A 1 4TI0NAL LIBRARY OF MEDICINE NLM 0052)035^ 7 SURGEON GENERAL'S OFFICE LIBRARY. ANNEX — , Section,_____________I—_---------- JVo. IShl] $7\ NLM005803597 OBSTETRIC OPERATIONS, THE TEEATMEET OF H^EMOEEHAGE. BY ROBERT BARNES, M.D., LOND., F.R.C.P., OBSTETRIC PHYSICIAN TO, AND LECTURER ON MIDWIFERY AND THE DISEASES OF WOMEN AND CHILDREN AT ST. THOMAS'S HOSPITAL; EXAMINER ON MIDWIFERY TO THE ROYAL COLLEGE OF PHYSICIANS, AND TO THE ROYAL COLLEGE OF SURGEONS ; FORMERLY OBSTETRIC PHYSICIAN TO THE LONDON HOSPITAL, AND LATE PHYSICIAN TO THE EASTERN DIVI8ION OF THE EOYAL MATERNITY CHARITY. m\i\ &frfctfums, BENJAMIN F. DAWSON, M. D., LATE LECTURER ON UTERINE PATHOLOGY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF NEW YORK : ASSISTANT TO THE CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS, N. Y. ; PHYSICIAN FOR THE DISEASES OF CHILDREN TO THE NEW YORK DISPENSARY J MEMBER OF THE NEW YORK OBSTETRICAL SOCIETY J OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK, ETC. SECOND AMERICAN EDITION. NEW YORK: D. APPLETON & COMPANY, 549 & 551 BROADWAY. ci • d.^roM GF ■■'F R ••; "-■'■> *-!;" f" iCt GGi.-il-i^' y 19 7 ^ Entered, according to Act of Congress, in the year 1870, by D. APPLETON & CO., In the Clerk's Office of the District Court of the United States for the Southern District of New York. TO T. GAILLARD THOMAS, M. D., PROFESSOR OF OBSTETRICS AND THE DISEASES OF WOMEN AND CHILDREN IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK ; VICE-PRESIDENT OF THE MEDICAL SOCIETY OF THE COUNTY OF NEW YORK, ETC., AS AN EVIDENCE OF THE HIGH BEQABD AND GRATITUDE OS1 THE EDITOR. EDITOR'S PREFACE. To the student and practitioner this work will prove of the greatest value, being, as it is, a most perfect text- book on "Obstetric Operations" by one who has fairly earned the right to assume the position of a teacher. Aware that it would have been presumptuous to have attempted any improvement of Dr. Barnes's valuable ad- dition to the science of Obstetrics, the editor has therefore simply inserted such notes and additions in the original work as the differences in procedure, and in instruments in this country, rendered necessary or advisable. He trusts, therefore, that any apparent shortcomings on his part will be excused, and that the work, as pre- sented for the first time to the profession of the United States, will meet with that favor which the name of its author should entitle it to receive. The second edition of this work is offered to the profes- sion, with a few additional pages, on subjects not treated of in the original work, but which were considered sufficiently important by the editor to merit incorporation into so popular a book. He hopes these additions, therefore, will help to render the work as popular in this country as it is in England. New York, 8 East Fifteenth Street, Ap-il, 1871. AUTHOR'S PREFACE. It has long been my intention to write a systematic work, embracing all the topics usually treated of in Manu- als of Obstetrics. When I first formed that intention, the task would have been comparatively easy. Increased experience, supplying greater store of mate- rial, and compelling to more searching judgment of current doctrines and practice, makes it more and more difficult to satisfy myself and to do justice to others. In the mean time, as occasion prompted, I have discussed in the form of monographs, or lectures published in the Transactions of Societies or in the medical journals, many of the most important questions in obstetrics. Among these, the " Lectures on Obstetric Operations," which were published in the Medical Times and Gazette, in 1867, 1868, and 1869, on the invitation of the editor, cover a consider- able range, and form a fairly comprehensive treatise on a great department of obstetric practice. I have received so many assurances that these Lectures supply, to a certain extent, a want long felt by practitioners and students, that I gladly accepted the proposal of the publishers to reissue them at once in the more convenient shape of a separate volume. viii AUTHOR'S PREFACE. To this I was further stimulated by the flattering offer of an American physician to edit the Lectures for me, with notes and additions by himself; and by the enterprise of American publishers, who have announced their intention to republish them. I did not respond to these obliging overtures, because I humbly felt that the author was the most competent person to revise his own work, he being fully conscious that it required revision; and because I hoped that a new edition, corrected and extended by my- self, and published in England in the English language, would be not less acceptable to my professional brethren in America than an imperfect reprint done on their side of the Atlantic. The design of these Lectures was to illustrate the mechanism of the various forms of difficult labor, carefully studying the ways of Nature in dealing with them, so as to deduce from this study indications how to assist Nature when she wanted help ; to illustrate and place upon exact foundations the powers and applications of the instruments and operations used in obstetrics; and to give such a view of operative midwifery as would represent more faithfully than was done in any systematic work the practice of those who are most actively engaged in coping with difficult cases. I believe that those who have had the greatest experi- ence in difficult midwifery will be the most ready to ac- knowledge that the existing manuals—and I do not limit this proposition to English manuals—are not on a level with the actual practice of the more scientific and skilful opera- tors. Every one who is frequently called upon to act under the sudden emergencies and various difficulties of obstetric AUTHOR'S PREFACE. ix practice, if he be endowed with any measure of indepen- dent thought and energy, will infallibly work out for him- self new principles and methods of action. He will very soon discover the defects left by routine teaching; he will quickly detect that much of that teaching is traditional, conventional; that it shows but faint impressions of hav- ing been proved and moulded in the conflict with actual work. Nothing has astonished me more than to find that the old English straight forceps, variously modified, indeed, but never emancipated from the narrow conditions which cripple the uses of the greatest of all conservative instru- ments, is still advocated by some men of position, to the exclusion of the long double-curved forceps. The inexorable consequence of the neglect of the dou- ble-curved forceps is the frequent destruction of the child, and protracted suffering of the mother. But this prejudice in favor of an instrument, feeble, and therefore limited in its application—a prejudice fatal to life, and fatal to all scientific progress—is, I know, giving way. "We shall not long be justly open to the reproach which our Continental brethren hurl against us, and which is thus expressed by Lovati, one of the chiefs of the Italian school: " In England they do not hesitate to kill the child, not only in order to save the mother from the dangers of the Caesarean section, but even to spare her the suffering of the simple application of the forceps," In the hope of helping on this desirable reform, I have devoted great pains to the illustration of the powers of the forceps, to the indication of the cases in which it may be of service, and to the description of the modes of using the X AUTHOR'S PREFACE. instrument. I believe that this subject is treated more fully and more accurately than has hitherto been done. In discussing what can be done by the forceps, and by turning, and by the proceedings for provoking and acceler- ating labor, I have striven earnestly to extend the range and applications of these conservative means, and to restrict within the narrowest limits the resort to the sacrificial operations. Pursuing a similar leading principle, that of giving to the mother the precedence over her unborn child which is her right, I have next sought to secure to her the highest degree of safety. This I do by showing that by the im- proved operations for lessening the bulk of the foetus, as by the craniotomy-forceps, the use of a cephalotribe at once powerful and compact like those of Simpson, Kidd, and Braxton Hicks, and by my new operation for reducing the head by sections by the wire-ecraseur, we may limit the Csesarean section to those extremely rare cases in which the pelvis measures less than one inch and a half in the conju- gate diameter. A treatise on operative obstetrics cannot be complete without a description of the methods of dealing with haemorrhage. I have, therefore, added new Lectures upon this deeply- important subject. My "Lettsomian Lectures" have been some time out of print, and I have thought it more convenient to incorpo- rate in this volume a compendious view of my matured opin- ions on the subject of placenta prsevia than to comply with the demand of my publisher for another edition. When I first ventured to put forth my views of the physiology and AUTHOR'S PREFACE. xi treatment of placenta prsevia, I did so on the conviction of their truth, derived from careful observation at the bedside and anxious study and reflection. I now find that these views have received confirmation from so many practitioners of repute, who have put them in practice, that I feel no hesitation in presenting them as containing the true prin- ciples of dealing with one of the most formidable of all the dangers attending pregnancy and labor. I have next sought to place upon its true physiological basis the treatment of the terrible haemorrhages which oc- cur after the birth of the child. All the ordinary methods of arresting uterine haemorrhage depend for their efficacy upon their power of directing nerve-force to the uterus to cause its contraction. But, if the woman has sunk so low that nerve-force enough for this purpose does not remain, the art of the physician is exhausted; unless, indeed, he can find in the system another power through which other remedies may act. This other power exists in the coagula- bility of the blood ; and there are styptics which will plug the vessels left open by the paralyzed muscular walls. The timely use of all the means we possess for arresting haemor- rhage will almost always keep the loss within limits com- patible with recovery; and, in those exceptional cases where haemostatic means have failed, we may still hope to save by the restorative operation of transfusion. Feeling strongly that there is something defective in our art, or in ourselves, if a woman is suffered to bleed to death, I have spent much care upon the exposition of the conditions upon which arrest of haemorrhage depends, and I have insisted upon the necessity of improving and extending the operation of transfusion. xii AUTHOR'S PREFACE. In seeking illustrations, I have drawn almost exclusively from my own experience and reflection. In so doing I may have failed somewhat in artistic nicety, but I believe that the diagrams are generally clear enough to serve their pur- pose. I was especially desirous to avoid the errors which ensue from the servile practice of copying ; a system fatal to progress, under which errors acquire the accumulating force of tradition, while in reality they are often losing what truth was originally in them. And, moreover, as I had many new ideas to express, I had, in most cases, no choice but to present new illustra- tions. In a few of the drawings I have had the able as- sistance of Mr. Dennison, the Librarian of St. Thomas's Hospital. To my friend and former Resident Accoucheur at the London Hospital, Dr. Woodman, I am indebted for ready and valuable assistance in helping the book through the press. The guiding principle I have kept steadily before me has been, to save the lives, to diminish the suffering, of wom- en in labor, and to rescue their offspring to the utmost extent consistent with that first imperative duty. That the attainment of these great objects may be promoted by dili- gent study of the principles and skilful execution of the practice set forth in this book is my most earnest yet con- fident aspiration. Robert Barnes. 31 Grosvenor Street, Grosvenor Square, November, 1869. CONTENTS. CHAPTER I. PAQB ■ Introductory—Description and Selection of Instruments, . . .11 CHAPTER II. The Powers of the Forceps—the Force by which it holds the Head—the Compressibility of the Child's Head,.......28 CHAPTER III. The Forceps—The Lever—Demonstration that the Lever is a Lever, not a Tractor; also that the Forceps is a Lever,.....38 CHAPTER IV. The Application of the Short Forceps—Head in First Position—Head in Second Position—Objections to Short Forceps,.....46 CHAPTER V. The Application of the Long or Double-curved Forceps—Introduction of the Blades—Locking—Causes of Failure in Locking—Extraction- How to measure the Advance of the Head—The Manoeuvre of " shelling out" the Head delayed at the Outlet—Relocking—The Head is seized obliquely by the Forceps—Time required for Extraction, . . .65 CHAPTER VI. Causes of Arrest in First Labors—Disturbed or Diverted Nerve-Force— The Uterine and Perineal Valves—The Ponding up of Liquor Amnii —The Forceps to deliver the After-coming Head, . . . .70 1 xiv CONTENTS. CHAPTER VII. PAGE Application of the Long Forceps in Fronto-anterior Positions of the Head —The Mechanism by which Fronto-anterior, Forehead, and Face Po- sitions generally, are produced—The Management of these Cases, . 78 CHAPTER VIII. The Forceps in Disproportion of the Pelvis—Degrees of Disproportion— Indications in Practice—The Mechanism of Labor in Contraction from Projecting Promontory—the Curve of the False Promontory— Debatable Territory on the Confines of the Several Operations—Pen- dulous Abdomen—The Cause of Difficulty in Pendulous Abdomen— Suspended Labor—The Mode of Management,.....90 CHAPTER IX. Dystocia from Faulty Condition of the Soft Parts—Contraction of the Cervix Uteri—Rigidity—Spasm—Deviation—Hypertrophy—Cicatrix —Closure—(Edema—Thrombus—Cancer—Fibroid Tumors—The Nat- ural Forces that dilate the Cervix—The Artificial Dilating Agents— Vaginal Irrigation—Water Pressure—Incisions—Resistance oflFered by the Vagina, Vulva, and Perinaeum—Thrombus of the Vulva, . 100 CHAPTER X. Turning—Definition—The Conditions which determine the Normal Posi- tion of Foetus — Causes of Malposition—Frequency of Change of Position of Foetus in Utero—The Powers of Nature in dealing with Unfavorable Positions of the Child—The Truth of Denman's Account of Spontaneous Evolution—The Mechanism of Head-labor the Type of that of Labor with Shoulder-presentation,.....116 CHAPTER XI. The Modes in which Nature deals with Shoulder-presentations analogous to those in which she deals with Head-presentations, . . . 130 CHAPTER XII. Definition of Spontaneous Version and Spontaneous Evolution—Varieties of Spontaneous Version—Mechanism of Spontaneous Version by the Breech—Spontaneous Evolution—Mechanism of, in the First Shoulder presentation, Dorso-anterior,........134 CONTENTS. xv CHAPTER XIII. PAGE Turning continued — Spontaneous Evolution—Mechanism of, in First Shoulder-presentation, Abdomino-anterior; in Second Shoulder-pre- sentation, Dorso-anterior and Abdomino-anterior—Spontaneous Evo- lution by the Head—The Mechanism of Spontaneous Version and of Spontaneous Evolution further illustrated. The Conditions requi- site for Spontaneous Version—Examples of Spontaneous Version by the Head and by the Breech,........146 CHAPTER XIV Applications of the Knowledge of the Mechanism of Spontaneous Version and Spontaneous Evolution to the Practice of Artificial Version and Artificial Evolution—The Bi-polar Method of Turning, History of— Artificial Version by the Head—Reasons why Version by the Breech is commonly preferred—Illustrations of Head-turning, or Correction of the Presentation, before and during Labor in Obliquity of the Uterus and Foetus, Shoulder-presentation, Forehead and Face Pre- sentations, Descent of Hand or Umbilical Cord by the Side of the Head,............]58 CHAPTER XV. Turning continued—The Management of certain Difficult Breech-pre- sentations, ... .......172 CHAPTER XVI. Podalic Bi-polar Turning—The Conditions indicating Artificial Turning in Imitation of Spontaneous Podalic Version, and Artificial Evolution in Imitation of Spontaneous Podalic Evolution—The several Acts in Turning and in Extraction—The Use of Anaesthesia in Turning— Preparations for Turning—The State of Cervix Uteri necessary—The Position of the Patient—The Uses of the two Hands—The three Acts of Bi-polar Podalic Version,........183 CHAPTER XVII. The Operation of Extraction after Podalic Version, or other Breech-first Labors.—The three Acts in Extraction; the Birth of the Trunk, in- cluding the Care of the Umbilical Cord ; the Liberation of the Arms ; the Extraction of the Head,........1 i XVI CONTENTS. CHAPTER XVIII. PAGE Turning when Liquor Amnii has run off, the Uterus being contracted upon the Child—The Principle of seizing the Knee opposite to the Presenting Shoulder illustrated,........210 CHAPTER XIX. Turning in the Abdomino-anterior Position—Incomplete Version, the Head remainiag in Iliac Fossa ; Causes of; Compression by Uterus; Treat- ment of—Bi-manual or Bi-polar Turning when Shoulder is impacted in Brim or Pelvis,...........-19 CHAPTER XX. Turning continued—Imitation or Facilitation of Delivery by the Process of Spontaneous Evolution—Evisceration—Decapitation—Extraction of a Detruncated Head from the Uterus,......225 CHAPTER XXI. Turning in Contracted Pelvis as a Substitute for Craniotomy—History and Appreciation—Arguments for the Operation: The Head comes through more easily, Base first; the Head is compressed laterally; Mechanism of this Process explained—Limits justifying Operation— Signs of Death of Child—Ultimate Resort to Craniotomy if Extraction fails—Indications for turning in Contracted Pelvis—The Operation— Delivery of the After-coming Head,....... 235 CHAPTER XXII. Craniotomy: The indications for the Operation: the Operation; two Or- ders of Cases; Perforation simple, and followed by breaking-up or crushing the Cranium, and Extraction—Exploration; Perforation- Extraction by Crotchet; by Turning; Delivery by the Craniotomy- Forceps—Use as an Extractor—as a Means of breaking-up the Cra- nium—Use in Extreme Cases of Contraction—Delivery by the Cephal- otribe—Powers of the Cephalotribe—Comparison with Craniotomy- Forceps—The Operation—Dr. D. Davis's Osteotomist—Van Huevel's Forceps-Saw—Injuries that may result from Craniotomy, . . . 258 CHAPTER XXIII. The Caesarean Section—The Indications for—The Moral Aspect of the Operation as between Mother and Child—Conditions that render the Operation necessary—Question between Caesarean Section and Turn- CONTENTS. xvii ing in Moribund and Dead Women to save the Child—The Time to select for the Operation—Preparation for operating—The Operation— The Dangers attending it and the Prognosis—Symphyseotomy—Gastro- Elytrotomy,...........281 CHAPTER XXIV. The Induction of Premature Labor—The Moral Bearing of the Operation— • The Fitness of the System and of the Genital Organs for Premature Labor—The Insufficiency of Simply Provocative Means—Two Stages of Premature Labor artificially induced—The Provocative; the Accel- erative—Discussion of the Various Provocative Agents—Danger of the Douche—Action of the Various Dilators—The Mode of Pro- ceeding—Provocation Over-night—Acceleration and Conclusion of Labor next Day—Description of Cases demanding Induction Labor— Mode of determining Epoch of Gestation—Proceeding in Contracted Pelvis or other Mechanical Obstructions—In Cases of Urgent Distress of the Mother—As a Prophylactic Resource in Midwifery, . . .311 CHAPTER XXV. Uterine Haemorrhage—Varieties : Classification of—From Abortion— Causes of Abortion : Maternal, Ovuline, and Foetal—Course and Symptoms of Abortion—Treatment—The Placental Polypus—The Blood Polypus—The Plug—Perchloride of Iron—Prophylaxis—Hy- datiginous Degeneration of the Ovum, ...... 350 CHAPTER XXVI. Placenta Prsevia—Historical References: Mauriceau, Portal, Levret, and Rigby—Modern Doctrines expressed by Denman, Ingleby, and Church- ill—The Old and the Author's Theories of the Cause of Haemorrhage in Placenta Praevia—The Practice of Forced Delivery, Dangers of— Theory of Placental Source of Haemorrhage, and Method of totally detaching the. Placenta—The Course, Symptoms, and Prognosis of Placenta Praevia—The Author's Theory of Placenta Praevia, and Treatment—The Plug—Puncture of the Membranes—Detachment of Placenta from Cervical Zone—Dilatation of Cervix by Water-pressure __Delivery—Series of Physiological Propositions in reference to Placenta Praevia—Series of Therapeutical Propositions—The so-called "Accidental Haemorrhage,"........365 CHAPTER XXVII. Haemorrhage after the Birth of the Child—Cases in which the Placenta is retained —Cases after the Removal of the Placenta—Secondary xviii CONTEXTS. Haemorrhage—Causes of Retention of Placenta—Mode of conducting Third Stage of Labor—Consequences of Retention of Placenta—En- cysted or Incarcerated Placenta—Hour-glass Contraction—Means of effecting Detachment and Expulsion of Placenta—Adhesion of the Placenta—Causes —Treatment—Placenta Succenturiata—Placenta Duplex—Placenta Velamentosa—Haemorrhage from Fibroid Tumor and Polypus—Inversion of the Uterus, Recent and Chronic—How produced—Treatment—Diagnosis,.......409 CHAPTER XXVIII. Haemorrhage after the Removal of the Placenta—Two Sources : The Pla- cental Site; the Cervix Uteri—Natural Agents in arresting Haemor- rhage—Symptoms, Diagnosis, and Prognosis of Haemorrhage from Inertia—Artificial Means of arresting Haemorrhage—Means designed to cause Uterine Contraction: passing the Hand into the Uterus, Ergot, Turpentine, Cold, kneading the Uterus, plugging the Uterus, Compression of the Aorta, Compression of the Uterus, Binder, and Compress—Indications how far to trust the foregoing Agents—The Dangers attending them—Means designed to close the Bleeding Ves- sels : by Coagula, the Perchloride of Iron—Restorative Means: Opium, Cordials, Salines, Rest—Transfusion—Secondary Haemorrhage, 437 CHAPTER XXIX. (Appendix.) Twin-labor—Head-locking of Twins—Haemorrhage in Twin-labor—Dorsal Displacement of the Arm—Delivery of Monsters, .... 476 LIST OF FIGURES. FIG. PAGE 1. Effect of Labor in modifying Form of Head,.....34 2. Effect of Labor in modifying Form of Head,.....35 3. Action of Lever,..........39 4. Action of Lever,..........40 5. Action of Lever,..........40 6. Action of Lever,..........41 7. Action of Lever,.......... 42 8. Action of Lever,..........43 9. Action of the Forceps,.........44 10. Action of the Forceps,.........45 11. Application of Sacral-blade of Short Forceps,.....48 12. Application of Pubic-blade of Short Forceps, .... 49 13. Single and Double-curved Forceps in situ,......53 14. The Long Forceps. First Stage of Introduction of First Blade, . 67 15. The Long Forceps. Second Stage of Introduction of First Blade, . 58 16. The Long Forceps. Last Stage of Introduction of First Blade and First of Second Blade,........59 17. Introduction of First Blade of Long Forceps,.....60 18. Introduction of Second Blade of Long Forceps, .... 61 19. The Long Forceps locked and grasped, . . .64 20. The Last Stage of Extraction,.......65 21. Arrest of Head by Anterior Uterine Valve,.....72 22. Arrest of Head by Posterior Uterine Valve,.....1& 23. Long Forceps applied to the after-coming Head,.....76 24. Long Forceps applied to the Head in Fronto-anterior Position, . 83 25. Changes from Vertex to Forehead-presentation,.....85 26. Manoeuvre in Forehead-presentation,......86 27. Long Forceps in delayed Face-presentation,.....87 28. Normal Pelvis and Curve of Carus,......91 XX LIST OF FIGURES. FIG. PAGB 29. Rachitic Pelvis, showing Curve of False Promontory and use of For- ceps in,...........92 30. Rachitic Pelvis, showing Curve of False Promontory and use of For- ceps in,...........93 31. Pendulous Abdomen,.........97 32. Pendulous Abdomen, use of Forceps in,.....98 33. The Author's Hydrostatic Dilator in situ,......108 34. Incision of rigid Os Uteri, ...".....HO 35. Model of Normal Pelvis,.........132 36. Slight Obliquity of Foetal Head,.......136 37. Mechanism of Shoulder-presentation,......138 38. Mechanism of Shoulder-presentation,......140 39. Cause of Dystocia in Shoulder-presentation,.....141 40. Cause of Dystocia in Shoulder-presentation (Wedge formed by Child),...........142 41. Right Shoulder; Child after Rotation,......143 42. Right Shoulder; First Position in Rotation round Symphysis, . 144 43. Second Position of Second Shoulder-presentation, . . . 147 44. Right Shoulder; Second Position after Rotation, .... 148 45. Left Shoulder ; First Position after Rotation......149 46. Left Shoulder ; Second Position after Rotation, .... 150 47. Diagram of Spontaneous Version,.......152 48. Diagram of Spontaneous Version,.......152 49. Diagram of Spontaneous Version,.......153 50. Diagram of Spontaneous Version........154 51. Breech-presentation,.........173 52. Mechanism of Breech-presentation,......175 53. Side-View of Breech-presentation,.......176 54. Breech-presentation: how to seize a Foot,......177 55. Seizure of Foot in Breech Labor,.......179 56. Extraction after Breech Labor,.......180 57. Delivery in Difficult Breech Labor,.......131 58. First Stage of Bi-polar Podalic Version,.....193 59. Second Stage of Bi-polar Podalic Version, First Act, . . . 194 60. Second Act of Bi-polar Podalic Version,.....194 61. Third Act in Progress,.........195 62. Third Act completed,.........196 LIST OF FIGURES. xxj PIG. PAGB 63. First Act of Extraction,.........200 64. Liberation of Posterior Arm,.......203 65. Liberation of Anterior Arm,........204 66. Manoeuvre for liberating Arms,.......205 67. Result of ditto,..........206 68. Extraction of Head,.........209 69. Version after Scanzoni,.........214 ' t Correct Methods,.........\ 71. S I 216 72. Porte-lacs,...........216 73. Turning in Abdomino-anterior Position,.....219 74. Turning in Left Shoulder presenting,......220 75. Correction of the Error,........221 76. Bi-polar Method of lifting Shoulder,......223 77. Extraction after Perforation of Chest,......227 78. Delivery by Decapitation, . ......231 79. Extraction of Trunk,.........232 80. Use of Craniotomy Forceps,........233 81. Head entering Contracted Brim,.......243 82. Mode of Extraction in Impacted Head,......254 83. Extraction after removing Calvarium,......269 84. Extraction after removing Calvarium,......270 85. Dr. Hicks's Cephalotribe in use,.......274 86. Diagram showing Division of Uterus into Zones, .... 375 87. Partial Placenta Praevia,........379 CHAPTEK I. Introductory—Description and Selection of Instruments. Two things have to be considered when attempting. to describe the operations in midwifery: 1. What are the emergencies which call upon the prac- titioner to operate % 2. What are the means, the instruments at his disposal ? If each accident or difficulty in labor were uniform and constant in all its conditions, it might be possible to apply to its relief the same operation or the same instrument. The history of operative midwifery might be told in an orderly series of simple mechanical formulae. But how different is the case in practice ! How infinite is Nature in her phases and combinations! The dream of Levret will never be realized. In proportion as observation unfolds these com- binations, ingenuity is ready to multiply the resources of art. To describe these combinations, and the means of meeting them, is a task of ever-growing difficulty. Partial success only is possible. The multitudinous array of instruments exhibited at the Obstetrical conversazione last year, vast as it was, gave but a feeble idea of the luxuriant variety that have been devised. If all these had their individual merits and uses, endless would be the labor of appreciation; the task of describing the op- erations of midwifery would be hopeless. It is, indeed, true that every instrument, even every modification of an instru- ment, represents an idea, although sometimes this idea is not 12 OBSTETRIC OPERATIONS. easy to understand. Fortunately, it is not always important that the idea should be understood. Many of these instru- ments are suggested by imperfect observation, by ill-digested experience; many are insignificant variations upon an idea which, in its original expression, was of little value. Huge heaps, then, of instruments may, without loss to science, and to the great comfort of womankind, be cast into the furnace; the ideas of their inventors melted out of them. All that is necessary in relation to them is, to preserve examples in museums, where they may serve as historical records marking the course of obstetric science in its ebb and flow; for, strange to say, obstetric science has its fluctuations of loss as well as gain, of going back as well as going forward. These his- torical specimens will also serve the useful office of warning against the repetition of exploded errors, and of saving men the trouble and vexation of reinventing. When Science finds herself in the presence of complicated and disordered facts and ideas, her resource is to classify— that is, to seize a few leading ideas under which the sub- ordinate ones may be grouped. In the first instance, the minor or subsidiary ideas—the epigenetic ideas they may be called—are disregarded. The grand or governing ideas only are studied. Then the process of analysis, the descent to details, to particulars, begins; and again, unless we keep a steady eye upon the governing principles, we are in danger of losing ourselves in the infinitely little, of falling into chaos, of running astray from the parent or guiding truth, in fruitless chase of the multitudinous splinters into which it has been subdivided. What, then, have we to do ? Knowing that, we will see how we can do it. Nature, although always requiring skil- ful watching, in the majority of cases does not want active assistance. But the cases are many in which pain, agony, may be averted; in which positive danger has to be en- countered and thrust aside; in which action must be prompt and skilful. Labor is a problem in dynamics. Three fac- FACTORS CONCERNED IN LABOR. 13 tors are concerned in the solution: 1. There is the foetus, the body to be expelled. 2. There is the channel, made up of the bony pelvis and soft parts, through which the body must be propelled; these two together constitute the resist- ing force, the obstacle to be overcome. 3. There is the ex- pelling power, the uterus and voluntary muscles. These factors must be harmoniously balanced, to produce a healthy labor. Labor may come to a stand from error in any one of these factors, or from disturbance of correlation. The permutations are almost infinite in kind and degree. There are many ways in which disturbance may arise. There are not so many ways in which compensation or correction may be made—that is, treatment is more simple than are the causes of disturbance. To take the third factor first. The expelling power may be deficient, the other factors preserv- ing their due relations. This power is a vis a tergo. The want of it may be made good in one of two ways. We may in some cases spur the uterus and its auxiliary muscles to act. The power may be dormant only; it exists potentially, capable of being roused by appropriate stimulus. This is the case for oxytocics, such as ergot, cinnamon, borax, or cinchona. But the power may not be there, or, if there, it may not be wise to provoke it to action. An interesting question arises here: Can we, without resorting to oxytocic medicines, arouse or impart a vis a tergo f Can we apply direct mechanical force to push the foetus out of the uterus, instead of dragging it out ? Now, in some cases this seems possible. Yon Ritgen,1 in a memoir on " Delivery by Pressure instead of Extraction," adverting to the fact that the natural mode is by pushing out, said that the artificial mode was by dragging out; and asked very pertinently, " Why do we always drag and never push out the foetus?" Dr. Kristeller2 has carried the idea into practice. By means of a dynamometric forceps he has shown that a force of five, six, or eight pounds only is often 1 Monatsschr. f. Geburlsh., 1856. 2 Ibid., 1867. 14 OBSTETRIC OPERATIONS. sufficient to extract a head that has lain for hours unmoved; so that the force to be administered in the form of pressure need not be very great. It is needless to premise that the presen- tation and the relations of foetus and pelvis must be normal. The method is as follows: The patient, lying on her back, the operator places his hands spread on the fundus and sides of the uterus, and combining downward pressure with the palms on the fundus, with lateral pressure by means of the fingers, the uterus being brought into correct relation with the pelvic axis, its contents are forced down into the cavity. The pressure is so ordered as to resemble the course and periodicity of the natural contractions. Of course, the press- ure will often excite uterine contraction to aid or even sup- plant the operator. But it seems that pressure alone is sometimes sufficient. As an adjuvant to extraction, press- ure is, I know, of great value. I never use the forceps or any extracting means without getting an assistant to com- press the uterus firmly, to maintain it in its proper relation to the axis of the brim, and to help in the extrusion of the foetus. This resource, then, should not be lost sight of. In certain cases it may obviate the necessity of using the for- ceps ; or it may stand you in good stead when instruments are not at hand. When a vis a tergo cannot be had, we have the alternative of supplying power by imparting a vis afronte. In the case we are supposing, the means of doing this reside chiefly in two instruments—the lever and the for- ceps. In the second order of cases there is a want of correla- tion between the body to be expelled and the channel which the body must traverse. There are many varieties of this kind of disturbance. The progress of the head may be op- posed by rigidity of the soft parts, especially of the cervix uteri. Patience is one great remedy for this. A dose of opium and a few hours' sleep will sometimes accomplish all that is desired. But patience may be carried too far. If the pulse rise and the sufferer show signs of distress, it is MECHANICAL RESOURCES. 15 proper to help. I have no faith in belladonna. To excite vomiting by tartar emetic is to add to the distress of the pa- tient without the certainty of relieving her. To bleed is also to indulge in a speculation that will certainly cost the patient strength she will need, and it promises only doubt- ful gain. We have two mechanical resources to meet this strictly mechanical difficulty. There is the hydrostatic di- lator, which I have contrived for the express purpose of ex- panding the cervix. In the case of a cervix free from dis- ease, dilatation will commonly proceed rapidly and smooth- ly under the eccentric pressure of these dilating water-bags, which closely imitate in their action the hydrostatic pressure of the liquor amnii. In the case of rigidity from morbid tissue, as from hypertrophy or cicatrices, something more may be necessary. The timely use of the knife wilP save from rupture, from exhaustion, or from sloughing. I have contrived a very convenient bistoury for this purpose. It is carried by the finger into the os uteri, multiple small nicks are made in its circumference, and by alternate distention with the water-bags the cervix may be safely and sufficiently dilated. The foetus and the channel may be duly proportioned, but the position of the child is unprqpitious. In this case all there is to do is to restore the lost relation of position. The hand, the lever, and the forceps, are the instruments. There is disproportion. This may be of various kinds and degrees. The varieties will be more conveniently unfolded hereafter. It is sufficient to say here that all resolve them- selves, in practice, into three classes : 1. Disproportion that can be overcome without injury to the mother, and with probable safety to the child. 2. Disproportion that can be overcome without injury to the mother, but with necessary sacrifice of the child. 3. Disproportion that can be overcome with possible or probable safety to both mother and child. The first class of cases may be relieved by the hands, or 16 OBSTETRIC OPERATIONS. by the forceps. The second by reducing the bulk of the child to such dimensions as will permit it to pass through the contracted channel. The perforator, the crotchet, the craniotomy forceps or cranioclast, the cephalotribe, the for- ceps-saw, are the principal instruments for bringing the bulk of the child down to the capacity of the pelvis. In the third class of cases we cannot insure the mother's safety by sacrificing her child. We therefore seek her 'probable safety by an operation—the Caesarian section— which evades the difficulty of restoring the relation of bulk and capacity between foetus and pelvis, by extracting the foetus through an artificial opening in the mother's abdo- men. The instruments required for this purpose are not specially obstetrical. But a bistoury, scissors, needles, and sutures, silk or silver, take but little room, and, as they may at any unforeseen moment be wanted, they should always be found in the obstetric bag. And we shall have to put into it a few other instruments and accessories in order to be prepared for all emergencies. Let us enumerate all in order. Obstetric Instruments—The Obstetric Bag. 1. A lever. 2. A pair of long double-curved forceps. 3. Roberton's apparatus for returning the pro- lapsed funis. 4. A craniotome or perforator. 5. A crotchet. 6. A craniotomy forceps. 6a.Simpson's cephalotribe? 7. Ramsbotham's decapitating hook. 8. A blunt-ended straight bistoury, with a cutting edge of three-quarters of an inch, to incise the os uteri in cases of extreme contraction or cicatrization. A hernia-knife answers very well. S3 3o OBSTETRIC INSTRUMENTS. 17 03 l-i n ° s8 9. A Higginson's syringe, fitted on my plan, with a flexible uterine tube (9 inches long), which serves for the injection of iced water or per- chloride of iron, to arrest haemorrhage, and also serves to expand. 10. A set of my caoutchouc hydrostatic uterine dilators. 11. Three or four elastic male bougies (No. 8 or 9). 12. A porcupine-quill to rupture the membranes. 13. A flexible male catheter. (The short silver fe- male catheter is often useless, and is generally less convenient than the flexible male catheter.) 11. A pair of scissors and thread. J| § ( 15. A bistoury. Ill 1 16. Sutures, silk, and silver. o Medicines. 1. Chloroform and inhaler. 2. Laudanum. 3. Hofmann's anodyne. 4. Ergot of rye. 5. Solution of perchloride of iron. The liquor ferri per- chloridi fortior (Brit. Pharm., 1867). An ounce of this diluted with six ounces of water is an efficient haemostatic. The most convenient mode of packing these instruments is to adapt a travelling leather-bag. There is always spare room for any thing likely to be wanted besides its ordi- nary furniture, or for bringing away a pathological speci- men ; and by turning out the obstetric furniture you have a travelling-bag again. [The instruments constituting the Obstetric Cases of Prof. George T. Elliot, of Bellevue Hospital Medical Col- lege, Prof. T. G. Thomas, of the College of Physicians and Surgeons, N. Y., and Prof. C. A. Budd, of the Medical De- partment of the University of New York, are as follows: 2 18 OBSTETRIC OPERATIONS. Prof. Elliot's Case. 1 Elliot's long forceps. 