wrapped with fresh disinfected gauze. This 
treatment is to be continued for six to eight days. 
To the above more or less pronounced advocates of intra-uterine in- 
jections we must add the names of Playfair, Braxton-Hicks, Schroeder, 
Gusserow, Muller, Dominico, Chiara, Stoltz, Courty, Laroyenne, Boucha- 
court, Delore, Pajot. The great majority of obstetricians, and we think 
rightly, reserve such injections for those cases where there is foetor of 
the lochia,, retention of septic products, in a word, putrid infection. 
Among those who reject such injections, or at least only resort to them 
exceptionally, we mention, in France, Jacquemier, Depaul, Blot. 
All French obstetricians, however, do not accept even vaginal injec- 
tions, and although Pinard and Budin, pupils of Tarnier, practise both 
uterine and vaginal injections, Tarnier himself, and Bailly and Gucniot, 
reject both entirely. Abroad, as we have stated, Fehling and Spiegel- 
berg use intra-uterine injections only exceptionally, and vaginal injections, 
as a routine measure, are rejected by Runge and Hoffmeier. Frommel, 
finally, reports a number of cases where accidents have resulted from the 
use of vaginal injections, such as those recorded by Kiistner, Fritsch, Rich- 
ter, Veit, Olshausen, Fischer, Staude, Tarnier, Bailly, Gucniot. 
The opponents of injections, whether vaginal or uterine, make the fol- 
lowing objections to them: 
1. They expose the Patient to the risk of entrance of Fluid into the Tubes 372 
A TREATISE ON OBSTETRICS. 
and thence into the Peritoneal Cavity. Although Ilaselberg, Barnes, and 
others, have cited cases where the solutions of iron have passed by the 
tubes into the peritoneal cavity, these were instances of hemorrhage 
where the uterus was relaxed, inert, capable of distension without power 
of contraction, and such is not the state of the uterus in the instances 
where intra-uterine injections are recommended, and the experiments of 
Guyon, Guichard, Danyau, Guerin, Delore, Fontaine, and others, prove 
that injections, in order to pass into the tubes, must be given with a cur- 
rent force never used in practice. The first objection is, therefore, not 
valid. 
2. They cause Hemorrhage.-Although Munster, Schucking, and Rich- 
ter have noted hemorrhage in certain instances, such cases are very ex- 
ceptional, and the hemorrhage in any event does not amount to much. 
3. They expose the Patient to the risk of entrance of Air into the Uter- 
ine Sinuses.-As Rendu with justice says, the instances recorded by 
Depaul, Olshausen, Litzmann, Spiegelberg, Scanzoni, Williams, Winc- 
kel, and others, concern vaginal injections used for the purpose of induc- 
ing labor. Matthews Duncan has reported a case where the solution en- 
tered the uterine sinuses. But, it is pertinent to ask, what do these few 
cases prove when compared with the innumerable ones where intra-uter- 
ine injections have been not only not harmful, but positively useful ? 
4. They provoke Chill, Metritis, Peritonitis.-As for metritis and per- 
itonitis, we believe there is an error of observation, for it was not the in- 
jection which in these cases caused these accidents, but, on the contrary, 
it was because they existed that the injections were administered. As 
for the chill, it is true enough frequently seen after intra-uterine injec- 
tions. But this chill is not, we think, pathological, for as a rule it is fol- 
lowed by amelioration, and it is constantly followed by notable diminu- 
tion in temperature and pulse. Certainly, in exceptional instances, intra- 
uterine injections may determine accidents, even as vaginal injections 
have aside from pregnancy or the puerperium; still, even as the majority 
of obstetricians are not thus deterred from ordering vaginal injections, 
even so we should not lose sight of the incalculable benefits to be derived 
from intra-uterine injections, because in a few instances they have seemed 
to be harmful. 
We are then a partisan in favor of vaginal and intra-uterine injections, 
but, in agreement with the majority of accoucheurs, while we cause vag- 373 
THE TREATMENT OF PUERPERAL DISEASES. 
inal injections to be administered to all our patients whether the puer- 
perium is normal or pathological, we reserve intra-uterine injections for 
those cases where they are strictly indicated, and necessarily so. We re- 
produce the rules which guide us in practice, rules which we have fol- 
lowed for six years and which have served us well, for during this period 
we have lost but two patients out of about 600 in private practice. If 
the labor is normal, if neither manual nor instrumental interference has 
been necessary, we limit ourselves immediately after labor to scrupulous 
cleansing of the external genitals with carbolic solution (1-20), a washing 
which is renewed every six hours. Vaginal injections of the same solu- 
tion, warmed, are administered from the day after delivery twice daily, 
and are thus given for a fortnight. At the end of this period, and until 
the return of the menses, warm water alone, or with the addition of co- 
logne oi- lavender water, etc., is substituted for the phenic acid solution. 
If we have been obliged to interfere during the labor, if the liquor 
amnii was tinged with meconium, if the infant was born macerated or 
putrified, if there is hemorrhage, etc., we administer a vaginal douche, 
and if need be an intra-uterine, immediately on the completion of the 
third stage, and the vaginal injections are repeated daily. In case the 
lochia become foetid, we repeat the vaginal injections daily, and we limit 
ourselves to such injections as long as the patient's condition is satisfac- 
tory. In case, however, there is retention of the placenta or of the mem- 
branes, especially after miscarriage, and above all if fever, chill, or other 
phenomenon pointing to putrid infection occur, we have recourse not 
only to vaginal, but to intra-uterine douches. 
Until Rendu's thesis was published, in 1879, without entirely rejecting 
intra-uterine injections, we were afraid to practise them. Since then, 
however, we have used them frequently, both in our private practice and 
in consultation cases, and they have always given us excellent results. 
Let it be understood, however, that intra-uterine douches are to be ad- 
ministered with care, and always by the physician himself. 
We proceed as follows: we use Stoltz's double current catheter and a 
syringe, with pointed canula, the capacity of which is about ten ounces. 
To each end of the catheter are adapted rubber tubes about nine and 
three-quarter inches long. One of these tubes receives the point of the 
syringe, the other is for the exit of the fluid. We use a one per cent, 
phenic acid solution for the irrigating fluid. 374 
The patient is placed across the bed, the buttocks at the very edge, 
lying on a rubber cloth. The index finger of the left hand is inserted to 
the cervix, and the catheter is guided along it into the cervix and to the 
fundus. The phenic acid solution is warmed to 85°, the syringe is filled 
with it, the canula is inserted into one of the rubber tubes, and the 
uterus washed out. A similar injection is given two or three times until 
the fluid returns clear, about a pint of the liquid being ordinarily used. 
The catheter is then withdrawn. By pushing the piston slowly the fluid 
is injected not in jets but continuously, and all shock is avoided. The 
intra-uterine injection is followed by a vaginal, and the process is repeated 
if necessary in twelve hours. 
In brief, then, the treatment, par excellence, we believe to be lavage of 
the uterus, by carbolized solutions, thus keeping the utero-vaginal canal 
in a state of perfect cleanliness, and thus preventing the retention of any 
body which through decomposition might cause septic infection. 
In case there eyists wound of the vagina, tear of the perineum or of 
the fourchette, we apply over the genitals a compress saturated in the 
phenic acid solution. At the same time we ventilate the lying-in room 
properly, and we stimulate our patients by giving them from one-half 
to one ounce of alcohol daily in the form of punch. 
Lucas Championniere, an antiseptic surgeon, does not approve particu- 
larly of vaginal injections during the puerperium. We reproduce the 
rules he insists upon at the Cochin hospital, by means of which he has 
been able to reduce the mortality considerably. 
" It is absolutely forbidden to touch a patient -without first washing the 
hands in a per cent, solution of carbolic. Carbolized oil I to 10 or 1 
to 5 is used for anointing the fingers; after delivery the vulva is washed 
with a 2^ per cent, carbolic solution, and often with the stronger solution, 
1 to 20. A compress dipped in the weaker solution is kept over the 
vulva, and if the vagina or the perineum has been torn, it is washed 
with' the stronger carbolized solution. Immediately after delivery the 
genitals are carefully washed with the same solution. After operations. 
which have necessitated the introduction of the hands or of instruments 
into the uterus or vagina, I wash out the utero-vaginal canal at once with 
the 2| per cent, carbolic solution, taking the precaution to secure free 
exit of the fluid. 
" The daily injections recommended by certain accoucheurs I absolutely 
A TREATISE ON OBSTETRICS. THE TREATMENT OF PUERPERAL DISEASES. 
375 
prohibit in my service, aside from exceptional cases, since I believe them 
to be the cause of irritation. When it is necessary to tampon I use only 
carbolized cotton. 
" Finally, suppress the use of plain water in maternities; disinfect all 
the linen by means of heat and carbolized water; never torment the geni- 
tals of the woman, even to obtain antisepsis; give the woman rest and a 
proper amount of food; insist on all the surroundings of the woman be- 
ing antiseptic." It is apparent, then, that Ch^mpionniere's rules are 
approximately our own, except in regard to injections (vaginal) which he 
dispenses with, and which we favor. 
[Charpentier's general deductions in regard to vaginal and intra- 
uterine douches during the puerperal state, are in accord with the prac- 
tice of the majority of practical accoucheurs in the United States. In 
certain details, however, many will differ from him. 
In studying this subject, it is above all necessary to bear in mind the 
vast difference which exists between maternity hospitals and private 
practice. In the one there are present conditions which are never met 
with in the other, and therefore, rules applicable to and essential in the 
one are not at all necessary in the other. In maternities we are face to 
face with the so-called hospital air, with the evil influences which neces- 
sarily follow on the crowding of a number of patients in one ward, with 
the risks which may result from neglect on the part of a practically ir- 
responsible house or nurse-staff; these and the like conditions call for 
stringent antiseptic rules, in order to insure what, after all, is at the 
bottom of the whole matter-cleanliness. In private practice, however, 
and not purely among the higher classes, but as well among that great 
middle class, where the women are still able to be confined at home, the 
conditions are very different. We are dealing with but one puerpera, in 
one room, and with one attendant. The chances for infection are hence 
so much the less, the possibility of cleanliness without antiseptics is so 
much the greater, and therefore it is why we would very sharply demar- 
cate the rules necessary, essential, in the one case, and scarcely at all so 
in the other. In the hospital, antiseptics are necessary, it would be crim- 
inal not to use them; in prifate practice, they are unnecessary where the 
prophylactic measures which we have dwelt upon at sufficient length are 
strictly attended to. We are speaking now, of course, of the average 
year, and not at all of one when puerperal fever is epidemic, when ob- 376 
A TREATISE ON OBSTETRICS. 
viously the rules for private practice should be no less stringent than 
those for hospital. If these views are granted as sound for city practice, 
how much the more so for country. 
While, therefore, we are as firm an advocate as any one for antisepsis 
of the strictest possible sort in hospital practice, we believe it not essential 
to success in ordinary private practice, provided we do obtain strict clean- 
liness, and this can be secured without the use of antiseptic solutions. 
The question as to the necessity of administering the vaginal douche as a 
routine measure after normal labor, and during the normal puerperium, is 
one on which there is much difference of opinion. It has been proved 
practically unnecessary at the New York Maternity hospital, whether so 
on account of the so-called occlusion binder, devised by Garrigues, and 
which the patients wear, or not, we cannot say; but the moral is that if 
they may be dispensed with in a hospital, they certainly can be in private 
practice, and it is not our custom to order them during the first week, 
unless in the presence of indications. Not that we are afraid to use 
them, for a carefully administered vaginal douche by means of a fountain 
syringe (Fig. 190), and through a tube without terminal opening, ought 
never to injure the patient in the least. The douche is certainly sooth- 
ing to the patient, it is cleansing, and if used, as it should be, hot, 112° 
F., about, and in sufficient amount (one quart at least), it unquestion- 
ably has a beneficial effect on involution. Our main reason for dispensing 
with it as a routine measure, is that it is impossible to give the douches 
ourselves, and we cannot always trust to the skill or absolute cleanliness 
of the nurse. Patients apparently do as well where the vaginal douches 
are not given, and therefore, except in the presence of some indication, 
we do not see any special utility in ordering them. Certain accoucheurs, 
however, are in the habit of using the douche twice daily as a routine 
measure, and the question is one which every accoucheur is at liberty to 
decide for himself. 
As for the intra-uterine douche, there exists absolutely the same indica- 
tions in maternity hospitals and in private practice. The difficulty is not 
so much to decide when to administer it, as how often to repeat it. As 
Munde has rightly insisted, there comes a time when repetition of the 
douche apparently does harm. 
The foremost indications for the intra-uterine douche are foetor of the 
lochia, in the presence ordinarily, therefore, of putrid infection, and, as 377 
THE TREATMENT OF PUERPERAL DISEASES. 
we have already stated, whenever the hand or instrument has been intro- 
duced into the cavity of the uterus. None of the accidents which are 
said to be possible as the result of administering such a douche, are at all 
likely to occur if a proper tube be used, if it be inserted carefully and full 
of the solution, and if we remember that our aim is to wash out the uterus 
and not to inject it-that is to say, it is better to use the continuous 
stream from a fountain syringe, and not the intermittent from a David- 
son. 
The injection tube which we prefer is the Chamberlain, although a 
Fig. 190. Fig. 191. 
Figs. 190 and 191.-Mundi's Douche Can and Bed-Pan 
double current catheter, or in an emergency a gum-elastic catheter will 
answer very well. It is not after all the kind of tube, but the manner of 
inserting and the manner of injecting, which are of the greatest impor- 
tance. The solution used, whether carbolic, or sublimate, does not we 
think make any special difference in the result. Our object is to wash 
out from the uterus the products of decomposition, and to disinfect the 
cavity. A point to be remembered is that certain patients are very sus- 
ceptible to mercury, and that, therefore, a solution of the strength of 1 
to 4000 is strong enough. The solution should be hot, at least 110° F., 
in order to avoid possible chill, and in order to obtain the styptic, con- 378 
A TREATISE OX OBSTETRICS 
tractile, effect of heat. At least one quart of water should be used at 
each injection. On several occasions we have used a mixture of iodine 
and water in equal parts, in case of endometritis with good results. A 
vaginal injection should be given before the intra-uterine, and it goes 
without saying that, in any case where the uterus is supposed to contain 
portions of placenta or secundine, which from their decomposition are 
causing the septic symptoms, careful exploration of the uterine cavity 
with the finger or curette under, if need be, an anaesthetic, should precede 
the intra-uterine douche. 
As to the frequency of administration, it is difficult to speak with posi- 
tiveness. In our hands the douche is used mainly for the purpose of 
cleansing the uterus, and not so much for its undoubted effect on the 
temperature. It has seemed to us, therefore, not advisable to repeat the 
douche more than twice, as long as foetor is absent. For the reduction of 
the temperature we depend rather on means to be mentioned shortly. In 
case of septic endometritis of high degree, the use of iodoform pencils in 
the uterus, to be inserted between the douches, has been strongly re- 
commended, but this seems to us inadvisable, because of the fact that we 
thus run the risk of disguising the danger signal, the call for another 
douche, that is to say, the foetor. We believe that in mild cases of endo- 
metritis one thorough douche will often be the only one requisite. In se- 
verer instances the douche may be given every two hours even, without 
fear of injuring the patient, but, on the contrary, to her positive benefit. 
There is one point in regard to the intra-uterine douche on which 
sufficient stress cannot be laid, and this is that it is useless and is not 
indicated except where the source of infection lies in the cavity of the 
uterus. Exudations around the uterus, whether of septic or traumatic 
origin, are not benefitted, but may be, on the contrary, intensified by 
manipulation of the uterus. The point to be decided is whether the 
endometrium is at fault, whether the cavity of the uterus contains a 
putrescent body, and this can only be settled by careful bi-manual palpa- 
tion under, if necessary, anaesthesia. Foetor, rise of temperature, chill, 
may depend on a lesion of the vagina or cervix, as well as on infection 
from the uterus. We must first differentiate the source of the infection, 
as nearly as may be, and where in doubt, in the absence of evidence of 
cellulitis or of peritonitis, it is a good and a safe plan to give with care 
one thorough intra-uterine douche. THE TREATMENT OF PUERPERAL DISEASES. 
379 
Reference to individual practice and methods is out of the question 
here., nor is it at all necessary. There is hardly an accoucheur of any 
note, who has not of late years expressed his views in regard to vaginal 
and uterine injections. The majority certainly grant the broad general 
principles on which the uterine douche in particular is based, even though 
they differ in minor details. Accurate diagnosis is above all necessary, 
and then, in the presence of strict indication, the uterus may and should 
be washed out, and thus frequently is a most forlorn hope saved. 
In administering the intra-uterine douche, there are certain details at- 
tention to which will facilitate the procedure, and render it less irksome 
and disturbing to the patient. It is above all necessary to determine at 
the outset the exact position of the uterus in order to insert the tube with 
as little traumatism as possible. This position may be ascertained by 
means of the bi-manual palpation. The choice of the tube is, we believe, 
a matter of somo importance. An inflexible tube is preferable to a 
rubber, for the reason that it cannot be compressed, and therefore a con- 
tinuous flow is assured. We have already insisted on the necessity of 
closure of the central orifice of the tube, for the reason, to quote Munde, 
"that, although not often likely to occur, it is still not impossible that 
the jet of injection fluid, thrown from the central terminal opening of a 
uterine tube, may dislodge a fresh thrombus at the placental site, ancf 
air enter the venous circulation, or a secondary hemorrhage be produced. 
. . . . In order that this may not occur with side openings, it is well to 
have the latter so arranged as to throw the jets slightly backward. " It is not 
at all essential to use a double current tube, for the reason that in all cases 
where the uterine douche is called for, the uterine orifices and cervical 
canal are wide open, and there is no obstruction to the return flow by the 
widest outlet. 
The patient should lie on a self-discharging bed-pan, since thus we 
are at liberty to use as much fluid as we desire continuously without 
disturbing the patient for the purpose of emptying the bed-pan, as is 
necessary when the ordinary china bed-pan is used. The external geni- 
tals are first to be carefully washed, and the tube, filled with the hot fluid, 
is then inserted into the vagina and this canal thoroughly douched. 
Then, guided preferably by the index of one hand, the tube, still full of 
fluid, is gently inserted into the cervical canal to the internal os, and then 
the handle is depressed or elevated or rotated, according to the position 380 
A TREATISE ON OBSTETRICS. 
of the uterus. When sufficient fluid has been allowed to flow into the 
uterus to acquire a clear return flow, the tube is withdrawn carefully and 
the manipulation is at an end. In case of a slight chill, this is of no im- 
port, and will soon subside of itself. 
We would conclude this matter with two recent expressions from 
eminent authorities which, we think, summarize this question of intra- 
uterine douching in a nut-shell. 
Munde says : " I desire to put myself on record in this matter of intra- 
uterine injections, which have been recommended by eminent authors in 
every instance of rise of temperature in the puerperal state. I do not 
agree with this practice unconditionally, for if there be no foetid lochia, 
no evidence of intra-uterine decomposition, I believe there is nothing 
to be gained by intra-uterine irrigation, even though there be a rise of 
temperature. On the othei* hand, the presence of offensive lochia without 
a rise of temperature does not necessarily call for intrauterine irrigation, 
since many women have offensive lochia without the slightest constitu- 
tional disturbance. In such cases I think vaginal irrigation all-sufficient. 
I wish to qualify these statements by saying that even in the absence of 
offensive lochia, if there be no obvious cause for the elevation of tempera- 
ture, it may be a wise precaution to irrigate the uterus once or twice; 
but after such irrigation, there being no detritus removed from the 
uterus, I should consider further irrigation useless, and perhaps even 
injurious, and whether the temperature fell or not, I should then look 
elsewhere for the cause of the rise, and seek to reduce it by other means. 
Finally, I believe that intra-uterine irrigation should be discontinued as 
soon as it fails to remove decomposing matter from the uterine cavity, 
even though the temperature may not be reduced, for I think that I have 
seen the continuance of uterine irrigation under such circumstances 
cause hemorrhage, chills, abdominal tenderness, and be even followed by 
increase of temperature, which symptoms I am inclined to attribute to 
the traumatic irritation caused by the passage of the tube and the injec- 
tion." 
Lusk says : "In the treatment of puerperal fever, the intra-uterine 
douche is warmly recommended, but it cannot be too strongly insisted 
upon that, in a rightly conducted confinement, infection does not begin 
in the uterine cavity, and that the need of such injections is a confession 
of faulty procedure. There are two forms of fever which cannot be THE TREATMENT OF PUERPERAL DISEASES. 
381 
reached by the uterine douche, one derived from sewer poisoning, and 
the other from peritonitis, starting from some of the recently studied 
forms of tubal disease."-Ed.] 
II. Curative Treatment. 
Where, notwithstanding all our precautions, puerperal affections arise, 
we must resort at once to the curative treatment. Is this treatment the 
same for all cases, does there exist, in a word, a general treatment appli- 
cable to every case ? Certainly not, and the treatment must vary with the 
variety of the disease. We believe, however, that there are two agents 
which should ever be employed, and which in many instances have a most 
marked beneficial effect. These agents are quinine and alcohol. The 
quinine should be used in doses of fifteen to thirty grains daily, and the 
alcohol is to be given in any suitable form. These two agents, combined 
with the carbolic douche, are for us the remedies par excellence. We 
much prefer them, and they appear to us much superior to either aconite 
and quinine, as recommended by Depaul, the eucalyptus globulus, the 
salycilate of soda used in Germany, the Warburg tincture, used in 
England. [Warburg's tincture will be found of special utility in those 
instances where the symptoms are not specially decided in favor of sepsis, 
but point rather to a malarial element complicating the puerperal state. 
It is best administered in capsules containing a drachm of the inspissated 
tincture, and the guide to the dose is the effect on the bowels. The 
combination acts to best advantage when the bowels are lightly touched, 
and in our experience two capsules administered each night will have the 
desired end. In case the woman is constipated, we have found it useful 
to prepare the way for the Warburg by giving a full saline laxative some 
hours previously to the first capsule. Obscure cases of fever in the puer- 
peral state, without special definite symptoms, but occurring in a neigh- 
borhood where the causes of malaria are rife, will often find their 
explanation in the way in which they yield to Warburg's tincture.-Ed.] 
To pass now to the treatment of the different forms of puerperal fever, 
we range these forms under the following heads. 
1. The inflammatory form, metritis, peri- and parametritis, circum- 
scribed and generalized peritonitis. 
2. Putrid infection. 382 
A TREATISE ON OBSTETRICS. 
3. Purulent infection. 
4. True septicaemia. 
5. Phlegmasia alba dolens. 
In the first four forms we must act energetically and quickly, since 
success will depend in great part on the little time which has elapsed 
between the appearance of the symptoms and the institution of treatment. 
1. Inflammatory Affections.-a. Metritis, perimetritis, parametritis.- 
The first phenomena are chill, pain, and fever, and it is against them that 
we must bring to bear our therapeutics. 
The first thing to do is to warm the patient by means of hot-water 
bottle, bed-clothes, warm alcoholized drinks, and next to control the 
pain and the first inflammatory symptoms. Local venesection by means 
of wet-cups or by leeches admirably subserve this purpose. We much 
prefer leeches applied over the site of the pain at the point of maximum 
intensity. Ten leeches on each inguinal region will ordinarily diminish 
the pain notably, and if this persists the leeching must be renewed. They 
are to be allowed to drop off themselves, and bleeding for a number of 
hours afterwards is to be encouraged by hot fomentations or by poultices. 