1 Tiny pair short forceps (straight). 1 Small " " " (curved). 1 Yectis, with Elliot's blades and curves. 1 Blot's Perforator. 1 Churchill's crotchet, double and dull-pointed. 1 Elliot's modification of Simpson's cranioclast. 1 Blunt Hook, with separate curves for handle. 1 Van Huevel's, Lomly Earle's, King's, and Francis's pelvime- ters. 1 Belloc's inst. for plugging post. nares (to carry a fillet). Barnes' and Tarnier's dilators. 1 Male gum-elastic catheter. Prof. Thomas's Case. 1 Elliot's long forceps. 1 Davis's short forceps. 1 Simpson's cephalotribe. 1 Simpson's cranioclast. 1 Trephine perforator. 1 Crotchet and blunt hook. 1 Silver catheter. 1 Gum-elastic catheter. 1 Batchelder's modification of Smel- lie's scissors. 1 Gardner's vectis. Prof. Budd's Case. 1 Budd's long forceps. 1 Short Simpson's forceps. 1 Davis's craniotomy forceps. 1 Braun's cephalotribe. 1 Blunt hook. 1 Gordon's crotchet (guarded). 1 Thomas's perforator. 1 Xaegele's perforator. 3 ij | square phials (chloroform, ergot, opium).] I will now say a few words in explanation of the instru- ments recommended: 1. The Lever.—The form adopted is that of Mr. Sy- monds, of Oxford. The blade or fenestra is rather strongly arched ; and there is a joint in the shank, enabling the in- strument to be doubled up for the greater convenience of carrying. 2. The Forceps.—There are several excellent models. I am not bigoted in favor of my own. The best are Simpson's 1 Prof. Elliot is having constructed a cephalotribe of an entirely new model, and is perfecting his Perineal Protector. He is also engaged in testing the value of Joulin's Aid-Forceps.—Ed. REQUISITES OF THE FORCEPS. 19 and Roberton's. The essential conditions to be contended for are—that the blades have a moderate pelvic curve; a head-curve also moderate; an extreme divergence, between the fenestrae, of three inches; the length of the arc of the cranial bow of about seven inches, to adapt it to the elonga- tion of the foetal head during protracted labor. There should be between the springing of the bows and the lock a straight shank to lie parellel with its fellow, to carry the lock clear of the vulva and save the perinaeum. In my forceps the shank is further lengthened by a semicircular bow, which forms a ring with its fellow when locked. The use of this is to give a hold for the finger of one hand while the other grasps the handles. In Simpson's instrument there is a hollowed shoulder at the head of each handle which answers a similar purpose, and perhaps better. The lock should be easy—a little loose. The English lock is not, I think, surpassed for convenience; but the French lock is a good one. The handles should not be less than five inches long. They should afford a good grasp. Unless they are strong and of fair length, they cannot exert any compressive force for want of leverage, for the fulcrum is at the lock. I think all forceps that have very short handles, especially if not provided with some means, such as the ring, or projecting shoulders, which will enable the operator to use both hands, ought to be rejected. A two-handed in- strument can be worked with the utmost nicety and economy of muscular force. A single-handed instrument is neces- sarily a weak one. The absurd dread of possessing power- ful instruments has long been the bugbear of English mid- wifery. It has been sought to make an instrument safe by making it weak. There can be no greater fallacy. In the first place, a weak instrument is, by the mere fact of its weakness, restricted to a very limited class of cases. In the second place, if the instrument is weak, it calls for more muscular force on the part of the operator. Now, it is some- times necessary to keep up a considerable degree of force for 20 OBSTETRIC OPERATIONS. some time, and not seldom in a constrained position. Fatigue follows ; the operator's muscles become unsteady ; the hand loses its delicacy of diagnostic touch, and that exactly-bal- anced control over its movements which it is all-important to preserve. Under these circumstances he is apt to come to a premature conclusion that he has used all the force that is justifiable—that the case is not fitted for the forceps—and takes up the horrid perforator ; or he runs the risk of doing that mischief to avoid which his forceps was made weak. The faculty of accurate graduation of power depends upon having a reserve of power. Yiolence is the result of strug- gling feebleness, not of conscious power. Moderation must emanate from the will of the operator; it must not be looked for in the imperfection of his instruments. The true use of a two-handed forceps is to enable one hand to assist, to relieve, to steady the other. By alternate action the hands get rest, the muscles preserve their tone, and the ac- curate sense of resistance which tells him the minimum de- gree of force that is necessary, and warns him when to de- sist. A similar reasoning applies to the perforator and the craniotomy forceps. # [In the United States the forceps of Elliot, Hodge, Thomas, and Bedford, are most generally used, especially those of the two former, the first of which has the addition of a sliding pin on one handle and which is invaluable in graduating com- pression and preventing its risks. By its aid we can decide upon the exact approximation of the blades desired, and thus relieve our minds of any risk of pressure. The slender and narrow blades of Prof. Elliot's forceps allow it the widest range of usefulness. On the whole, however, it is impossi- ble to name any instrument which is suitable for every case. In his " Obstetric Clinic " Prof. Elliot gives the following requisites for a forceps: " All that can be expected from a single instrument is that it should take up as little room as is consistent with strength, and its uses; that it should afford every opportunity for powerful traction, without risking THE FORCEPS, THE PERFORATOR, ETC. 21 compression, until compression should be demonstrated to be unavoidable ; that it should have such a pelvic curve as may enable the operator to convert occipito and mento- posterior positions into anterior positions, provided no other conditions prevent; that it should have no edges liable to project unduly and risk the laceration or cutting of maternal tissues. It is my belief that fenestrae diminish somewhat the risk of injuring the head, especially the ear ; but it is com- paratively unimportant whether they are present or not. Straight forceps may be used to deliver through the brim. It is, however, my conviction that a slight pelvic curve is desirable, and that it diminishes the risk of lacerating the perinEeum and vagina, in cases where this is projecting and rigid, and tractions have to be carefully made in the direc- tion of the superior strait. On the whole, it is my conviction that a slight pelvic curve will render this instrument better for beginners."—pp. 302, 303.] Robertorts Tube for Prolapsed Funis.—There are many contrivances for returning the prolapsed cord. Braun's is an excellent one; one by Hyernaux, of Brussels, is also very ingenious and useful, but Roberton's appears to me the most simple. By the postural method [known in the United States as " Thomas's method"], indeed, all instruments may be dispensed with ; but still it is well to be provided with this very simple apparatus. The Perforator.—The instruments designed to open the skull are classed in the Obsterical Society's Catalogue under four types: 1. The wedge-shaped scissors, having blades cutting on the outer sides. 2. The spear-head. 3. The conical screw. 4. The trepan. Mr. Roberton uses a spear- head. The form most in use in this country is some modi- fication of Smellie's wedge-shaped scissors , but many of these instruments are very clumsy and inefficient. It re- quires sometimes considerable force to penetrate the crani- um. A weak instrument is here especially dangerous: it is apt to slip, to glide off the globe of the head at a tangent 22 OBSTETRIC OPERATIONS. and to tear the uterus. The conditions of efficiency^ are these : The perforating blades must be strong and straight. The curve sometimes given is of no use whatever, as it throws the force out of the perpendicular. The shanks must be long, eight inches at least, so as to reach the pelvic brim without interfering with the working of the handles. There should be a broad rest for the hand, to give a powerful and steady hold. Almost all the instruments in use fail in this point. The best of all those I have tried and seen is the modification of Holmes's and Naegele's by Dr. Oldham; it fulfils every indication. On the Continent, especially in Germany, the trepan, first introduced by Assalini, at times variously modified, is chiefly used. To use a trepan, the crown of which can hardly be less than an inch in diameter, you must have at least an equal amount of surface of the cranium accessible, and the crown must be applied quite perpendicularly to the cranium. Now, these conditions are not always present. I have been much pleased in some cases with the trepan of Professor Ed. Martin, of Berlin. But in others, where the pelvic deformity was great, and especially where it was necessary to perforate after the body was born, there was no room for the passage or appli- cation of the instrument. I found no difficulty with Dr. Oldham's perforator ; it will run up through the merest fis- sure wherever the finger will go to guide it, and will readily penetrate any part of the skull. This, then, is the perfora- tor to be preferred.1 The Crotchet.—The design of the crotchet was to seize and extract, by taking a hold inside the cranium, after per- foration. For this purpose the best crotchet is the one used in the Dublin Lying-in Hospital. It has a curve in the shank, which is set in a transverse bar of wood for a handle. This gives an excellent hold for traction, that does not fatigue or cramp the operator. The crotchet, however, as an extracting instrument, has been greatly displaced by the 1 It is figured in the Obstetrical Society's Catalogue of Instruments, p. 167. CRANIOTOMY FORCEPS AND CEPHALOTRIBE. 23 craniotomy forceps. The use to which I now almost restrict the crotchet is to break up the brain and tentoria, so as to facilitate evacuation and collapse of the skull. The Craniotomy Forceps.—The use of this instrument is twofold. It should be able to break up and pick away the bones of the cranial vault, and to grasp firmly the skull to serve as an extractor. In the majority of cases the lat- ter action alone is necessary. For extraction, the essential condition is to have the blades so made that, when grasping, they shall be perfectly parallel. Unless this be obtained, the blades will only pinch at one point, and the effect will be to break through the bone, to tear through the scalp, and to come away. Each time the attempt is renewed, if ever so little traction is necessary, you are exposed to the same mishap, until you may find no place left that will afford a hold. To remedy this defect, many instruments are armed with horrent teeth and spikes, which only add to the evil; whereas, if the blades are parallel, they grip firmly over a wide surface, and do not break away. The hold is obtained by compression, by accurate apposition, not by teeth or spikes. To secure the grasp without fatiguing the hands by compressing the handles, I have adapted a screw to bind the handles together. It is also important that the blades should be distinct, so as to admit of being introduced sepa- rately, like the ordinary forceps. These principles are fairly carried out in my craniotomy forceps, and others as well as myself are well satisfied with its merits. But recently they have been more conveniently adapted in an instrument de- vised by my friend Dr. Matthews. He makes the female blade to revolve on a central pivot, so that, the moment it touches by either end the included scalp and cranium, it ad- justs itself in accurate parallelism, and the grip is secured by a sliding ring on the shanks. With such an instrument it is very rarely necessary to take a second hold. The Cephalotribe.—I have marked the cephalotribe with a sign of interrogation, because it has scarcely yet estab- 24 OBSTETRIC OPERATIONS. lished a footing in this country, and because, although I be- lieve it is a valuable instrument, the work it is designed to do can be accomplished by the craniotomy forceps. Cases, however, arise where a preference may fairly be given to it. The unwieldy bulk and formidable appearance of most of the Continental cephalotribes, requiring, as they do, an as- sistant in their use, must preclude their extensive adoption. Almost every objection is removed in Sir James Simpson's instrument. Sufficient power to crush down the base of the cranium after perforation is combined with a minimum oi size and weight. But this instrument need not add to the load already accumulated in the bag. It may be left at home, and fetched when wanted. The Decapitating Hook.—This instrument will be very rarely required, but, when the occasion arises, the service it renders is very great. In a protracted transverse presenta- tion, when the child is dead from compression, the uterus spasmodically and closely contracted upon the child, turning cannot be accomplished without subjecting the mother to much suffering and some danger. In such a case it is ob- viously preferable—the child being past help—to save the mother to the utmost. This hook can be carried over the child's neck, and, by a movement of sawing and traction, the head can be severed in a few seconds. Then the body is extracted by pulling on the prolapsed arm. The head, re- maining alone in ute?'o, can be easily extracted by the craniotomy forceps. Thus delivery can be effected, with little cost to the mother, in a few minutes. The same ob- ject can be attained by a pair of strong scissors (Dubois's), which is made to divide the cervical spine. An excellent decapitator was exhibited' by Jacquemier ; in general form it resembles Ramsbotham's, but it has a concealed or sheathed decapitator, the cutting being effected by movable blades and saw-links. Pajot, again, decapitates by carrying a strong cord round the neck. 1 See Obstetrical Society's Catalogue, p. 47. THE OBSTETRIC HAND. 25 The Syringe, Uterine Tube, and Caoutchouc Dilators.— These are perhaps the most frequently useful of all the instru- ments enumerated. A Higginson's syringe [Davidson's syringe is better known in the United States] is fitted with a mount, to which the flexible uterine tube or any one of my dilators can be adapted. Three sizes of the dilators are suffi- cient. They are now in extensive use at home and abroad. The elastic male bougies are useful as the best means of inducing labor—that is, of provoking labor and the prepara- tory stage. The porcupine-quill is the most con venient instrument for piercing the membranes; and, although a common pin or a steel pen will answer the purpose, these are not always at hand. The special instruments, as stilets, etc., are really superfluous. [The sharpened nail of the operator's finger often answers as well as any thing.] The remaining instruments require no special description. And, lastly, let me add a few words concerning the ob- stetric hand, as the master-instrument of all, not only as guiding all the rest, but as performing many most impor- tant operations unarmed. In ordinary labor it is the only instrument required. It is also the only instrument called for in many of the greatest difficulties. In malpresentations, in placenta praevia, in many cases of contracted pelvis, in not a few cases where, after perforation, the crotchet and craniot- omy forceps have failed to deliver, the bare hand affords a safe and ready extrication. One cannot help seeing that practice is often determined by the accidental perfection of or familiarity with particular instruments. Thus, a man who has only reached that stage of obstetric development which is content with a short forceps will be armed with a good perforator and crotchet. He cannot fail to acquire skill and confidence in embryotomy, and greatly to restrict the application of the forceps. Again, the preference generally given on the Continent to cephalotripsy over craniotomy and extraction by the crotchet or craniotomy forceps is the result 26 OBSTETRIC OPERATIONS. of the great study directed to the perfecting of the cephalo- tribe. At the present day we may boast of having good and effective instruments of all kinds, each capable of doing ex- cellent work in its own peculiar sphere, and moreover en- dowed with a certain capacity for supplanting its rival in- struments. For example, the long forceps is adapted to supplant craniotomy in a certain range of cases of minor dis- proportion. Hence it follows that it is of more importance to have a good forceps which can save life than it is to have a good perforator and crotchet which destroy life. At the same time, it is eminently desirable to possess the most per- fect means of bringing a foetus through a very narrow pel- vis, in order to exclude or to minimise the necessity of re- Borting to the Caesarean section. Our aim should then be to get the most out of all our instruments—to make each one as good of its kind as possible. And admirable is the persever- ance, marvellous and fertile the ingenuity, that have been brought to this task. I will not say it has all been misdi- rected ; but certainly the cultivation of the hand, the study of what it can do in the way of displacing cold iron, has been much neglected. It would not be less instructive than curious to carry our minds back to the days when the for- ceps and other instruments now in use were unknown, and to confront the problem which our predecessors, Ambroise Pare, Guillemeau, and others, had to solve—namely, how to deliver a woman with deformed pelvis without instruments. That they did successfully accomplish in many instances with the unarmed hand what we now do by the aid of various weapons, there can be no doubt. If this implies greater poverty of resources on their part, it not the less im- plies also greater manual skill. I am confident that the possession of instruments, especially of the craniotomy in- struments, has led, within the last century, to a neglect of the proper uses of the hands, which is much to be deplored. We are only now recovering some of the lost skill of oui ancestors. THE HAND IN OBSTETRIC OPERATIONS. 27 Obstetric surgery has this peculiarity : its operations are carried on in the dark, our only guide being the information conveyed by the sense of touch. The mind's eye travels to the fingers' ends. The hand thus possesses an inestimable superiority over all other instruments. Its every movement is regulated by consciousness. It is right, then, to ascend a little the stream of knowledge, and to endeavor to recover from the experience of our forefathers their secret of chi- rurgery / to regain, to extend, that power over the great in- strument from which the surgeon derives his name. CHAPTER II. The Powers of the Forceps—the Force by which it holds the Head—the Com- pressibility of the Child's Head. To arrive at a just idea as to the application of instru- ments in difficult midwifery, it is first of all necessary to study carefully what these instruments can do. What, for example, are the powers of the forceps, the lever, of the crotchet and craniotomy forceps, and of the cephalotribe ? When we know these, and have formed a correct idea of the nature of the labor—that is, of the difficulty to be over- come—we shall know which instrument to select, and how to use it. The powers of an instrument must obviously depend upon its construction; but this is true to an extent not often thoroughly appreciated. Take, for example, the noblest of all—the forceps. It is difficult to exaggerate the importance of developing to the fullest extent the powers of this instrument. The more perfect, the more powerful, we make it, the more lives we shall save, and the more we throw back into reserve those terrible weapons which only rescue the mother at the sacrifice of her offspring. [It is not saying too much to pronounce the invention of the forceps one of the greatest improvements in the history of obstetric science, and, although at times danger- ous to mother or child, yet its life-saving power is so great as to cancel the evil results which have often followed its use.] Three distinct powers or forces can be developed in the POWERS OF THE FORCEPS. 29 forceps. First, by simply grasping the head and drawing upon the handles, it is a tractor, supplementing a vis a froute for the defective vis a tergo. Secondly, the forceps consist- ing of two blades having a common fulcrum at the joint or lock, we can by a certain manipulation use it as a double lever. Thirdly, if the blades and handles are long enough and strong enough, and otherwise duly shaped, the forceps becomes a compressive power capable of diminishing certain diameters of the child's head, so as to overcome minor de- grees of disproportion. Now, all these powers may be brought into use, and all may be in great measure lost, according to our choice of a good or a bad model. Thus, if we rest satisfied with the short forceps of Denman, we shall only have a feeble tractor, a feeble lever, and an instrument having almost absolutely no compressive force. It is obvious that such a forceps can have but a restricted application. It can only serve to de- liver the child when the head is in the pelvis, when very lit- tle tractile power is required. Ask yourselves what this means. What are the consequences in practice? Simply this : you are driven, in a multitude of cases, to perforate, to destroy the child. Such an alternative may well make us reflect whether we cannot extend the powers and the appli- cation of the forceps. By simply lengthening the blades and shanks and giving the blades an additional curve adapted to the curved sacrum, we can reach the head detained at the brim of the pelvis. By moderately lengthening the handles and making the instrument stronger, we increase the lever- age and tractile power, and we gain a moderate compressive power. Thus we bring within the saving help of the forceps a further number of children that must otherwise be given up to the perforator, or run the risk of turning. You ask, Why hesitate to endow the forceps with this great privilege % Why has the feeble forceps of Denman so long held its sway in this country ? The reason is, that there are limits beyond which we cannot push the saving powers of the forceps. If 30 OBSTETRIC OPERATIONS. we pass beyond these limits, we run into danger of injuring the mother and of losing the child. Now, the great contest in all matters of strife is about boundary-lines ; and it is concerning these limits that authorities have differed. Some men are afraid of giving power, lest it should be abused. They are so terrified at the possible mischief which great power may work, that they would rather abandon the good which great power is equally capable of working. They tremble lest we should be unable to acquire the skill and the discretion necessary to direct that greater power. Such men virtually say, you shall not apply the forceps where the head has not descended into the pelvic cavity—an arbitrary limit dictated by fear, and fixed by ignorance that the for- ceps is just as capable of safely delivering a child whose head is arrested at the brim. For here, as is continually the case in medicine, experience arbitrarily limited excludes prog- ress in knowledge and bars improvement in practice. For example, how can a man acquire a just knowledge of the power of the forceps to deliver a head delayed by slight dis- proportion at the brim, if he always delivers under this diffi- culty by perforating \ Clearly, he bars himself from acquir- ing that knowledge; and, giving up his intelligence to the delusive dictates of his wilfully limited experience, he re- fuses even to accept the evidence of those whose experience is greater, because it is directed by a freer spirit of research, by greater confidence in the resources of art. [Dr. Churchill gives the following as the statistics of the frequency of the use of the forceps, among the British, French, and German physicians : " Among the British we find 594 forceps cases in 147,645 cases of labor, or about one in 249. Among the French, 339 cases in 47,175 labor cases, or about one in 140. And among the Germans, 7,074 cases in 755,593 cases, or about one in 106-J. If we add the whole together we find 8,007 forceps cases in 850,713 cases of labor, or one in 106-J."] l 1 ChurchiWs System of Midwifery. American edition, pp. 339, 340. FORCE BY WHICH THE FORCEPS HOLDS. 31 Let us, then, go back to the study of the powers of the forceps, unshackled by any preconceived opinions as to what the instrument can do or can be permitted to do. First, as to its tractile powers. In order to draw, the instrument must take hold. How does it take hold ? You may at first sight suppose that this is accomplished by grasping the handles. But in the case of the ordinary forceps, especially the short-handled forceps, there is little or no compressive power, so that the hold cannot be due to the handles. The hold is really due to the curvature of the blades, which fit more or less accurately upon the globular head, and the compression of the bows of the blades against the soft parts of the mother, supported by the bony ring of the pelvis. This may be made clear by a simple experiment. Take an india-rubber ball, slightly larger in diameter than a solid ring; place the ball upon the ring. Then seize the ball through the ring by the forceps. The blades will be opened out by the ball. Then drawing upon the handles, even without squeezing them together, you will see the blades pressed firmly upon the ball by gradual wedging, as the greatest diameter or equator of the ball comes down into the ring. Just so is it with the child's head and the pelvic brim and canal. The blades are held in close apposition to the head by the soft parts and the pelvis of the mother. In many cases this outward pressure upon the bows of the blades is enough to serve for traction. It is not necessary to tie the handles of the forceps. You may even do without handles altogether. Thus, one of the earliest attempts, stimulated by the desire to realize the concealed discovery of the Chamberlens—that of Palfyn—consisted in applying two opposed levers, which did not cross, and therefore could not exert any compressive force. Assalini's forceps was con- structed on this principle. It is essentially a tractor, with slight leverage power. Professor Lazarewitch, of Kharkov, brought to the Obstetrical Exhibition a beautiful forceps, constructed on Assalini's principle. This instrument I ap- 32 OBSTETRIC OPERATIONS. plied in two cases. It held admirably; but all its holding power is due to the pressure exerted by the mother's parts upon the blades. Mattei, of Paris, has made another instrument, whose blades do not cross, whose shanks, parallel, are set in a cross- bar of wood to serve for traction ; and quite recently Dr. Inglis has proposed a forceps in which the handles are done away with altogether, there being nothing but a short curve of the shank, representing the shoulders on the handles of Simpson's forceps, to serve for traction. I think this sacri- fice of all compressive and leverage power, reducing the instrument to a weak tractor, is a retrograde movement. But it proves the proposition that the hold upon the child's head is the result of the adaptation of the curved blades and the outward wedge-pressure of the mother's parts upon the bows of the blades. Now, the strength of the hold depends mainly upon the degree of curvature of the blades and the width of the fenestrae. If the curve is one of large radius, so that the two blades, when in opposition, approach parallelism, and especially if the fenestrae be nar- row, the hold will be feeble, and moderate traction will cause the forceps to slip, and this in spite of any compres- sion you can exert upon short handles. But increase the curves so that the blades in opposition form nearly a circle, and the instrument will not slip. This increased head-curve is one feature of the French or Continental forceps. The hold is further strengthened by making the points approach nearer together. In the English patterns the points are generally distant from each other an inch or more. In the foreign forceps the distance is often much less than an inch. There is some danger, from this proximity, of pinching or abrading the skin of the face. So much for the grip and traction. Let us now study the compressive power. This is in- considerable in almost all the English forceps, but is an im- portant feature in most of the foreign long forceps. The essential condition for compression is, indeed, present in INSTRUMENTAL AND NATURAL MOULDING OF HEAD. 33 English and foreign. This consists in the crossing of the blades, and in the greatest divergence of the blades, when the handles are brought together, being less than the great- est transverse diameter of the child's head. This diameter is normally from 3f- to 4 inches ; the greatest divergence of the blades is rarely more than 3 inches. Therefore, when the blades are sitting loosely on the head, the handles di- verge. Practically, the head is rarely grasped exactly in its transverse diameter, but generally in one more or less oblique—something between the transverse and the lon- gitudinal diameter. This, of course, is even longer than the transverse. Now, if we are to exert any direct com- pression upon the head, we can only do it by squeezing the handles together. For this purpose the handles must be long and strong on one side of the lock, and the blades must be strong, but not much longer, on the other side of the lock, than are the handles. It would be useless to provide this compressing power if the head were not compressible. That the head is compressible—that is, that we may dimin- ish some of its diameters by lengthening others—is easily proved: First. It is known that in normal pelves the head in passing, if the labor be protracted, undergoes elongation; from round it becomes conical; the greatest transverse diam- eter—the interparietal—becomes merged in the lesser or inter-auricular, while the longitudinal diameters are corre- spondingly increased. These changes I have demonstrated by actual measure- ments and outlines.1 These diagrams may be taken as types of the normal head and of the form impressed in protracted labor. Thus, just as the pressure of the soft parts and the pelvis is a main agent in fixing the forceps upon the head, so it is tn moulding the head to allow of its passing. Indeed, I think this pressure almost entirely accounts for the alter- 1 Obstetrical Transactions, vol. vii. 3 34 OBSTETRIC OPERATIONS. ation of form the head undergoes when the English forceps is applied. I can show outlines of heads as strongly altered under the natural forces of labor as they often are under forceps delivery. Fig. 1. Fig. 1.—The original form of the head before being affected by labor. [We may prove that the normal foetal head is moulded and compressed during labor in the following manner: After having repeatedly practised forceps delivery upon the cada- ver, we are then to fill the foetal head with plaster of Paris, and, allowing it to become hard, then again attempt to de- liver with the forceps. This we will find almost, if not absolutely, impossible, owing to the acquired incompressible state of the foetal head, and we may even straighten a strong pair of forceps in our efforts. This happy illustration is made use of by Prof. T. G. Thomas when lecturing to his class in New York on the compressibility of the foetal head.] Secondly. Numerous experiments have been made with strong forceps upon dead children, to determine this point. INSTRUMENTAL MOULDING OF THE HEAD. 35 ■ Baudelocque found that he could lessen the transverse diam- eter by a quarter to a third of an inch. Siebold gained half an inch. Osiander and Yelpeau claim quite as much. More conclusive are the observations of M. Joulin and of M. Chas- sagny. These gentlemen, in experiments designed to de- monstrate the utility of continuous compression and traction by powerful forceps upon the head in difficult labor, have completely proved that a degree of moulding may be effected Fig. 2. Fig. 2.— Head moulded by protracted labor. much beyond that commonly observed. This moulding con- sists in the elongation of the head, the elongation being gained by the lessening of the equatorial diameter. The process resembles that of reducing wire by drawing it through holes in an iron plate. Now, another question arises: the head is indeed com- pressible, but to what extent is it compressible without sacrificing the child's life ? For, if the maximum of plas- ticity compatible with life is represented by that degree which is common in severe first labors, then we ought to 36 OBSTETRIC OPERATIONS. give the mother all the ease in our power by lessening the diameter of the child's head by perforating. It is very dif- ficult to fix this limit with accuracy. Baudelocque thought compression to the extent of a quarter or a third of an inch was compatible with the safety of the child. The important fact is, that in many cases the child survives, although its head has undergone very great compression and moulding. The following conditions influence the result: The de- gree of development of the head as to size and ossification ; and the mode in which the compressing force is applied. If this force be applied gradually and continuously, a much greater extent of moulding, with less injury to the child, may be obtained than what Baudelocque thought possible. At one time it was the practice—more probably with the view of securing the hold than of compressing the head —to tie the handles together ; and, even now that tying is generally abandoned and condemned, the old custom asserts itself in the preservation of the grooves near the extremities of the handles made to receive the ligature. The objection to tying is this: the continuous compression is opposed to the course of Nature, which intermits the expulsive act, giv- ing periods of rest, during which it is presumed that the brain may better adapt itself, and its circulation be main- tained. Hence the law that we ought in forceps labors, and, generally, in all operative labors, to imitate this intermitting action, by interposing intervals of rest, endeavoring so to time our efforts as to be simultaneous with, and in aid of, the natural expulsive efforts. The argument is good both in logic and in physiology. It is not wise to disregard it. But experience proves that there are cases where the mould- ing of the head can be accomplished more quicklv, and without endangering the child, by continuous pressure. Some practitioners, therefore, have recurred to the old prac- tice. Dr. Gayton has adapted a clip to the handles of the forceps, which answers much better than the ligature. Whatever the mechanism resorted to, it is essential that it HOW TO ECONOMIZE TRACTION AND COMPRESSION. 37 admit of being instantaneously removed, in order to allow the blades to be taken off. Delore, who has made many dynamometric observations, concludes that pressure exerted either by the forceps or by the genital organs may be harm- less to the head if spread over a large surface. It is limited and angular pressure that is dangerous. He has also shown that the greater the traction the greater is the pressure. The pressure is equal to about half the traction. Thus, if you exert a traction force of fifty pounds, the pressure upon the head is about twenty-five pounds. To economize traction, then, is to economize pressure. How do we economize traction % There are three principal rules : First. Take sufficient time to allow the head to mould. Secondly. Take care to draw in the axis of the brim— that is, traction must be perpendicular to the plane of the brim. If this is neglected, additional force is required, in- creasing with every degree of angular difference. Thirdly. To use slight movements of laterality or oscil- lation. This uncertainty and inconstancy in the degree to which compression may be carried, with safety to the child, is a justification for tentative or experimental efforts with the forceps. It is the reason why, in doubtful cases, where the disproportion in size between pelvis and head is not very decided, we are called upon to make a reasonable trial of the forceps before resorting to craniotomy. It appears to me quite certain that in this country we are yet far from having utilized the powers of the forceps to the highest legitimate extent. I might go further, and say that, during Denman's time and until quite recently, we had actually lost ground in this respect, and had reverted to the use of instruments scarcely better than the original rude forceps of the Chamberlens. More than one hundred years ago Smellie contrived and used the long forceps. Perfect used it, and it seems that in his time the long forceps was better known than it was at the beginning of the present century. CHAPTER III. The Forceps—The Lever—Demonstration that the Lever is a Lever, not a Tractor; also that the Forceps is a Lever. Knowing what the forceps can do, and having an ap- proximate idea of the extent of compressibility of the child's head compatible with the preservation of life, we may now study the various cases in which the instrument may be used, and the modes of applying it. It is well to begin with the simplest case. This occurs when the head, presenting in the first position, has de- scended into the cavity of a well-formed pelvis, and is ar- rested on the perinaeum from want of expelling power. In such a case very moderate leverage and tractile power—a force of a few pounds, perhaps—is all that is required. Often the lever or tractor, like that of Symonds, of Oxford, will be quite sufficient. The moulding or diminution of the equatorial diameters will be effected by the sole compression of the mother's structures. The occiput lying behind the left foramen ovale, the tractor may be slipped over it, and the head drawn down toward the pubic arch, using your fingers as a fulcrum. This may be enough, for often, when the head is once started, expulsive action returns. If not, then the tractor may be shifted to the opposite side, so as to lie over the child's face and chin, in the hollow of the sa- crum. Then drawing down, you give the extension-move- • ment to the head, and the cranium soon emerges through the outlet. Several skilful practitioners, who frequently re- APPLICABILITY OF THE LEVER. 39 sort to this instrument, contend that it is a true tractor, and point, in confirmation of this view, to the great curve of the blade. But I think reflection will show that it is essentially a lever. It does not directly draw down the head, but, by pressing upon one side or point of the head-globe, it causes the globe to revolve upon its centre, its axis representing another lever. If the point opposite to that seized by the lever be movable, of course, when leverage is applied, the head will roll up on one side as it comes down on the other; but if the opposite point be more or less fixed, as the occiput Fig. 3. generally is, against the foramen ovale or left ramus of the pubes, then leverage on the face and chin will effect rotation on that fixed point as a centre, and the bulk of the head will have descended. The accompanying diagrams will illustrate the action of the lever bringing the head down by alternate flexion and extension. The lever is supposed to be applied alter- 40 OBSTETRIC OPERATIONS. nately over the occiput and the face. In Fig. 3, C repre- sents the centre of rotation. The lever applied to the occi- Fig. 4. Fig. 5. ACTION OF THE LEVER ON THE HEAD. 41 put will bring down the pubic hemisphere of the head- globe, the forehead remaining nearly fixed against the sacrum at C. Flexion is preserved. Fig. 6. In Fig. 4 the lever is reversed. Tha centre, C, is at the pubes; the facial or sacral hemisphere descends with ex- tension. In Fig. 5 the lever is shifted back to the occiput, which is made to descend by flexion, the face resting in the sacrum, but at a lower point than in Fig. 3. In Fig. 6 the lever shifts to the face. The centre, C, is at the public arch. The facial hemisphere is now made to sweep down over the perinaeum, performing the extension- movement of delivery. Figs. 7 and 8 further illustrate the same points. In Fig. 7 the lever is seen applied to the occiput, bringing down the pubic hemisphere, while the opposite point is fixed in flex- ion at C in the sacrum. 42 OBSTETRIC OPERATIONS. In Fig. 8 the lever is applied over the face, which is brought down in extension, the occiput resting against the pubes. A similar principle of leverage may be applied by the two blades of the short forceps. But in this case the lever- Fig. 7. age is applied to the transverse diameter of the head. (The lever can in like manner be applied to the side of the head, and occasionally this is more convenient than to the occiput and face.) When the blades are crossed and locked, the common fulcrum is at the lock. Then, by gently bearing upon either handle alternately, swaying the instrument backward and forward, avoiding all pressure against the LEVERAGE OF THE SHORT FORCEPS. 43 pelvic walls, you cause the head-globe to rotate to a small extent alternately in opposite directions upon its own cen- tre. At each partial rotation a little descent is gained, owing to the point opposite to the lever in action being partially fixed by the other blade, and by gentle traction Fig. 8. upon the handles. In very many cases this gentle double leverage is enough to effect delivery. Traction is hardly called for at all. The alternate action of the forceps is illustrated in Figs. 9 and 10. In Fig. 9, the head grasped transversely, the handles are first carried to the left. The right or pubic hemisphere descends. The forceps is at right angles with the transverse line which cuts the pelvis obliquely. 44 OBSTETRIC OPERATIONS. In Fig. 10 the handles are carried across to ^ the right. The left or sacral hemisphere descends. It is easy to demonstrate this simple leverage action on the phantom. Thus, if I take each blade of the forceps alternately, unlocked, and use it as a lever, the head ad- Fig. 9. vances by a series of alternate side-movements, until it is actually extracted by this power alone. Is it reasonable to throw away a power by means of which we can safely economize the more hazardous traction-force ? It is, how- ever, disapproved of by some authorities, who enjoin trac- tion alone. But I believe that pure traction is almost im- possible, and I am equally certain that a gentle and careful leverage will enable you to deliver with a great economy of force and time, which means, of course, greater safety—to the mother. [That the pure tractive force of the forceps may be advan- TRACTION FORCE OF THE FORCEPS. 45 tageously used in difficult cases, is the experience of many eminent obstetricians who have found powerful tractions the only means of terminating a labor, excepting embry- otomy. Fortunately, however, we are rarely called upon to test our own strength and that of our instrument.] Fig. 10. CHAPTER IV. The Application of the Short Forceps—Head in First Position—Head in Second Position—Objections to Short Forceps. [Before considering the mode of application of the long and short forceps, it is well to call attention to the circum- stances in which the instrument is resorted to: when the head is engaged at the inferior strait; in the pelvic canal at any point between the two straits; at the superior strait; after the head only remains at the brim, in the pelvic cavity, or at the outlet ? When compelled by the urgency of the case to resort to forceps delivery, it is advisable to inform the patient and her friends of the procedure, and at the same time remove their apprehension of any injury being done to the child or mother. Understanding this, the pa- tient will the more readily and cheerfully submit, and thus expedite matters considerably.] We now come to the mode of applying the short forceps. The head we assume to be in the pelvis, lying in the right oblique diameter. The child's right ear will be a little to the right of, and above, the symphysis pubis. We have first to consider certain conditions, some of which are necessary to the proper use of the forceps—some of which are not ne- cessary, but favorable. 1. The membranes must be rup- tured. 2. The cervix uteri must be fairly dilated. 3. The bladder should be empty. 4. The patient must be in a con- venient position. Abroad, the patient is usually placed in lithotomy position, on the edge of the bed. With us the APPLICATION OF THE SHORT FORCEPS. 47 pelvis is simply drawn to the edge of the bed, the patient lying on her left side. I think it needless to enter into con- troversy upon the relative advantages of the two positions. We shall probably adhere to custom. The English method involves much less disturbance of the patient; it involves no exposure; it requires no second assistant; and is, in many respects, most convenient in home practice. But, in cases of convulsions, where the patient is unconscious or un- manageable, it is at times necessary to apply the forceps in the dorsal position. If we use the long French forceps, there is, indeed, little" choice. The patient must be in lithotomy position, or, if on her side, the pelvis must over- hang the edge of the bed to an inconvenient extent. The conditions rendering the dorsal position preferable will be pointed out as the occasions arise. [In the United States it is almost the universal practice to place the patient in the dorsal position. Her hips are placed on the edge of the bed, with folded sheets or blankets under them to make a plane surface ; each leg is held by an assistant, the thighs and legs being flexed at right angles and the feet resting on the assistant's knees; one hand of each assistant is placed upon the knee of the patient and the other holds and steadies the foot. The operator either kneels between his assistants or sits upon a low chair.] The operation may be divided into four stages or acts. 1. Introduction of the blades ; 2. Locking; 3. Traction and leverage ; 4. Removal of the instrument. 1. Which blade do you pass first f—In the case of the short forceps, both blades being alike, you cannot take up the wrong one. Seizing, then, either blade, you have to pass it between the head and the sacrum, and, feeling the pubic ear, you know the sacral ear is exactly opposite. This blade becomes the posterior or sacral blade. Holding the blade lightly in the right hand, the handle raised and di- rected forward, so that the blade shall cross the mother's right thigh obliquely, the point will be guided over the 48 OBSTETRIC OPERATIONS. perinaeum by two fingers of the left hand, which are passed up carefully between the child's head and the cervix uteri. The all-essential point is to make out clearly the edge of the os uteri, to pass your fingers inside this edge, and to touch the head itself; then slipping the point of the blade along Fig. 11. Fig. 11.—Showing application of first or sacral blade of the short forceps. A, first stage, blade being guided on to the head.' The handle A is then carried slightly downward and backward, to get round the head and up into side of the pelvis in the line A B. At B the blade is in situ. the inside of your fingers, the os uteri resting on the outside of your fingers, the blade will strike the head. This done, you have to adapt the blade to the convexity of the head. The point, therefore, must follow this convexity. This is APPLICATION OF THE SHORT FORCEPS. 49 done by lowering the handle and drawing it backward, the point being still guided by the fingers of the left hand. When the convexity is well grasped, the handle is further pushed well back against the perinaeum, to give room for the manipulation of the second or pubic blade. Fig. 12. Fig. 12.—Introduction of the short forceps—the second or pubic blade. A, the first stage. As the blade passes up thepelvis and round the head, the handle travels in the direction of the line A B. At B the blade is in situ. The two blades of Figs. 11 and 12, therefore, correspond at B, and will lock. Introduction of the Second Blade.—The fingers of the left hand are shifted forward, so as to raise the os uteri from the pubic side of the head. The handle is held very low and slightly forward, crossing the mother's left thigh obliquely. 4 50 OBSTETRIC OPERATIONS. Running the point along the palmar aspect of the fingers behind the right pubic ramus, when the point strikes the head the handle is raised and carried backward, so as to take the blade over the convexity of the head. Here you must proceed with the utmost gentleness. It is not by force that you will succeed in passing the blade. Force is quite out of place. You may take this as an axiom : If you are met by resistance that only force can overcome, you are going wrong ; and, vice versa, if the blades are slipping in easily, the probability is that you are going right. The rule, then, is this: hold the blade lightly; let it feel its way, as it were; let it insinuate itself into position. It will be sure to slide into the space where there is most room—that is, one blade will go nearly opposite the sacro-iliac synchon- drosis, the other will go opposite the foramen ovale.1 The blades introduced, the left hand is withdrawn from the vagina, and the second act, or locking, is to be done. You seize lightly a handle with each hand, draw them into opposition, and if they have been correctly introduced they will readily lock. A smooth lock is generally an indication that the head is properly grasped. During locking be care- ful to pass your finger round the lock, in order to remove any hair or skin that might otherwise get pinched. This is especially necessary in using the short forceps. Then come, thirdly, traction and leverage. These must be exerted in the direction of the pelvic axis. Thus at first the traction will be backward in a line drawn from the um- bilicus to the coccyx. Gradually, as the head descends, the handles will come more forward, and the face turning a lit- tle backward into the hollow of the sacrum, the handles will also rotate, so that the instrument will approach the trans- 1 The adherents of the short forceps generally recommend to pass the upper or anterior blade first. It would not be easy to prove any advantage in this method. I believe the most skilful practitioners in London and Edinburgh now follow the method recommended in the text—namely, of passing the lower or sacral blade first. APPLICATION OF THE SHORT FORCEPS. 51 verse diameter of the pelvis. As the head emerges, the vertex appearing under the pubic arch in the genital fis- sure, the handles, following the extension movement of the head, will describe a circle around the symphysis as a centre, and will therefore at the moment of exit be applied nearly to the mother's abdomen. At this moment, and even earlier if active uterine action have set in, the fourth act—removal of the instrument—must be effected. This often requires some smartness. You abandon the grasp of the handles, seize the handle of the pubic blade, draw it downward and backward off the head; then, taking the handle of the sacral blade, you draw it upward and a little backward. Head in the Second Position, or occiput to right foramen ovale. In this case you still feel for the pubic ear, which will guide you to the other ear opposite the right sacro-iliac synchondrosis. As the rule is to apply the short forceps over the ears, the introduction of the blades must be gov- erned by the position of the head. You must first, then, determine the position of the head. So say most, if not all, our systematic authors. So many positions of the head, so many varying modes of applying the forceps ! Now listen to the voice of experience—experience that so often sets at naught the refinements of theory, and clears out for herself a straight and simple path through the intricacies woven in the closet. Dr. Ramsbotham says:1 "In employing the short forceps I lay it down as a rule that the blades should be passed over the ears; the head is more under command when embraced laterally, and there is less danger of injur- ing the soft parts during extraction. But I confess that 1 have for many years been accustomed, however low the head may be, to introduce the blades within each ilium, because they usually pass up more easily in that direction." I think I am not wrong in believing that many others do the same thing, some not knowing it, and even imagining that they are following the ancient rule. It is a habit of mine 1 Medical Times and Gazette. 1862. 52 OBSTETRIC OPERATIONS. to examine the head in every case of delivery. I have thus many times seen the stamp of the fenestrae on the brow and side of the occiput. This is as clear to read as the impres- sion of a seal on wax. It says unmistakably that the blades found their way into the sides of the pelvis with at most a slight deviation toward an oblique diameter. All this suggests the question whether it be really so necessary to " feel the ear " before applying the forceps as has been imagined. If the blades will find their way to the sides of the pelvis, clearly it is not necessary to know where the ears are. To feel an ear must in most cases put the patient to much suffering. You can, however, scarcely feel an ear unless the os uteri be well expanded. This being so, we have an argument in favor of the old rule—not of much worth, it is true, for we can have the assurance that the cervix is properly expanded by other means. With the long forceps, the ancient rule is clearly superfluous. There is one case in which the short forceps is of especial value. It is when the head descends into the pelvis, its long diameter keeping nearly in the transverse diameter of the pelvis, until it is arrested on the shelf formed by the sacro- sciatic ligaments. At this point, from want of propelling power, the head does not take its screw-movement of rota- tion on its axis so as to bring the occiput forward. If the short forceps be now applied in the transverse diameter of the head, by a slight rotatory movement, the axial turn is given, the occiput comes forward, the face goes to the sa- crum, and the head is released. In two cases of this kind I thus easily succeeded in delivering after failing with my long forceps. These are the only two cases in which I have ever found the short forceps preferable to the long. And the , simple lever would have answered as well. One merit the short forceps has, not without importance to the novice : it is easier to use than the long forceps. There are objections to the single-curved forceps, short or long: DISADVANTAGES OF SINGLE-CURVED FORCEPS. 53 1. One objection is in the introduction, others in the injuries likely to be inflicted on mother or child. To intro- duce the second or upper blade, the handle must be much depressed, nearly at right angles with the mother's left thigh, which is flexed upon her abdomen. Now, to do this, the patient's nates must be dragged over the edge of the bed. To procure and to maintain this position is often a matter of great difficulty and inconvenience. Fig. 13. Fig. 13.—Showing the short and long forceps in situ. The short forceps presses back upon the perinamm, putting this structure on the stretch. The shanks of the long forceps keep clear of the perinaeum, the whole instrument approximating to Carus's .curve. You may facilitate the introduction of the second blade by introducing a joint into the shank, so as to allow the handle to be doubled up out of the way. Dr. Giles showed at the Obstetrical Exhibition an instrument so modified. 54 OBSTETRIC OPERATIONS. 2. In extraction, the handles, nearly to the last moment, must be directed more backward than is necessary with the double-curved forceps, and, owing to the bows springing directly from the lock, the perinaeum is wedged open, and not seldom unavoidably torn. In some cases, this injury may be avoided by taking off the blades before the greatest diameter of the head passes. But then the work is not al- ways done, and you may have to put them on again. I may perhaps be told that to suffer the short forceps to tear the perinaeum implies want of skill. I reply that men of the highest skill and the largest experience with this instru- ment have confessed to me that this objection is a real one. The best short forceps is perhaps that of Dr. Beatty, of Dublin. It much resembles the short forceps of Smellie. I used it for some time, but have given it up because of these two faults and of its inadequacy to cope with a large range of cases which come within the power of the long forceps. 3. The posterior or sacral blade is extremely apt to bruise, by one of its edges, the sciatic nerve. The effect is the crushing of some fibres and more or less protracted paralysis of the leg. 4. If the blade be applied as usually taught—i. e., near- ly in the transverse diameter of the head—an edge is very likely to press upon the portio dura as it emerges from the temporal bone. The result is paralysis of the facial muscles to which the branches are distributed. The child cannot shut the eye; it cannot suck. I have known a child die of starvation from this cause. From all these objections the long forceps I recommend is nearly altogether free. CHAPTER Y. The Application of the Long or Double-curved Forceps—Introduction of tha Blades—Locking—Causes of Failure in Locking—Extraction—How to measure the Advance of the Head—The Manoeuvre of " shelling out" the Head delayed at the Outlet—Relocking—The Head is seized obliquely by the Forceps—Time required for Extraction. The application of this instrument is governed by a dif- ferent law from that which governs the use of the short for- ceps. The short forceps, according to the recognized rule, must be applied with the blades quite or nearly over the transverse diameter of the head. The head determines the manner of applying it. But with the long forceps it is the pelvis that rules the application. The position of the head may be practically disregarded. The pelvic curve of the blades indicates that these must be adapted to the curve of the sacrum in order to reach the brim. They must, there- fore, be passed as nearly as may be in the transverse diam- eter of the pelvis. One blade will be in each ilium, and the head, whatever its position in relation to the pelvic diameter, will be grasped between them. The universal force of this rule much simplifies and facilitates the use of the instru- ment. Not only does it apply to the position of the head in relation to the pelvic diameters, but also to all stages of progress of the head, from that where it lies above the brim down to its arrest at the outlet. It has been contended that the short forceps should be preferred in cases where the head is arrested in the cavity, 56 OBSTETRIC OPERATIONS. and as a corollary it is urged that in cases of arrest at the brim, where the head has been brought into the cavity by the long forceps, this instrument, after serving so far, should be discarded and replaced by the short forceps. I do not concur in this view. I doubt whether any one, who has had any considerable practice with the long forceps, has found it worth while to change instruments in the course of delivery. The long forceps possesses a more scientific adaptation to the pelvis throughout the whole canal than the short forceps. And if the long forceps is found in prac- tice capable of taking the head through the pelvis from brim to outlet, it follows that, since the whole contains the parts, the long forceps is qualified to take up the head at any point below the brim. The pelvis has been compared to a screw. I think a better idea may be formed of its mechanical properties by comparing it to a rifled gun, and the child's head to a coni cal bullet. But even then the comparison is not complete, for the pelvis, unlike a gun, is a curved tube. Now, just as the head must traverse the pelvis in a helicine course, deter- mined by the relation of form between pelvis and head, so is it natural that an instrument designed to grasp the head should be so modelled as to be fitted to follow this helicine course during introduction and extraction. This indication a well-modelled long forceps fulfils; no single-curved forceps can fulfil it. First, as to the application when the head is delayed at the brim. Mode of applying: Position of the Patient.—The pa- tient should lie on her left side, the knees drawn up toward the abdomen ; the head should be only slightly raised. She should lie across the bed, with the nates near the right edge, about midway between the head and foot. This will facili- tate the introduction of the blades, and give room for the sweep of the handles round the pubes at the end of the operation. I do not find it necessary to bring the nates to APPLICATION OF THE LONG FORCEPS. 57 hang over the edge of the bed. I have often passed both blades when the patient has been lying in the middle of the bed. Sometimes it is very desirable to move her as little as possible. [As already mentioned, it is the general practice in the United States to place the patient on her back; her hips being near the edge of the bed, well supported, and both feet and thighs held by two assistants, the operator sitting on a low bench between the thighs.] FIRST ACT—INTRODUCTION OF THE BLADES. Selection of the Blades.—First dip them in warm water, wipe dry, and lubricate with oil, or lard, or cold cream. Join them, and, holding the instrument with the concavity of the Fig. 14. Fig. 14.—Showing the first stage of introduction of the first blade. pelvic curve forward, and the blades in the position which they are to occupy in the pelvis, you take that one first which is to lie in the left or lower side. 58 OBSTETRIC OPERATIONS. First Stage.—One or two fingers of the left hand are passed inside, in at the perinaeum and between the cervix uteri and the head. Then, bearing in mind the relative forms of the instrument, the head, and the pelvic canal, the point of the blade is passed along the palmar aspect of the fingers at first, nearly directly backward toward the hollow of the sacrum. Second Stage.—The handle is now raised so as to throw the point downward upon the left side of the head. As the Fig. 15. Fig. 15.—Showing second stage of introduction of first blade. The point is running un round the head and into left side of the pelvis. ° point of the blade must describe a double or compound curve—a segment of a helix—in order to travel round the head-globe, and at the same time to ascend forward in the direction of Carus's curve so as to reach the brim of the pel- vis, the handle rises, goes backward, and partly rotates on its axis. Third Stage.—The handle is now carried backward and downward to complete the course of the point around the APPLICATION OF THE LONG FORCEPS. 59 head-globe and into the left ilium. Slight pressure upon the handle ought to suffice. This will impart movement to the blade ; the right direction will be given by the relation of the sacrum and head. The blade is now in situ; the shank is to be pressed against the coccyx by the back of the operator's left hand while he is introducing the second blade. Introduction of the Second Blade—First Stage.—Two fingers of the left hand, the back of which is supporting the Fig. 16. Fig. 16.—Showing last stage of Introduction of the first blade and the crossing_ the shank of the first blade by the second blade in the first stage of its introduction. first blade against the perinaeum, are passed into the pelvis between the os uteri and the side of the head which lies nearest the right ilium. The instrument held in the right hand lies nearly parallel with the mother's left thigh, or crossing it with only a slight angle. The point of the blade is slipped along the palmar aspect of the fingers in the vagina, across the shank of the first blade in situ, inside the perinaeum toward the hollow of the sacrum. 60 OBSTETRIC OPERATIONS. Second Stage.—As the point has to describe a helicine curve to get round the head-globe and forward in the direc- tion of Carus's curve, the handle is now depressed and carried backward until the blade lies in the right ilium. When it Fig. 17. Fig. 17.—Introduction of the first or left blade of the long forceps. 1. First stage, or introduction of point of blade in the hollow of the sacrum; A, the handle, is then raised, and at the same time carried across, rotating partly on its axis to B, so that the point C, turning round in the hollow of the sacrum to E, strikes the head, and rises toward the left side of the pelvis. 2. The second stage, or advance of the blade round the head and up in the left ilium. 3. Third stage: The handle B has travelled in the direction B C, still rotating slightly, until at C it is at rest in situ, the shank near the coccyx, where it is held by the back of the operator's left hand, while the point of the second blade is passed over and across it inside the perinseum, as seen in the next figure. APPLICATION OF THE LONG FORCEPS.—LOCKING. 61 has reached this position the handle will be found near the coccyx, nearly in opposition to the first blade. The application of the long forceps is further illustrated in Figs. 17 and 18. Fig. 18. Fig. 18.—Introduction of the second or right blade of the long forceps. 1. First stage of second blade: 2. Second stage of second blade ; X, the first blade m szlu. A.,the handle, at the moment at passing C, the point, inside the Renn«™ into*^„???f>12 of the sacrum, across X, the first blade ; the handle then drops and go.ef backward to B, the point C travelling round the head, and advancing into the right ilium m the direction of the axis of the brim to D ; when it has reached thisposition, it will be found nearly opposed to the first blade, X; the locking is effected by bringing the handle X over the handle B. The Locking.—-This is effected by a slight movement of adaptation. A handle is seized in each hand. The handle 82 OBSTETRIC OPERATIONS. of the first blade is brought a little forward over the handle of the second blade. If one blade is a little deeper in the pelvis than the other, it is either brought out, or the other is carried in until the lock is adjusted. This is commonly facilitated by pressing both handles backward against the coccyx. This movement, by throwing the blades well into the ilia, where there is room, allows the handles to be rotated a little, so as to fall into accurate relation. Accurate locking is generally evidence that the blades are properly adjusted to the head, and that the pelvis admits of the successful use of the instrument. On the other hand, their not locking is proof of their not being properly intro- duced, or of the pelvis not admitting of their application. In the first case, that of improper introduction, the failure is generally due to neglect in passing the blades exactly in the same diameter of the pelvis—that is, in passing the sec- ond blade exactly opposite to the first, so that if the first blade is applied in the left ilium, opposite one end of the transverse diameter, the right does not lie at the opposite end of that diameter. To remedy this error, the blade must be partly or wholly withdrawn and readjusted. In the second case, that of pelvic unfitness, the locking is prevented by the projecting promontory or other deform- ity, so distorting the pelvic diameters that the two blades cannot find room to lie in the same diameter opposite to each other. It will commonly be found that the blades will pass one on each side of the promontory, the inside of the blade not looking toward its fellow, but toward the opposite foramen ovale, where you cannot get a blade to lie. When you find this happen, you must give up the attempt to use the forceps. Pass the hand into the pelvis, if necessary; explore its dimensions and form carefully; and determine between turning and craniotomy. A correlative proposition may here be stated: Wherever the long forceps will lock «* without force, it may be reasonably concluded that the case is a fit one for the trial of this instrument / and a reason- APPLICATION OF THE LONG FORCEPS.—EXTRACTION. 63 able attempt should be made to deliver by its aid before pass ing on to turning or perforation. 3. The Extraction.—Get the nurse to press upon the right hip and support the back. Grasp the handles with one hand, and apply the fingers of the other hand to the ring or shoulders at the lock. Draw at first backward in the axis of the brim during the pains, if any be present, and at intervals of a minute or so, if there be none. Concur- rently with traction, alternate slight leverage movements may be executed by swaying the handles gently from side to side, always taking care not to press the shanks against the pelvic walls. Each blade is the fulcrum to its fellow. The finger which is used in the ring from time to time gauges the advance of the head. The advance of the head is measured by the following standards: First, you feel if the occiput approaches the pubic arch, by passing a finger below and behind the pubic bones. Secondly, you sweep your finger round the- circum- ference of the brim, and thus feel if the equator of the head- globe is pressing lower down through the brim. Thirdly, by feeling the direction of the sagittal suture. If you find that it is approaching parallelism with the conjugate diam- eter, you may be certain that the head is descending. Fur- ther evidence is found in the rotation of the forceps. As the head can hardly turn upon its cervico-vertical axis with- out at the same time descending in the pelvis, if the handles of the forceps are observed to rotate, this rotation, being imparted by the head, is evidence of advance. Again, as the head descends, of course more and more of the shanks and blades will become visible. This, indeed, is open to a fallacy. Allowance must be made for some degree of slip- ping, which takes place with all the English instruments whose blades have only a moderate bow. And further, when the head is fairly in the pelvic cavity, the blades lose something of that external support which, as explained in Chapter II., is the chief force in maintaining the grasp 64 OBSTETRIC OPERATIONS. upon the head. This is still more marked when the head has partly emerged from the vulva. At this time the blades will be apt to slip away altogether, and it will be ne- cessary to increase the compression on the handles in order to keep your hold. Fourthly, by two or more fingers you measure the space or degree of tightness between the vertex and the floor of the pelvis. At first the fingers find free Fig. 19. Fig. 19.—Showing the long forceps locked, and grasped by the two hands. The head being at the brim, traction is backward. space; gradually the vertex leaves no room for the fingers. Then the soft floor of the pelvis, the perinaeum, is distended by the advancing vertex; it bulges out; it puts the peri- naeum tightly on the stretch. The anus is protruded. Faeces are often squeezed out. Indeed, the pressure upon the sphincter ani at this stage sets up reflex action. The call to strain or bear down to expel the pelvic contents, whether uterine or rectal, is uncontrollable. Turbulent expulsive action, then, and defecation, constitute certain signs that EXTRACTION WITH THE LONG FORCEPS. 65 the head is advancing. To some extent the increasing scalp-swelling or caput succedaneum may give a false im- pression that the cranium itself is descending. But a little practice and attention will correct this error. Wken the vertex has reached the floor of the pelvis, the handles of the forceps are found to have turned a little upon their axis, to lie more nearly in the transverse diameter of the pelvis. Fig. 20. Fig. 20—Representing the last stage of extraction. The handles have travelled from A to B so as at last to touch the abdomen. The dotted line shows the course of the handles, and the slight oscillations practised during the descent of the head. This is the result and the indication of the screw-rotation of the head. You have no hand in producing it. It is effected by the descending head adapting itself to the cavity of the pelvis. The handles may now be directed more for- ward during traction. The shanks thus avoid stretching the perineum, and the traction is in the axis of the outlet. 5 66 OBSTETRIC OPERATIONS. An assistant is now useful in holding up the right knee, so as to leave room for the operator to carry the handles well round the pubes in Carus's curve. Here it is often con- venient to push the handles forward rather than to pull. This action is seen in Fig. 20. During extraction it occasionally happens that the blades will lose their hold, that the handles will twist in opposite directions, and thus unlock. This is generally owing to the operator carrying the handles forward too early. The effecl of this is to throw the blades off the head-globe over the face. It is another illustration of the law that the position of the forceps is determined by the relation of the head to the pelvis, and that, if you reverse the order by attempting to make the forceps alter this relation, you are immediately at fault. The remedy is to carry each handle well back again toward the perinaeum, when they will relock. If the head is in the genital fissure, and there is suffi- cient uterine energy, you may proceed to the FOURTH ACT--THE REMOVAL OF THE BLADES. If the head should not be propelled, you may often assist it by a manoeuvre which it is well to understand. You ap- ply the palms of both hands, one on either side and behind, to the perinaeum distended by the head; and bearing upon this structure so as to press it a little backward, while the head is pushed forward toward the pubic arch, the head is, as it were, shelled out by being made to complete its move- ment of extension. Steady pressure by the hands of an assistant or by a binder upon the fundus uteri will much assist the extension of the head. In this manner I once extricated myself and my patient from an awkward predica- ment. I had been summoned into the country without knowing the nature of the case, and had no instruments. I found a lady who had been many hours in labor, the head on the perinaeum, and no pains. The lever or the forceps would have delivered her in a minute. Neither was to be MANUAL PROPULSION IN DELIVERY. 67 had. But the manoeuvre I have described perfectly suc- ceeded, and put an end to a state of extreme anxiety, and even danger. Another manoeuvre is occasionally serviceable. This is to pass a finger into the rectum, so as to get a point of pres- sure upon the forehead. In this way it is sometimes possi- ble to bring the face downward, to start the extension move- ment, and thus to extricate the head delayed at the outlet. And if at the same time firm downward pressure be made upon the breech through the fundus, as described in the first chapter, the force propagated through the spine will aid ma- terially in giving the extension movement. This combina- tion of the principles of " pushing," of leverage, and of " shelling-out," may in certain cases enable you to deliver without resorting to the forceps or lever. When the blades are adjusted, they will not lie exactly in the transverse diameter of the pelvis. The head, lying between the transverse and right oblique diameter, will tend to throw off the blades toward the opposite or left oblique diameter. The head then will be seized obliquely, one blade grasping the right brow, the other the left occiput. This is clearly demonstrated by the impressions of the fenes- trae left on the scalp. The blades naturally find their way into this position if they are introduced gently. One ten- dency of this oblique seizure is to assist the head in its axial rotation, face sacrumward, as it descends into the pelvis. It is also an answer to an objection urged against the use of the long forceps at the brim—namely, that by seizing the head in its long or fronto-occipital diameter, compression in this direction makes the opposite or biparietal diameter bulge out, thus increasing the difficulty of passing the small or conjugate diameter of the pelvis. In most cases the objec- tion is theoretical only—it is mainly based upon experiments made on the dead foetus on the table. Elongation or moulding, we have seen, is the result of gradual compression of the equatorial zone. Now the pelvis 68 OBSTETRIC OPERATIONS. and the forceps together constitute the compressing ring. Pressure, then, upon the transverse diameter of the head by the opposing points of the sacrum and pubes, simultaneously with pressure upon the longitudinal diameter between the blades of the forceps, tends to diminish both diameters by lengthening out the head. Of course it must be understood that the pelvic contraction is of moderate degree only—in short, that the case is a proper one for the forceps. If the conjugate diameter be less than 3.25 inches, the prospect of effecting the desired elongation within a reasonable time is greatly diminished. I have said that the head is very rarely seized exactly in its longitudinal diameter. An exception occurs in the case of the very flat pelvis, in which there is conjugate con- traction with very little projection of the promontory. In this case, the head will lie very nearly in the transverse diameter. If, in presumed contraction of the brim, the marks of the blades are on the brow and side of the occiput, the projection of the promontory is not great. The Time required for Extraction.—If the head be delayed in the cavity of the pelvis for want of expulsive action, or because it rests upon the ischia, maintaining a too near approach to the transverse diameter, and there is no marked hinderance on the part of either the anterior or pos- terior valve, it is generally sufficient to use slight traction and oscillation for a few minutes. As soon as the head is started by the forceps, the uterus takes up its work, helps the operator, and the labor is quickly over. If the uterine and perineal valves obstruct the passage of the head, a little more time and caution are required. If the head has to be seized at the brim on account of delay from want of uterine action, time may often be saved by placing the patient on her back, and supporting the uterus against the spine by the hands of an assistant or a binder. This proceeding, by adjusting the axis of the uterus to that of the brim, will greatly facilitate the entry of the • TIME AND MEASURES FOR EXTRACTION. 