At the same time, about ten grains of the sulphate of quinine should be 
administered, to be repeated morning and evening on the following days. 
The leech-sites are to be thickly spread with belladonna ointment (pnguent 
uapolitaine belladonne), morning and evening, and over this hot poultices 
are to be kept. The bowels are not to be moved till the third day and then 
by means of oil and glycerin enemata. If this does not suffice, a mild purga- 
tive should be given. From what we have already stated, the patient re- 
ceives a carbolized douche morning and evening, repeated more frequently 
if the lochia become foetid. In case the disease is complicated by peri- or 
parametritis, if the pain recurs, we renew the leeching, although in this 
event we prefer a large fly-blister. We abstain from local examination. 
Later, rf the affection changes into phlegmon, or pelvic peritonitis, we 
resort to the blister, and when the affection abates, we administer baths. 
In certain cases, where the tongue is markedly coated, we have begun the 
treatment with advantage by giving an emeto-cathartic. 
Nourishment during tire early period should be limited to milk, 
bouillon, punch, lemonade, beer. 
Such is the treatment which ordinarily suffices in case of metritis and 
pelvic peritonitis. There is one point on which we specially insist. THE TREATMENT OF PUERPERAL DISEASES. 
383 
When indurated masses appear around the uterus recovery is very slow. 
If the exudation suppurates, the fever persists for many days, the chills 
are frequent, the temperature rises every evening, sometimes with very 
acute exacerbations. Often diarrhoea and vomiting set in. The abscess 
once open, notable amelioration ensues, and then either it discharges 
freely and the patient convalesces well, or else after the lapse of a few 
days the discharge of pus ceases, the abscess refills, and chill and fever 
reappear. These phenomena may be repeated a number of times, grad- 
ually sapping the woman's strength, and often she dies of hectic. It is 
sometimes of advantage to enlarge the cavity, but this is not always pos- 
sible. When the abscess, as is the rule, opens by the vagina or rectum, 
enlargement presents more risks than advantages, and it is only when the 
opening is in the abdominal wall that it is sometimes of advantage to en- 
large it, or even to incise it deeply without awaiting spontaneous opening. 
[We would disagree somewhat with Charpentier. Abscess in the pelvic 
cellular tissue or encysted in the peritoneum, should be opened as soon 
as it points, the cavity washed out and drained, or if small, it should be 
packed with iodoform gauze. In other words, abscess in this locality 
should be treated on the same surgical principles as are applicable to ab- 
scess in other parts of the body. There is every advantage to the woman, 
for we not only save her strength and control the hectic, but we also 
forestall possible rupture into the rectum, or worse still into the general 
peritoneal cavity. The treatment of such abscesses really belongs to works 
on gynecology, and we will not' enter upon it here. It is well to state 
that recent views tend to the teaching that many such abscesses are intra- 
peritoneal and result from tubal or ovarian disease, and this brings up 
the question whether for cure abdominal section and removal of the puru- 
lent sac is not the preferable and necessary method. For an answer to 
this question, however, we must refer to recent and current literature. 
It should be stated, however, that the majority of puerperal exudations 
tend, under proper treatment, towards spontaneous cure.-Ed.] 
If, on the contrary, the exudations tend towards absorption, it is still 
only after weeks or months that convalescence is assured. 
In one or another case our general treatment is the same. Revulsion 
over the exudation by iodine, fly-blisters, and sulphate of quinine and 
general tonic alimentation. The patient, however, must remain in bed 
as long as there exists induration at all painful. After an examination 384 
A TREATISE ON OBSTETRICS. 
at the outset, to make our diagnosis, we abstain from local interference, 
unless there be special indication, until the patient is convalescing, and 
we do not allow our patients to rise until the uterus is fairly movable. 
Although, in general, recovery is generally complete, the patient often 
complains for long of abdominal pains, the result of traction on the pelvic 
organs, by the adhesions which have formed between them, the intestines 
and the pelvic walls. 
b. Peritonitis.-The treatment of this affection is similar to that of 
metritis at the outset, leeches, quinine, belladonna ointment. The qui- 
nine, however, should be given in larger dose, at least thirty grains daily. 
But peritonitis is accompanied by gastric and intestinal disorders, nausea, 
vomiting, tympanites, against which numerous agents have been recom- 
mended. Doulcet, Willis, Leake, Fincke, Osiander, and others, have 
advocated an emeto-cathartic, and we have ourselves in certain instances 
given it with success. Puzos, Helm, Denman, Chaussier, Gordon, advise 
purgatives. 
It is not uncommon, indeed, for the patients to suffer from obstinate 
constipation. Calomel and jalap have been often used. We believe in 
being very reserved in their use, for as a rule, a profuse diarrhoea suc- 
ceeds the constipation, and Hervieux has noted an alternation between 
the diarrhoea and the vomiting. 
Baglivi, Clarke, Baudelocque, Velpeau, Championniere, recommend 
blisters; covering the entire abdomen is Velpeau's advice. Champion- 
niere uses them from the outset to combat the initial symptoms. We 
believe in vesication, but not at the beginning of the affection. On the 
fourth or the fifth day, and even later, when the peritonitis is subsiding, 
this is when we believe them useful. Hervieux, who uses them from 
the outset, admits that they have disadvantages, such as the production 
of retention of urine, of cystitis, of ulceration, of diphtheritic patches, 
gangrene, etc. We prefer leeches to blisters in Case of pain, and it is 
especially as resolvents that we use the latter, that is to say, at the end of 
the disease. The blister has seemed to us especially useful when the 
peritonitis has resulted in the formation of those masses, sometimes enor- 
mous, which fill the hypogastric region and even beyond. It is in such 
instances that frequently repeated blisters have rendered us real service. 
Mercurials have been recommended, and although we reject them in- 
ternally, we approve of them externally. This is the practice of Depaul. THE TREATMENT OF PUERPERAL DISEASES. 
385 
We have been struck by one fact, and this is that the only patients who 
have recovered, are those who have been salivated. Hervieux has made 
the same remark, and has noted that as soon as the buccal signs of mer- 
curialism have appeared the inflammatory symptoms have decreased. 
Behier has advocated applications of ice, but we have tested them with- 
out success, and in a hospital case we witnessed gangrene of the abdomi- 
nal integument as the result of too prolonged application. 
Opium is of great utility, either by the mouth or subcutaneously. 
As for baths administered during peritonitis, we do not think they 
should ever be employed until convalescence, and then with great care. 
To resume then the treatment we advocate: As soon as the initial 
symptoms appear, twenty leeches on the abdomen, fifteen grains of sul- 
phate of quinine, opium, and carbolized vaginal injections. After the 
leeches have fallen and the bleeding has ceased, mercurial ointment 
should be rubbed over the abdomen, one ounce in the twenty-four hours. 
Alcohol in the form of punch should be administered. On the third day, 
an enema of oil and glycerin, and. if called for by obstinate constipation, 
a purgative. About the fifth day repeated blisters. 
Phenic acid internally has not seemed to us useful. In a single case 
we saw Depaul puncture the intestine without relief to the tympanites. 
[The treatment of puerperal peritonitis which is preferred to-day by 
many authorities, differs essentially from that which is favored by Char- 
pentier. At the outset of inflammatory symptoms in the puerperal state, 
it is believed to be good practice to administer a sharp saline purgative, 
in order to produce free derivation from the intestinal canal. This ac- 
complished, opium in sufficient doses to absolutely quiet the pain is indi- 
cated. As long as the temperature remains below 102°, hot poultices, 
changed frequently, are called for. Just as soon, however, as the tem- 
perature rises above 102°, the ice coil should be substituted for the poul- 
tice, and kept over the abdomen if need be, for days. It will not cause 
gangrene of the abdominal walls if the precaution is taken not to apply 
it directly against them. The ice-coil not only checks the temperature 
rise, but lessens markedly the tympanites. For the special relief of this 
condition, enemata of turpentine administered through a long rectal tube 
are of great service. If the distension becomes so great as to seriously 
interfere with respiration, puncture, repeated if need be, of the intestine 
will often give relief. For the fever, aside from the usefulness of the 
Vol. IV.-25 386 
A TREATISE ON OBSTETRICS. 
ice-coil, our reliance to-day should be not on quinine, but on antipyrin. 
This drug should be pushed cautiously but boldly, to the extent even of 
fifteen or twenty grains every two or three hours. It had best be admin- 
istered in suppository, since we should aim to keep the stomach as quiet 
as possible. To guard against the depressing effect of antipyrin on the 
heart, alcohol should be administered freely, and when giving the drug in 
large doses, an occasional hypodermatic injection of digitalin is useful. 
As for food, it should be given as freely as possible and predigested. 
Peptonized milk, raw eggs, brandy, alcohol, these are indicated to the 
extent which the stomach will stand. In case the stomach refuses every- 
thing, give it absolute rest, and support the patient on stimulants hypo- 
dermatically, and peptonized milk per rectum. By washing out the 
rectum with cold water before giving each nutrient enema, it will not 
react against them, usually, for some time. As for blisters, we consider 
them more harmful than useful, as long as the inflammation is at all 
acute. 
The great indications in puerperal peritonitis are: Clean out the primes 
vice at the outset; keep down the temperature; feed the patient. These 
indications are all fulfilled by the treatment we have outlined, a treatment 
which requires faithful application and constant watchfulness, true 
enough, but in case of puerperal peritonitis, it is a bitter fight for our 
patient's life, and the measures we have recommended will often, if re- 
sorted to in time, save this life.-Ed.] 
2. Putrid Infection.-In this affection, whether it results after mis- 
carriage or labor at term, whether it is due to retention of the placenta, 
membranes, clots, or to the penetration of infectious germs (Pasteur and 
Doleris), there is one symptom which leads all others, and this is foetor 
of the lochia. Therefore we place first among therapeutic measures in- 
jections, not only vaginal but intra-uterine. Two intra-uterine injections 
daily of 1-100 phenic acid solution, and five to six vaginal injections in 
the intervals-such is the treatment, in addition to quinine as much as 
forty-five grains to one drachm in the twenty-four hours, and alcohol in 
in one or another form. 
If the removal of the placenta, membranes, or clots can be readily ac- 
complished, we must begin by this, but we reject all those methods which 
come to us from the other side of the Rhine, and which consist in remov- 
ing these remnants by means of curettes. We allow such remnants to THE TREATMENT OF PUERPERAL DISEASES. 
387 
detach themselves, and we prefer to wash them out by means of injec- 
tions, or wait for their appearance at the cervix before attempting their 
removal. It is only in cases of absolute necessity that we interfere. Here 
the local condition does not amount to much, but it is the general condi- 
tion which calls for action, and we limit our efforts to inunctions of bella- 
donna and to laudanum poultices over the abdomen. 
Sustain the patient by soups, beef extracts, alcohol; fight the sepsis by 
sulphate of quinine and phenicacid douches-such are the methods which 
are for us rational. We thus gain time, and we thus give Nature a chance 
to shake off the putrid matter, and the patient a chance to eliminate the 
poison. 
[From the criticisms made in Vol. IL, under the subject of Miscarriage, 
it is apparent that we cannot accept this doctrine. Indeed, as soon as we 
suspect the presence of any foreign body in the uterus, we would at once 
proceed to remove it by the finger if possible, by Munde's curette and 
forceps if the finger failed. We contend and we know that such mani- 
pulation is harmless if performed with care, and we utterly fail to see 
what is to be gained by waiting on Nature. The source of the sepsis is 
in the uterus, and as long as it remains there the patient is more deeply 
impregnated. The experience of some of our most distinguished authori- 
ties, here and in Germany, proves that manual or instrumental removal 
of placental debris, secundines or clots, is safer for the woman than leav- 
ing them in the uterus. We insist anew, therefore, on the justifiability 
of a practice very much opposed to the one which Charpentier recom- 
mends. It goes without saying that these are the cases of all where the 
intra-uterine douche is indicated, but always together with removal of the 
products of decomposition. 