69 head and encourage the action of the uterus. If there is no obstacle from narrowing of the pelvis or want of dilatation of the soft parts, gentle traction and oscillation during ten minutes will generally complete the labor. In the event, however, of arrest from pelvic contraction or from want of dilatability of the soft parts, time is a neces- sary element. The process of moulding, of elongation of the head, can only be effected gradually. Here oscillation or leverage must be used with great care. What is wanted is steady compression and traction extended, with moderate intervals of rest, over thirty minutes, or even an hour. Should the head be found to make no advance in entering the brim in that time, the question whether the forceps must not be laid aside for turning or perforation will have to be considered. CHAPTER VI. Causes of Arrest in First Labors—Disturbed or Diverted Nerve-Force—The Uterine and Perineal Valves—The Ponding up of Liquor Amnii—The Forceps to deliver the After-coming Head. A vert large proportion of cases that call for the forceps are first labors. It is therefore well to take a survey of the conditions which lead to this necessity. Disproportion, as a cause of arrest, we will put aside for the present. In the great majority of first labors, the difficulty does not arise from disproportion. The frequency of an easy second labor proves this. The difficulty, then, lies in the soft parts of the parturient canal. And this maybe either from want of contractile energy of the uterus or from excessive resist- ance of the os uteri, vagina, or vulva. I will endeavor to explain the nature of these cases. First, the suspension of uterine and other muscular force. This may be the result of exhaustion from fatigue, or of the discharge of the vis nervosa in other directions—metastatic labor, as Dr. Power calls it. Emotion, fear, the shrinking before pain, will fre- quently cause such a derivation of nerve-force that all labor is suspended. It is in such cases that chloroform finds one of its happiest offices. By removing the sense of pain and of fear, the emotional disturbance is eliminated, the nerve- force responds to the natural call, and labor is frequently resumed and carried out to a successful termination. It is not a figure of speech to say that here chloroform acts like a charm. It may even save the necessity of resorting to in- struments. ARREST OF THE HEAD BY ANTERIOR LIP OF CERVIX. ?1 But not seldom, combined with more or less emotional disturbance, the expelling force gives way before a real mechanical obstacle. It is this : In primiparae the cervix dilates slowly. The vertex partly enters the pelvis, capped by the cervix. The anterior portion of the cervix especially is carried down before the head, much below the brim. It even gets jammed between the head and the symphysis, and becomes perhaps more unyielding from oedema. Now, this anterior segment of the uterus forms a valve or plane which guides the head backward into the sacral hollow in the direction of the axis of the brim. So far it fulfils a useful function, but, having done this, it ought to retire. In pluri- parae it commonly does so, and then the head encounters the second valve formed by the perinaeum, which is exactly opposed to the first or uterine valve. The function of this is to guide the head forward under the pubic arch in the direction of the outlet. Now, it frequently happens in primiparae that these valves maintain their resistance too long. The uterine valve may still cap the head when it is propelled to the very floor of the pelvis. In this case the head is prevented from receiving the full impact from the inclined planes of the ischia ; it is impeded in its half-quar- ter axial turn, occiput forward, and also in its movement of extension. Hence a double difficulty: there is the opposing valve, there is malposition. Clearly the valve must be got out of the way. How to do it ? Sometimes patience will do it 3 but, as patience on the part of the physician may involve agony and danger to the woman, this should not be over- strained. Sometimes one or two fingers may be insinuated between the valve and the head in the intervals of pains, and then the valve may be held back so that the equator of the head may pass it. But you must be careful, lest, by over- meddling, you cause more swelling and rigidity. You may pass up the lever or one blade of the forceps, and, bearing upon the occiput, just as you use a shoe-horn, the valve, like the heel of the shoe, is held back while the head descends 72 OBSTETRIC OPERATIONS. upon the inclined plane of the instrument. And here you often get another beneficial result. The head-globe has been lying closely fitting to the ring of the cervix uteri like a ball-valve, ponding up the liquor amnii behind, and im- peding the full action of the uterus by over-distending it. The lever or forceps opens a channel for the escape of the pent-up fluid. The uterus then acts immediately, and the labor proceeds. I have often used the forceps successfully for no other purpose than this. Fig. 21. Fig. 21.—Showing the head arrested in the pelvis by the anterior or uterine valve A, which is carried down into contact with the posterior or perineal valve B. The uterine valve A helps to guide the head into the pelvis, in the axis of the inlet C D. Well, we have now disposed of the uterine valve. The perineal valve and the vulva oppose another barrier, all the more troublesome because it has to be encountered by dimin- ished forces. Arrest on the floor of the pelvis, nothing but this valve obstructing, is very common. The lever applied alternately over the occiput and face, or over the sides of ARREST OF THE HEAD BY THE PERINEUM AND VULVA. 73 the head, answers perfectly in this case. But many will prefer the forceps. The delay at the vulva is often further increased by intense emotional and sensational nervous disturbance. The uterus seems instinctively to hesitate to contract, lest, by forcing the head upon the acutely-sensitive structures of the Fig. 22. Fig. 22 shows the head arrested at the outlet by the posterior or perineal valve B; the anterior or uterine valve A has slipped up above the equator of the head, ine posterior valve guides the head out of the pelvis in the axis ol the line 1). vulva, it cause intolerable pain. The consequence of this protracted shrinking before pain is twofold : there is, first, exhaustion of nerve-force; there is, secondly, a condition which I can best describe as a kind of shock, producing prostration, if not collapse, which supervenes whenever an urgent function is suspended, or remains unfulfilled. Another cause of delay may, of course, reside in the mechanical condition of the resisting structures ; rigidity of the cervix uteri, of the perinaeum or vulva, may be 74 OBSTETRIC OPERATIONS. added to other unfavorable conditions. Kigidity may be due to thickening, oedema, hypertrophy of the tissues, or there may be rigidity without discoverable alteration of tex- ture ; and there are the more serious cases of partial or com- plete occlusion from cicatricial tissue, the result of previous injury or disease. Obstruction from these causes demands special treatment, which will be discussed hereafter. Most authors describe the application of the forceps to the after-coming head—that is, when the head is delayed after the birth of the trunk in breech, footling, or turning labors. The position of the child with its head delayed at the brim, probably compressing the cord, is indeed perilous. Prompt delivery alone can rescue it from asphyxia. How shall we best reconcile the two conditions of promptitude and the minimum of force ? It is a point of extreme interest to know what is the greatest time a child can endure being cut off from placental and aerial respiration, and yet re- cover. For within that time the head must generally be extricated in order to save life. That time is certainly very brief. Here it may truly be said that " horae momento cita mors venit, aut victoria laeta." The data are necessarily want- ing in precision. Hugh Carmichael,1 in two cases, removed the foetus from the uterus within fifteen minutes of the death of the mother. In both cases the foetus was quite dead, although, on the mother's evidence, it was living just before her dissolution. A similar case has occurred to me. Dr. Ireland was called to a woman who had died suddenly from a blow received from her husband. The Caesarean section was performed, and a live child was extracted. The interval here was estimated at eight or ten minutes. The following case occurred at St. Thomas's: * A woman, in her ninth month, was run over in St. Thomas Street, at 7.35, and car- ried to the hospital. She died at Y.55. Mr..Green opened the abdomen at 8.8, and the child was withdrawn by Dr. Blundell asphyxiated. Its lungs were inflated, and it sur- 1 Bub. Journ. of Med., vol. xiv. 2 Med.-Chir. Trans. 1822. DELIVERY OF THE AFTER-COMING HEAD. 75 vived thirty-four hours.1 Here, then, we have an instance of partial recovery at the end of thirteen minutes from the mother's death. Cases of extraction of live children within ten minutes are not very rare. But perhaps examples of this kind are not exactly in point. They are not quite analogous to the case of compression of the cord during labor. Numer- ous observations lead me to conclude that the child will be' asphyxiated beyond recovery if aerial respiration do not begin within three, or, at most, five minutes after the stop- page of the placental respiration. I think it must be ac- cepted as a general law that, if the head compress the cord, the child must be extracted within three minutes. Even if this be done, there will commonly be considerable asphyxia and cerebral congestion, and restorative means will be re- quired. Now, the practical question arises, What is the readiest way of delivering the after-coming head ? We can extract by the hands or by the forceps. Which is to be preferred ? In many cases, undoubtedly, the hands are the best instrument. Where the cervix is fully expanded, and the brim of the pelvis is roomy, well-directed manipulation will deliver in a few seconds. And, again, if there be any marked contraction of the conjugate diameter, the forceps will probably fail, whereas the hands may extricate the head very quickly. But still some cases may occur in which the forceps will be useful. How to apply it ? In the first place, draw down the cord gently, so as to take off any dragging upon the umbilicus, and lay the part which trav- erses the brim in that side in which the face is found; there is most room for it there. The head is engaged with its long axis more or less nearly in the transverse diameter of the brim. The blades should grasp it in an oblique diameter, approaching the antero-posterior. To be able to effect this, the trunk must be carried well forward over the 1 It is worthy of remark that, in the history of this case, Mr. Green espe- cially calls attention to the depressing effect of the warm-bath—a point since enforced by Milne Edwards and Marshall Hall. 76 OBSTETRIC OPERATIONS. symphysis, in the direction of Carus's curve, and held there by an assistant, so as to leave the outlet clear for manipula- tion. Then, passing your left hand into the vagina, you carry the fingers to the left side of the pelvis, between the cervix uteri and the head. The blade is slipped up along the palmar aspect of the fingers to its place. The like pro- ceeding is then repeated on the right side of the pelvis, and the blades are locked. The assistant supporting the child's body, you then draw the head into the pelvis in the axis of the brim. As soon as this is cleared, you may take off the blades, and finish the extraction by the hands. This is done Fig. 23. Fig 23 illustrates the application of the long forceps to the after-coming head. by hooking two fingers of the right hand over the back of the neck, on the shoulders, while the left hand seizes the feet above the ankles, a napkin interposed. You then draw in the axis of the outlet. It is the work of a few seconds. Some will prefer completing the extraction with the forceps. DELIVERY OF THE AFTER-COMING HEAD. 'j'j If you select this mode, you find the face turned toward the sacral hollow when the head has cleared the brim ; the for- ceps, following this, rotates a little in your hands. When the occiput is appearing under the pubic arch, carry the handles well forward, so as to bring the face over the peri- naeum with the least possible strain upon this structure. The face and forehead sweep the perinaeum, describing a curve around the occiput resting upon the pubes. The use of the forceps in this case was strongly incul cated by Busch, of Berlin, who attributes to this practice the extraordinary success of turning in his hands. Of forty-four cases of turning, only three children are stated to have been lost from the effects of the operation. The late Dr. E. Rigby and Dr. Meigs insist also upon the advantage of the practice. [Even if we do not determine to deliver the after-coming by the forceps, it is always a satisfaction to have the instru- ment at hand and ready for immediate use, for we then feel equal to any contingency that may arise. But should the instrument not be on hand, and we be obliged to send for it, as Dr. Meigs has said, " the child may die while the messen- ger is putting on his boots."] CHAPTER VII. Application of the Long Forceps in Fronto-anterior Positions of the Head— The Mechanism by which Fronto-anterior, Forehead, and Face Positions generally, are produced—The Management of these Cases. Such, then, is the story of the long forceps applied to the head in the first position at the brim. If the head be in the second position, the blades will seize it—one on the left brow, the other on the right occiput. The occiput will emerge under the right pubic ramus. Here special care is necessary. When the head emerges occiput to the right, if the shoulders are so large as to demand extraction in aid of expulsion, be very careful to direct the face downward— i. e., to the mother's left thigh—for if, through inadvertence, you turn the face upward to the right thigh, you may give a fatal twist to the child's neck, or impede the turn of the shoulders into the antero-posterior diameter of the outlet. In the case of the third and fourth positions of Naegele, the head will still be seized obliquely; and as it enters the pelvic cavity, it will generally make a quarter axial rotation, face backward, so as to bring the occiput under a pubic ramus. In the case of fronto-pubic position, the head will be grasped more nearly in its transverse diameter. As it descends into the pelvis this position may be preserved; and it becomes a question whether delivery should be completed with the forehead forward, or an attempt made to turn it back into the hollow of the sacrum. The cause of arrest of labor, of difficulty, when the posi- ARREST OF THE HEAD IN OCCIPITO-POSTERIOR POSITIONS. 79 tion is occipito-posterior, is, I believe, this:—the head im- prisoned in the pelvis is not able to take its normal exten- sion movement. In occipito-anterior positions, the propel- ling force propagated through the spinal column causes the head to roll up from the floor of the pelvis out by the open space under the pubic arch. But in occipito-posterior posi- tions the propelling force acts against the escape of the head by driving it against the floor of the pelvis, the occiput naturally rolling back into the hollow under the prom- ontory. If extension-movement then takes place, this, by throwing the occiput against the back, rather increases the difficulty. Release can only be obtained by a move- ment of flexion. Now, flexion may be useful under two circumstances: first, as already explained, by supplying the essential condition for the spontaneous turn of the face into the sacrum ; secondly, by taking the symphysis as the centre of rotation, and the point against which the root of the nose or the forehead is fixed, while the vault of the cranium is made to roll over the floor of the pelvis and through the outlet. The first question that arises in the presence of an occi- pito-posterior position is, whether we can hope for the change, spontaneously or by art, to an occipito-anterior position. Dr. R. U. West* has proved the practicability of procuring the rotation of the face backward by artificial means. He ap- plied his fingers to the frontal bones, turning this part back- ward, and at the same time raising it up until he felt the posterior fontanelle come down. In another case he brought the occiput down by the lever. As soon as the occiput came down, the rotation seems to have been effected by Nature. This, indeed, is the essential thing to do—to get the occiput down, to restore flexion. On the other hand, I am persuaded that the head often turns of its own accord when we think we are helping it. 1 Glasgow Med. Journal, 1856. 80 OBSTETRIC OPERATIONS. The evidence of Dr. Miller is quite to the purpose: " I met," he says, " a good many cases of occipito-posterior positions in which anterior rotation was effected; but the efficiency, I believed, belonged to me, and not to Nature, because I labored assiduously to promote it after the man- ner recommended by Baudelocque and Dewees.....I have since experimentally allowed Nature to take her course in a considerable number of such cases, and I find that the desired mutation is generally accomplished about as well without as with my assistance." Dr. Leishman, whose excellent book' is full of instruc- tion, says: " My impression is that rotation can only be effected by artificial means when the head is free above the brim, or when it has quite descended to the floor of the pel- vis." If the forehead has come down, Dr. Leishman says: "No mere rotation can bring about the desired change. Rotation must be so managed that it is combined with a descent of the occiput and a corresponding retreat of the forehead." I have found that the occiput must be brought down be- low the edge of the sacro-sciatic ligament in order to permit the rotation of the face backward. It is judicious, I think, to make a reasonable attempt, after the methods of Dr. R. U. West, to bring the occiput down and forward. This is entirely an affair of leverage. You may act upon either end of the lever represented by the long diameter of the head; or, better still, upon both ends simultaneously. You may apply the blade of the lever as nearly as possible over the occiput, on that side which is most remote from the pubes; draw downward and forward at the same time that, with the point of the finger resting on the frontal bone, you press the forehead upward and backward. By this manoeuvre, under favorable circum- stances, the desired change to an occipito-anterior position may be effected. 1" The Mechanism of Parturition." 1864. THE FORCEPS IN OCCIPITO-POSTERIOR POSITIONS. The leverage may be applied by the forceps. In this case the " single-curved" forceps will occasionally answer better than the double-curved. The head being grasped in its transverse diameter, or with only moderate obliquity, a movement of rotation of the instrument on its axis will turn the face backward into the sacrum. But the forceps cannot at the same time so well bring down the occiput as the lever combined with the fingers can do. But I cannot give more than a qualified assent to the propriety of attempting to rectify the position. It is only exceptionally useful; still more rarely is it necessary; and it is not free from danger. The head can be born very well preserving the occipito-posterior position throughout. In- deed, I think this occurs more frequently than Naegele rep- resents. Nor does the case call for any amount of force. By aid of the forceps the delivery is nearly as easy as when this instrument is applied to an occipito-anterior position. In the event of delay, I therefore advise resort to the long forceps." The blades should be applied in the sides of the pelvis; they will be guided by the head into the most suitable po- sition. Extraction, then, simply, without troubling your- selves about rotation, is all that is necessary. If Nature prefer or insist upon rotation, your business is to consent. As the head advances, the occiput may come forward, and you will feel the handles of the forceps turn upon their axis. But in a large proportion of cases Nature will not insist upon bringing the occiput forward ; and here, again, your part is simply that of a minister of Nature. The forehead will emerge under the pubes; the cranium will sweep the sacrum and perinaeum. As the blades of the forceps preserve their original posi- tion, the handles will turn with the head. It is labor lost— it is encumbering Nature with superfluous help—it is a sin against that most excellent maxim, "ne quid nimis," to attempt to promote this turn by twisting with the forceps. 6 82 OBSTETRIC OPERATIONS. In this latter case there are two things to be observed : first, the perinaeum is put more upon the stretch, and there- fore requires more care; second, if the handles of the forceps are carried forward toward the mother's abdomen too soon, the blades will be apt to slip off. The superiority of the long forceps in saving the perinaeum is very marked. The propriety of not attempting to turn the face back- ward is even more decided in those marked cases of fronto- anterior positions, in which the forehead looks nearly di- rectly forward. It appears to me that this position is due to unusual flatness of the promontory—a very slight projec- tion of this part. A pronounced projection of the promon- tory will scarcely permit the head to occupy the antero- posterior diameter; it will throw the occiput to one or the other iliac hollow, so that, the moment the head dips into the pelvis, the anterior pole is turned into the hollow of the sacrum or to one side of it. Upon this point I am glad to quote the authority of Dr. Ramsbotham, whose experience is unsurpassed: "I prefer extracting it, if possible, with the face under the arch of the pubes, because, as the rotation is made over only one-quarter of the half-pelvis, there is less chance of injuring the soft parts. Besides, should the child's body be strongly em- braced by the uterine parietes while we are acting, and should it not follow the turn which we are forcing the head to take, we should twist the child's neck, perhaps fatally." ' In truth, there is no very serious difficulty in extracting with the face forward.9 The case is, however, more severe if it is a complete face- presentation. You can hardly by aid of the forceps so far 1 Medical Times and Gazette, 1862. 8 The practitioner or student who wishes to gather instruction from Dr. Ramsbotham is advised to study his clinical reports published in the Medicai Times and Gazette, 1862. These give the matured conclusions of this eminent teacher, and show that his practice, elaborated out of, and gradually formed in, his encounters with diflBcult cases, was even superior to the formal and more conventional doctrines in his systematic work. MECHANISM OF BROW AND FACE-PRESENTATIONS. modify the position of the head as to render its course through the pelvis easy ; and, when you have succeeded in dragging it into the cavity, you may find yourselves left with no alternative but to perforate. It is very true that a large proportion of face-labors end happily without assist- ance. It is equally true that face-presentations supply some of the most difficult cases in practice. Fig. 24. Fig. 24.—Showing the application of the forceps to the head in fronto-anterior position. The promontory of sacrum shows very little projection. The head is seized nearly in its transverse diameter. The symphysis, C, is the centre of rotation. The vertex and occiput sweep the perinaeum, producing a movement of flexion. It is convenient in this place to examine how brow-pre- sentations and face-presentations are produced. These may be regarded as transitional between vertex and face presenta- 84 OBSTETRIC OPERATIONS. tions ; and, by analyzing the mode in which brow and face presentations arise, we shall have the best indications for prevention and treatment. Consider the head as a lever of the third order, the power acting about the middle. The fronto-occipital diameter or axis represents the lever; the atlanto-occipital articulation is the seat of the power. Riding upon this point, the head moves in a seesaw manner backward and forward. A force which is generally unnoticed in ob- stetrics is friction ; and, if friction were uniform at all points of the circumference of the head, it would be unimportant, from a purely dynamic point of view, to regard it. But it is not always so. Friction at one point of the head may be so much greater than elsewhere, that the head at the point of greatest resistance is retarded, while at the opposite point the head will advance to a greater extent; or resistance at one point may quite arrest the head at that point. In either case the head must change its position in relation to the pelvis. Let us, then, take the case where excess of friction bears upon the occiput directed to the left foramen ovale. This point will be more or less fixed, while the opposite point or forehead, receiving the full impact of the force propagated through the spine to the atlanto-occipital hinge, will descend —that is, the forehead will take the place of the vertex, and be the presenting part. If this process be continued, the head rotating back more and more upon its transverse axis, the face succeeds to the forehead. Now, if we can transpose the greatest friction or resist- ance to the forehead, and still maintain the propelling force, it is clear that the occiput must descend, and that the nor- mal condition may be restored. In practice this is actually done. When at an early stage of labor we find the forehead presenting, we can, by applying the tips of two fingers to the forehead, during a pain, retard its descent, and the occi- put comes down. This effected, the rest will probably go on naturally, because, the atlanto-occipital joint being some- THE FORCEPS IN ARRESTED FACE-PRESENTATIONS. 85 what nearer the occipital than the frontal end of the lever, the shorter or occiptal arm of the lever will keep lowest. But, if there should still be excess of resistance at the occipi- tal end, we have only to add so much resistance to the frontal end as will maintain the lever in equilibrium. This manoeuvre is illustrated in the following diagrams. The face may enter the pelvis, take its turn forward, and then be arrested, just as the head in cranial presentation may be arrested. In such a case the forceps may be useful. Fig. 25. E r4] y fee Fig. 25 represents a change in progress from an original vertex presentation to a fore- head. C is the altanto-occipital joint, or point where the force propagated througn the spine E C impinges upon the lever ABC. D is the point of greatest resistance. Therefore the arm A of the lever descends. C E, the force, forms an obtuse angle with the arm A. The application is as follows: Assume that it is the first face-position; remember that the object to be accomplished is, to make the vault of the cranium and the occiput roll over the floor of the pelvis around the symphysis as a centre, so as to restore flexion. The blades should seize the head nearly in its transverse diameter. Now, the face presents some degree of obliquity in relation to the pelvis. ^ The first or sacral blade, therefore, must pass up the left side of the pelvis somewhere between the sacro-iliac joint and the left 86 OBSTETRIC OPERATIONS. extremity of the transverse diameter. The second or pubic blade will pass in the opposite point of the pelvis—that is, between the foramen ovale and the right extremity of the Fig. 26. E In Fig. 26 the fingers applied to the forehead at D transpose the greatest resistance to this point. The force propagated from E to C will therefore drive down B, the occi- pital or shorter arm. The force E C C will form an acute angle with the long arm A, and the tendency will thus be greater to keep the occipital arm B lowest in the pelvis. Or we may help to overcome the resistance at the occipital end of the lever by apply- ing the palm or the right hand externally and pressing the occiput downward. transverse diameter. When locked, traction is at first directed downward, to get the chin fairly under the pubic arch. Then the traction is directed gradually more and more forward and upward, so as to bring the vault of the cranium out of the pelvis. The posterior part of the head puts the perinaeum greatly on the stretch. It requires great care to extract. Give time for the perinaeum to dilate. Carry the forceps well forward, so that the shanks are out of the way ; but not too soon, lest the blades slip off. Ex- / tract gently. But we shall not always be so fortunate even as this. THE FORCEPS IN ARRESTED FACE-PRESENTATIONS. 87 Several of the most difficult cases in which my assistance has been sought have been face-presentations. In some the face will not enter the brim. This is the first order. What shall we do here ? If we apply the forceps, one blade is likely to seize beyond the jaw and compress the neck, bruis- ing the trachea. If the atttempt be made to seize the head by applying the blades in the oblique diameter, they must be passed very high, and even then may slip. If firmly grasped Fig. 27. Fig. 27 shows the long forceps applied to the head in face-presentation delayed in the pelvis. The curve of Cams—the dotted circle—indicates the direction of traction. and traction be made, the faulty extension of the head is increased; the compression of the vessels of the neck and the danger of apoplexy are augmented; and, after all, ex- traction may have to be completed by perforation. Turn- ing can be effected with infinitely less trouble, and with a better prospect for the child. In the second order of cases, 88 OBSTETRIC OPERATIONS. the face has descended into the cavity. The birth of a full- grown living or recently-dead child, with the forehead main- taining its direction forward, is almost impossible. The ex- tension of the neck is extreme, the head being doubled back upon the nucha. The face represents the apex of a wedge, the base of which is formed by the forehead, the entire length of the head, and the thickness of the neck and chest. This must be equal to at least seven inches. The bregma and occiput become flattened in, it is true, but much is not to be expected from moulding. Compression, bearing upon the neck, if great and long continued, is almost necessarily fatal to the child. Hence arrest or impaction. The turn of the chin forward under the pubic arch, so as to release the head by permitting flexion round the symphysis, cannot take place. Aid becomes necessary. We have to consider the following points: 1. Can the head be rotated on its transverse axis, restor- ing flexion, and so bring the cranium down ? This may be accomplished, while the head is above the brim, but scarcely when it is squeezed into the cavity. 2. Can the turn of the chin forward be effected by the hand, the lever, or the forceps ? This is sometimes possible, and should be tried. It is thus described by Smellie: " After applying the short or long curved forceps along the ears, push the head as high up in the pelvis as is possible, after which the chin is to be turned from the os sacrum to either os ischium, and afterward brought down to the in- ferior part of the last-mentioned bone. This done, the operator must pull the forceps with one hand, while two fingers of the other are fixed on the lower part of the chin or under jaw to keep the face in the middle and prevent the chin from being detained at the os ischium as it comes along, and in this manner move the chin round with the forceps and the above fingers till brought under the pubes, which done, the head will easily be extracted." 3. Can the head be brought down by the forceps without RELIEF OF IMPACTED FACE-PRESENTATIONS. 89 turning the chin forward ? This is a practice against Nature. If the forceps grasp—and it will generally slip—it will bring more of the base of the wedge into the brim. The head must be small, or the pelvis large, to admit of success by this mode. 4. Shall we extricate the head by perforating ? The wedge may be lessened, but, even after this, delivery is not always easy unless part of the cranial vault be removed, so as to allow of the flattening in of the head. 5. Can we turn simply ? It is the best course, but, if the head is low, it may be difficult to accomplish. 6. The chin will sometimes turn forward at the very last moment, when the face is quite on the floor of the pelvis. If not, it may be possible to hitch the chin over the perinae- um by drawing the chin forward by forceps, and pulling the perinaeum backward. The chin thus outside, the for- ceps or lever may be applied to draw the occiput down under the pubes and backward, so as to make the head re- volve on its transverse axis, thus restoring flexion. You are, in fact, decomposing the base of the wedge. You deliver by a process the reverse of that of ordinary occipito-anterior labor. In this, the occiput escapes by a process of exten- sion. In the mento-sacral position you deliver by promot- ing flexion. Or, to take our illustration from the mechan- ism of face-labor, you obtain flexion by causing the chin to turn over the coccyx or sacro-sciatic ligament as a centre, instead of over the symphysis. The latter is the natural mode, but it may be that the first alone is possible. This is a case in which incision, bilateral, of the perinaeum—here acting as an obstructing posterior valve—may be performed in order to facilitate the release of the chin. [Much may often, however, be accomplished in some cases, by availing ourselves of every opportunity which may serve to coax the chin to rotate. Such efforts, however, must be made cautiously, as we may destroy the life of the child by twisting its neck too strongly.] CHAPTER YIII. The Forceps in Disproportion of the Pelvis—Degrees of Disproportion—In- dications in Practice—The Mechanism of Labor in Contraction from Pro- jecting Promontory—the Curve of the False Promontory—Debatable Ter- ritory on the Confines of the Several Operations—Pendulous Abdomen— The Cause of DiflBculty in Pendulous Abdomen—Suspended Labor—The Mode of Management. Now we have to consider what the forceps can do in cases of disproportion—for instance, where the brim is too small to allow the head to pass by the unaided powers of the uterus. This brings up the problem of the compressi- bility of the head under the forceps, and the comparison of the advantages of the forceps with those of turning. The degrees of contraction of the brim may be classified approxi- matively in the following manner : Scheme of Relation of Operations to Pelvic Contractions, Labor at Term, Conjugate Diameter reduced to First degree...........4 to 3X inches, admits the forceps, opposed to the bi-parietal diameter of 3X to 4 inches. Second degree......... S% to 3 inches, admits of turning, opposed to the bi-mastoid diameter of 3 inches. Third degree...........3}£ to 2 inches, of craniotomy and cephalotripsy. Fourth degree.........below 2 inches, of Caesarean section. If you have the advantage of bringing on labor at seven months, then you may eliminate the Cassarean section, and slide down the scale of operations, so that craniotomy shall correspond with the fourth degree, turning with the third, and the forceps with the second; while the first degree, THE FORCEPS IN DISPROPORTION OF THE PELVIS. 91 being reduced to the conditions of natural labor, may re- quire no operation at all. Scheme of Relation of Operations to Degrees of Pelvic Contraction under Labor at Seven Months. Conjugate Diameter reduced to First degree....................4 to 3X inches, admits spontaneous labor. Second degree..................3% to 3 inches, admits of forceps. Third degree....................3X to 2 inches, admits of turning. Fourth degree..................below 2 inches, admits of craniotomy. Ciesarean section is eliminated. The range of application of the forceps is, I believe, not great. The head cannot be compressed by it quickly. The proper use of it is to aid that natural process of moulding which always takes place in protracted labor. Now, this is a gradual, even a slow process. The head is seized by the Fig. 28. Fig 28—Normal pelvis. S, the symphysis pubis, the centre of Carus's curve C D; A E the axis of the brim, forming an acute angle, not less than 30°, with the datum- line'A B The uterus and the child's body nearly corresponding with the axis of the pelvic brim the head enters its natural orbit, represented by Carus's curve, at once. 92 OBSTETRIC OPERATIONS. long forceps in the way already described. The handles are firmly grasped with both hands, and especial care is required to extract well backward in the axis of the brim, so as to make the head revolve round and under the projecting, overhanging promontory as a centre. Here I may pause to show that, in labor, with conjugate contraction from rickets, the promontory possesses a like importance at the brim or entry of the pelvis to that which the symphysis pubis pos- sesses at the outlet. The promontory is a turning-point—a centre of revolution of the head, just like the symphysis. The curve round the pubes, which Cams described, has its Fig. 29. Fig. 29.—Pelvis contracted by rickets to show the curve of the false promontory. S, the symphysis, the centre of Carus's curve CD; F P, the false promontory, the centre of the false curve E G; G, the point of intersection of the two curves where the head passes from the false to the true orbit; A H, the axis of the brim, forming a very acute angle, varying from 30° to 20° or less, with the datum-line A B. The bead is thrown over the pubic symphysis by the projecting promontory. The forceps draws backward in line A H to bring the head under the promontory in the orbit of the false promontory. counterpart in a curve round the promontory. In ordinary labor, with a well-constructed pelvis, the head enters the PROJECTING PROMONTORY IN RELATION TO DELIVERY. 93 pelvis, and reaches nearly to the floor, without deviating much from the straight line which represents the axis of the brim. Thus it enters its orbit, the circle of Carus, at once. But a projecting promontory, involving, as it does com- monly, a scooped-out sacrum below, disturbs this course. The promontory must be doubled. The head must move round this before it can strike into its natural orbit. I pro- pose to call this curve the curve of the false promontory. Fig. 30. Fio 30 -A B datum-line; C D, Carus's curve; E F, curve of the false promontory; C, F point of intersection of the'two curves where the head passes jrom the.&J>etothe true orbit. The forceps now draws the head.in the direction of the outlet in Carus s curve. This curve is the chart by which to steer in turning on account of contracted pelvis. # Bearino- this in mind, and assuming that the head is 94 OBSTETRIC OPERATIONS. seized nearly in its transverse diameter, which is very rarely effected, the blade corresponding to the anterior or pubic side of the head must describe a large circle, while the sacral side of the head, and the blade in relation with it, moves but little until the promontory is rounded, and the head has entered the pelvis. When this point is reached, the direction of traction is that of Carus's curve. The head, which was compelled to traverse the brim nearly in the transverse diameter, will quickly rotate, face to sacrum. This turn, imparted to the handles of the forceps, and sud- den transition from resistance to ease—a sort of jerk—mark the completion of the first circuit and the beginning of the second. The rest falls within the laws of natural labor. It happens, however, in these cases of contracted con- jugate diameter, that the head commonly presents at the brim with its long diameter very nearly, if not quite, in cor- respondence with the transverse diameter of the pelvis. The blades of the forceps, also finding most room in this diame- ter, will grasp the head in its longitudinal diameter. In extraction, therefore, both blades will move equally around the false promontory. What is the extreme degree of narrowing that will ad- mit of the useful application of the forceps ? I have stated it in the table at three and a quarter inches, but it cannot be defined absolutely. A head slightly below the normal size, and less firmly ossified than usual, may be brought through a conjugate diameter of only three inches. And, as we cannot know with sufficient precision what the properties of the head still above the brim are, we are justified in mak- ing tentative, experimental, efforts with the forceps before resorting to turning, which is, perhaps, more hazardous to the child, or to craniotomy, which is certainly destructive to it. This uncertainty, or want of fixity, in the relations be- tween the head and the pelvis, compels us to leave a range or border-land of debatable territory between the more clear- ly-recognized or conventional limits assigned to the several DYSTOCIA FROM PENDULOUS ABDOMEN. 95 operations. This debatable territory is further liable to in- vasion from either side, according to the relative skill with which the competing operations are carried out. And here- in lies the source of the great controversies in obstetric practice. Thus one operator, possessing a good long for- ceps, and confident in his skill in handling it, will use this instrument with success where the contraction is three and a quarter inches ; while another, possessing only a single- curved forceps, or a bad double-curved one, must either turn or perforate. So, again, the region between the second and third degrees of contraction, the region assigned to turning, may be invaded on the one side by the forceps, on the other by the perforator, and become the subject of a partition- treaty, which shall dispossess turning, the rightful power, altogether. It unfortunately happens that perforation, being an easy operation, is apt to carry its inroads further than the forceps; and thus the child falls under a wide, arbitrary, and fatal proscription. [Prof. George T. Eniot, in his " Obstetric Clinic," states that, " in a conjugate diameter of three inches and upward, with a living child and head-presentation, my first choice would be for forceps. Between two and a half and three inches, if the child were living, I should perform version."] There is a condition causing dystocia, called the pendu- lous abdomen. It is most frequent in women who have borne many children, and in whom the abdominal walls are much relaxed. Where this exists, the uterus hanging down in front of the pubes is out of the axis of the brim, and, if it con- tracts, would only direct the child over the brim, backward against the promontory. This may sometimes be remedied by putting the patient on her back, and making up for the want of support from the abdominal muscles by applying a broad binder, so as to lift the fundus of the uterus upward and backward. This will restore the relation between the axis of the uterus and pelvic brim. But, if contractile energy be still insufficient, the long forceps will come into 96 OBSTETRIC OPERATIONS. use. And this is a case where the dorsal decubitus will much assist the delivery. If the patient continue on her side, the uterus not only hangs forward, but swags down- ward to the dependent side, constituting a further deviation, and increasing the obstacle to parturition. How to determine the choice between forceps and turn- ing ? There are two cases : First, the liquor amnii has drained away, and the head is pressing into the brim ; the forceps is strongly indicated here. Secondly, the head is mobile above the brim, and not easy to grasp in the blades; here turning may be preferable. I have several times rescued a living child by turning under these circum- stances. The second case may sometimes be reduced to the first, and thus brought within the more desirable dominion of the forceps. One result of the pendulous abdomen and uterus is to form a kind of reservoir in which the liquor amnii is dammed up. Hence an added impediment to contraction of the uterus. Now, the waters can be drained off by lifting the fundus uteri up to its normal position against the spine, laying the patient on her back, and making a channel past the head to the uterine reservoir, by introducing the lever or one blade of the forceps. Having accomplished this, the uterus, under the combined advantages of restora- tion to its natural axis, and of steady pressure by the hands or a belt, may recover its power, and expel the child. If not, the forceps supplies an easy remedy. In the following diagrams, the mechanism of labor ob- structed by this form of malposition of the uterus is illus- trated. Until the uterus is brought back to its normal position, it is clear that two causes concur to render labor difficult. First, the uterus being thrown forward, its fundus is carried away from the diaphragm and upper part of the abdominal walls. It loses, therefore, the aid which the expiratorv muscles, acting powerfully when the glottis is closed and LABOR WITH PENDULOUS ABDOMEN. 97 the chest is fixed, usually give. This expellent power of the expiratory muscles is so great that it appears to be of itself sufficient in some cases to complete labor, the uterus re- maining quite passive. When the uterus is thrown forward across the pubes, any force propagated downward from the diaphragm will strike the posterior wall of the uterus at a right angle with the body of the uterus and of the long axis of the foetus. It will, in short, drive the uterus and its con- tents down upon the symphysis, or even more forward still, since the body of the child, which lies in front of the sym- physis, forms the longer arm of a lever, and the force is ex- pended upon it. Secondly, the uterus itself, if not paralyzed, acts in a wrong direction. It loses the stimulus to action which the normal pressure and support of the diaphragm and abdomi- nal walls supply, and therefore acts languidly. Its inde- Fig. 31. '• ■-... D Fig 31 —A B datum-line; A E, axis of pelvic brim and normal axis of uterus; F B, axis of uterus pointing to sacrum ; C D, Carus's curve pendent power is also weakened by another circumstance. It is a law of which the patient observer will not fail to dis- cover many proofs in the progress of difficult labor, that, 7 98 OBSTETRIC OPERATIONS. whensoever a mechanical obstacle is encountered, before long, the uterus, conscious, as it were, of the futility of its efforts, intermits its action, takes a rest, lies dormant, until the time shall arrive when it can act with advantage. This provision protects for a long time against exhaustion from protracted labor. Indeed, what appears to be protracted labor is often Fig. 32. FiG; 32.—Sbowing the mechanism of labor in pendulous, belly. A B, datum-line deter- mining position of the pelvis; C D, Carus's curve; H I, axis of uterus and of child directed toward the promontory; FG,line of force of expiratory muscles cutting the axis of the uterus and of child; A E, normal axis of pelvis; U if, the umbilicus. simply suspended labor. And suspended labor may evqn pass into whatT)r. Oldham has so aptly called " missed labor." LABOR IN PENDULOUS ABDOMEN. 99 The remedy is obviously to restore the uterus to its nor- mal position. In Fig. 31, the uterus and child are repre- sented lying across the symphysis pubis, like a sack across a saddle. H I is the line in which the proper uterine force would be exerted; F G is the line of force of the expiratory muscles striking the long axis of the uterus nearly at a right angle. These two forces, which ought to coincide, thus cross each other, and the error is but imperfectly compensated by the resultant force obtained between the two. But raise the uterus to its normal position, as indicated by the dotted out- line, Fig. 32, and immediately the expiratory force and the uterine force coincide with the axis of the child and of the pelvic brim, and both conspire to expel the contents of the uterus. Not even the forceps will act efficiently until this restoration is made. [Although pendulous abdomen is not a very common condition, yet the fact, that in some cases it will greatly in- crease the troubles of delivery, lends weight to the advan- tage of.the " dorsal decubitus " as the best obstetric position, for in such position the axis of the uterus must of necessity be more that of the pelvic brim than when the woman lies on her side.] CHAPTER IX. Dystocia from Faulty Condition of the Soft Parts—Contraction of the Cervix Uteri — Rigidity— Spasm—Deviation—Hypertrophy—Cicatrix—Closure— ffidema—Thrombus—Cancer—Fibroid Tumors—The Natural Forces that dilate the Cervix—The Artificial Dilating Agents—Vaginal Irrigation- Water Pressure—Incisions—Resistance offered by the Vagina, Vulva, and Perinseum—Thrombus of the Vulva. Dystocia from faulty condition of the soft parts of the parturient canal is only incidentally and occasionally related to the history of the forceps. This incidental relation, how- ever, makes it convenient to discuss the question in this place. The cervix uteri, the vagina, or the vulva, including the perinaeum, may refuse to yield a passage to the child, and to permit the application of the forceps. The conditions which lead to this result are various : First, as to the cervix uteri, including the os externum uteri. The following causes of obstruction may be observed: 1. Spastic annular contrac- tion. 2. Thickening from oedema. 3. The cervix may have an abnormal direction and position. The cervix is not in the line of the axis of extrusion. Perhaps it is bent down at a more or less acute angle upon the body. A more fre- quent condition is the pointing of the os uteri backward toward the promontory, and very high up, so that it is diffi- cult to reach, perhaps impossible, without passing the hand into the vagina. In such a case the head bears unduly upon the anterior segment of the lower part of the uterus. This is often the result of slight narrowing of the pelvic brim, DYSTOCIA FROM RIGIDITY OF THE CERVIX. 101 which throws the head upon the anterior wall of the pelvis. This may persist so long that, the tissues become worn and their texture softened, so that, when the head is driven down into the pelvis, the damaged cervix rends. 4. From contrac- tion of the brim, or from the presentation of some part of the child—as the arm, face, or feet—not adapted to descend early and fairly upon the cervix, there is insufficient dilata- tion. 5. The cervix may be organically diseased. The most marked causes of this kind are hypertrophy, occlusion from false membrane, fibroid tumor, or cancer. To this may be added abnormal formation. 6. The cervix may be closed by cicatricial atresia. It is further customary to refer to cases in which no os uteri can be found. There is another condition, which, although not in itself abnormal, will be properly considered in connection with the above. The os and cervix may be met with closed or only imperfectly dilated under circumstances which render speedy delivery eminently desirable. In such a case the cer- vix must be treated as one that is rigid or otherwise diseased. It obstructs labor; and, just as in the cases where the closure of the os is the primary cause of obstruction, it must be opened. The first of the conditions enumerated includes what is commonly understood as rigidity. It is really much more rare than is supposed. Most frequently when the os will not dilate, it is because the presenting part of the child can- not come down upon it. But if the membranes are rup- tured prematurely, and the presenting part comes to press upon the os before this is at all dilated, then it often acts as a source of irritation, and produces this spastic annular con- traction. Before discussing the second cause of rigidity, it will be useful to examine what are the forces that dilate the cervix. This study will throw light on the causes and pathology of rigidity, and furnish useful indications in treatment. By 102 OBSTETRIC OPERATIONS. some it is held that the opening of the cervix is the direct result of the active contractions of the longitudinal uterine muscles, which, pulling the os toward the fundus, thus draw it open. I very much doubt if more than a very inconsid- erable opening is effected in this manner. It is a matter of observation that the os uteri does not expand in any marked degree,-until either the bag of mem- branes or the child's head comes to bear upon.it.. These distend the cervix and os as a direct mechanical force; they are, in fact, wedges, themselves inert,'but propelled by the contractions of the-uterus, and the abdominaimuscles. Un- der this distending force, the circular- fibres of the cervix yield, just as the sphincter' ani^or*the sphincter vesicas.yields under the pressure from above. The yielding of the cervix uteri is indeed a question of the preponderance of the vis a tergo exercised by the body of the. uterus; and the expiratory muscles over the resistance offered by the cervix.- Sorne^ times the normal harmony between this preponderance and resistance is disturbed; the active force or the.passive resist- ance is in excess ; or the resistance may become active, and the force may be reduced to inefficiency. There is, in fact,. a translation or metastasis of the nervous energy from the body of the uterus to the neck. This disturbance most fre- quently arises from an inversion in time, in the'order of suc- cession of the parturient phenomena. Thus, if the liquor amnii escape prematurely, the presenting part of the'child will bear too early upon the cervix, and excite it to irregu- lar action. This, by diverting and disordering the nervous supply to the body of the uterus, disables this part of the organ ; and concurrently the cervix itself, becoming con- gested and thickened by undue pressure, irritation, and action, loses its natural capacity for dilatation. A very instructive illustration of the theory that the dilatation of the cervix uteri is essentially dependent upon the eccentric pressure exerted by the liquor amnii and foetus driven into it is found in the equivalent action of my hydro^ ARTIFICIAL DILATATION OF THE CERVIX. 103 static cervical dilator. This instrument is inserted within the cervix in a collapsed state, and then gradually distended with water as seen in Fig.. 33. It very nearly represents the normal action of the liquor amnii distending the sac of the amnion. Uiider this pressure, the cervix yields smoothly and gradually, just as in natural labor ; the speed, however, being very much within the discretion of the operator. In this instrument we possess a power in midwifery, at once; safe and efficient, that brings the cervix, and therefore the course of labor, completely within the control of skill. How> shall we restore the due relation between the ex- pulsive and the resisting forces ? How, in other words, shall we overcome the rigidity of the cervix uteri ? This may be done 'in one of two principal ways. We may increase the power of the body of; the uterus, so as to restore its prepon- derance over the cervix, or we may apply direct means to the cervix to dilate it, doing ourselves the work that- the uterus cannot do. Great judgment is necessary in. selecting be- tween these two courses. Before deciding in favor of the first, we must be satisfied that the resistance opposed by the cervix is of such kind and degree that it may be overcome by moderate force. We must also be satisfied that there is potential energy enough in the system and in the uterus to respond to the stimulus, to the whip we propose to admin- ister. To give ergot, for example, when the frame and the uterus are exhausted, is to equal the folly of the. heavy rider who drives his spurs into his jaded horse when he ought to dismount and lead him. It will almost always be proper, as the first step—that is, before seeking to rouse the uterus to increased action—to secure a more favorable condition of the cervix. How is this to be done ? Let us take the case of spastic rigidity, the cause of which we have just glanced at. The first indi- cation is to soothe, to subdue nervous irritability. Bella- donna in the form of extract has been smeared upon the part. One sees the action of this drug in expanding the 104 OBSTETRIC OPERATIONS. pupil. I have never felt it on the os uteri. The analogy is probably defective in theory; I believe it is not in the least degree to be relied upon in practice. It is at best an ex- pedient for passing time. Chloroform is often of signal service. It acts by annul- ling the sense of pain and the fear of pain, and by restoring the equilibrium of the nervous system by removing disturb- ing causes that divert the nerve-force from its appropriate distribution ; the sphincteric spasm relaxes, the body of the uterus contracts as it ought to do, and the labor proceeds. Opium is a remedy sometimes of equal value to chloro- form. Thirty drops of the tincture or twenty of the sedative liquor combined with thirty drops of compound sulphuric ether will assuage pain, procure rest, and restore the har- mony of the distribution of nerve-force ; and, if not in itself sufficient, it will aid in the carrying out of other measures. Tartar-emetic in small doses to provoke nausea has been recommended. In some cases I have proved its use, but I am not now disposed to resort to it, at the cost of postponing means at once more prompt and less distressing in their action. Bleeding has been much extolled. In certain cases, as of convulsions, apoplexy, or such states of system as threaten these catastrophes, this proceeding may be adopted. But, apart from a decided special indication of this kind, it is not wise to bleed a woman in labor. Nor can bleeding be de- pended upon, as may be frequently seen in cases of placenta prsevia, where even flooding ad deliquium will fail to relax the rigid or spastic cervix. Warm baths have been much praised, and no doubt have a certain degree of power in inducing relaxation of tissue. But a warm bath is rarely at hand, and, if it were, the inconvenience of putting a woman in labor into it must often be insurmountable. [Prof. G. T. Elliot and others recommend sponge or tangle tents as being valuable where the dilators or the douche ARTIFICIAL DILATATION OF THE OS. 105 cannot be procured or used. The manual dilatation he also considers serviceable in cases where there is dilatability with- out dilatation, and where the douche cannot be employed. Where the latter means are at hand, however, manual dila- tation should not be resorted to, as it is inferior to them, and in difficult cases there is danger of bruising the cervix. The procedure is described further on.] The most valuable of all preparatory measures is the irrigation of the cervix and vagina with a stream of tepid water. We know that this is even efficacious in the induc- tion of labor. And it is obviously useful to apply our knowledge of the agents that are effective in the solution of the major problem to the minor one, how to facilitate, to accelerate labor that has begun. In many cases this irri- gation will be enough. Presently the cervix softens and yields, spasm is subdued, and abnormal action of the cervix is turned into normal activity in the body of the uterus. The mode of proceeding is simple. Introduce the vaginal tube connected with Davidson's or Higginson's syringe into the vagina, guided by the fingers of the left hand to the os uteri —not into the os uteri, there is danger in that—so that the stream of water shall play upon the cervix and fundus of the vagina. This may be continued for ten or fifteen min- utes at a time, and repeated after an equal interval. When the cervix has become disposed to yield, it may not yield. The dilating force has still to be found. You may now, perhaps, give ergot. But, when you have given ergot, you are likely to be in the position of Frankenstein. Tou have evoked a power which you cannot control. Ergot- ism, like strychnism, will run its course. If it acts too long or too intensely, you cannot help it. The ergotic contraction of the uterus, when characteristically developed, resembles tetanus. Then woe to the mother if the cervix does not yield, if the pelvis is narrowed, if, in short, any obstacle should delay the passage of the child! And woe to the child itself if it is not quickly born ! I very much prefer to use 108 OBSTETRIC OPERATIONS. weapons that obey me, that will do as much, or even less) than I wish. I fear to use weapons that will do more. The cervix may be dilated by the hand. Two or three fingers are insinuated within the os one after another, so as to form a conical wedge. This wedge is gently and gradu- ally pushed farther into the cervix, and, widening as it goes, the cervix gives way. This wedge has the advantage of being a sentient force. It tells you what !itis doing. But what it will tell you is sometimes this: it is that the fingers, with their hard joints, form, a rather painful and irritating wedge. As. it proceeds, it' is apt to renew the spasmodic contractions you have taken such pains to allay. If the head is pressing upon,the cervix, you may, as has been al- ready mentioned, help the dilatation by hooking down the anterior lip with one or two fingers,, holding the os open as it were to; allow the head to engage in it. But this applica- tion is limited ; and, T think, what is called manual dilatar tion of the spasmodic cervix should be abandoned, except in the case of spasmodic contraction after the expulsion of the child—as, for example, when the placenta is retained, or clots are filling and irritating the uterus. In such a case the steady Onward pressure of the hand-wedge will in a few minutes wear out the spasm and effect a passage enabling you to clear out the cavity. Water pressure is the most natural, the most safe, and the most effective. An os uteri that will admit one finger will admit No. 2 dilator in the collapsed state. The intro- duction is effected in this way: Insert the point of the uterine sound, of a male catheter, or any convenient stem, into the little pouch at the end of the bag; roll the bag round the stem, anoint it with lard or soap, then pass it into the cervix guided by the forefinger of the left hand which is kept on the os uteri. When the bag is passed so far that the narrow or middle part is fairly embraced by the cervi- cal ring, withdraw the sound, keeping the guiding finger on the os to insure the preservation of the bag in situ. Then THE HYDROSTATIC DILATORS IN RIGID OS. JO7 pump in water gradually. Continue - distending the bag until you feel it is tightly: nipped by the os. When this is done, wait a while; close the stop-cock, and give time for the distending eccentric force to wear out the. resistance of" the cervix. No muscle can long resist a continuous elastic force. From time to time inject a little more water, so as to maintain and improve the gain. But be careful not to dis- tend the bag beyond its strength. There is of course a limit to the distensibility, even of india-rubber, and I have been told of cases where the bag has burst. I think this accident ought to be avoided. It has never happened to me, and I think it need not happen if the bags are well made. When you have got all the dilatation out of No. 2 that it is capa- ble of giving, remove it and introduce No. 3, which is larger and more powerful. The dilatation No. 3 will give is com- monly enough to afford room for the forceps or the hand. The time required for this amount of dilatation will range from half an hour to two hours. But, not to lose time, it is desirable to keep your finger on the edge of the os, so as to be sure that the bag does not slip forward into the uterus altogether, or is not driven down into the vagina by uterine action. If it slips wholly into the uterus, it may displace the head. When you have gained your end, open the stop- cock, the water is ejected in a stream, and the bag is easily withdrawn. The cervical dilator serves yet another purpose. Taking the place of the liquor amnii, it does duty for the bag of membranes. It not only directly expands the cervix, but, setting up a quasi-normal reflex excitation, it evokes the regular- action of the body of the uterus. The proceeding I have described will succeed in the great majority of instances, especially where the closure of th^cervix is due to spasmodic action, or where, the tissue of the cervix being .normal, it cannot expand for want of an eccentric expanding force, as when the bag of membranes or 11 the child does not bear upon it. But in certain cases where 108 OBSTETRIC OPERATIONS. there is rigidity from alteration of tissue, as oedema, hyper- trophy, cicatrix, something more is required. And that is found in the knife. There is nothing new in this use of the knife. It is an old resource too much neglected. Coutouly, Yelpeau, Holil, Scanzoni, indeed all the most eminent Con- Fio. 33. Fia. 33. This figure shows the hydrostatic dilator distended in situ within the cervix uteri. tinental practitioners, advocate it. Judiciously employed, the knife can do no harm. It will save life when nothing else can. You are sometimes in the presence of this alternative : exhaustion, sloughing, or rupture of the uterus, on the one hand, or the timely use of the bistoury on the other. It would be as absurd to hesitate as it would be to refuse to perform the Cassarean section to give birth to a child which INCISION OF THE OS TO OVERCOME RIGIDITY. 109 cannot be delivered by the natural passages. Indeed, it would be far more absurd, for the Csesarean section is a most dangerous operation, while vaginal hysterotomy of the kind under discussion is free from danger. There are various cases in which vaginal hysterotomy, or dilatation of the cervix by incisions, is necessary. First, no os uteri is to be found. Of course, at the time of conception there was an os uteri; it may have been sub- sequently closed by a false membrane or by cicatricial con- traction. You will rarely fail to feel a nipple or depression where the os ought to be. It is generally very high up and far backward, near the promontory. Pressure with a sound or the finger will mostly break down a false membrane and offer a sufficient opening to admit a hernia-knife or the special knife described in the first chapter. This is long and straight, probe-blunted at the end, having a cutting edge of about three-quarters of an inch near the end. The fore- finger on the left hand is kept on or in the os uteri as a guide. The knife is then slipped up, lying flat upon this finger, until its cutting edge is within the os. This edge is then turned up, the back supported by the guiding finger, which takes cognizance of what is to be done and of what is done ; and an incision of about a quarter of an inch deep, a slight nick rather, is made in the sharp ridge of the os. The knife is then carried round to another part of the ring of the os, and another nick is made. In this way four or five nicks are effected. Each gives perhaps little; but the aggregate gain of these minute multiple incisions is consid- erable. I do not think it matters much at what particular points of the circumference of the os these incisions are made ; perhaps the two sides are to be preferred. ^ Before extending or repeating these incisions, it is proper to observe the effect of uterine action in continuing the dila- tation. And, if nothing is gained in this way, introduce the hydrostatic dilator ; distend this gently, carefully testing by the finger its action. This plan of combining the water- 110 OBSTETRIC OPERATIONS. dilator with . incisions is especially valuable in cases of rigidity from hypertrophy of the cervix, or of atresia of the os or vagina from cicatrices. Fig. 34: Fig. 34.—This figure shows the operation of dilating the rigid or hypertrophied cervix. uteri by incision. When the. forceps will pass—and it is quite possible to apply it when the os will allow three fingers to pass as far as the knuckles—this instrument may serve to dilate further. But this must be done with great caution. The head being INCISIONS IN RIGIDITY OF THE VAGINA-VULVA, ETC. m grasped, you may draw steadily down; and, by keeping up gentle traction, the wedge formed by the blades and the head will gradually dilate the os, perhaps enough to allow it to pass, and thus save, the child's life. But it will occasionally happen that, neither by incision, water-pressure, the hand, nor the forceps, will you obtain an opening sufficient without danger of laceration or other mis- chief. In such a case, you are justified in reducing the head to the capacity of the cervix by perforation. Narrowing and rigidity may exist in the vagina in con- sequence of similar conditions, and may be treated on the same principle. The small rigid vagina of a primipara is best dilated by irrigation and the hydrostatic dilator. This will often singularly shorten labor. Atresia from cicatrices presents a more formidable obstacle. I have found the pas- sage constricted by dense cartilaginous tissues so as to per- mit no more than a probe to pass. Tn such a case, a careful process of incisions, multiplied in all points of the circumfer- ence, alternating with water-pressure, is necessary; and it is, after all, probable, that. you will have to meet the diffi- culty half-way by perforating the head. Lastly, obstruction may occur at the vulva and perinae- um. In primiparae especially the vulva may form a small rigid oblong ring, scarcely permitting the scalp of the pre- senting head to show through: it. The expulsive pains cause the perinaeum behind this ring to protrude; but the ring itself will not open; in fact, theperinasum will yield first. It bulges more and more,.and may give way in the raphe, just behind the commissure, this part remaining, for a time at least, intact. A central rent is thus made, through which the child has occasionally been expelled, instead of through the vulva. Or, if the perinaeum does hot yield, something else must. The uterus will cease to act, or, struggling in •vain, may burst. Hero, again, you. may- avoid mischief by incisions. The forefinger is passed between the head and the edge of the vulva, and two or three: small nicks are made 112 OBSTETRIC OPERATIONS. on either side, nearer to the posterior commissure than to the anterior. The relief sometimes gained in this way is sur- prising. Spasm, irritation, pain subside ; the vulva dilates, and labor is soon happily at an end. The bleeding is insig- nificant; and the minute wounds left when the parts have contracted quickly heal. Sometimes the vulva, including the labia majora, is so greatly swollen, by serous infiltration, as to offer a serious obstacle to labor. This condition is commonly associated with albuminuria and convulsions. And out of this associa- tion a double difficulty arises. The convulsions urge to the acceleration of labor; the state of the soft parts forbids active interference. If the head comes down through tissues thus distended by fluid, not only laceration, but subsequent sloughing or gangrene, may result. The obstacle to labor, and the local mischief, may be avoided by pricking the skin and mucous membrane in numerous points, so as to let the serum drain off. The operation is performed by a lancet held by the blade between finger and thumb, at a distance of a quarter of an inch- from the point, so that the stabs made shall not exceed that depth. Any point of the parturient canal may be swollen so as to impede the descent of the child by a submucous infiltra- tion of blood—the so-called thrombus. I have seen a large tumor formed in this way on the os uteri; but the more common seat is the labia of the vulva. It is not desirable to open these collections of blood, if it can be avoided. But, if the obstacle be so great that the head, in passing, threatens to burst and rend the tumor, it is better to open it with a lancet. As soon as the child is born, the part should be carefully examined, to see if it bleeds; and pressure upon it by plugging will be necessary. In cases of formidable obstacle from cancerous or fibrous growth, recourse to the ultima ratio—the Caesarean section— may be indicated. [In the American Journal of Obstetrics and Diseases of VAGINAL THROMBUS COMPLICATING DELIVERY. Women and Children, vol. i., No. 3, November, 1868, a remarkable case of a large thrombus of the vagina, com- plicating labor, is recorded by Prof. G. T. Elliot, of New York. The thrombus was exceedingly large, distended the vaginal walls and perinaeum enormously, and finally burst through the mucous surface of the left labium with great violence during the efforts at forceps delivery, which were facilitated by freely incising the labium. The child was born alive, and its mother made a good recovery. The severity, extent, and suddenness, with which the thrombus advanced are mentioned as being startling. Prof. Fordyce Barker, of New York, in the journal above mentioned, vol. iii., No. 3, November, 1870, also gives the history of two cases and the following excellent remarks on this accident: " It may occur at any period of gestation ; it may be found as a complication during labor ; or it may not become manifest until after the labor is terminated. It has been mistaken for labial hernia, inversion of the uterus, thrombus of the bladder, for the foetal head and placenta praevia. Thus, in very many cases, it has escaped diagnosis. It seems that, in all these cases, the mistake must have arisen from ignorance that such an accident was liable to occur. Making an examination while the extravasated blood has simply infiltrated the cellular tissue and not yet lacerated it, you find the tumor hard, and feeling very much like the foetal head covered with the tumefied scalp. After lacera- tion of the cellular tissue, you get the sensation of fluctua- tion, and then the tumor could not be mistaken for the foetal head. The character of the haemorrhage which occurs, and its want of coincidence with the uterine pains, should pro- tect you from mistaking the case for one of placenta praevia. The sac may be ruptured, and the effusion of blood take place either high up in the cavity of the vagina, or near the junction of the mucous membrane with the skin. " There is always intense pain until laceration of the cel- lular tissue takes place; after this the pain is less severe, 8 114 OBSTETRIC OPERATIONS. because the parts more readily yield before the pressure to which they are subjected. The moment the head has es- caped, there is, of course, an excessive flow of blood. " Where extravasation takes place during labor, the dan- ger is very much increased, notwithstanding that Yelpeau says there are no vessels in these parts of sufficient size to occasion danger from loss of blood. It is the fact that in some of these cases the amount of blood lost is very great, so as to produce death from this cause alone. In the cases apparently occurring immediately after delivery, there is no doubt that the rupture of the vessels has been produced dur- ing the labor, although the extravasation has been delayed by the pressure of the child's head. " There are one or two points on which my experience is opposed to the statements of the writers on the subject: First, it is asserted that the accident is almost always a conse- quence of varicose veins. Now, in neither of my two cases, in neither of Prof. Sayre's, nor yet in Prof. Wood's, were there any varicose veins at all. And I can say the same of the cases I have seen in which the thrombus appeared previous to labor. Another point: Cazeaux states, and so do other authors, that the rupture occurs just as the head, or the pre- senting part, is escaping from the vulva. This was not the fact in my cases. The head was in the pelvic cavity, pretty well down toward the perinaeum, but not yet in the least distending this or the vulva." When this accident is recognized as complicating labor, Prof. Barker says: " Incise at once, then, so as to relieve the parts from pressure, and relieve the patient from the shock of the severe pain attending the tearing of the tissues—a shock far greater than even that of the ordinary labor-pains; turn out the clots, find out the exact point of laceration, and arrest the haemorrhage promptly and surely by applying di- rectly to the bleeding surface that powerful styptic, persul- phate of iron. " The next question is between speedy delivery by artifi- VAGINAL THROMBUS COMPLICATING DELIVERY. H5 cial means, and waiting till the system recovers from the shock, and trusting to Nature to deliver the woman. I have already shown that the accident is not due to varicose veins; but the exciting cause is arrest of the venous circulation by the mechanical pressure of the presenting parts of the foetus. If this be so, the sooner the pressure is removed, the sooner will the danger be over, and the less will be the injury to the parts. Deliver as soon and as rapidly as possible, and be prepared to meet the great gush of blood that you must expect as soon as this is accomplished. Apply compresses of cotton-batting saturated with solution of persulphate of iron directly to the bleeding part, and keep up pressure until the haemorrhage stops. It is an important point in the dress- ing not to detach the coagulum formed by the persulphate; you must never remove any part of it, except such as is com- pletely loosened." As to the origin of thrombus of the vulva, it is well to state that Prof. Scanzoni (lehrbuch fur Geburtshulfe) re- cords fifteen cases, with only one connected with varicose veins. In eight of these cases it occurred before the birth of the child; in six during delivery of the placenta; and once in a twin case between the birth of the first and second child. He applies forceps and delivers immediately, and only in- cises the tumor first when it offers mechanical hinderance to birth.] CHAPTER X. Turning—Definition—The Conditions which determine the Normal Position of Foetus—Causes of Malposition—Frequency of Change of Position of Foetus in Utero—The Powers of Nature in dealing with Unfavorable Posi- tions of the Child—The Truth of Denman's Account of Spontaneous Evolu- tion—The Mechanism of Head-labor the Type of that of Labor with Shoul- der-presentation. If we were restricted to one operation in midwifery as our sole resource, I think the choice must fall upon turn- ing. Probably no other operation is capable of extricat- ing patient and practitioner from so many and so various difficulties. In almost every kind of difficult labor with a pelvis whose conjugate diameter exceeds three inches, it would be possible to deliver by turning with a reasonable prospect of safety to the mother, and in many instances with probable safety to the child. We might very greatly restrict craniotomy. We might dispense with the forceps; but neither forceps nor craniotomy will serve as a substitute for turning in its special applications. It is difficult, therefore, to ex- aggerate the importance of carrying to the utmost limit the perfection of this operation. Yet the text-books exhibit a very inadequate appreciation of the subject. Turning by the feet was once said, not inaptly, to be the master-stroke of the obstetric practitioner. And still the operation was very imperfectly developed. I propose to describe and illustrate with some fulness the conditions upon which mobility of the foetus in utero de- CONDITIONS DETERMINING NORMAL POSITION OF FffiTUS. 