We would emphasize here again Lusk's words, that the necessity for 
such intervention will not exist where the labor has been properly con- 
ducted.-Ed.] 
3. Purulent Infection.-Here the chances of recovery are less still. 
The patient is more profoundly affected and will almost infallibly die. 
The local state is nothing compared to the general. Here often the pajise 
of infection cannot be determined. The patient is assailed by a true 
purulent diathesis, and all we can do is to fight the different manifesta- 
tions as they appear. Alcohol and sulphate of quinine are to be given 
in high dose, since they seem to be more advantageous than numerous 388 
A TREATISE OX OBSTETRICS. 
other remedies which have been recommended, such as aconite, saly- 
cilic acid, salycilate of soda. The muscular abscesses are to be opened as 
they form; the articular abscesses are to be treated by blisters. 
[This form, the pyaamic, we have twice seen in the practice of others 
follow close upon the preceding. In both instances a portion of the pla- 
centa had been left for Nature to eliminate. She failed, and when the 
physician was allowed to attempt removal, the putrid infection had passed 
into the purulent. The issue in each case was fatal.-Ed.] 
4. True Se^jticoemia.-Here the entire system is in the grasp of sepsis, 
and alternately one and another organ is affected, without the lesion be- 
ing at all tangible. This is the gravest of all forms. We have seen re- 
covery in only one case, and then contrary to all our expectations. We 
cannot lay down any absolute rules for treatment. We have used phe- 
nic acid internally, but without success. The disease, in short, abso- 
lutely disarms the physician. He is utterly powerless, so rapid in its pro- 
gress, so intense and variable its manifestations. 
[It is in place to give here briefly the treatment of use in so-called 
puerperal diphtheria, of which, as we have stated, Garrigues would make 
a special puerperal affection. He recommends repeated cauterization of 
the patches with a one to one solution of zinc chloride. Lusk and others 
prefer the sub-sulphate of iron and iodine, equal parts, as being just as 
effective and not so likely to cause cicatrization.-Ed.] 
5. Phlegmasia alba dolens.-This is a benign affection in the great ma- 
jority of instances, and its tendency is towards spontaneous cure. The 
treatment is simple: Elevate the limb extended on a splint, immobilize 
it, cover it with poultices, or belladonna or mercurial ointment, and keep 
the patient quiet as long as possible. Where the temperature is high we 
give quinine. The patient should never be allowed to rise until the fever, 
pain, and oedema, have disappeared. We must never forget that phleg- 
masia predisposes to embolism, and that this is the most common cause 
of sudden death during the puerperal state. The women then must as- 
sume the erect position by slow degrees, and they must walk only when 
all morbid phenomena have vanished. For months afterwards the pa- 
tient should wear an elastic stocking. 
Where the phlegmasia proceeds to abscess, this should be opened exten- 
sively on strict antiseptic surgical principles. INDEX- 
ABDOMEN: 
anterior region of, i. 25. 
lateral regions of, i. 26. 
size of in pregnancy, i. 151. 
Abdominal bandag'e, i. 458. 
Abdominal ballotement, i. 271. 
Abdominal mtfscles, contractions of, 
i. 323. 
irregular contractions of, iii. 12. 
Abdominal palpation, i. 265. 
Abdominal pregnancy, ii. 359. 
Abdominal pains in pregnancy, ii. 194. 
Abdominal tumors, iii. 162. 
Abdominal walls, i. 24. 
Abortion (vide Miscarriage): 
Abscess, puerperal pelvic, treatment 
of, iv. 383. 
Absence of vagina, iii. 154. 
Accouchement-force, in placenta prae- 
via, iii. 212. 
After-pains, i. 486. 
Albuminuria: 
of labor, ii. 85. 
diagnosis of, ii. 85. 
prognosis of, ii. 85. 
of pregnancy, ii. 70. 
milk diet in, ii. 87. 
Allantois, i. 169. 
Amnion, i. 168, 201. 
diseases of, ii. 254. 
Amniotic cords, ii. 281. 
Amniotic liquid, i. 202. 
alterations of, ii. 279. 
Anatomy of organs of generation, i. 1. 
Anatomy of pelvis, i. 3. 
Angle, sacro-vertebral, i. 3, 17, 18. 
Anemia: 
in pregnancy, ii. 65. 
pernicious in pregnancy, ii. 65. 
treatment of, ii. 66. 
Anesthesia in normal labor, i. 456. 
Anomalies: 
arrest of development, iii. 281. 
fusion of organs, iii. 281. 
g'enesis of, iii. .280. 
in mechanism of labor, i. 357. 
in face presentations, i. 376. 
in pelvic presentations, i. 393. 
in vertex presentations, i. 357. 
Ankylosis of the foetus causing dysto- 
cia, iii. 278. 
Anteversion of the uterus in pregnancy, 
ii. 202. 
Aorta, compression of in post-partum 
hemorrhage, iii, 240. 
Aponeurosis, pelvic, superior, i. 29. 
perineal, i. 30. 
Apron, Hottentot, i. 70. 
Arches, visceral, i. 165. 
Areola, mammae, i. 75. 
Articular rheumatism, ii. 184. 
Articulations of pelvis, i. 12. 
Artificial fecundation, i. 117. 
Artificial respiration, i. 467. 
Schultze's method, i. 467. 
Arteries: 
pelvic, i. 26. 
umbilical, i. 219. 
uterine, i. 51, 147. 
Ascites: 
congenital, iii. 271. 
in pregnancy, ii.' 61. 
treatment of, ii. 63. 
Atrophy: 
of the placenta, ii. 239. 
of the villi of the chorion, ii. 225. 
Attitude of foetus, i. 240. 
Atresia of the vagina, iii. 154. 
Auscultation: 
diagnosis of sex of foetus by, i. 278. 390 
INDEX. 
Axes of pelvis, i. 18, 368. 
Axis-traction forceps, iv. 79. 
Axis tractor, Wells's, iv. 82. 
Bag of waters, i. 331. 
Ballottement: 
abdominal, i. 271. 
vaginal, i. 287. 
Bandage, abdominal, i. 458. 
Bandl's ring, i. 134. 
Bartholini, glands of, i. 72. 
Bath of new-born infant, i. 462. 
Battledoor placenta, i. 218. 
Bi-manual palpation, i. 288. 
Bladder, i. 64. 
hernia of, iii. 159. 
Blastoderm, formation of, i. 160. 
Blastodermic vesicle, i. 160. 
Blood: 
changes of in pregnancy, i. 152. 
menstrual, i. 99. 
transfusion of in post partum 
hemorrhage, iii. 238. 
Body of uterus, i. 45. 
Bony pelvis in general, i. 13. 
Borders of the uterus, i. 45. 
Boundaries of the uterus, i. 47. 
Breasts: 
care of in the puerperal state, i. 505. 
changes in during pregnancy, i. 
150. 
Breech, forceps to the, iv. 139. 
presentations, i. 382 (vide Pelvic 
Extremity.) 
Broad ligaments, i. 54. 
Bulb of ovary, i. 38. 
Caesarean section, iv. 204. 
after-treatment of, iv. 223. 
indications for, iv. 210. 
modified, iv. 207. 
operations of, iv. 215. 
post mortem, iv. 233. 
prognosis of, iv. 224. 
statistics of, iv. 205. 
uterine suture in, iv. 208. 
Calculus: 
vesical, obstructing labor, iii. 161. 
Cancer, of the cervix in pregnancy, 
iii. 166. 
diagnosis of, iii. 167. 
Cancer, influence on, iii. 166. 
treatment of, iii. 167. 
Caput succedaneum, i. 360. 
in face presentations, i. 379. 
in breech presentations, i. 398. 
in shoulder presentations, i. 409. 
in vertex presentations, i. 360. 
Cardiac diseases, complicating preg- 
nancy, ii. 45. 
Care: 
of infant during labor, i. 429. 
of new-born infant, i. 460. 
of mother during labor, i. 421. 
of mother immediately after labor, 
i. 458. 
of the puerperal state, i. 502. 
Carunculae myrtiformes, i. 62. 
Cavity of the pelvis, i. 14. 
Cephalic version, external, iv. 11. 
Cephalotomy, iv. 266. 
Barnes's method of, iv. 269. 
Cephalotribe, iv. 249. 
Bailly's, iv. 250. 
Pajot's, iv. 249. 
Lusk's, iv. 251. 
Tarnier's, iv. 251. 
Cephalotripsy, iv. 246. 
indication for, iv. 253. 
operative method, iv. 255. 
prognosis of, iv. 258. 
Cerebral eclampsia, ii. 99. 
Cervix uteri, i. 45. 
cancer of, iii. 166. 
diagnosis of, iii. 167. 
influence of, on pregnancy, iii. 166. 
treatment of, iii. 167. 
changes in, i. 129. 
dilatation of in labor, i. 325. 
elongation of anterior lip, obstruct- 
ing labor, iii. 165. 
expulsion of placenta through, i. 
449. 
mucous membrane of, i. 146. 
obliteration of in labor, iii. 163. 
rupture of, iii. 194. 
symptoms, iii. 196. 
treatment, iii. 198. 
rigidity of, i. 456; iii. 161. 
Treatment, iii. 162. 
shortening of in pregnancy, i. 129. 
Chloral, i. 457. INDEX. 
391 
Chloral in feeble contractions in labor, 
iii. 10. 
Chloroform, i. 456. 
Chorea in pregnancy, ii. 185. 
Chorion, i, 169, 199. 
villi of, i. 199. 
atrophy of, ii. 225. 
Ciliated epithelium: 
influence of on migrati on of ovum, 
i. 86. 
Circulation: 
during the puerperium, i. 475. 
foetal, i. 236. 
Clefts, visceral, i. 165. 
Clitoris, i. 71. 
Coccyx, bones of, i. 6. 
Coccygean gland, i. 35. 
Cocaine, i. 457. 
Colostrum, i. 498. 
Conception, iii. 151. 
Conjugate of pelvis, i. 15. 
Copulation, i. 103. 
Contractions: 
of abdominal muscles, i. 323. 
uterine, i. 320. 
Congenital syphilis, ii. 297. 
Cord, umbilical, i. 460. 
length of, i. 214. 
structure of, i. 219. 
twists in, i. 215. 
anomalies in, iii. 250. 
care of, i. 460. 
prolapse of, iii. 250. 
causes of, iii. 251. 
diagnosis of, iii. 252. 
treatment of, iii. 255. 
reposition of, by posture, iii. 256. 
hemorrhage of, in placenta prae- 
via, iii. 225. 
management of in pelvic presenta- 
tions, i. 437. 
marginal insertion of, i. 449. 
rings formed by, i. 220. 
rupture of, in third stage of labor, 
iii. 227. 
Corpus luteum, i. 87. 
Cranioclast, iv. 261. 
Simpson's, iv. 261. 
Braun's, iv. 261. 
Cranioclasty, iv. 260. 
results from, iv. 263. 
Creation of sex at will, i. 115. 
Credo's method of placental expression, 
i. 451. 
Cysts: 
influence of on pregnancy, iii. 182. 
on the puerperium, iii. 183. 
of the placenta, ii. 240. 
ovarian differentiated from preg- 
nancy, iii. 178. 
Cystic tumors, influence of on deliv- 
ery, iii. 182. 
Cystocele, vaginal, iii. 160. 
Death, apparent, of new-born infant: 
amemic form, i. 464. 
apoplectic form,, i. 465. 
Decapitation, iv. 279. 
Decidua: 
diseases of, ii, 216. 
in extra-uterine pregnancy, ii. 357. 
reflexa, i. 140, 166. 
serotina, i. 140, 166. 
vera, i. 140, 166. 