117 pends, the various modes by which the foetus may be made to change its position, and the applications of this knowl- edge to the practice of turning, embodying the teaching of Wigand, d'Outrepont, Eadford, Simpson, d'Esterle, Lazzati, Braxton Hicks, and myself. Having regard to the various allied operations which it is convenient to class under a general description, I would define turning as including all those proceedings by which the position of the eh ild is changed in order to produce one more favorable to delivery. There are three things which it is very desirable to know as much about as possible before proceeding to the study of turning as an obstetric operation : 1. What are the conditions which determine the normal position of the foetus in utero f 2. "\V~hat are the conditions which produce the frequent changes from the ordinary position \ 3. What are the powers of Nature, or rather the methods employed by Nature, in dealing with unfavorable positions of the foetus % 1.—The Conditions that determine the Normal Position of the Fcetus in TJtero. It would be idle to do more than glance at the fanciful ideas upon this subject that have obtained currency at vari- ous times, although most have an element of truth in them. Ambroise Pare believed that the head presented owing to the efforts made by the child to escape from the uterus. Even Harvey believed that the foetus made its way into the world by its own independent exertions. Dubois endeav- ored in a long argument, to show that the foetus has in- stinctive power, which determines it to take the head-posi- tion. Simpson, rightly concluding that the maintenance of normal position depends very much upon the life of the foetus, observes that it has no power of motion except mus- 118 OBSTETRIC OPERATIONS. cular motion, and infers that the foetus adapts itself to the uterus by reflex muscular movements excited by impressions —as by contact with the uterus—upon its surface. Thus we come down by a curious scale of theories, in which the philosopher may trace the influence of contemporary physio- logical doctrines or knowledge. First, the foetus is endowed with the high faculty of volition ; then it falls to the lower faculty of instinct; and, lastly, it is degraded to the lowest nervous function, that of reflex motion. I should be dis- posed to estimate at a still lower point the influence of the foetus as an active agent in maintaining its position during pregnancy or labor. It is incontrovertibly true that the normal position of the foetus and the course of labor are in- timately dependent upon the life of the foetus. But I think I am enabled to affirm from very close observation that a foetus, if full grown, and only recently dead—that is, for a few hours—may be nearly as well able to maintain its posi- tion and to conduce to a healthy labor as one that is alive. How is this ? It depends simply upon the preservation of sufficient tone and resiliency in the spinal column and limbs to maintain the form and posture of the foetus. While alive, or only recently dead, the spine is firmly supported in a slight curve, the limbs are flexed upon the trunk, the whole foetus is packed into the shape of an egg, which is very nearly the shape of the cavity of the uterus. It has a long axis, represented by its spine. This long axis, being endowed with sufficient solidity, resembles a rod, rigid or only slightly elastic. It is a lever. Touched at either pole, the force is propagated to the opposite pole. If the head impinge upon one side of the uterus, the breech will be driven into con- tact with the opposite point of the uterus ; head and breech will move simultaneously in opposite directions. In labor, when the uterus is open to admit of the passage of the foetus, the propelling power applied to the breech is propagated throughout the entire length of the spine or long axis, so that the head, the end farthest from the direct force, is CONDITIONS DETERMINING NORMAL POSITION OF FffiTUS. ng pushed along in the direction of least resistance, turning at those points where it receives the guiding impact of the walls of the canal. When the foetus has been some time dead, the elasticity and firmness of its spine are lost; flaccidity succeeds to tonicity. Force applied to one extremity is not propagated to the other extremity—or, at least, very imperfectly so ; the long axis bends, doubles iip like a rod of gutta-percha softened by heat. If, the foetus in utero being in this state, pressure be applied to one side of the head, the head will simply move toward the opposite side of the uterus. And, if labor be in progress, the propelling force applied to the breech will not be duly transmitted to the head, but will tend to double up the trunk, to make it settle down in a squash in the lower segment of the uterus or in the pel- vis. The head—the cervical spine having lost its resiliency —will not take the rotation and extension turns. It will run into the pelvis like jelly into a mould. Or, at an ear- lier stage, the limbs, especially the arms, having lost their tonicity, drop or roll in any direction under the influence of gravity or of pressure ; and hence may fall into the brim of the pelvis, constituting what are called transverse pre- sentations. The influence of this law is clearly seen in the course of that process called " spontaneous expulsion," by which a dead child is expelled, a shoulder presenting. Other factors besides the child have to be considered. Scanzoni correctly observes that the frequency of head-pre- sentation is dependent on the operation of various causes. 1. There is the force of gravitation; 2. The form of the uterine cavity; 3. The form of the foetus (to which must be added the properties I have described due to life or death) ; 4. The quantity of amniotic fluid ; 5. The contrac- tions of the uterus during pregnane^ and the first stage of labor. In the early stages of pregnancy the embryo is so small relatively to the cavity containing it that it floats suspended in the liquor amnii. But, about the middle of 120 OBSTETRIC OPERATIONS. pregnancy, the foetus grows rapidly; it acquires form ; and, at the same time, the uterus grows more in its longitudinal than in its transverse diameter. As soon, therefore, as the foetus—an ovoid body—attains a size that approaches that of the capacity of the uterus, the walls of the uterus will impose upon the foetus a vertical position. The foetus has become too long to find room for its long diameter in the transverse diameter of the uterus. Mutual adaptation re- quires that the long diameters of foetus and uterus shall coincide. A condition not, to my knowledge, hitherto noticed, which has a powerful influence upon the determination of the child's position in utero, is the normal flattening of the uterus in the antero-posterior direction. In the non-preg- nant uterus, the cavity of the body—the true and only ges- tation-cavity—is a flat triangular space, the angles of which are the orifices of the Fallopian tubes and the os internum uteri. A similar triangular superficies is marked out on each half of the uterus, anterior and posterior. The an- terior superficies lies flat against the posterior superficies, touching it as if the two were squeezed together. When pregnancy supervenes, these surfaces are necessarily sepa- rated to form a cavity for the growth of the ovum. But the original form is never entirely lost. The cavity is always more contracted from before backward than from side to side. This is proved by direct observation if the fingers are introduced after abortion, or the hand after labor at term. The uterine cavity is closed by the flattening of the anterior and posterior walls together. This takes place the moment the uterus contracts. If the finger or hand be in the uterus at the time, this is plainly felt. Now, this flattened form of the uterus is the reason why the foetus takes a position with either its back or belly directed for- ward. The foetus is broader across the shoulders than from back to front, and therefore its transverse diameter is fitted to the transverse diameter of the uterus. There is a physio- CONDITIONS CAUSING CHANGES IN POSITION OF FffiTUS. 121 logical design that dictates the downward position of the head. The fundus is the part designed for the implantation of the placenta, where it can grow undisturbed, and con- tinue its function during the expulsion of the child. The lower part of the cavity is therefore left free for the devel- opment of the embryo. Why the back is commonly directed forward to the mother's belly is this: The child's back is firm and convex; its head is also firm and convex behind. The anterior aspect of the child's body is plastic and concave, and therefore fits itself better to the firm convexity of the mother's spine. It is clear that the two solid convex spines of mother and child would naturally repel each other; and, the child being movable, it is the child's back that recedes, turning forward. [It is also stated as probable that, when the belly of the foetus is toward that of its mother, it thus presenting an irregular surface, any irritation of the mother's abdomen is reflected to the soles of the feet, hands, etc., of the child, feeling which it spontaneously turns, in order to present a more even surface—its back. This occurrence has been noted in practice by many obstetricians.] 2.—The Conditions which produce the frequent Changes in the Child's Position. Any considerable disturbance of the correlation of the factors which keep the foetus in its due position, of course favors malposition. The principal disturbing conditions may be stated as follows: An excess of liquor amnii acts in two ways : first, it favors increased mobility of the foetus; secondly, it tends to destroy the elliptical form of the uterus. The transverse diameter increasing in greater proportion than the longitudinal, the cavity becomes rounder. Hence the foetus is no longer kept in a vertical position for want of the proper relation between its form and size and those of the uterus. 122 OBSTETRIC OPERATIONS. Obliquity of the uterus was considered by Deventer to be a main cause of malposition. It is now very much dis- credited, but I am disposed to believe that it has, not sel- dom, a real influence. Dubois and Pajot showed that, in one hundred women, seventy-six exhibited a marked lateral obliquity to the right, four to the left, and twenty an anterior obliquity. Wigand had shown that deviations of the uterus to the right and forward were far the most frequent. The normal direction of the non-pregnant uterus is nearly that of the axis of the pelvic brim. As it grows during preg- nancy, rising above the brim, the projecting sacro-vertebral angle and the curve of the lumbar column deflect its fundus to one or other side; and, if the abdominal walls be very thin and flaccid, the fundus will fall forward. The tendency of these obliquities, if carried beyond ordinary measure, is to throw the axis of the uterus out of the axis of the pelvic brim, and to bring some other part than the vertex of the foetus to present. The probability of this will be increased by the irregular contractions of the uterus likely to be ex- cited by parts of the foetus pressing unequally upon its walls. For example, in extreme lateral obliquity the breech may press strongly upon one side of the fundus ; contraction taking place here, will drive the head farther off the brim on to the edge, where, if it finds a point d'appui, it will rotate on its transverse axis, producing forehead or face pre- sentation, and favoring the descent of the shoulder. Wigand explains how a too loose and shifting relation of the uterus to the pelvis disposes to cross-birth. In this condition it is observed that the head is now fixed in one place, now in an- other, and now not felt at all. He further1 says, that any obliquity of the uterus ex- ceeding an angle of 25° is unfavorable; and that even a lesser obliquity, with excess of liquor amnii or a small child, is likely to cause the presenting head to be dis- placed, and to bring a shoulder into the brim, especially 1 Die Geburt des Menschen. Berlin, 1820. Vol. ii., p. 137. INFLUENCES CAUSING MALPOSITIONS OF THE FffiTUS. 123 if strong pains or bearing-down efforts be made early in labor. He explained that the os uteri might be brought over the centre of the brim by internal drawing upon the os, combined with external pressure upon the fundus in the opposite direc- tion, thus putting in practice the principle of acting simul- taneously upon the two poles of the uterus. Deformity of the pelvis or lumbar vertebrae is often a powerful factor. The comparative frequency of transverse presentations in cases of deformed pelvis is certainly greater than where the pelvis is well formed. I think, however, that slight deformity has more influence in causing malposi- tion than extreme degrees. In these latter, malpositions are rarely observed. The attachment of the placenta to the lower segment of the uterus is, as Levret has clearly shown, a cause of mal- position by forming a cushion or inclined plane, which tends to throw the foetal head out of the pelvic axis across the brim. Hence the frequency of cross-birth and of funis-pre- sentation in cases of partial placenta praevia. But there are numerous cases in which the placenta dips into the cervical zone, growing downward from the posterior and lateral walls of the uterus, without leading to haemorrhage, and thus not suspected to be cases of placenta praevia, which, neverthe- less, form an inclined plane behind or on one side, and pro- duce malposition. Then there is the influence of external forces, as of press- ure applied to the uterus through the abdominal walls. The dress of a woman at the end of pregnancy is a matter of no small moment. The pressure of a rigid busk of wood or steel upon the fundus of the uterus, modified by the various move- ments and postures of the body, may flatten in the fundus, thus reducing the longitudinal diameter of the uterus, or it will push the fundus to one side, causing obliquity. It will, at the same time, press directly upon the breech, and thus tend to give the foetus an oblique position, throwing the 124 OBSTETRIC OPERATIONS. head out of the pelvic axis. Pluriparae should do the re- verse of this. They should wear an abdominal belt, which supports the fundus of the uterus from below upward. Want of tone in the uterus, which implies inability to preserve its elliptical form, and a tendency to fall into rotun- dity, a form which obviously favors malposition. Irregular or partial contractions of the uterus cause malposition. Naegele insisted upon this. He found that, in some cases, malposition was averted by allaying spasm. The researches conducted by several German physicians, among whom I may cite Crede, Hecker, and Yalenta,3 estab- lish the fact that the foetus changes its position with remark- able frequency. Yalenta examined three hundred and sixty- three multiparas and three hundred and twenty-five primi- parae in the latter months of pregnancy. He found that a change of position took place in forty-two per cent. Change was more frequent in multiparas, and in these in proportion to the number of previous pregnancies. Narrow pelves very frequently cause change of position. Circumvolutions of the cord, so often observed, are produced by changes of position, and hence bear evidence to the correctness of the proposi- tion. It is interesting to observe that the general tendency of changes of position is toward those which are most pro- pitious. Thus, cranial positions are least liable to change. Oblique positions are especially liable to change. These mostly pass into the long axis by spontaneous evolution. Self-evolution is a very frequent resort of Nature. In some cases several changes of position have been observed in the same patient. The presentations are made out by exter- nal manipulations. Yalenta thus describes his method of ascertaining a breech-position during pregnancy: He lays his right hand flat on the fundus uteri, and then strikes the tips of the fingers as suddenly as possible toward the cavity of the uterus, against the part of the child lying at the fun- dus. By this manoeuvre he has always succeeded in recog- 1 Monatsschr. f. Geburtsh. 1866. POWER OF NATURE TO CORRECT MALPOSITIONS. 125 nizing the head, if lying at the fundus, by its peculiar hard- ness and evenness. He detects the head in oblique and cross positions in the same manner. P. Miiller1 relates a case in which, within five days, a complete version of the foetus was effected six times. Yet the fact of the " spontaneous evolution " of a living child, as described by Denman from actual observation, has been doubted! We now come to study— 3. The Powers of Nature, or rather the Methods employed by Nature, in dealing with unfavorable Positions of the Foetus. I will do no more at present than glance at those minor deviations from the natural position in which the long axis of the child's body still maintains its coincidence with the axis of the pelvic brim. With some additional difficulty, Nature is in most of these cases able to effect delivery with- out materially modifying the position. Forehead and face positions have, indeed, already been described in some detail. Difficult breech-positions will be specially considered at a later period of the description of turning. From the time of Hippocrates, who compared the child in utero to an olive in a narrow-mouthed bottle, it has been known that the child could hardly be born if its long axis lay across the pelvis. But before the time of Denman it was not clearly explained that a correction of the position, or a restitution of the child's long axis to coincidence with the axis of the pelvic brim, could be brought about by the spontaneous operations of Nature. And observations of this most deeply interesting of natural phenomena are so rare that many men, even at the present day, do not hesitate to deny the accuracy of Denman's description. I would, with all deference, suggest for the consideration of these skeptics, 1 Monatsschr. f. Geburish. 1865. 126 OBSTETRIC OPERATIONS. whether they do not carry too far their regard for the maxim, " Nulla jurare in verba magistri." In matters of deduction, of theory, that maxim can hardly be too rigor- ously applied. But to reject as false or impossible matters of fact, observed and recorded by men of signal ability and conscientiousness like Denman, is to push skepticism to an irrational degree. There are subjects, and this is one, which are not questions of opinion, but of evidence. Shall we re- ject the testimony of Denman ? Whose shall we, then, ac- cept in contradiction ? Shall it be the testimony of those who deny that Denman saw what he says he saw, because they themselves have never seen it ? This is simply to give the preference to negative over positive evidence, to say nothing of the relative weight or authority of the witnesses. There is no man whose experience is so great that nothing is left for him to learn from the experience of others. Let us first call Denman into the box. He says : " In some cases . . . the shoulder is so far advanced into the pelvis, and the action of the uterus is at the same time so strong, that it is impossible to raise or move the child. . . . This impossi- bility of turning the child had, to the apprehension of wri- ters and practitoners, left the woman without any hope of re- lief. But in a case of this kind which occurred to me about twenty years ago, I was so fortunate as to observe, though it was not in my power to pass my hand into the uterus . . . that, by the mere effect of the action of the uterus, an evolu- tion took place, and the child was expelled by the breech. . . . The cases in which this has happened are now become so numerous, and supported not only by many examples in my own practice, but established by such unexceptionable authority in the practice of others, that there is no longer any room to doubt of the probability of its happening, more than there is of the most acknowledged fact in midwifery. As to the manner in which this evolution takes place, I pre- sume that, after the long-continued action of the uterus, the body of the child is brought into such a compacted state as to SPONTANEOUS EVOLUTION AND EXPULSION. receive the full force of every returning pain. The body in its doubled state being too large to pass through the pelvis, and the uterus pressing upon its inferior extremities, which are the only parts capable of being moved, they are gradu- ally forced lower, making room as they are pressed down for the reception of some other part into the cavity of the uterus which they have evacuated, till the body turning, as it were, upon its own axis, the breech of the child is expelled, as in an original presentation of that part. I believe that a child of the common size, living, or but lately dead, in such a state as to possess some degree of resilition, is the best cal- culated for expulsion in this manner. Premature or very small children have often been expelled in a doubled state, whatever might be the original presentation ; but this is a different case to that we are now describing." Denman cited, in confirmation, the evidence of Dr. Garth shore, Consulting-Physician of the British Lying-in Hospital, who related to him a case of the kind, in which the child was living, and the not less trustworthy evidence of Martineau of Norwich. But, before Denman's time, simi- lar cases had been observed, although not understood. Thus Perfect: " The arm presented ; and, after endeavors were ineffectually made to get at the feet to turn the child, the patient was thereupon left to herself, and delivered, in a few hours, of a live child without any assistance whatever." D'Outrepont cites Sachtleben, Loffier, Christoph von Siebold, Wilhelm Schmitt, Wiedemann, Yogler, Saccombe, Ficker, Simons, Elias von Siebold, Hagen, Wigan, as all having witnessed self-turning, chiefly, indeed, by the head. He says he himself has frequently witnessed it. Since Denman's time, evidence has accumulated. Prof. Boer of Yienna, a name in the first rank of the illus- trious in medicine, described, in 1801, a case of arm-presen- tation the fingers having been seen at the vulva. He was i preparing to turn, when he found the hand higher than when he had examined before. As the pains continued, 128 OBSTETRIC OPERATIONS. Boer rested with his hand in the pelvis. The arm distinctly moved up. At this time the whole cavity of the pelvis was filled with the breech of the child. The body and head of a fresh living child were expelled. Yelpeau, a man remark- able for the precision of his observations, is equally decided in corroboration. What observations can be more positive, exact ? Who can give evidence more carefully ? Who is more worthy of belief? Upon what grounds is evidence so distinct im- peached ? There are two grounds. In the first place, there is the observation of a fact, of a different method of spon- taneous or unaided delivery under arm-presentation from that which Denman described. In the second place, there is the assumption that this different method is the only true one. Now, let us admit the accuracy of the observation, which we may do unreservedly: does it follow that the assumption which excludes the possibility of the occurrence of any other mode of unaided delivery is to be received ? Denman, more logical and more philosophical than his opponents, is not so ready to impose limits upon the resources of Nature. He not only observed the " spontaneous evolution " or version of living children, and described this as one resource, but he also observed the " spontaneous expulsion " of dead or pre- mature children by doubling-up, and described this as a second and different resource. Not only, therefore, did Douglas fail to correct or to displace the explanation of Denman, but Denman had actually left nothing for Douglas to discover. In two papers published in the London Medi- cal Journal in 1784, Denman relates several cases of spon- taneous birth with arm-presentation — some observed by himself, some communicated to him. In these the child was born dead, and the shoulders remained fixed at the pubes. They are clearly described, and certainly anticipate the description given by Dr. Douglas in 1811. But it is fair to add that at this time Denman had not arrived at that SPONTANEOUS VERSION AND EXPULSION. 129 sharp distinction which he afterward drew (1805, see fifth English edition " Introduction to Midwifery") between spontaneous version and expulsion. These are the facts—the evidence. The assumption to which I have referred is further rebutted by abundant collat- eral testimony. The observation of Denman, so far from being incredible or improbable, is in entire harmony with the phenomena of gestation and labor. 9 CHAPTEE XL The Modes in which Nature deals with Shoulder-presentations analogous to those in which she deals with Head-presentations. We will now endeavor to trace, with more precision, the modes employed by Nature in dealing with shoulder- presentations. The mechanism of labor with shoulder-pre- sentation is strictly analogous to that of ordinary labor. It is, therefore, desirable to set before our minds the picture of an ordinary head-labor. In the first head-position, the occiput is directed to the left cotyloid foramen, the face looks to the right sacro-iliac joint, the vertex points downward to the os uteri, while the long axis or trunk corresponds with the long axis of the uterus, which is coincident, or nearly so, with the axis of the pelvic brim. The head, in its progress to birth, undergoes five successive movements: 1. A Movement of Flexion.—The posterior fontanelle placed opposite the cotyloid cavity descends and approaches the centre of the brim, the chin is strongly pressed upon the chest, the neck comes to bear upon the cotyloid wall, while the forehead rises on the right, and the anterior fontanelle is applied to the right sacro-iliac joint. By this movement the head fixes itself upon the trunk, and presents its smaller diameters to the greatest or oblique diameters of the pelvic brim. 2. A Movement of Descent or of Progression.—This begins commonly with the escape of the head from the MECHANISM OF NATURAL HEAD-LABOR. 131 mouth of the uterus, the clearing of the brim, and ends with the total expulsion of the foetus. 3. A Movement of Rotation.—This takes place in the lower part of the pelvic cavity. The forehead and the an- terior part of the region of the vertex resting on the right sacro-iliac ligament, or on the right posterior wall of the pelvic cavity, follow the incline backward and downward, turning toward the sacral cavity, while the back of the neck slides behind the left foramen ovale, or the left anterior wall of the pelvis, and, following the incline forward and a little upward, turns toward the upper part of the pubic arch. 4. A Movement in a Circle.—The back of the neck is arrested under the symphysis pubis; the posterior fontanelle is nearly in the centre of the pelvic outlet; the occiput, the vertex, the forehead, the face, and, lastly, the chin, roll suc- cessively over the posterior commissure of the vulva, travers- ing the concavity of the lower part of the sacrum and the distended perinaeum. 5. A Movement of Restitution.—As soon as the head is freed from the pelvis, the occiput turns quickly to the left, and the face and forehead to the right. This last move- ment of the head is the effect of the first of a succession of movements similar to those described which is now pursued by the trunk. The shoulders, entering the brim in the left oblique diameter, turn the head, now freed from all restraint, bring- ing the face forward to the right. The movements undergone by the trunkJ are three : 1 An easy method of realizing a description of some positions of the foetus is to follow them with a pelvis and a small lay-figure, such as is used by artists. It is not even necessary to have a pelvis. A partial equivalent may be made by tracing a drawing of a pelvis on a piece of cardboard, and cutting out the oval which represents the brim and the space beneath the symphysis pubis. The following figure will serve as a model. Cut out the parts shaded dark. A if small lay-figure of corresponding size must be procured. 132 OBSTETRIC OPERATIONS. 1. A Movement of Descent or of Continuous Progres- sion.__The right shoulder is forward to the right, the left is behind to the left; the child's back is directed forward to the left. 2. A Movement of Rotation.—The shoulders and the upper part of the trunk having descended into the excava- tion, the right shoulder turns toward the apex of the pubic arch, and the left rotates toward the concavity of the sacrum. The child's back, after the rotation, is turned to the left. Fig. 35. 3. A Movement in a Circle.—The right shoulder re- maining fixed beneath the pubic arch, the left shoulder, fol- lowed by the corresponding side of the trunk and the left hip, describe the arc of a circle; and gradually the right shoulder rises over the mons Yeneris, while the parts placed behind traverse the sacro-perineal concavity. These move- ments are governed by the form of the pelvis. Labor with shoulder-presentation must obey the same laws. Shoulder-presentations may be primitive or secondary. The primitive exist before labor has set in, and are almost necessarily associated with obliquity of the uterus. The sec- ondary are formed during the initiatory stage of labor, under SPONTANEOUS DELIVERY IN SHOULDER-PRESENTATIONS. 1,33 conditions which lead to the deflection of the head from the pelvic brim when it is made to move under the influence of force applied to the breech or trunk. In Nature we observe two chief shoulder-positions, and each of these has two varieties. In the first position, the head lies in the left sacro-iliac hollow. In the second posi- tion, the head lies in the right sacro-iliac hollow. Now, in either position, either the right or the left shoulder may present. Thus, if the head is in the left ilium, the right shoulder will descend when the child's back is directed for- ward ; and the left shoulder will descend when the child's belly is directed forward. In the case of the second or right cephalo-iliac position, the right shoulder will descend when the child's "belly is turned forward, and the left shoulder when the child's back is turned forward. CHAPTER XII. Definition of Spontaneous Version and Spontaneous Evolution—Varieties of Spontaneous Version—Mechanism of Spontaneous Version by the Breech —Spontaneous Evolution—Mechanism of, in the First Shoulder-presenta- tion, dorso-anterior. It is especially necessary, before we proceed, to define with precision the significance that attaches to the terms employed, the more especially that I find it desirable to use some terms in a different sense from that current in this country. Dr. Denman used the term " spontaneous evolu- tion " to express the natural action by which the pelvis or head was substituted for the originally presenting shoulder. The term " spontaneous expulsion " has been applied to the process of unaided delivery described by Douglas, in which the child is driven through the pelvis doubled up. Neither of these terms is free from objection. The first, especially, is inaccurate, and has given rise to much misapprehension. The process described by Denman is a true version or turn- ing. All German, French, Italian, and Dutch authors apply to this process the term " spontaneous version "—" versio spontanea." It might be called natural version, to distin- guish it from artificial version effected by the hand of the obstetrician. All Continental authors likewise call Doup:- las's process by the name " spontaneous evolution," the pro- cess being one of unfolding, as it were, of the doubled-up foetus. It is of great consequence to bring our nomenclature into harmony with that of our brethren abroad, and it is of VARIETIES OF SPONTANEOUS VERSION AND EVOLUTION. 135 still greater consequence to bring our nomenclature into harmony with Nature. It is clear, therefore, that the change in terms should be made by us. I shall use the terms " ver- sion " and " evolution " in the correct sense. There are two varieties of spontaneous version—one in which the head is substituted for the shoulder, the other in which the pelvis is substituted for the shoulder. These varieties of spontaneous version correspond with two similar varieties of artificial turning. There are likewise two varieties of spontaneous as well as of artificial evolution. The head or the trunk may be evolved or extracted first. These processes I will describe successively, beginning with the spontaneous or natural operations, since these are conducted in obedience to mechanical laws which must be respected in the execution of the artificial operations. In Fig. 36 I have endeavored to represent the very earli- est stage or condition of things in shoulder-presentation. The long axis of the child, and of the uterus, stands obliquely to the plane of the pelvic brim. It is not, indeed, very distant from the perpendicular. It is a very serious error to regard these presentations as entirely cross or transverse. It is only in the advanced stages of labor with shoulder-presentation, when the liquor amnii has been long drained off, when the uterus has been contracting forcibly, driving the shoulder deeply into the pelvis, that the child can truly be said to lie across the pelvis. Diagrams copied from text-book into text- book seem to have fixed this false idea firmly in the obstetric mind.1 I venture to say that, except in cases of dead, mon- strous, or small children, or with loss of form of the uterus through excess of liquor amnii, a true cross-birth, such as is commonly pictured and generally accepted, does not exist at 1 It has been my habit, when making notes of cases coming under my ob- servation, to record the position of the child by means of sketches. It is from these graphic memoranda that most of the illustrations in these lectures of the phenomena of shoulder-presentation and turning will be taken. 136 OBSTETRIC OPERATIONS. the commencement of labor. It would be better, because certainly true as a fact, and because it does not commit us to any theory, to call these presentations shoulder-presen- tations, and to discard the terms " cross-birth " and " trans- verse presentation" altogether. In shoulder-presentation, an oblique position of the child becomes transverse in the course of labor; but the presentation is not transverse ah initio. The neglect of this fact has been a main cause of the errors that prevail in the doctrine and practice of turning. Fig. 36. In the diagram (Fig. 36), the child and the uterus, E F, stand obliquely, at an angle of about 15° or 20° to a perpen- dicular C D drawn upon the plane of the pelvic brim. The MECHANISM OF SPONTANEOUS VERSION. 137 head is nearly in a straight line with the spine. It stands half over the brim, and half projecting beyond into the left iliac fossa. That is the first act. This act may pass into natural head-labor. Wigand, Jorg, and D'Outrepont say this position is common, and that the effect of the first uterine contractions is usually to bring the long axis of the uterus and of the child into due relation with the pelvic brim. This phenomenon is, in fact, a form of self-turning or natural rec- tification. If this attempt at rectification fails, then we have the transition into shoulder-presentation. The shoulder or arm cannot come down into the pelvis until the second act, a movement of flexion of the head upon the trunk, takes place. This happens in the following manner : The muscles of the fundus uteri contracting, aided or not by the downward pressure of the abdominal muscles and diaphragm, bring a force acting primarily upon the breech which lies at the fun- dus. This force will strike with greatest effect upon the left or uppermost side of the breech, at an angle with the long axis of uterus and child. The line G H represents the direc- tion of this force. The result is that the breech descends. And now mark what follows: If the cavity of the uterus were as broad as long—that is, a flattened sphere or short cylinder like a tambourine—the child's long axis formed by spine and head might preserve its rectilinear character ; and, as the breech descended, the head would simply rise on the opposite side until it comes round to the spot abandoned by the breech, performing, in fact, a complete version. But the uterus, we know, is narrower from side to side than from top to bottom. The head will find great difficulty in rising; it therefore bends upon the neck. The shoulder, pertaining to the trunk, is kept at the lowest point in a line with it. The head is thrown more into the iliac fossa, where it rests for a while. Fig. 37 represents this second position of the foetus. A B is the plane of the brim ; C D the perpendicu- lar to" the plane, representing the axis of entry to the pelvis; 138 OBSTETRIC OPERATIONS. E F is the axis of the child, now a bent line; and G H shows the direction of the downward force, which now strikes the uterus and breech at a greater angle with the perpendicular. Fig. 37. G 1 c Jw ' ^ Mr D Now the arm will commonly be driven down, and the hand may appear externally. The observation of the hand will tell the position of the child. The back of the hand looks forward, the palm backward, the thumb to the left. All this tells plainly that the head is in the left iliac MECHANISM OF SPONTANEOUS VERSION. 