Deformities: 
of head in face presentations, i. 379. 
of head in vertex presentations, i. 
360. 
pelvic (vide Pelvis Contracted.) 
De Graaf, follicles of, i, 40. 
Delivery: 
in case of fibroid tumors, iii. 174. 
in twin pregnancy, i. 454. 
of placenta, i. 449. 
prediction of day of, i. 232. 
Development of the ovum, i. 156. 
Diameters: 
of the foetal head, i. 364. 
of the pelvis, i. 15, 21. 
Differences in pelves, i. 19. 
Digital pelvimetry, iii. 96. 
Dilatation of the cervix, i. 325. 
Dimensions: 
of the foetus, i. 228. 
normal, of the pelvis, iii. 85. 
Discus proligerous, i. 87. 
Diseases: 
of the foetus, ii. 284. 
of the heart, influence of on preg- 
nancy, ii. 45. 
of the ovum in pregnancy, ii. 216. 
of pregnancy, ii. 37. 392 
INDEX. 
Encephalocele, pathological anatomy 
of, iii. 270. 
symptoms of, iii. 270. 
Epithelium of the tubes, i. 58. 
Ergot, i. 459. 
contra-indications of in parturition, 
iii. 213, 241. 
in placenta praevia, iii. 212. 
method of administration, iii. 346. 
physiological action of, iii. 339. 
Ergotine, iii. 347. • 
Erysipelas in pregnancy, ii. 11. 
Ether, i. 456. 
Evolution, spontaneous, i. 406. 
Examination of the gravida, i. 310. 
external, i. 264. 
by vaginal touch, i. 283. 
Expression of placenta, i. 447. 
Expulsion of placenta, i. 449. 
External cephalic version, iv. 11. 
External podalic version, iv. 10. 
External genital organs, i. 68. 
Extension of head, i. 372. 
Extra-uterine pregnancy, ii. 350. 
abdominal, ii. 359. 
interstitial, ii. 357. 
ovarian, ii. 359. 
tubal, ii. 358. 
decidua in, ii. 357. 
development of foetus in, ii. 361. 
diagnosis of, ii. 372. 
duration of, ii. 367. 
electricity in, ii. 375. 
external examination in, ii. 365. 
internal examination in, ii. 366. 
rectal examination in, ii. 366. 
intermittent uterine contractions 
in, ii. 365. 
laparotomy in, ii. 377. 
pathological anatomy of, ii. 354. 
placenta in, ii. 361. 
implantation of ovum in, ii. 356. 
symptomatology of, ii. 363. 
termination of, ii. 369. 
treatment of, ii. 374. 
Face presentations, i. 369. 
anomalies of labor in, i. 376. 
deformity of head in, i. 379. 
diagnosis of, i. 370. 
forceps in, iv. 130. 
Diseases : 
of the urinary system of the foetus, 
iii. 272. 
Displacements of the uterus in preg- 
nancy, ii. 197. 
Duration: 
of pregnancy, i. 291. 
of labor, i. 417. 
of menstruation, i. 99. 
of menstrual life, i. 101. 
Dystocia: 
due to the foetus, iii. 250. 
due to the foetal annexes, iii. 260. 
in twin pregnancy, iii. 306. 
maternal, iii. 3. • 
Ducts of Muller, iii. 149. 
Eclampsia, ii. 91. 
causes of, ii. 91, 103. 
distension of the uterus, ii. 96. 
length of labor, ii. 96. 
chloral hydrate in, ii. 139. 
course and duration of, ii. 114. 
diagnosis of, ii. 119. 
general mortality in, ii. 115. 
pathological anatomy of, ii. 117. 
primiparity in, ii. 95. 
treatment of, ii. 127. 
during confinement, ii. 129. 
curative, ii. 130. 
medical, ii. 130. 
obstetrical, ii. 142. 
preventive, ii. 128. 
termination of, ii. 115. 
Ectromelic foetuses, iii. 288. 
Ectopic gestation, (vide Extra-uterine 
Pregnancy. 
Edema of the foetus, iii. 278. 
Electricity: 
in extra-uterine pregnancy, ii. 375. 
in feeble uterine contractions, iii. 9. 
in post-partum hemorrhage, iii. 
235. 
Embryo, formation of, i. 162. 
Embryonic spot, i. 174. 
Embryotomes, iv. 276. 
Embryotomy, iv. 240, 273. 
method of performing, iv. 275. 
Embryogenetic vesicle, i. 41. 
Emphysema of the foetus, iii. 278. 
Encephalocele, congenital, iii. 268. INDEX. 
393 
Face, mechanical phenomena in, i. 372. 
Fallopian tubes, i. 57. 
Faradism: 
in feeble uterine contractions, iii. 10. 
in post-partum hemorrhage, iii. 
237. 
Fecundation, i. 103. 
artificial, i. 117. 
Female pelvis, i. 20. 
Filet, the, iv. 150. 
Flattened pelvis, iii. 24. • 
Flexions of the uterus in pregnancy, 
ii. 201. 
Floor, pelvic, i. 29. 
Foetus, the, i. 227. 
abnormalities of, obstructing labor, 
iii. 260. 
acephalic, iii. 303. 
anengephalic, iii. 297. 
ankylosis of, iii. 278. 
ascites of, iii. 271. 
action of maternal blood on vitality 
of, ii. 302. 
at different months of pregnancy, 
i. 173. 
at term, i. 228. 
attitude and situation, i. 240. 
cadaveric rigidity of, i. 310. 
development of in extra-uterine 
pregnancy, i. 361. 
death of, ii. 301. 
deformity of in transverse presen- 
tations, i. 409. 
dimensions of, i. 228. 
diseases of, ii. 284. 
the cerebrum, ii. 284. 
the circulatory organs, ii. 287. 
the digestive tract, ii. 285. 
the respiratory organs, ii. 284. 
the skin and cellular tissue, ii. 
287. 
the urinary system, iii. 272. 
diagnosis of sex by auscultation, i. 
278. 
edema of, iii. 278. 
emphysema of, iii. 278. 
encephalocele obstructing labor, 
iii. 268. 
exencephalic, iii. 291, 293, 294. 
excess in volume of head, iii. 260. 
gibbous, iii. 278. 
Foetus, hydrocephalus, obstructing la- 
bor, iii. 262. 
hydrothorax of, iii. 270. 
influence of eclampsia on, ii. 123. 
of placental lesions on, ii. 237. 
of high maternal temperature on, 
ii. 300. 
lesions of during delivery, in pelvic 
presentations, i. 441. 
in transverse presentations, 
i. 442. 
luxations of, ii. 289. 
maceration of, ii. 308. 
movements of, i. 272. 
mummification of, ii. 308. 
peritonitis in, ii. 285. 
presentations of, i. 247. 
pseudencephalic, iii. 296. 
putrefaction of, ii. 309. 
retention of urine in, iii. 272. 
scrofulous affections of, ii. 287. 
signs and symptoms of death of, 
ii. 306. 
spontaneous amputations in, ii. 289. 
total excess in volume of, iii. 261. 
weight of, i. 228. 
Fcetal, head, at term, i. 229. 
diameters of, i. 364. 
deformity of in vertex presenta- 
tions, i. 360. 
dystocia, iii. 250. 
circulation, i. 236. 
membranes, i. 165, 198. 
positions, i. 255. 
souffle, i. 282. 
heart-sounds, i. 276. 
Fontanelles: 
large, i. 234. » 
small, i. 234. 
Foot presentations, i. 382. 
Follicles, ovarian, i. 40. 
Foramen ovale, i. 239. 
Foramina of sacrum, i. 3. 
Force: 
compression of forceps, iv. 109. 
uterine, mensuration of, i. 323. 
Forceps, iv. 50. 
action of, iv. 105. 
application of, 
to after-coming head, iv. 137. 
to the breech, iv. 139. 394 
INDEX. 
Forceps, application of, in face presen- 
tations, iv. 130. 
in vertex presentations, iv. 112. 
in pelvic deformities, iii. 125. 
artificial rotation by, iv. 118. 
as a compressor, iv. 109. 
as a tractor, iv. 105. 
as an oxcytoxic, iv. 112. 
axis traction, iv. 79. 
Chamberlen, iv, 51. 
Chassagny's, iv, 58. 
conditions requisite for application 
of, iv. 84. 
extraction with, iv. 99. 
frequency of application of, iv. 
144. 
general rules for, iv. 89. 
Hartmann's, iv. 73. 
Herrmann's, iv. 72. 
Hubert's, iv. 73. 
indications for, iv. 83. 
insertion of blades, iv. 92. 
Joulin's, iv. 59. 
Levret's, iv. 52. 
method of insertion, iv. 95. 
locking of, iv. 97. 
Pajot's, iv. 54. 
Palfyn's, iv. 51. 
preliminary precautions, iv. 87. 
prognosis of, iv. 147. 
Pros de la Rochelle, iv. 65. 
Simpson's, iv. 55. 
Smellie's, iv. 52. 
special rules for, iv. 112, 
Tarnier's, iv. 74. 
traction with, iv. 100. 
Funis (vide Umbilical Cord) prolapse 
of, iii. 250. * 
Gelatine, of Wharton, i. 219. 
Generation, anatomy of organs of, i. 1. 
Genital organs, external, i. 68. 
internal, i. 36. 
during the puerperium, involution 
of, i. 478. 
Gibbous foetus, iii. 278. 
Gingivitis of pregnancy, ii. 67. 
Gland, coccygean, i. 35. 
Glands, vu Ivo-vagin al, i. 72. 
Goitre in pregnancy, ii. 30. 
Graafian follicles, i. 40. 
Graafian vesicle, rupture of, i. 83. 
Gravida, examination of, i. 310. 
Head, after-coming, forceps to, iii. 135. 
at term, foetal, i. 229. 
deformity of, in face presentations, 
i. 379. 
descent of, in contracted pelvis, 
iii. 131. 
excess in volume of, iii. 260. 
extension of, i. 372. 
flexion of, i. 346. 
Heart sounds, foetal, i. 276. 
Hegar's sign of pregnancy, i. 289 
Hemorrhage, in miscarriage, ii. 331. 
in placenta praevia, iii. 209. 
puerperal, iii. 200. 
in third stage of labor, iii. 225. 
post partum, causes of, iii, 233. 
symptoms of, iii. 234. 
transfusion of blood in, iii. 238. 
transfusion of milk in, iii. 238. 
secondary puerperal, iii. 246. 
symptoms of, iii. 247. 
treatment of, iii. 247. 
Hermaphroditism, iii. 284. 
apparent, iii. 285. 
by lateral excess, iii. 285. 
by unilateral excess, iii. 285. 
lateral without excess, iii. 285. 
of the excretory apparatus, iii. 286. 
of the glands, iii. 285. 
true, iii. 285. 
with two ovaries, iii. 286. 
with two testicles, iii. 286. 
Hernia, iii. 159. 
of the bladder, iii. 159. 
of the intestine, iii. 160. 
Heterotaxy, iii. 283. 
partial inversion of the viscera, 
iii. 284. 
total inversion of the viscera, iii. 
283. 
Hottentot, apron, i. 70. 
Hour-glass contraction of uterus, iii. 
230. 
Hydatid gestation duration of, ii. 246. 
Hydramnion, inflammatory lesions in, 
ii. 273. 
Hydrocephalus, iii. 262. 
causes of, iii. 263. INDEX. 
395 
Hydrocephalus, diagnosis of, iii. 265. 
during- pregnancy, iii. 265. 
mechanism of labor in, iii. 266. 
pathological anatomy of, iii. 263. 
presentation of pelvic extremity in, 
iii. 265. 
prognosis in, iii. 266. 
treatment of, iii. 267. 
Hydrothorax, iii. 270. 
Hygiene, of lactation, i. 505. 
of pregnancy, i. 505. 
of new-born infant, i. 508. 