139 fossa, and that the child's back is turned forward to the mother's abdomen. The right scapula will lie close behind the symphysis pubis; the acromion and right side of the neck will rest upon the left edge of the pelvic brim; and the right axilla and right side of the chest will rest upon the right edge of the pelvic brim ; while the belly and legs of the child, turned toward the mother's spine, will occupy the posterior part of the uterus. At this stage, even after the liquor amnii has been drained off, spontaneous or natural version may still be effected. The process described as the second act still con- tinuing, the breech is driven lower down; the trunk bends upon its side; the curve thus assumed by the long axis car- ries on the propelling force in a direction across the pelvic brim; the head tends to rise still higher into the left iliac fossa; the presenting shoulder and prolapsed arm are drawn upward a little out of the pelvis. This third act, one of in- creased lateral flexion of the child's body, and of movement across the pelvic brim, is represented in Fig. 38. If spontaneous version is to be completed, the fourth act succeeds. The breech being the most movable part, and the trunk being capable of bending upon itself, partly on its side, partly on its abdomen, is drawn lower and lower, the right shoulder being forced well over to the left side of the pelvic brim, and the head being fairly lodged in the upper part of the iliac fossa, the brim is comparatively free for the reception of the trunk. This enters in the following manner: The right hip comes first into the brim; it is forced lower, and is followed by the breech. As soon as the breech enters the pelvis—that is, as soon as it gets below the sa- cral promontory—a movement of rotation takes place anal- ogous to the rotation which the head takes in head-labor. There is most room in the sacral hollow, and there the breech will turn. This turn of the trunk brings the body from the transverse position it occupied above the brim to one approaching the antero-posterior ; and commonly the 140 OBSTETRIC OPERATIONS. head yields somewhat to the altered direction of the spine by coming more forward.1 When this rotation movement is effected, or rather si- multaneously with it, a movement of descent or progress in an arc of a circle round the pubic centre goes on. The Fig. 38. G/ E \ / C ■ ¥( flexion of the spine is now reversed. Above the brim the trunk was concave on its left side, as seen in Figs. 37 and 38. When the breech has dipped into the pelvis, the trunk becomes concave on its right side. The breech descends first. The right ischium presents at the vulva. Then the 1 This part of the mechanism of spontaneous version will be illustrated in future chapters. DIFFICULTY OF DELIVERY IN SHOULDER-PRESENTATION. 141 whole breech sweeps the sacral concavity and perinaeum. The trunk follows. The right arm, which has not always completely risen out of the way, comes next; then the left arm ; and lastly the head, taking its rotation-movement, and its movement in a circle. The cause of the difficulty that opposes delivery in shoulder-presentation is obvious. The pelvic canal is too narrow to permit the child to pass freely when its long axis lies across the entry. On looking at the diagram (Fig. 39) we see the shoulder driven into the pelvis, forming the apex A of a triangle whose base B C is considerably longer than E F, the transverse diameter of the pelvic brim. To overcome this difficulty, Nature struggles to shorten the base B C. To a certain extent she generally succeeds, and occasionally she succeeds completely: Fig. 39. The uterus contracts concentrically, tending to shorten all its diameters, especially its transverse diameter. The axis formed by the trunk and head of the child, which go to make up the resisting base of the triangle, is flexible ; there- 142 OBSTETRIC OPERATIONS. fore A and B admit of being brought nearer to each other. But, when the utmost approximation has been obtained in this manner, we still have the entire thickness of the head equal to four inches, and only very slightly compressible plus the thickness of the body, which, after all possible gain by compression is effected, is equal to at least two inches more, being an inch or more in excess of the available space in the pelvic brim. As a general rule, it may be stated that no part of the child, except a leg or an arm, can traverse the pelvis along with the head, the head alone being quite large enough to fill the pelvis. Fig. 40 Fig. 40 shows the position of the child after the escape of liquor amnii. The head ia strongly flexed upon the trunk, forming together the base of a wedge too large to enter the brim. The lne E F represents the liine of decapitation, by which proceed- ing the base of the opposing wedge is decomposed. The head thus being put aside, the axis of the trunk will easily be brought into coincidence with the axis of the brim, permitting delivery. One result of the great compression exerted by the con- centric contraction of the uterus is to cause such pressure upon the chest and abdomen of the child, and so to compress MECHANISM OP SPONTANEOUS EVOLUTION. the placenta and cord, that the child is asphyxiated and killed. The death of the child, leading to the loss of resili- ency, will, after sufficient time, admit of a much further degree of compression, and then, possibly, the child may be so doubled up and moulded that it may enter the pelvis. The condition, therefore, of spontaneous evolution is the death of the child. If not already dead at the commence- ment, the child will almost certainly, if of medium size or larger, be killed in the course of the process. Herein lies a great distinction between spontaneous evolution and spon- taneous version. A living child is favorable to version, a dead one to evolution. Spontaneous evolution from the first position proceeds as follows : At first we have the oblique position of foetus and uterus represented in Figs. 36 and 37 (see pages 134, 136): the head is in one iliac fossa, the trunk and breech in the other. Secondly, strong flexion of the head upon the trunk, and Fig. 41. Fig. 41.—Right shoulder; first position after rotation. descent of the shoulder into the pelvis (see Figs. 39 and 40). At this stage, commonly, the membranes burst, and the arm 144 OBSTETRIC OPERATIONS. falls into the vagina, the hand appearing externally. Third- ly, increased descent of the shoulder and protrusion of the forearm, doubling with compression of the body, so that the breech is driven into the pelvis; as soon as this takes place, a movement of rotation succeeds (see Fig. 41). The in- clined planes of the ischia direct the breech backward into the sacral hollow; this backward movement of the trunk throws the head forward over the symphysis pubis; from transverse, as the child was above the brim, it now ap- proaches the fore-and-aft direction, the right side of the head, near its base, is forcibly jammed against the symphysis, the side of the neck corresponding to the presenting shoulder Fig. 42. Fig. 49.—Right shoulder; first position during movement in circle around symphysis. is fixed behind the symphysis pubis, and the shoulder itself is situated under the pubic arch. Fourthly, the expulsive force continuing, can only act upon the breech and trunk, MECHANISM OF SPONTANEOUS EVOLUTION. the shoulder being absolutely fixed; the trunk bends more and more upon its side, the presenting chest-wall bulges out, and makes its appearance under the pubic arch. Then, lastly, the movement in a circle of the body round the fixed shoulder is executed. The side of the trunk and of the breech sweep the perinaeum and concavity of the sacrum; the legs follow. When the whole trunk is born, the move- ment of restitution is effected, the back turning forward, the belly backward. The head escapes from its forced position above the symphysis, the chin turns downward, the occiput looks upward to the fundus uteri, the nucha is turned to the right foramen ovale. It enters in the left oblique diameter, it takes the rotation movement in the pelvis, the occiput coming under the pubic arch ; then the movement in a cir- cle is executed. The chin first appears, followed by the mouth, nose, and forehead, which successively sweep the perinaeum. The occiput, which had been applied to the symphysis, comes last. So strict is the subjection through- out this progress to the laws which govern the mechanism of ordinary labor, that Lazzati' does not hesitate to describe spontaneous evolution as the natural delivery by the shoulder. [There are many obstetricians who doubt the practica- bility of the delivery, by spontaneous evolution, of a foetus at full term from a pelvis of ordinary dimensions, especially in a primiparous labor. This incredulity is doubtless owing to the fact that spontaneous evolution is an exceedingly rare occurrence, and may never be witnessed during a large ob- stetric practice. Prof. Bedford, of New York, in his excel- lent work on the " Principles and Practice of Obstetrics," states : " I have never in the course of my observations met with an instance of what may be properly termed spontane- ous evolution." The opinion of its impossibility, or occur- rence only before term, is wholly untenable, for the records of cases are sufficiently numerous and reliable to remove all doubt.] CHAPTER XIII. Turning continued—Spontaneous Evolution—Mechanism of, in First Shoulder- presentation, Abdomino-anterior; in Second Shoulder-presentation, Dorso- anterior and Abdomino-anterior—Spontaneous Evolution by the Head— The Mechanism of Spontaneous Version and of Spontaneous Evolution further illustrated. The Conditions requisite for Spontaneous Version— Examples of Spontaneous Version by the Head and by the Breech. The case we have just described in the preceding chapter is the most common form of spontaneous evolution. It is the type of the rest. Keeping its mechanism well in mind, there will be little difficulty in tracing the course of spontaneous evolution when the child presents in any other position. If the head lies in the right iliac fossa, constituting the second shoulder-position, as in the first position, the child's back may be directed forward or backward. In the first case we have exactly the counterpart of the process de- scribed in the preceding chapter. It would be superfluous to repeat the description, when all is told by simply substi- tuting the words " right " for " left " and " left " for " right." It is, however, useful to trace the course of a labor in which the child's belly is directed forward. Let us take the second position—head in the right iliac fossa. This will involve the presentation of the right shoulder (see Fig. 43). A represents the presenting shoulder forming the apex of the triangle, whose base B C is formed by the long axis of the child's body. The expulsive force and the concentric contraction of the uterus draw the head toward the breech, shortening the opposing base by bending the SPONTANEOUS-EVOLUTION IN SHOULDER-PRESENTATIONS. 147 head upon the chest and the trunk upon itself. This is the movement of flexion. This movement continuing is com- bined with movement of descent. The right side of the chest is driven more deeply into the pelvis, and is followed by the breech. Then rotation takes place (see Fig. 44).' The head comes forward over the symphysis; the breech rolls into the sacral hollow. The right side of the chest Fig. 43. Fig. 43.—Second position of second shoulder-presentation above the brim ; stage of flexion. A, apex of triangle wedged into pelvis ; B C, base of triangle opposing entry into D E, brim of pelvis. emerges through the vulva; the trunk and breech sweep the perinseum; the left arm follows, and lastly the head, the occiput taking up its fixed points at the pubic arch forming the centre of rotation. The presentation of the left shoulder in the first position offers no essential difference in its course from that pursued in the case of right shoulder with dorso-anterior position. The foetal head is in the left iliac fossa; its sternum is 148 OBSTETRIC OPERATIONS. directed forward ; the thumb of the prolapsed arm is turned to the left, the back of the hand looks backward, the palm toward the pubes. The lateral flexion of head upon trunk and of trunk upon itself taking place, the left shoulder with the corresponding side of the chest descending into the Fig. 44. Fig. 44.—Eight shoulder—second position after rotation. pelvic cavity, the rotation movement takes place and carries the head over the symphysis pubis (see Fig. 45). The basilar part of the left temporal region will be applied to the an- terior part of the brim ; the sternum will turn to the right, the dorsum to the left and backward. Then the movements of descent and in a circle follow. The side of the chest, trunk, and breech, sweep the sacrum and perinaeum. The body having escaped, the movement of restitution is per- formed—the back will be directed to the left and forward. The head will be above the brim, with the nucha turned to SPONTANEOUS EVOLUTION IN SHOULDER-PRESENTATIONS. the left and forward behind the left foramen ovale, the face looking to the right sacro-iliac joint. Thus it will be born according to the mechanism observed in breech-labor. In the case of the dorso-anterior position, with the head in the right ilium, we have, as has been stated, simply the reverse of the dorso-anterior position with the head in the left ilium—the left shoulder becomes wedged in the brim Fig. 45. Fig. 45.—Left shoulder—first position after rotation. the left side of the head gets fixed upon the symphysis, the left side of the chest bulges out of the vulva. (See Fig. 46.) Such, in brief, is the description of spontaneous evolution. The process is the normal type of labor in shoulder-presenta- tion. Were it more often justifiable to wait and watch the efforts of Nature, we should probably not seldom enjoy opportunities of observing it; but the well-grounded fear lest Nature should break down disastrously impels us to bear assistance. To be useful in the highest degree, that 150 OBSTETRIC OPERATIONS. assistance must be applied in faithful obedience to the plans of Nature. In seeking to help, we must take care not to defeat her objects by crossing the manoeuvres by which she attains them. Whenever we lose sight of this duty, when- Fig. 46. ever we try to overcome a difficulty by arbitrary operations, greater force, running into violence, is required, and the risk of failure and of danger is increased. It has been already said (see Chapter XII). that sponta- neous evolution may be effected by the head traversing the pelvis first. The case is indeed rare, but the process and the conditions under which it occurs deserve attention. The essential idea of spontaneous evolution is, that the presenting shoulder remain fixed, or, at least, shall not rise up out of the pelvis into the uterus. Therefore, if the head comes down, it must do so along with the prolapsed arm. This simultaneous passage of the head, arm, and chest, can hardly take place unless the child is small. If the child is very small, the difficulty is not great. If the child be moderately large, it will be far more likely to be born according to the SPONTANEOUS EVOLUTION IN SHOULDER-PRESENTATION. i51 mechanism already described and figured, in which the side of the chest corresponding to the presenting shoulder emerges first, and the head last. But some cases of head- first deliveries have been observed. Pezerat1 relates a case that seems free from ambiguity. The child was large, the shoulder presenting. Pezerat tried to push it up, but could not. A violent pain drove the head down. Fichet de Flichy2 gives two cases. In both the midwife had pulled upon the arm. Balocchi relates a case.8 It was an eight-months' child. He says the case is unique rather than rare, but still regards it as a natural mode of delivery in shoulder-presenta- tion. Lazzati thinks the descent of the head in these cases is always the result of traction upon the presenting arm. As the expelling power is exerted mainly upon the breech, tending to drive the head away from the brim, it is indeed not easy to understand how spontaneous action can restore the head, if the shoulder is forced low down in the pelvis. Monteggia4 held the same opinion. He relates two cases, in both of which tractions had been made. I myself have seen an instance of the kind. It is so important, as a guide to the artificial means of extricating a patient from the dangers of shoulder-presenta- tion, to possess, accurate ideas of the mechanism of spontane- ous version and evolution, that I am led to present a further illustration of these processes. To make the mechanism of spontaneous version clearer, let us represent the child's body by a rod, flexible and elas- tic, as the spine really is. In diagram 47, A B 1 is the rod fixed at B by a sort of crutch formed by the head and neck against an edge of the pelvis. A, the breech, being mov- able, receives the impulse of the force, and is drawn down- ward. The rod, or spine, therefore bends. But the rod, 1 Journal Complementaire, tome xxix. 8 " Observ. Med.-Chir." 3 " Manuale Complete di Ostetricia." Milano. 1859. 4 " Traduzione de l'Arte Ostetricia di Stein." 1796. 152 OBSTETRIC OPERATIONS. being elastic, constantly tends to straighten itself. This effort will, if the head is not immovably fixed, lift the head Fig. 47. off the edge of the pelvis, and carry it higher into the iliac fossa. The force continuing to press upon A, as in 2, will Fig. 48. drive it still lower, and the rod still bending, and tending to recover its straightness, the head will rise farther from the MECHANISM OF SPONTANEOUS EVOLUTION. 153 edge of the pelvis. At last (see Fig. 48) there will be room for the end A to enter the pelvis, and the rod, springing into straightness by the escape of A from the pelvis, the whole may emerge, B coming last. For this process to take place, it is obvious that the rod must be endowed with elasticity or spring, and therefore, as Denman said, a live child is best adapted to undergo spontaneous version. The mechanism of spontaneous evolution may also be illustrated in like manner. Let us represent the child's body by a rod, flexible, but almost without elasticity. In Fig. 49. Diagram 49, one end of the rod, B, is fixed against the edge of the pelvis; the other end, A, being movable, receives the impulse of the downward force, and is driven first to 2 ; the rod continuing to bend, A falls to 3, and, as B is fixed, the rod forms a strong curve, with its convexity downward, in the cavity of the pelvis. This convexity will be the first part of the rod to emerge. The force urging on the end A more and more of the convex rod will emerge, until A itself escapes. Then, and not till then, can the rod recover its straightness, and the end B will follow. (See diagram 50) In the case of spontaneous version, as well as 111 that of 154 OBSTETRIC OPERATIONS. spontaneous evolution, it is necessary to exhibit first a pelvis seen from the front, then a section as seen from the side, be- cause in the earlier stages the movement is across the pelvis, and in the later stages the head comes forward above the symphysis, and the movement in a circle around this centre is from behind forward. Now, we may ask, What are the conditions required for the execution of spontaneous version, or natural turning ? Some of them, probably, are not understood. Certain it is that we are hardly yet in a position to predicate in any Fig. 50. given case of shoulder-presentation, seen at an early stage, that spontaneous version will take place, as we might be if all those conditions were known and recognizable. They would be more familiar if the law to turn were not laid down in such imperative terms—if the dread of evil as the consequence of neglect of that law were not so overwhelm- ing. But if Nature be always superseded, if the physician always resort to artificial turning as soon as he detects a shoulder presenting, how can we obtain sufficient oppor- tunities for discovering the resources of Nature, and how she acts in turning them to account ? The principal condi- CONDITIONS NECESSARY FOR SPONTANEOUS VERSION. 155 tions seem, however, to be these: 1. A live child, or one so recently dead that the tone or resiliency of its spine is still perfect. 2. A certain degree of mobility of the child in utero. 3. Strong action of the uterus and auxiliary muscles. A roomy pelvis does not appear to be always necessary. Spontaneous version is not likely to take place when the shoulder has been driven down in a point with a part of the chest-wall low in the pelvis, and the uterus is strongly grasp- ing the foetus in every part, bending its long axis by approxi- mating the head and breech. It is not likely to take place when the head has advanced toward a position above the symphysis pubis—that is, when the movement of rotation has commenced. But the practical question will arise, Is spontaneons ver- sion ever so likely to occur that we shall be justified in trust- ing to Nature ? Ample experience justifies an answer in the affirmative. But it appears to me that the great lesson taught by the observation of the phenomena of spontaneous version is this : If Nature can, by her unaided powers, ac- complish this most desirable end, we may by careful study and appropriate manipulation assist her in the task. We shall be the better ministers to Nature in her difficulties as we are the better and humbler interpreters of her ways. Natura enim non nisi parendo vincitur. It has been already stated that spontaneous version may take place either by the head or by the pelvis. It may be interesting to cite further examples of either process occur- ring under the observation of competent practitioners. I will first give an example of spontaneous turning by the head. Velpeau1 relates the following case of cephalic version. A woman was in labor at the Ecole de Medecine (1S25). The os was little dilated. The left shoulder was recognized. The waters escaped five hours after this examination. Four students recognized the shoulder. The pains were neither strong nor frequent; and, " being not without confidence in i " Traite complet de l'Art des Accouchements." 1835. 156 OBSTETRIC OPERATIONS. Denman" Velpeau did not search for the feet. In five hours later the shoulder was sensibly thrown to the left iliac fossa. The pains increased, and the head occupied the pelvic brim. The vertex came down, and the labor ended naturally. Dr. E. Copeman, of Norwich, records the following case:1 Some time after the waters had escaped in great quantity, the child was found lying across the pelvis, with the back presenting: neither shoulders nor hips could be felt. At a later period, preparing to turn, Dr. C. was surprised to find the pelvis filled. He endeavored to pass his hand over the right side of the child toward the pubes, but in so doing he felt the child recede, and therefore confined himself to raising the child's pelvis with his flat hand and fingers ; while the pains forced down the occiput, the head de- scended, and delivery was quickly completed. Dr. C. thinks, if he had waited a little longer, spontaneous evolu- tion would have occurred, and the child would have been born even without manual interference. The child was a full-grown male, lively and vigorous. [Prof. G. T. Elliot, in his " Obstetric Clinic," p. 346, relates the following interesting case of spontaneous expul- sion by cephalic version of the second twin, which had pre- sented originally in a transverse position. The case occurred during his service as resident physician in the New York Lying-in Asylum : " A woman fell in labor, and a breech- presentation was recognized. The pains were very power- ful, and the child was forcibly expelled during one of them, neither the arms nor head requiring the slightest attention. It weighed eight pounds. Finding then that the arm of a second child was presenting at the brim, and the head in the left iliac fossa, I sent at once, according to the rule, for Dr. Beadle, one of the physicians, who lived near by, and came promptly. But, before he arrived, in one of these powerful pains, the head of the child was driven into the pelvis, and the elbow turned down so as to pass with it into the world. 1 J. G. Crosse's " Cases in Midwifery." 1851. SPONTANEOUS VERSION BY THE PELVIS. 157 The whole child was driven out of the vagina without assist- ance. It weighed four and a half pounds. Both living. Mother did well."] Here is a remarkably clear case of spontaneous version by the pelvis. Dr. H. Scholefield Johnson, of Congleton, communicated to Dr. Murphy1 the following history: At- tending a patient in her first labor, he diagnosed a head-pre- sentation in the third position. At this time the os uteri was somewhat larger than a crown-piece, and the mem- branes were unbroken. No further examination was made until the liquor amnii had escaped, when the os uteri was found three parts dilated and the breech presenting. The funis also descended. The child was nearly still-born, but was restored ; it had a swelling on the upper part of the left parietal bone extending toward the occipital, thus con- firming the first diagnosis of head-presentation. In reply to questions addressed to Dr. Johnson, he informs me that the child was of full size, and healthy; that the liquor amnii was not remarkably above the usual quantity, and that he does not think any external pressure was concerned in the production of the version. Here is another case, equally instructive, communicated to me by the same gentleman: " In December last (1862), I had a labor. I found a com- pound presentation. I felt both feet with the backs of the legs toward the left sacro-iliac synchondrosis, the right hand with the palm lying in front of the right ankle, a small loop of funis anterior to the wrist. Above the os I could feel the head, but could not make out the part. I waited for the membranes to burst. The feet descended lower, and the head passed out of my reach. I brought down the feet, and delivered. When the child was born, I carefully examined it. The right hand was slightly swollen, and there was a distinct swelling (gone the next day) on the right side of the head and up the right margin of the anterior fontanelle. Now, I do not doubt, if I had come to this case later, I should have only found a footling case." 1 Dublin Quarterly Journal of Medical Science. 1863. CHAPTEE XIY. Applications of the Knowledge of the Mechanism of Spontaneous Version and Spontaneous Evolution to the Practice of Artificial Version and Artificial Evolution—The Bi-polar Method of Turning, History of—Artificial Version by the Head—Reasons why Version by the Breech is commonly preferred —Illustrations of Head-turning, or Correction of the Presentation, before and during Labor in Obliquity of the Uterus and Foetus, Shoulder-presenta- tion, Forehead and Face Presentations, Descent of Hand or Umbilical Cord by the Side of the Head. From the observation of the spontaneous or accidental changes of position of the foetus i/n utero, the transition is natural to the account of those changes which can be effected by art. The observations already referred to prove that the foetus in utero may, under certain conditions, change its posi- tion with remarkable facility. It follows that the judicious application of very moderate forces may, under favorable circumstances, effect similar changes. We have seen that spontaneous version may be effected by the substitution of the head for the shoulder, and of the pelvic extremity for the shoulder ; also that spontaneous evolution may be effected by the descent of the head with the presenting shoulder and arm, or by the descent of the chest and trunk with the presenting shoulder and arm. Now, each of these natural or spontaneous operations for liberating the child may be successfully imitated by art. Let us study the conditions which guide us in the selection of the natural operation we should imitate, and the methods of carrying out our imitations. THE BI-POLAR METHOD OF VERSION. 159 A successful imitation of natural version by the head or by the inferior extremity demands the concerted use of both hands. You must act simultaneously upon both poles of the foetal ovoid. This combined action may be exerted altogether externally—i. e., through the walls of the abdomen—or one hand may work externally, while the other works internally through the os uteri. The first method—that practised by Wigand, d'Outrepont, d'Esterle, and others—has been called the bimanual proper. The second, which has been most clearly taught by Dr. Braxton Hicks, has been called by him combined internal and external version. But the same principle governs both. As I have already said, you must act at the same time upon both poles of the long axis of the foetus. It would be more correct to describe them both as forms of the bi-polar method of turning. It is an accident, not a fundamental difference, if, in one case, it is more con- venient to employ the two hands outside; and, in another, to employ one hand outside, and the other inside. Each form has its own field of application. We should be greatly crippled, deprived of most useful power, if we were restricted to either form. At the same time, I am of opinion that the combined internal and external bi-polar method has the more extensive applications to practice. I have found the bi-polar method a serviceable adjuvant in every kind of labor in which it is necessary to change the position of the child. It is true that a rather free mobility of the foetus in utero is most favorable to success; it is true that the external bi-polar method can hardly avail unless at least a moderate quantity of liquor amnii be still present; it is true that the internal and external bi-polar method re- quires, in its special uses, if not the presence of liquor amnii, at any rate a uterus not yet closely contracted upon the foetus. But I am in a position to state that, among upward of one hundred and fifty cases of turning of which I have notes, there was scarcely one in which I did not turn the bi-polar principle to more or less advantage ; and in not a 160 OBSTETRIC OPERATIONS. few cases of extreme difficulty from spasmodic concentric contraction of the uterus upon the foetus, with jamming of the shoulder into the pelvis, where other practitioners had been foiled, I have, by the judicious application of this prin- ciple, turned, and delivered safely. The history of the bi-polar method of version, the steps by which this the greatest improvement in the operation has been brought to its actual perfection, deserve to be carefully recorded. From what has been already said, it is clear that Wigand, d'Outrepont, and others, who took up Wigand's views, had acquired an accurate perception of the theory of bi-polar turning, and had, moreover, successfully applied that theory in practice. They had applied it to the purpose of altering the position of the child before labor, chiefly by bringing the head over the centre of the pelvis, restoring at the same time the uterus and foetus from an oblique to a right inclina- tion. This they did generally by external manipulation; but not exclusively, for sometimes one or two fingers intro- duced into the os uteri served to drag the lower segment or pole of the uterus to a central position, while the hand out- side acted in the opposite direction upon the upper pole. Here the application seems to have stopped short. At least, I am not aware of any distinct description of the application of the bi-polar principle to produce version. In one form, indeed, the bi-polar principle of turning by the feet has been in use for a long time. It not uncommonly happens, when turning is attempted after the waters have escaped, and when the uterus has contracted rather closely upon the child, that, even when one or both legs have been seized and brought down, the head will not recede or rise from the pelvis—that is, version does not follow. It then becomes obvious that by some means you must push up the head out of the way. The operation by which this is effected —an exceedingly important one—will be fully explained here- after. It is enough to say in the present place that it con- FALSE AND TRUE PRINCIPLE OF BI-POLAR VERSION. 161 sists in holding down the leg that has been seized, while a hand or a crutch introduced into the pelvis pushes up the head and chest. In this operation it will be observed that both hands work below the pubes, while, in the true bi-polar method, one hand works below and inside, and the other above and outside. In several obstetric works (Moreau, Caseaux, Churchill, etc.) diagrams illustrating the operation of turning are given, representing one hand applied to the fundus uteri outside, and the other seizing the feet inside. But it would be an error to infer that these indicate an appreciation of the prin- ciple of bi-polar turning. They simply indicate the principle of supporting the uterus, so as to prevent the risk of lacera- tion of the cervix, while pushing the hand through the uterus and up toward the fundus. The true bi-polar method does not involve passing the hand through the cervix at all. The following passage from the late Dr. Edward Eigby (" Library of Medicine," Midwifery, 1844) may be taken as a description of the diagrams referred to: " In passing the os uteri ... we must at the same time fix the uterus itself with the other hand, and rather press the fundus downward against the hand which is now advancing through the os uteri. In every case of turning we should bear in mind the necessity of duly supporting the uterus with the other hand, for we thus not only enable the hand to pass the os uteri with greater ease, but we prevent in great measure the lia- bility there must be to laceration of the vagina from the uterus in all cases where the turning is at all difficult." The same precept is even more earnestly enforced by Prof. Simpson1: "Use both your hands," he says, ^ " for the operation of turning. In making this observation, I mean that, while we have one hand internally in the uterus, we derive the greatest possible aid in most cases from ma- nipulating the uterus and infant with the other hand placed externally on the surface of the abdomen. Each hand assists I London and Edinburgh Monthly Journal of Medical Science. February, 1845. 11 162 OBSTETRIC OPERATIONS. the other to a degree which it would not be easy to appre- ciate except you yourselves were actually performing the operation. It would be extremely difficult, if not impos- sible, in some cases to effect the operation with the single introduced hand; and in all cases it greatly facilitates the operation. The external hand fixes the uterus and foetus during the introduction of the internal one; it holds the foetus in situ while we attempt to seize the necessary limbs, or it assists in moving those parts where required toward the introduced hand, and it often aids us vastly in promot- ing the version after we have seized the part which we search for. Indeed, this power of assisting one hand with the other in different steps of the operation of turning forms the principal reason for introducing the left as the operating hand." Here the consentaneous use of the two hands is well de- scribed. But the bi-polar principle is at best but dimly fore- shadowed. Dr. Eobert Lee, in his " Clinical Midwifery," relates several cases in which he succeeded in converting a head or shoulder presentation into a pelvic one, by introducing one or two fingers only through the os uteri, when, indeed, this part was so little expanded that to introduce the hand would have been impossible. These cases were mostly cases of placenta prsevia, the foetus being premature and small. He managed this by gradually pushing the presenting part toward one side of the pelvis until the feet came over the os uteri. Then he seized the feet and delivered. But there is no mention of the simultaneous or concerted use of the other hand outside, so as to aid the version by pressing the lower extremity of the child over the os, or to carry it within reach of the hand inside. It is a manoeuvre of limited application. It differs in principle from the bi-polar method, which requires the consentaneous use of both hands, and which enjoys a far wider application. A process of synthetical reasoning, especially if informed SUPERIORITY OF BI-POLAR VERSION. 