Hymen, the, i. 61. 
persistence of, iii. 155. 
Hysteria in pregnancy, ii. 27. 
Icterus in pregnancy, ii. 21. 
Infant, apparent death of, i. 464. 
care of during labor, i. 429. 
new-born, care of, i. 460. 
hygiene of, i. 508. 
weight of, i. 462. 
Inferior strait, i. 16. 
Influence of labor, on infant, i. 415. 
on the mother, i. 410. 
Influence of high maternal temperature 
on the vitality of the fcetus, ii. 301. 
of pregnancy on disease of the 
heart, ii. 45. 
of syphilis on pregnancy, ii. 24. 
of tobacco on pregnancy, ii. 27. 
Inflammation of the pelvic articula- 
tions, ii. 178. 
of the symphyses, ii. 178. 
Injections, intra-uterine, i. 504; iv. 370. 
in post partum hemorrhage, iii. 
235. 
vaginal, i. 503; iv. 370. 
Inlet, of pelvis, i. 19. 
Illiac bones, i. 6, 9. 
Inertia uteri, i. 459. 
Innominate bones, i. 6, 9. 
Internal genital organs, i. 36. 
Inspection, i. 264. 
Instrumental pelvimetry, iii. 85. 
Intestine, hernia of in labor, iii. 160. 
Intra-uterine rachitis, ii. 292. 
Insanity of women just delivered and 
of nursing women, ii. 169. 
Inversion of the uterus, iii. 240. 
Involution of the uterus, i. 479. 
Iron, injection of in post partum hem- 
orrhage, iii. 236. 
Jaundice in pregnancy (vide Icterus.) 
Jorissenne's sign of pregnancy, i. 263. 
Knots in the umbilical cord, i. 224. 
Knee presentation, i. 384. 
Kyphotic pelvis, iii. 58. 
Labia majora, i. 68. 
minora, i. 70. 
Labor, i. 313. 
abnormal contractions in, iii. 11. 
causes of, iii. 11. 
treatment of, iii. 11. 
abnormalities of foetus obstructing, 
iii. 260. 
anesthesia in normal, i. 456. 
anomalies in mechanism of, i. 357. 
care of infant during, i. 429. 
care of infant after, i. 509. 
care of mother during, i. 424. 
care of mother after, i. 458. 
causes of, i. 315. 
determining, i. 315. 
efficient, i. 318. 
deviations of cervix in, iii. 165. 
duration of, i. 417. 
elongation of anterior lip obstruct- 
ing, iii. 165. 
excessive contractions in, iii. 4. 
causes of, iii. 4. 
treatment of, iii. 4. 
feeble contractions in, iii. 5. 
causes of, iii. 6. 
chloral in, iii. 10. 
electricity in, iii. 9. 
prognosis of, iii. 7. 
treatment, iii. 7. 
hernia of the bladder in, iii. 159. 
incarceration of the placenta in, 
iii. 231. 
induction of (vide Premature La- 
bor). 
lacerations of the perineum in, i. 
427; iii. 143. 
of the vagina, iii. 199. 
mechanical phenomena of, i. 337. 
in contracted pelvis, iii. 114. 
in different positions, i. 388. 396 
INDEX. 
Lever, to after-coming head, iv. 161. 
Ligaments of uterus, i. 53. 
round, i. 54. 
broad, i. 54. 
of ovaries, i. 37. 
of sacrum, i. 12. 
sacro-uterine, i. 54. 
vesico-uterine, i. 53. 
Ligature of umbilical cord, i. 460. 
Liquor amnii, i. 202. 
Lochia, i. 496. 
Lusk's axis traction forceps, iv. 82. 
Maceration of the foetus, ii. 308. 
Malarial fever in pregnancy, ii. 5. 
Male pelvis, i. 20. 
Malformations of foetus (vide Monstrosi- 
ties). 
of the uterus, iii. 149. 
of the vagina, iii. 153. 
Mammae, i. 75. 
anomalies of, i. 79. 
areola of, i. 75. 
form of, i. 75. 
situation of, i. 75. 
structure of, i. 76. 
Mania, ii. 170. 
in pregnancy, ii. 166. 
puerperal, ii. 169. 
Marginal insertion: 
of the cord, i. 449. 
of the placenta, iii. 203. 
Maternal dystocia, iii. 3. 
Measles in pregnancy, ii. 11 
Measurements of pelvis, i. 14 ; iii. 96. 
Meconium, i. 509. 
Mechanical phenomena of labor, i. 337. 
Mechanism of labor: 
anomalies in, i. 357. 
in contracted pelves, iii. 108. 
in the different positions, i. 388. 
in face presentations, i. 372. 
in pelvic presentations, i. 388. 
in transverse presentations, i. 405. 
Mechanical tractors, iv. 67. 
of Poullet, iv. 65. 
of Tarnier, iv. 69. 
Melancholia, ii. 170. 
Membranes, fcetal, i. 165. 
retention of, ii. 331. 
rupture of, i. 331. 
Labor, mechanical phenomena of in 
pelvic presentations, i. 388. 
lesions of foetus in, i. 441 
in transverse presentations,!. 405. 
multiple, i. 418, 443. 
obliteration of cervix in, iii. 163. 
pelvic deformity complicating, iii. 
106. 
contracted pelvis in, iii. 108. 
prognosis of, iii. 121. 
position of gravida during, i. 425. 
post partum hemorrhage in, iii. 232. 
prolapse of vagina in, iii. 159. 
physiologfcal phenomena of, i. 320. 
precursory, i. 319. 
preservation of perineum in, iii. 
145. 
rigidity of cervix in, iii. 161. 
treatment, iii. 162. 
rigidity of the perineum in, iii. 143. 
of the vagina, iii. 142. 
of the vulva, iii. 142. 
third stage of. i. 446. 
adhesions of placenta in, iii. 227. 
artificial removal of placenta in, 
iii. 225. 
excessive size of placenta in, iii. 
226. 
hemorrhage in, iii. 225. 
rupture of cord in, iii. 227. 
spasmodic uterine contractions 
in, iii. 230. 
uterine inertia in, iii. 226. 
tardy, iii. 3. 
vesical calculus obstructing, iii. 161. 
Lactation, hygiene of, i. 505. 
Laparotomy, in extra-uterine preg- 
nancy, ii. 377. 
Laparo-elytrotomy, iv. 215. 
statistics of, iv. 217. 
description of, iv. 216. 
Lateral regions of the abdomen, i. 26. 
Layer, ovigenetic, i. 39. 
Lead-poisoning in pregnancy, ii. 26. 
Leucorrhcea of pregnancy, i. 330; ii. 
192. 
Lever, the, iv. 157. 
action cf, iv. 157. 
use of, iv. 159. 
in face presentations, iv. 161. 
in vertex presentations, iv. 161. INDEX. 
397 
Membranes, rupture o<, in placenta 
praevia, iii. 212. 
spontaneous rupture of, i. 333. 
Menopause, i. 101. 
Menstruation: 
anatomical modifications produced 
by, i. 92. 
duration of, i. 99. 
first appearance of, i. 96. 
phenomena of, i. 100. 
Menstrual blood, character of, i. 98. 
Menstrual life, duration of, i. 101. 
Mensuration of uterine force, i. 323. 
Meatus, urinary, i. 71. 
Method of placental expression, Credo's, 
i. 450. 
Metritis, iv. 381. 
Microbe, Noeggerath's, iv. 315. 
Micrococci, iv. 301. 
Migration of ovum, influence of cilli- 
ated epithelium on, i. 86. 
Migration of ovules, i. 85. 
Milk : 
composition of, i. 498. 
modifications in during puerper- 
ium, i. 498. 
secretion of, i. 498. 
Miscarriage, ii. 311. 
causes of, ii. 315. 
active interference in, ii. 343. 
complications of, ii. 331. 
diagnosis of, ii. 327. 
erg-ot in, ii. 339. 
faradic current in, ii. 341. 
frequency of, ii. 314. 
hemorrhage in, ii. 331. 
induction of, iv. 199. 
in pelvic deformity, iv. 200. 
in uncontrollable vomiting, iv. 
201. 
prognosis of, ii. 330. 
treatment of, ii. 335. 
control of hemorrhage in, ii. 339. 
signs of impending, ii. 318. 
tamponnade in, ii. 340. 
retention of placenta and ovum, ii. 
331. 
Moles, hydatidiform, ii. 245. 
Monstrosities, ii. 274 ; iii. 287. 
simple, iii. 288. 
autosites, iii. 288. 
Monstrosities, simple omphalosites, iii. 
302. 
parasites, iii. 322. 
composite, iii. 309. 
autosites, iii. 309. 
complex, iii. 322. 
general considerations on, iii. 328. 
Mons Veneris, i. 68. 
Mother, care of after labor, i. 458. 
influence of labor on, i. 410. 
Movements of foetus, ,i. 272. 
Muller's ducts, iii. 149. 
Multiple labor, i. 418. 
Multiple pregnancy, i. 294. 
frequency, and causes of, i. 296. 
locking- of children in, iii. 306. 
placenta in, i. 454. 
signs and diagnosis of, i. 300. 
Mucous membrane of cervix, i. 146. 
of uterus, i. 140. 
Muscles of pelvis, i. 24. 
external, i. 24. 
internal, i. 27. 
sacrum, i. 12. 
Muscles of the perineum, i. 32. 
Muscular rheumatism, ii. 184. 
Mummification of the foetus, ii. 308. 
Naegele, oblique pelvis, i. 18; iii. 43. 
Nerves of uterus, i. 53, 147. 
Nervous system during- pregnancy, ii. 
162. 
during the puerperium, i. 478. 
Neuralgias in pregnancy, ii. 144. 
New born infant, i. 508. 
asphyxia of, i. 465. 
care of, i. 508. 
circulation in, i. 241. 
ophthalmia of, i. 509. 
resuscitation of, i. 468. 
weight of, i. 508. 
Nipples, i. 76. 
care of, i. 506. 
Nubility, i. 83. 
Nursing- (vide Lactation). 
Nutrition of foetus, i. 233. 
Oblique oval pelvis (Naegel6's), iii. 43. 
Occipito posterior positions, i. 342, 344, 
355, 356. 
Obstructed labor, prolapse of the limbs, 
iii. 334. 398 
INDEX. 
Omphalo-mesenteric artery and vein, 
i. 237. 
Ophthalmia neonatorum, i. 509. 
Organs, genital, external, i. 68. 
internal, i. 86. 
of generation, anatomy of, i. 1. 
Os, deviations of in labor, iii. 165. 
externum, obliteration of, iii. 164. 
treatment of, iii. 164. 
internum, obliteration of, iii. 164. 
Ossa innominata, i. 6, 9. 
Osteomalacic pelvis, iii. 37. 
Outlet, pelvic, i. 19. 
Ova, early, i. 156. 
Ovaries, ligaments of, i. 37. 
Ovaries, situation, direction, volume, 
form, i. 36. 
structure of, i. 38. 
Ovarian cyst, diagnosis from pregnan- 
cy of, iii. 178. 
pregnancy, ii. 359. 
follicles, i. 40. 
tumors, influence of pregnancy on, 
iii. 181. 
Ovary, bulb of, i. 38. 
tunica albuginea of, i. 38. 
Oviducts or tubes, i. 57. 
Ovigenetic layer, i. 39. 
Ovulation, i. 83. 
Ovule, i. 41. 
migration of, i. 85. 
Ovum, development of the, i. 156. 
segmentation of, i. 158. 
yolk of, i. 164. 
zona pellucida of, i. 161. 
Oxytocic, ergot, iii. 336. 
oxytocic, forceps as an, iv. 112. 
Palpation, abdominal, i. 265. 
bi-manual, i. 288. 
Paraplegias, ii. 151. 
Pelvic arteries, i. 26. 
articulations, i. 12. 
inflammations of, ii. 178. 
axes, i. 18. 
bones, i. 3. 
cavity, i. 14. 
diameters, i. 15. 
deformity, diagnosis of, iii. 83. 
forceps in, iii. 125. 
influence of on pregnancy and la- 
bor, iii. 103. 
Pelvic deformity, labor in, iii. 106. 
version in, iii. 125. 
floor, i. 29. 
inlet, i. 19. 
measurements, i. 14; iii. 96. 
muscles, i. 27. 
planes, i. 19. 
outlet, i. 19. 
presentations, i. 382. 
anomalies of labor in, i. 393. 
arms in, i. 400. 
lesions of foetus during delivery 
in, i. 441. 
management of cord in, i. 437. 
mechanism of labor in, i. 388. 
walls, leng-th of, i. 19. 
Pelvimeters, iii. 86. 
Pelvimetry, digital, iii. 96. 
instrumental, iii. 85. 
Pelvis, adult, i. 23. 
anatomy of, i. 3. 
axes of, i. 368. 
bony, in general, i. 13. 
contracted, rupture of uterus in, iii. 
190. 
descent of head in, iii. 131. 
version in, iii. 113. 
differences in, i. 19. 
female, i. 20. 
flattened, iii. 24. 
forms and types of deformity of, 
iii. 23. 
male, i. 20. 
normal dimensions of, iii. 85. 
oblique, of Naegele, iii. 43. 
osteomalacic, iii. 37. 
osteomalacic, rachitic pelvis, iii. 34. 
rachitic, iii. 26. 
spondylolisthetic, iii. 63. 
spondylozematic, iii. 63. 
transversely contracted, iii. 47. 
Perineal aponeurosis, i. 30. 
floor, i. 29. 
lacerations, i. 427. 
Perineum, causes of laceration of, iii. 
144. 
laceration of, treatment of, iii. 147. 
preservation of in labor, iii. 145. 
rigidity of, in labor, m. 143. 
muscles of, i. 32. 
Peritonitis, puerperal, iv. 384. INDEX. 
399 
Perforation, iv. 241. 
Pernicious anaemia, ii. 65. 
Phenomena of labor, mechanical, i. 
337. 
physiological, i. 320. 
precursory, i. 319. 
Phenomena of menstruation, i. 100. 
Phlegmasia alba dolens, iv. 340. 
treatment of, iv. 388. 
Placenta, anatomy of, i. 204. 
abnormal insertion of, iii. 202. 
albuminuric changes in, ii. 243. 
adhesions of, ii. 243. 
artificial removal of, iii. 229. 
atrophy of, ii. 239. 
battledoor, i. 218. 
cysts of, ii. 240. 
delivery of, i. 449. 
diseases of, ii. 221. 
excessive size of, iii. 226. 
expression of, Credo's method, i. 
447. 
expulsion of, i. 449. 
through the cervix, i. 449. 
extravasations in, ii. 226. 
extraction of incarcerated, iii. 232. 
foetal surface of, i. 204. 
formation of, i. 202. 
hypertrophy and edema of, ii. 238. 
incarceration of, iii. 231. 
in extra-uterine pregnancy, ii. 361. 
in multiple pregnancy, i. 454. 
marginal insertion of, iii. 203. 
maternal surface of, i. 204. 
partial insertion of, iii. 202. 
passage of through vagina and 
vulva, i. 449. 
retention of, i. 450; ii. 331. 
signs of adhesions of, iii. 228. 
structure of, i. 204. 
praevia, iii. 202. 
accouchement force in, iii. 212. 
after treatment in, iii. 223. 
ergot in, iii. 213. 
frequency of, iii. 204. 
hemorrhages in, iii. 209. 
concealed, iii. 224. 
from cord. iii. 225. 
pathological anatomy of, iii. 203. 
prognosis of, iii. 210. 
rupture of membranes in, iii. 212. 
Placenta praevia, separation of placenta 
in, iii. 222. 
symptoms of, iii. 205. 
tampon in, iii. 213. 
treatment of, iii. 211. 
version in. iii. 220. 
sclerosis of, ii. 240. 
syphylitic lesions of, ii. 242. 
tumors of, ii. 241. 
varieties of, i. 203. 
Placentitis, ii. 221. 
Pleurisy, complicating pregnancy,ii. 17. 
Pneumonia complicating pregnancy, 
ii. 12, 14. 
Porro's operation, iv. 227. 
Positions of the foetus, i. 255. 
changes in, i. 259. 
diagnosis of, i. 340. 
by auscultation, i. 280. 
Position of gravida during labor, i. 425. 
Post partum hemorrhage, iii. 232, 234. 
intra-uterine injections in, iii. 235. 
Pregnancy, i. 121. 
abdominal, ii. 369. 
abdominal and uterine pains in, 
ii. 194. 
abdomen in, i. 151. 
albuminuria in, ii. 70. 
amenorrhea of, i. 262. 
ascites in, ii. 61. 
auscultation in, i. 273. 
ballottement in, i. 287. 
cardiac diseases, ii. 45. 
chang-es in blood, i. 152. 
in breasts, i. 150. 
organic and functional, i. 152, 
155. 
cholera in, ii. 3. 
chorea in, ii. 185. 
colic in, ii. 3. 
cysts in, iii. 182. 
diagnosis of, ii. 372. 
differential diagnosis, i. 303. 
diseases of, ii. 37. 
the skin in, ii. 170. 
the vulva and vagina in, ii. 191. 
displacements and deviations of 
uterus in, ii. 197. 
anteversion of the uterus, ii. 202. 
flexions, ii. 201. 
prolapse, ii. 197. 400 
INDEX. 
Pregnancy, retroversion, ii. 206. 
duration of, i. 291. 
dystocia in twin, causes of, iii. 306. 
eclampsia in, ii. 123. 
endometritis in, ii. 116. 
erysipelas in, ii. 11. 
extra uterine, ii. 350. 
diagnosis of, ii. 372. 
duration of, ii. 367. 
electricity in, ii. 375. 
laparotomy in, ii. 377. 
termination of, ii. 369. 
treatment of, ii. 374. 
foetal heart-sounds in, i. 276. 
foetus, at different months of, i. 173. 
fibroid tumors of the uterus in, iii. 
169. 
funic souffle in, i. 282. 
gingivitis in, ii. 67. 
goitre in, ii. 30. 
Hegar's sign of, i. 289. 
hernia of uterus in, iii. 180. 
hemiphlegiain, ii. 145. 
hydramnion in, ii. 274. 
hygeine of, i. 305. 
hysteria in, ii. 27. 
icterus in, ii. 21. 
intermittent fever in, ii. 5. 
Jorisenne's sign of, i. 263. 
lead-poisoning in, ii. 26. 
leucorrhea in, i. 330; ii.192. 
malarial fever in, ii. 5. 
mammary changes in, i. 150. 
measles in, ii. 11. 
multiple, i. 294. 
nausea in, ii. 38. 
neuralgias, in, ii. 144. 
ovarian tumors in, iii. 181. 
paraplegias in, ii. 151. 
partial paralysis in, causes of, ii. 
164. 
pelvic deformity in, iii. 103. 
pernicious anaemia in, ii. 65. 
pleurisy in, ii. 17. 
pneumonia in, ii. 12. 
prolapse of the uterus in, ii. 197. 
pruritus vulvas in, ii. 191. 
ptyalism in, ii. 67. 
pulmonary tuberculosis in, ii. 18. 
sacculation of the uterus in, ii. 213. 
scarlet fever in, ii. 10. 
Pregnancy, shortening of cervix in, i. 
129. 
signs of, i. 263. 
size of abdomen in, i. 151. 
small-pox in, ii. 8. 
spurious, i. 303. 
syphilis in, ii. 23. 
tobacco, influence of on, ii. 27. 
traumatism during, ii. 28. 
traumatic paralysis in, ii. 156. 
twin, delivery in, i. 454. 
typhoid fever in, ii. 12. 
ulceration of cervix in, ii. 32. 
uterine rheumatism in, ii. 195. 
uterine souffle in, i. 274. 
uterus bi cornis in, iii. 151. 
uncontrollable vomiting in, ii. 39. 
varices in, ii. 51. 
vegetations of vulva and vagina in, 
ii. 193. 
Premature labor, induction of, iv. 163. 
comparative results in, iv. 165. 
indications for, iv. 164. 
methods of,'iv. 177. 
by internal drugs, iv. 177. 
by excitation of cervix, iv. 178. 
by douches, iv. 179. 
by Braun's colpeurynter, iv. 179. 
by dilatation of cervix, iv. 180. 
by separation and perforation of 
membranes, iv. 182. 
mortality in, iv. 176. 
prognosis of, iv. 187. 
statistics of, iv. 173. 
statistical results, iv. 188. 
Presentations, i. 247. 
changes in, i. 259. 
contracted pelvis, influence of on, 
iii. 104. 
diagnosis of by auscultation, i. 278. 
face, i. 249, 369. 
forceps in, iv. 130. 
extension of head in, i. 372. 
pelvic, i. 253, 382. 
use of forceps in, iv. 139. 
transverse, i. 254, 399. 
causes of, i. 401. 
diagnosis of, I. 402. 
spontaneous evolution in, i. 406. 
version in, i. 406. 
vertex, i. 249, 338. 401 
INDEX. 
Presentations, vertex, forceps in, iv. 
162. 
Primitive streak, i. 162. 
Prolapse of cord, iii. 250. 
of limbs, iii. 334. 
Proligerous disk, i. 87. 
Pseudencephalic foetus, iii. 296. 
Pulmonary tuberculosis in pregnancy' 
ii. 18. 
Puberty, i. 83. 
Pubic bones, i. 8. 
Puerperium, physiological, i. 472. 
circulation during, i. 475. 
cysts, influence of on, iii. 183. 
digestion during the, i. 476. 
fibroid tumors complicating the, 
iii. 180. 
involution of genital organs during 
the, i. 478. 
modifications in the milk during 
the, i. 498. 
pathogeny of the, iv. 285. 
respiration during the, i. 475. 
temperature during the, i. 474. 
urinary function during the, i. 476. 
weight during, i. 473. 
Puerpera, food of the, i„ 505. 
Puerperal breasts, care of, i. 505. 
convulsions, ii. 143. 
hemorrhages, iii. 200. 
secondary, iii. 246. 
Puerperal diphtheria, iv. 388. 
metritis, iv. 382. 
parametritis, iv. 382. 
perimetritis, iv. 382. 
peritonitis, iv. 327. 
phlegmasia alba dolens, iv. 388. 
purulent infection, iv. 336. 
putrid infection, iv. 333. 
pyemia, iv. 336. 
septicemia, iv. 388. 
curative treatment of, iv. 381. 
prophylactic, iv. 360. 
before labor, iv. 362. 
during labor, iv. 363. 
after delivery, iv. 367. 
intra-uterine injections in, iv. 367. 
objections to, iv. 371. 
method of administering, iv. 
373, 379. 
vaginal injections in, iv. 367. 
Puerperal fever microbes in, iv. 299. 
pathological anatomy of, iv. 346. 
pathogeny of, iv. 287. 
prognosis of, iv. 355. 
theories of origin of, iv. 288. 
varieties of, iv. 319. 
Puerperal paralysis, ii. 145. 
pelvic abscess, treatment, iv. 383. 
mania, ii. 125. 
rheumatism, ii. 180. 
Puerperal state, care of the, i. 502. 
sudden death in the, iv. 342. 
Quickening, i. 272. 
Rachitis, intra-uterine, ii. 292. 
Rachitic pelvis, hi. 26. 
Rectum, i. 66. 
Relaxation of the symphyses, ii. 174. 
Repositor, Braun's, iii. 257. 
catheter used as, iii. 259. 
Dudan's, iii. 257. 
pessary used as, iii. 260. 
Reposition of cord, iii. 256. 
Respiration, artificial, i. 467. 
during the puerperium, i. 475. 
Retention of the membranes, ii. 331. 
of placenta, i. 450; ii. 331. 
Retroversion of the uterus in pregnan- 
cy, ii. 206; iii. 178. 
Rheumatism, articular, ii. 184. 
muscular, ii. 184. 
puerperal, ii. 180. 
Rigidity of cervix, iii. 161. 
Ring of Bandl, i. 134. 
Round ligaments, i. 54. 
Rosenmuller, organ of, i. 55. 
Rotation, artificial, by the forceps, iv. 
118. 
Rupture, of the cervix, iii. 194. 
symptoms of, iii. 196. 
treatment of, iii. 198. 
of the Graafian vesicle, i. 83. 
of the membranes, i. 331. 
of the symphyses, ii. 179. 
of the uterus, iii. 188. 
in contracted pelvis, iii. 190. 
symptoms of, iii. 189. 
treatment of, iii. 198. 
of the vagina, iii. 199. 
Sacro-iliac symphysis, i. 9. 
Vol. IV.-26 402 
INDEX. 
Sacro-uterine ligaments, i. 54. 
Sacro-vertebral angle, i. 3, 17, 18. 
Sacrum, i. 3. 
foramina of, i. 3. 
joints of, i. 8. 
ligaments of, i. 12. 
muscles of, i. 12. 
Sacculation of the uterus in pregnancy, 
ii. 213. 
Scarlet fever in pregnancy, ii. 10. 
Scoliotic pelvis, iii. 53. 
Scolio-rachitic pelvis, iii. 55. 
Schultze's method of artificial respira- 
tion, i. 467. 
Sclerosis of the placenta, ii. 240. 
Secretion of milk, i. 498. 
Segmentation of ovum, i. 158. 
Semen, i. 104. 
Semen in genital organs, progress of, i. 
113. 
Septicemia, puerperal, iv. 294, 338. 
manner of contagions, iv. 311. 
micro-organisms in, iv. 297. 
recent views on, iv. 312. 
Sericeps, the, iv. 150. 
Sex at will, creation of. i. 115. 
Sex of foetus, diagnosis by auscultation, 
i. 278. 
Shoulder presentations (vide trans- 
verse) . 
Signs of pregnancy, probable, i. 263. 
certain, i. 264. 
Sinuses, uterine, i. 147, 448. 
Situation and form of mammae, i. 75. 
Small-pox in pregnancy, ii. 8. 
Souffle, foetal, i. 282. 
uterine, i. 274. 
Sounds, foetal heart, i. 276. 
Spermatozoa, i. 104. 
Spondylolisthetic pelvis, iii. 63. 
Spontaneous amputation, intra-uter- 
ine, ii. 291. 
delivery of placenta, i. 446. 
evolution, i. 406. 
rupture of the membranes, i. 333. 
version, i. 406. 
Spurious pregnancy, i. 303. 
Sterility, i. 116. 
Strait, superior, i. 15. 
inferior, i. 16. 
Structure of mammae, i. 76. 
Structure of ovaries, i. 38. 
of placenta, i. 204. 
of uterus, i. 49. 
Super-fecundation, i. 296. 
Super-foetation, i. 296. 
Superior pelvic aponeurosis, i. 29. 
Surfaces of the uterus, i. 45. 
internal, i. 4.6. 
Sutures of foetal head, i. 230. 
Symelic foetus, iii. 290. 
Symphysis pubis, inflammation of, ii. 
178. 
relaxation of, ii. 174. 
rupture of, ii. 179. 
sacro-iliac, i. 9. 
sacro-vertebral, i. 9. 
Symphyseotomy, iv. 238. 
Syphylis, congenital, ii. 297. 
in pregnancy, ii. 23. 
of the placenta, ii. 242. 
Tampon in placenta praevia, iii. 213. 
in post-partum hemorrhage, iii 
238. 
Temperature during the puerperium, 
i. 474. 
Teratology, iii. 278. 
Third stage, the, of labor, i. 446. 
Thrombus of the vagina, iii. 156. 
causes of, iii, 156. 
diagnosis of, iii. 158. 
symptoms of, iii. 156. 
treatment of, iii. 158. 
of vulva, iii. 156. 
causes of, iii. 156. 
diagnosis of, iii. 158. 
symptoms of, iii. 157. 
treatment of, iii. 158. 
Touch, vaginal, i. 283. 
Transforator, Hubert's, iv. 271. 
Transfusion of blood and milk in post- 
partum hemorrhage, iii. 238. 
Transverse presentations, i. 399 
causes of, i. 401. 
diagnosis of, i. 402. 
foetal deformity in, i. 409. 
lesions of foetus during delivery 
in, i. 442. 
Traumatism, influence of pregnancy 
on, ii. 29. 
during pregnancy, ii. 28. INDEX. 
403 
Triple monsters, iii. 327. 
Trunk presentations (vide transverse). 
Tubal pregnancy, ii. 358. 
electricity in, ii. 375. 
injections of morphia in, ii. 375. 
laparotomy in, ii. 376. 
Tubes or oviducts, i. 57. 
Tumors of the ano-perineal region, iii. 
273. 
cystic, influence of on delivery, iii. 
182. 
fibroid, delivery in case of, iii. 174. 
diagnosis of in pregnancy, iii. 177. 
during- the puerperium, iii. 180. 
influence of on pregnancy, iii. 
171. 
treatment of in pregnancy, iii. 
179. 
foetal, causing dystocia, iii. 273. 
of the neck, iii. 278. 
ovarian in pregnancy, iii. 181. 
influence of pregnancy on, iii. 
181. 
of the placenta, ii. 241. 
of the vagina, iii. 156. 
of the vulva, iii. 159. 
Tunica albuginea, i. 38. 
Turning (vide Version). 
Twin labors, i. 443. 
Twins, conjoined, iii. 309. 
Typhoid fever in pregnancy, ii. 12. 
Ulcerations of the cervix during 
pregnancy, ii. 32. 
Umbilical artery, i. 219. 
cord, anomalies in, iii. 250. 
care of, i. 460. 
knots of, i. 224. 
ligature of, i. 460. 
prolapse of, iii. 250. 
causes, iii. 251. 
diagnosis, iii. 252. 
frequency, iii. 251. 
prognosis of, iii. 253. 
postural treatment of, iii. 257. 
reposition of, iii. 257. 
souffle, i. 258. 
vein, i. 219. 
vesicle, i. 164. 
Urachus, i. 170. 
Uraemia, in eclampsia, i. 103. 
Urethra, i. 66. 
Urinary function during- the puerpe- 
rium, i. 476. 
meatus, i. 71. 
Urine, retention of in foetus, iii. 272. 
Uterine contractions, i. 320. 
deviations, ii. 200. 
flexions, ii. 201. 
inertia, iii. 226. 
rheumatism, ii. 195. 
sinuses, i. 147, 448. 
souffle, i, 274. 
Utero-sacral ligaments, i. 54. 
Uterus, anomalies of, iii. 149. 
bi-cornis, iii. 149. 
pregnancy in, iii. 151. 
bilocularis, iii. 150. 
borders of, i. 45 
body of, i. 45. 
boundaries of, i. 47. 
cardiformis, iii. 150. 
deficiens, iii. 150. 
duplex, iii. 149. 
during pregnancy, changes in body 
of, i. 125. 
in cervix of, i. 129. 
in vessels of, after delivery, i. 
438. 
properties of, i. 147. 
form, situation, volume, i. 41. 
fibroid tumors of, iii. 169. 
hernia of, iii. 180. 
hour-glass contraction of, iii. 230. 
inertia of, i. 459. 
in third stage of labor, iii. 225. 
intermittent contractions of, i. 273. 
internal surface of, i. 46. 
inversion of, iii. 240. 
frequency of, iii. 241. 
methods of reducing, iii. 245 
production of, iii. 242. 
symptoms of, iii. 244. 
involution of the, i. 479. 
ligaments of, i. 53. 
lymphatics of, i. 51. 
malformations of, iii. 149. 
preventing conception, iii. 151. 
mucous membrane of, i. 50. 
muscular fibres of, i. 50. 
nerves of, i. 53, 147. 
relations of, i. 47. 
retroversion of gravid, iii. 178. 
rupture of, iii. 188. 404 
INDEX. 
Uterus, in contracted pelvis, iii. 190. 
symptoms of, iii. 189. 
treatment of, iii. 198. 
septus, iii. 150. 
spasmodic contractions of, in third 
stage, iii. 230. 
structure of, i. 49. 
surfaces of, i. 45. 
vessels of, i. 51. 
Vagina, i. 59. 
abnormal openings of, iii. 153. 
absence of, iii. 154. 
atresia of, iii. 154. 
double, iii. 154. 
inperforate, iii. 153. 
laceration of, iii. 199. 
orifice of, i. 68. 
passage of placenta through, i. 149. 
prolapse of, in labor, iii. 159. 
rigidity of, in labor, iii. 142. 
rupture of, hi. 199. 
tampon of, iii. 218. 
thrombus of, iii. 156. 
causes of, iii. 156. 
diagnosis of, iii. 158. 
symptoms of, iii. 156. 
treatment of, iii. 158. 
tumors of, iii. 159. 
vegetations of, iii. 193. 
Vaginal ballottement, i. 287. 
injections, i. 503. 
cystocele, iii. 160. 
touch, i. 283. 
Varices, in pregnancy, ii. 51. 
Vectis, iv. 157. 
Vein, umbilical, i. 219. 
Version, iv. 3. 
before labor, iv. 7. 
bi-polar, iv. 9. 
by conjoined manipulations, iv. 9. 
by external manipulations, iv. 3. 
during labor, iv. 8. 
evolution of the foetus in, iv. 25. 
extraction of the foetus in, iv. 27 
frequency of, iv. 46. 
in contracted pelvis, iii. 113. 
indications for, iv. 6. 
in placenta praevia, iii. 220. 
internal, iv. 12. 
internal cephalic, iv. 12. 
obstacles and difficulties, iv. 31. 
in evolution, iv. 38. 
in extraction, iv. 38. 
in seizing the feet, iv. 34. 
podalic, iv. 14. 
indications for, iv. 16. 
operative method of, iv. 19. 
preliminary precautions in, iv. 
18. 
prognosis of, iv. 46. 
spontaneous, i. 406. 
Vertex presentations (vide presenta- 
tions, vertex). 
Vesicle, blastodermic, i. 60. 
embryogenetic, i. 41. 
umbilical, i. 164. 
Vesico-uterine ligaments, i. 53. 
Vessels, of uterus, i. 51, 147. 
Vestibule, i. 71. 
Villi of chorion, i. 199; ii. 225. 
changes in, ii. 229. 
Vinegar in post-partum hemorrhage, 
iii. 235. 
Visceral arches, i. 165. 
Visceral clefts, i. 165. 
Vitellus, segmentation of, i. 158. 
Vomiting of pregnancy, ii. 38. 
Vulva, i. 68. 
atresia of, iii. 154. 
laceration of. iii, 142. 
passage of placenta through, i. 449. 
rigidity of in labor, iii. 142. 
thrombus of, iii. 156. 
causes of, iii. 156. 
diagnosis of, iii. 158. 
symptoms of, iii. 157. 
treatment of, iii. 158. 
tumors of, iii. 159. 
Vulvo-vaginal secretory glands, i. 72. 
Warburg's tincture, iv. 381. • 
Waters, bag of, i. 331. 
Weaning (vide Lactation). 
Weight during the puerperium, i. 473. 
of the foetus, i. 228. 
of the new born infant, i. 462. 
Wharton's jelly, i. 219. 
Wolffian bodies, i. 56. 
Yolk of ovum, i. 164. 
Zona pellucida, i. 161. 
Zymotic diseases in pregnancy, ii. 1. 
,\ %'as a cause of septicemia, iv. 295.