163 by the light of experience in practice, might construct out of the elements thus contributed by Wigand and his follow- ers, by Eigby, Simpson, and Eobert Lee, a complete theory and practice of bi-polar turning in all its applications to podalic as well as to cephalic version. I am conscious my- self of having in this manner evolved that theory, and applied it in practice. Dr. Eigby's was the work I had adopted as my guide from the commencement of my career; and my attention was especially directed by Dr. Tyler Smith to the admirable lecture of Prof. Simpson, from which the passage above quoted is drawn, at the time of its appear- ance. Since then I must have turned at least two hundred times. In no case have I failed to observe the precept of using both hands; and gradually I found out that the exter- nal hand often did more than the internal one—so much so, indeed, that the introduction of one or two fingers through the os uteri, to seize the knee pressed down upon the os by the outside hand, was all that was necessary. I feel that I am entitled to say this much, and not a few of my profes- sional brethren who have honored me by seeking my assist- ance can bear witness to the fact that it was by the applica- tion of the bi-polar method that I have been enabled to complete deliveries where others had failed. But, in saying this, I should be sorry indeed if it were interpreted as a desire on my part to detract in any degree from the merit of my colleague, Dr. Braxton Hicks. His claim to originality in working out and expounding the application of the external and internal bi-polar method of podalic version is indisputable. I know of few recent con- tributions to the practice of obstetrics that possess greater interest or value than his memoirs on " Combined External and Internal Version," published in the lancet in 1860, in the Obstetrical Transactions, 1863, and in a special work in 1864. If the proposition which I have already urged with refer- ence to the forceps be true—namely, that the carrying to 164 OBSTETRIC OPERATIONS. the greatest possible perfection of an instrument that saves both mother and child is an object of the highest interest— it is scarcely less true of turning, also a saving operation. I cherish a fervent hope that the exposition of the principles and methods of turning which will be made in the following pages will, in conjunction with those on the forceps, be the means of materially enlarging the field of application of the two great saving operations, and, as a necessary result, of supplanting, in a corresponding degree, the resort to the revolting operation of craniotomy. As head-presentation is the type of natural labor, it fol- lows that to obtain a head-presentation is the great end to be contemplated by art. It seems enough to state this prop- osition to command immediate assent. But in practice it is all but universally contemned. No one will dispute that the chance of a child's life is far better if birth takes place by the head than if by the breech or feet. Yet delivery by the feet is almost invariably practised when turning, or the substitution of a favorable for an unfavorable presentation, has to be accomplished. Why is this ? The answer is not entirely satisfactory. It rests chiefly upon the undoubted fact that in the great majority of in- stances, at the time when a mal-presentation comes before us, demanding skilled assistance, turning by the feet is the only mode of turning which is practicable. Frequent experi- ence of one order of events is apt so to fill the mind as to exclude the reception of events that are observed but rarely. Many truths in medicine escape recognition because the mind is preoccupied by dogmas and narrowed by an arbitary and enslaving empiricism. Many things are not observed because they are not sought for with an intelligent and in- structed eye. And then, reasoning in a vicious circle, some men will boldly deny the existence of that which their un- trained faculties cannot perceive. They go further: by dog- gedly and consistently following a practice which arrests Nature in her course, substituting a violent proceeding of HISTORY OF ARTIFICIAL CEPHALIC VERSION. their own, they never give Nature a chance of vindicating her own powers, and they consequently never give them- selves a chance of learning what those powers are, or of realizing the imperfection of their own knowledge. They close the shutters at noonday, and say the sun does not shine. In the seventeenth and in the beginning of the eigh- teenth centuries, Velpeau remarks, cephalic turning was hardly ever mentioned unless to be condemned. But, if the practice of podalic turning was then so general, it was justified because the forceps was not known. In many cases it is not enough to correct the position—it is also ne- cessary to extract. Without the' forceps our predecessors could only extract by the legs. But now, if the head is brought to the brim, the forceps affords ready means of extraction. Flamant appears to have been among the first to revive the practice of turning by the head; he did it by external manipulation. Osiander and Wigand (1807) investigated the subject with remarkable sagacity and skill. D'Outre- pont pursued it; and many other names might be cited. The researches of Wigand, however, contain the germ of all the subsequent inquiries. Flamant strenuously contended that head-turning was best. In two cases of arm-presentation he raised the breech toward the fundus uteri. The' head thus made to descend was seized by the hand. The liquor amnii had long es- caped. He worked in these cases entirely by internal ma- nipulation. Wigand accomplished the same object by ex- ternal manipulation, saving the children. D'Outrepont had a case of a woman who had lost three children by foot-turn- ing. In her fourth labor she had a shoulder-presentation. There was slight conjugate contraction. The head lay to the right, the feet to the left; the back of the chest was above the brim. He seized the child by the back, placed his rio-ht thumb and the right side of four fingers on its left 166 OBSTETRIC OPERATIONS. side ; then he pushed it to the left and upward; then he re- leased the back, and seized the neck, while he pressed upon the shoulder with his thumb, and the palm and four fingers on the back. The head came over the brim, and the child was safely delivered. In a second case, the breast was on the brim, the head to the left; he pushed up the chest and brought down the head, which entered by the face, and was so delivered. Strong pains prevented his reducing the face to a cranial position. In a third case he was equally successful. D'Outrepont afterward practised with success Wigand's method of head-turning by external manipula- tion. Here is a case of bimanual and bi-polar head-turning by d'Outrepont. The head lay in the right side. He placed the patient on her left side raised. During each pain he imparted gentle pressure on the side where the head lay, directing it toward the brim; and at the same time he pressed with his other hand in the opposite direction upon the fundus where the breech lay. In the intervals of pain, he planted a pillow in the side where the head lay. The head was brought into the pelvis, and a large living child was born. Prof. E. Martinl has carefully described the operation, and practised it with great success. Hohla says turning by the head is much less esteemed than it ought to be, and that it would be more esteemed if more pains were taken to instruct pupils how to do it on the phantom. Head-turning, or simple rectification of the presentation, may be indicated under the following circumstances: A. Before the Accession of labor.—When the uterus and foetus are placed obliquely in relation to the pelvic brim; and in some cases where the shoulder is actually presenting. B. 1. When labor has begun.—When the uterus and foetus are placed obliquely in relation to the pelvic brim, 1 Froriep's Notizen. 1850. s Lehrbuch der Geburtshiilfe. 1862. CEPHALIC VERSION BEFORE THE ACCESSION OF LABOR. 167 which obliquity may be preparatory to the complete sub- stitution of the shoulder for the head. 2. In some cases of shoulder-presentation, the membranes still intact. 3. In some cases of shoulder-presentation, the membranes having burst, but considerable mobility of the child being still preserved. 4. The forehead or face presenting. 5. Descent of hand by the side of the head. 6. Prolapse of the umbilical cord by the side of the head. A. Head-turning, or Rectification before labor.—This has been often practised by Wigand, d'Outrepont, and others. I will describe the operation after Esterle. It was the observation of the frequent occurrence of spontaneous version in the eighth and ninth months of gestation that led this eminent obstetrician to practise external bi-polar ver- sion.1 He observed that a large number of shoulder-presen- tations in the last two months, if left to themselves, were converted into natural presentations, either on the approach of labor or after the beginning of labor. He had further remarked that spontaneous version had occurred after the escape of the liquor amnii, and the shoulder was sensibly down. The most efficient cause of spontaneous version, he says, is the combined action of the movements of the foetus and of its gravity, the centre of gravity not being far from the head. The extension of the feet must drive the breech away from the uterine wall as the feet strike it, and so the head is brought nearer to the brim. His method was as fol- lows : The patient must be placed in such a posture as to pro- duce the greatest possible muscular relaxation. Bearing in mind the conditions which take part in spontaneous version, it is necessary to imitate them as much as possible. Among these is the lateral and partial contraction of the uterus, which diminishes the transverse diameter, and which exerts » " Sul Rivolgimento Esterno:" Annali Universali di Medicina. 1859. 168 OBSTETRIC OPERATIONS. a convenient pressure upon the ovoid extremities of the foe- tus ; and the movements of the foetus, the repercussion of its head, and its descent when the centre of gravity of the foetal body favors its fall. To imitate this, the lateral con- tractions must be replaced by lateral pressure. This is ap- plied toward the fundus or the neck, according to the situ- ation of the part which it is sought to raise or to depress. This pressure is assisted greatly by the gentle strokes or succussions made by the palm of the hand alternately tow- ard either ovoid extremity. These strokes are then made, in rapid succession, simultaneously upon the two extremi- ties, one giving a movement of ascent, the other a move- ment of descent; or we may act upon the head alone while the other hand makes a steady pressure on the con- trary side, the more to diminish the transverse diameter. The desired position being effected, it is necessary to main- tain it. This may be done by the adaptation of a suitable bandage. Lazzati operates in a similar manner. He maintains the uterus and foetus in due position by the adaptation of cushions or pads to the sides of the opposite poles of the foetal ovoid. B. 1, 2, and 3.—Head-turning or correction of the pre- sentation may be attempted in cases of moderate obliquity, where the liquor amnii is still present or has only recently escaped. It is also necessary that the action of the uterus be moderate. Correction, as we have seen, consists in re- storing the head, which has passed across the brim of the pelvis into the ilium, back to its due relation to the brim. This operation involves the rectification of the uterus, as well as of the child. It may in certain cases be effected entirely by external manipulations. Supposing the case be one in which the head is deviated to the left ilium, and the fundus, with the breech, is directed to the right of the mother's spine, the first step is to place the patient in a fa- vorable position. Now, by laying her on her left side, the CEPHALIC VERSION DURING LABOR. 169 fundus of the uterus, loaded with the breech and being mova- ble, will tend to fall toward the depending side. This will act as a lever upon the uterine ovoid, and raise the lower or head end of the uterus, so as to facilitate its return to the brim. In such cases Wigand rcommends that the posture should be repeatedly changed, so as to ascertain which' is the best to maintain the head in the central line of the pel- vis. When this is found, the sooner the membranes are rup- tured the better. The patient must thenceforward be kept carefully in the same posture, the uterus being supported in due relation by the hands externally. But I believe that in many cases the dorsal position will lend the greatest facility. We must apply pressure to the uterus toward the median line of the mother, both at its fundus and at the lower part which contains the head. The head will thus be pushed by one hand to the right, while the fundus uteri is pushed by the other hand to the left. When the head has been thus brought over the brim, the difficulty is to secure it there. If the correcting pressure be removed, the uterus tends to resume its obliquity. If labor has begun, we may combine internal with exter- nal manipulation. We may press upon the fundus with one hand while with a finger m the os uteri we pull this over the centre of the brim (Wigand). External pressure by a cush- ion, or pillow, laid in the hollow of the ilium in which the head lay, will aid this manoeuvre. Then, having got the head into proper position, and while it is kept so by aid of an assistant, rupture the membranes. The contraction of the uterus tends to restore its natural ovoid shape. And this will tend to keep the child's long axis in relation. If by this contraction the head should happily become fixed in the brim, the manoeuvre has succeeded. The labor has be- come natural. But, if the head still shows a disposition to recede, grasp it at once with the long double-curved forceps, and hold it in the brim until it is sufficiently engaged to be safe. 170 OBSTETRIC OPERATIONS. 4. The mode in which forehead and face presentations arise out of excess of friction or resistance encountered by the occiput has been described in Chapter TIL, pp. 83, 84. Sometimes correction ol these presentations may be ef- fected by restoring the equilibrium of resistance to the ante- rior part of the head. Sometimes this is effected by simply keeping the tips of the fingers upon the forehead, trusting to the expulsive efforts propagated through the child's spine to cause the head to rotate upon its transverse axis, and bring down the occiput. Sometimes further aid is neces- sary. The tips of two fingers of the left hand are applied internally upon the forehead, and at the same time the occiput must be pressed down by the fingers of the right hand applied externally in the iliac fossa. In some cases a rougher method has been pursued. The hand introduced into the uterus has seized the head by the occiput, and brought it down. This manoeuvre is by no means easy, and, if the child is mature, will rarely succeed. Wigand, when the head was not too low in the pelvis, first pushed the face upward, so as to convert the face into a forehead-presentation, if not into a cranial; then he applied the forceps. Smellie had already deliberately put in practice the res- toration of a lost head-position.1 In one case, feeling the face presenting through the membranes, he raised the fore- head ; then letting the waters escape, the head was fixed in its proper position, and the labor terminated successfully. In the second case, a hand presented. Smellie grasped the head, and brought it into the brim, having pushed up the shoulder. In this position the head was fixed by the escape of the liquor amnii and bearing-down pains. The child was delivered naturally. In a third case, in which the breast presented, he was equally successful in bringing down the head. 5. Descent of the hand by the side of the head. When 1 " Cases and Observations," vol. ii. 1754. CEPHALIC VERSION IN PROLAPSE OF THE HAND, ETC. 171 this accident occurs, it is apt to proceed to shoulder-presen- tation, the hand and arm slipping down and wedging the head off the brim to one or other iliac fossa. Hence the impor- tance of correcting this presentation as early as possible. While the parts are still movable, it is commonly possible to push up the presenting hand by means of your left fin- gers in the vagina ; and at the same time, by pressing down the head by the external hand toward the brim, you make the head fill the space until the double-curved forceps is applied. Then, drawing the head into the brim, the hand cannot again descend. 6. Prolapse of the umbilical cord by the side of the head may sometimes be managed successfully in a similar manner. The first thing to be done is to replace the cord above the presenting head. The postural or knee-elbow position will much facilitate this operation; but it is not always avail- able or necessary. Braun's repositorium, or, better still, Eoberton's, may be used to carry up the loop of prolapsed cord. As soon as this is done, press the head down upon the brim, and, while it is supported by the two hands of an assistant, seize it with the double-curved forceps. [ The " postural treatment" of prolapsed funis is undenia- bly one of the most important advances in obstetric science. The credit, though denied by some European physicians, of having first advocated this procedure, belongs to Prof. T. G. Thomas, of New York, and is recommended by him and others as the safest, surest, and most ready means of return- ing and retaining the prolapsed cord. The procedure con- sists of placing the woman upon her knees, with her chest resting flat on a hard bed ; the cord is then seized and car- ried high up into the uterus, and sheltered behind some por- tion of the foetus. In some cases it may be necessary to first push up the foetal head slightly. The retention of the cord will greatly depend upon its being placed where it is less influenced by uterine contractions.] CHAPTEE XY. Turning continued—The Management of certain Difficult Breech-presentations Before proceeding to the discussion of podalic turning, strictly so called, it will be both convenient and useful to deal with certain cases of difficult breech-presentation. It will be remembered that I defined " turning as including all those proceedings by which the position of the child is changed in order to produce one more favorable to delivery P (See Chap. X., third paragraph.) Now, the cases of breech- presentation to which I refer cannot be brought to a satisfac- tory conclusion unless the position of the child, or at least of some of its parts, be changed. They, therefore, fall within our definition. But, since the breech or podalic extremity of the child is already presenting, a great part of the end contemplated in podalic turning is already accomplished. The problem, so far, then, is simpler than that of effecting complete version, and may, therefore, logically precede the latter in the order of discussion. The simplicity is, indeed, more apparent than real, more theoretical than practical. The task of delivering a breech-case, such as I shall presently describe, vies in difficulty with that which has to be encoun- tered in the most severe forms of shoulder-presentation. In a considerable proportion of breech-cases, the labor is premature. In these, generally, there is no difficulty. In- deed, I have commonly observed in these premature breech- labors a remarkably active, even stormy character in the uterine contractions, driving the child through with unex- DISPOSITION OF THE LEGS IN BREECH-PRESENTATIONS. 173 pected rapidity. But, when the child is mature and well developed, a breech-labor is by no means easy. There are two principal conditions of breech-presentation under which labor may become arrested or difficult. Whether the position of the foetus be dorso-anterior or abdomino-ante- rior, the legs may be disposed in one of two ways. First— and it is the most common case—the legs may be placed upon the thighs so that the heels are near the nates, and (what is very important to recollect) therefore not far from Fig. 51. the os uteri. (Fig. 51.) Secondly, the legs may be extended so that the toes are pointed close to the face. (Fig. 52.) Several causes concur in obstructing delivery. The breech is not nearly so well adapted as the head to traverse the pelvis. Instead of taking a movement analogous to the extension of the head forward under the pubic arch, the breech tends to bend backward in the hollow of the sacrum. The spine, tending to curve in a sigmoid form, is not so 174 OBSTETRIC OPERATIONS. well fitted to transmit the expulsive force applied to the head by the fundus uteri. Then there is the wedge formed by the legs doubled up on the abdomen, which does not easily allow of more than the apex—represented by the breech—descending into, or traversing, the pelvis. Now, the apex of this wedge, represented by the breech and the thighs bent on the abdomen, can enter the pelvis very well. But then comes the widest part or base of the wedge, formed by the chest, shoulders, arms, head, and legs. This often exceeds the capacity of the brim in mere bulk. But, in addition, there is an impediment to rotation of the child on its long axis, which rotation is necessary to easy descent. There is yet another obstacle. It arises out of the con- dition of the uterus. The cervix opens just in proportion to the dimensions of the body which traverses it. The breech, being of less bulk than the head and other parts constituting the base of the wedge, does not open the cervix widely enough to allow this base to descend. The uterus is apt to contract firmly upon the parts still retained in its cavity; and, the cervix encircling the wedge about its middle, a state of spastic rigidity ensues, which tends to lock up the head and chest and to impede descent and rotation. In Fig. 52 I have endeavored to depict some of the conditions described. Sometimes the cause of arrest is simple inertia: a little vis a fironte to compensate for defective vis a tergo may be all that is necessary. It is in the hope of extricating the child by this means that traction in various forms is resorted to. If this is unsuccessful, the case is rather worse than it would have been if left alone. The apex is dragged down a little more, the mother's pelvis is more tightly filled, and the uterus has become more irritable. I have, on this ac- count, arrived at the conclusion that it is better not to resort to direct traction upon the breech in any case where there is arrest. The proper course is, I believe, to bring down MANAGEMENT OF ARRESTED BREECH-PRESENTATIONS. 175 a foot in the first instance. Then traction, if still indicated, can be exerted by aid of the leg with safety and with in- creased power, and under the most favorable conditions for the descent and rotation of the child. Fig. 52. Pig 52 —The position of the foetus with the legs extended as seen from a front view. The breech has descended into the pelvis. The fcetus forms a wedge, of which the apex A is turned forward under the pubic arch. The base B C formed by the head and legs is wider than B C, the transverse diameter of the pelvis. I have seen fruitless and injurious attempts made to ex- tract by fingers, hooks, and forceps. I believe that all the best authors—that is, of those who have encountered and have had to overcome this difficulty, for it is little consid- ered in our text-books—condemn the use of hooks and for- ceps. Chiari, Braun, and Spaeth,1 Eamsbotham, H. F. Naegele, are decided in their reprobation. Hohl says2 the forceps is neither necessary nor effectual. The breech is already in the pelvis. To apply the blades safely, the hand must be passed into the vagina, and, having done this, it may as well do the right thing at once—that is, bring down a foot. Special forceps made to seize the breech are, also, superfluous. i Klinik der Geburtshulfe. 1855. * Lehrbuch der Geburtshulfe. 1862. 176 OBSTETRIC OPERATIONS. I have always succeeded in delivering these cases by the simple use of the unarmed hand, and, since the cases in which I did so succeed were the most difficult that can be encountered, it follows that the unarmed hand is sufficient to overcome the cases of minor difficulty of the same kind. To determine us to reject hooks and forceps, it should be enough to remember that the child is probably alive, and that, under proper skill, it may be born alive. Now, hooks and forceps will, in all likelihood, either destroy the child or involve its death through the delay arising out of their in- efficiency, or they may seriously injure the child. The blunt hook may fracture the femur, contuse the .femoral vessels, or at least inflict severe bruises on the soft parts. The for- ceps may injuriously press upon the abdominal viscera. The difficulty is seldom manifest until the breech has entered the pelvis, and this is the great cause of the obstacles opposing operative measures. To traverse the pelvis, the child's body must take a sinuous course, represented in Fig. 53. Fig. 53. Fig. 53 represents a side view of a breech-presentation, in which the breech has entered the pelvis. It shows the sigmoid form imparted to the trunk in its- effort to traverse the sacrum. The clear indication is to break up or decompose the ob- structing wedge. This is done by bringing down one foot MANAGEMENT OF ARRESTED i.llh^CH-PRESENTATIONS. 177 and leg. For this purpose, pass your hand through the os uteri in front of the breech where the feet lie; seize one by the ankle with two fingers; draw it down, and generally the breech will soon descend. It is better to leave the other leg on the abdomen as long as possible, as it preserves greater rotundity of the breech, and helps to protect the cord from pressure. It will escape readily enough when the breech comes through the outlet. Fig. 54. Fig. 54 represents a breech-presentation with the legs flexed upon the thighs, and the mode of seizing a foot. The first thing to do is to determine the position of the breech in its relation to the pelvis, in order that you may know where to direct your hand to the feet. The breech simulates the face more than any other part, and so it is from the face that the breech is chiefly to be distinnished. There are four principal diagnostic points in the breech: the sacrum and anus behind, the genitals in front, an ischiatic protuberance on either side. The sacrum is distinguished 178 OBSTETRIC OPERATIONS. by its uneven spinous processes from any thing felt in a face- presentation ; and this is the most trustworthy characteristic, for the malar-bones may pass for the ischia, and the mouth for the anus. In all cases of doubtful diagnosis it is well to pass the fingers, or hand if necessary, well into the pelvis, so as to reach the higher presenting parts. In a breech-case you will thus reach the trochanters, and above them the groins, where a finger will pass between the child's body and the thigh flexed upon it. Then in front will be the fissure between the thighs themselves; and here, if the legs are flexed upon the thighs, will be the feet to remove all doubt. These are what you are in search of. But you only want one. It is much more easy to bring down one foot than both; and it is, moreover, more scientific. The ques- tion now comes, Which foot to bring down ? I believe the one nearest to the pubic arch is the proper one to take. -To seize it, pass the index-finger over the instep; then grasp the ankle with the thumb, and draw down backward to clear the symphysis pubis. When the leg is extended out- side the vulva, it will be found that traction upon it will cause the half-breech to descend, and the child's sacrum to rotate forward. The further progress of the case falls within the ordinary laws of breech-labor. The second case—that in which the feet lie at the fundus of the uterus close to the face—is far more difficult. The wedge formed by the extended legs and the upper part of the trunk must, in some instances at least, be decomposed before delivery can be effected. The cause of the difficulty will be understood on looking at the diagram, Fig. 52, and on reflecting that the breech or wedge may in great part be driven low down into the pelvis, leaving but little space for the operator's hand to pass; and further, that the hand must pass to the very fundus of the uterus to reach a foot. No ordinary case of turning involves passing the arm so far. The mode of proceeding is as follows : Give chloroform to the surgical degree; support the fundus of the uterus with MANAGEMENT OF ARRESTED BREECH-PRESENTATIONS. 179 your right hand on the abdomen ; pass your left hand into the uterus, insinuating it gently past the breech at the brim, the palm being directed toward the child's abdomen, until you reach a foot—the anterior foot is still the best to take— a finger is then hooked over the instep, and drawn down so as to flex the leg upon the thigh. Maintaining your hold upon the foot, you then draw it down out of the uterus, and thus break up the wedge. The main obstacle is thus re- moved, and you have the leg to exert traction upon if more assistance is necessary. One caution is necessary in perform- ing this operation. It is this : the finger must be applied to the instep. It is of no use to attempt to bend the leg by acting upon the thigh or knee. You must therefore carry your finger nearly to the fundus of the uterus. This, and the filling up of the brim—and even of a part of the pelvic Fig. 55. cavity sometimes—by the breech, render the operation one of considerable difficulty, demanding great steadiness and gentleness. I have brought a live child into the world by this proceeding on several occasions, where forceps, hooks, 180 OBSTETRIC OPERATIONS. and various other means had been tried in vain for many hours. The reason of the operation, you will see, is analo- gous to that which indicates turning in arm-presentation. The further management of podalic or feet-first labors will be described in the next chapter. Fig. 56. It is quite excusable, before proceeding to so difficult an encounter, to try some other method. The child may be small and the pelvis large, and so a moderate degree of trac- tile force may be enough to bring the wedge through with- out decomposing it. Yarious manoeuvres have been adopted. You may hook one finger in a groin and draw down ; or, what I have found better, you may with the forefinger hook TRACTION ON THE GROINS, ETC. 181 down each groin alternately. (See Fig. 51.) In this way the breech will sometimes move. Or you may pass a piece of tape or other soft cord over the groins, as Giffard did in a case quoted by Perfect. The left buttock presented. Gif- fard, not being able with the forefinger of each hand, placed on each side of the thigh, near the groin, to draw out the feet, succeeded by putting a soft string over the end of his finger; and, getting that up on one side over the thigh and 0 finger on the other side, he drew the string out, and, fixing it close up to the hips, he took hold of the ends that hung Fig. 57. out, and thus extracted, being aided by the pains. An ap- paratus, having a curved flexible spring, might be used to carry the string over the hips, or the object might be accom- plished by a catheter first carried across, and then, having tied the string to the end, it could be drawn through—the 182 OBSTETRIC OPERATIONS. proceeding resembling that adopted to plug the posterior nares for epistaxis. Dr. Eamsbotham recommends the slipping a silk hand- kerchief over the groins. But it is possible that these and like measures may fail, and that you have nothing left but to break up the wedge by separating its component parts, and this, I repeat, is the proper thing to do in the first instance. [Belloc's instrument for plugging the posterior nares is admirably suited for carrying a fillet over the groins. It is contained in the obstetric cases of many obstetricians, and is highly recommended by them for the above purpose.] CHAPTEE XYI. Podalic Bi-polar Turning—The Conditions indicating Artificial Turning in Imi- tation of Spontaneous Podalic Version, and Artificial Evolution in Imita- tion of Spontaneous Podalic Evolution—The several Acts in Turning and in Extraction—The Use of Anaesthesia in Turning—Preparations for Turn- ing—The State of Cervix Uteri necessary—The Position of the Patient— The Uses of the two Hands—The three Acts of Bi-polar Podalic Version. The conditions indicating podalic turning are : 1. Generally, those which are not suited for head-turn- ing, or for the imitation of spontaneous evolution. 2. And more especially, shoulder-presentations of living children, in which the knees or feet are nearer to the os uteri than is the head. 3. Cases in which the shoulder has entered the brim of the pelvis, and especially those in which the arm is pro- lapsed. 4. Most cases in which the cord has prolapsed with the arm or hand, and some cases where the cord alone is pro- lapsed, and cannot be returned or maintained above the presenting part of the child. 5. Cases of shoulder-presentation in which the liquor am- nii has drained off, and in which the uterus has contracted so much as to impede the mobility of the foetus. 6. Certain cases in which it is desirable to expedite la- bor on account of dangerous complications, present or threatening—as haemorrhage, accidental or from placenta praevia; convulsions. In these cases it is indifferent what the presentation may be. 184 OBSTETRIC OPERATIONS. 7. In some cases of inertia, the head presenting, as in pendulous belly and uterus, where the head cannot well be grasped by the forceps. 8. In certain cases of face presentation (see Chapter YII.). 9. Certain cases of minor contraction of the pelvis, or of the second degree (see Chapter YIII.), which are beyond the power of the forceps, and which ought not to be given over to craniotomy. 10. In certain cases of morbid contraction of the soft parts. 11. As a part of the operation for the induction of pre- mature labor in certain cases in which the pelvis is con- tracted, or other circumstances do not permit the spontane- ous transit of the foetus with sufficient ease and quickness to secure a live-birth. 12. In some cases after craniotomy, as the readiest mode of extracting the foetus. 13. In certain cases of rupture of the uterus, the child being still in the uterine cavity. 14. In certain cases of death of the mother during labor, in the hope of rescuing the child, when Caesarean section cannot be performed. Here, then, is a wide range for the exercise of skill in podalic turning. We will now discuss what are the conditions necessary or favorable to turning in imitation of the spontaneous 'podalic version. These are: 1. The pelvis must be capacious enough to permit the passage of the foetus without mutilation. 2. The vulvo-uterine canal must be dilated, or sufficiently dila- table to permit of the necessary manipulations and of the passage of the foetus. 3. The presenting part must not be deeply engaged in the pelvic cavity. 4. The uterus must not be contracted to such an extent that the foetus has been in great part expelled from its cavity, which is hence so diminished that the presenting shoulder or head cannot be CONDITIONS FAVORABLE TO VERSION. 185 safely pushed on one side into the iliac fossa. If the shoulder is free above the brim, the hand not descended, it will be easy to push it across to the nearest iliac fossa. If the shoul- der is movable, even if the hand has fallen into the vagina, the operation is practicable, often not even difficult. If the shoidder has been driven low down into the pelvis, near the perinaeum, the body being firmly compressed into a ball by the spasmodic contraction of the uterus, the child is almost certainly dead, and turning may be difficult or im- possible without extreme danger to the mother. This is the indication for imitation of the natural spontaneous evo- lution. Let us, first of all, take the more simple order of cases where turning is resorted to on account of symptoms indicat- ing danger to the mother, as haemorrhage from placenta praevia, the head presenting, and the cervix uteri sufficiently dilated. I take such a case first because it requires complete turning, and therefore best illustrates the mechanism of the bi-polar method. It is important, at the outset, to bear in mind that turn- ing—that is, the changing the position of the child in order to produce one more favorable to delivery—is one thing, and that extraction, or forced delivery, is another thing. Sometimes turning alone is enough, Nature then taking up the case and completing delivery. Sometimes extrac- tion, or artificial delivery, must follow, and complement turning. It will, however, give a more complete exposition of the subject to describe the two operations of turning and extrac- tion continuously, assuming a case in which both are neces- sary. Each operation again admits of useful division into stages or acts. The several acts in turning are these : 1st Act.—The removal of the presenting part of the child from the os uteri, and the simultaneous placement there of the knees. 186 OBSTETRIC OPERATIONS. 2d Act.—The seizure of a knee. 3d Act.—The completion of version by the simultaneous drawing down of the knee, and the elevation of the head and trunk. These three acts complete turning. The several acts in extraction are: 1st Act.—The drawing the legs and trunk through the pelvis and vulva. An incidental part of this act is the care of the umbilical cord. 2d Act.—The liberation of the arms. 3d Act.—The extraction of the head. Before commencing the operation, there are certain pre- paratory measures useful or necessary to adopt. The question of inducing ancesthesia arises. It would partake too much of the nature of a digression to discuss at length the indications for chloroform as an aid in turning. I will do no more than glance at the principal points. Chloroform is resorted to in the hope of accomplishing two objects: The first is to save the patient pain; the sec- ond is to render the operation easier to the operator. The attainment of both objects is sometimes possible; sometimes not. It is not difficult to render the patient insensible; but you will not always at the same time make the operation more easy. It will commonly be necessary to push anaesthe- sia to the surgical extent. If you stop short of this degree, the introduction of the hand will often set up reflex action, and you will be met by spasmodic contraction of the vaginal and uterine muscles, and perhaps by hysterical restlessness of the patient. You will have lost the aid of that coura- geous self-control which Englishwomen preeminently possess. You must then carry the anaesthetic further, to subdue all voluntary and involuntary movements, and to lessen the reflex irritability of the uterus. Then, but not always, you will secure passiveness, moral and physical, on the part of the patient; the uterine muscles will relax; they will no longer resent the intrusion of the hand. These advantages DILATATION OF THE OS NECESSARY FOR VERSION. 187 are not, indeed, always obtained without drawbacks. A perfectly flaccid uterus indicates considerable general prostra- tion, and predisposes to flooding. The state of the cervix uteri has to be considered. It is one of the natural consequences of a shoulder-presentation that the cervix uteri is but rarely found dilated sufficiently for turning and delivery until after—perhaps long after— the indication for turning has been clearly present. A shoul- der will not dilate the cervix properly. The same may be said of many cases where turning is indicated by danger to the mother from convulsions, haemorrhage, etc. To wait for a well-dilated cervix would be to wait till the child or mother is dead. It follows, therefore, that we must be pre- pared to undertake the operation at a stage when the cervix uteri is only imperfectly dilated. What is the degree of dilatation necessary ? If the ques- tion be simply one of turning, it is enough to have a cervix dilated so as to admit the passage of one or two fingers only, since it is not necessary, in the class of cases we are now dis- cussing, to pass the hand into the uterus. But, since the ulterior object contemplated is delivery— with the birth of a live child, if possible—we must have a cervix dilated, or dilatable enough to allow the trunk and head of the foetus to pass without excessive delay. The modes of dilating the cervix artificially have been described in Chapter IX., page 103. It is sufficient here to call to mind the two principal modes, viz., by the hydrostatic dilators and by the hand. The water-bag properly adjusted inside the cervix, if labor has begun at term, will commonly produce an ade- quate opening within an hour. Sometimes the fingers alone will succeed as quickly. Quite recently, in a case where the head presenting could not bear upon the cervix to dilate it because of slight conjugate contraction, I expanded it by the fino-ers sufficiently to admit the narrow blades of Beatty's forceps" within a few minutes. The instrument, however, was not powerful enough to bring the head through. I 188 OBSTETRIC OPERATIONS. therefore turned and made the breech and trunk complete the dilatation. The head required considerable traction to bring it through the narrow conjugate; but the child was saved. At the beginning the os barely admitted one finger; yet the patient was delivered within an hour. But we can- not always proceed so quickly. Nor is it commonly possible to effect by artificial means that comj)lete dilatation which is required to permit the head to pass freely. The average obstetric hand will easily traverse a cervix that is too small to allow the head to pass; so that after all, even in head-last labors, as in head-first labors, the head must generally open up the passages for itself. What we have to do is, to take care that the parts shall be so far pre- pared when the head comes to be engaged in the cervix that the further necessary dilatation may take place quickly; for this is the stage of danger to the child from compression of the funis between the os uteri and the child's neck. The management of this stage will be described further on. It is enough now to point out that a cervix uteri expanded so wide as to admit of three fingers manoeuvring without in- convenience is enough for turning under the circumstances of the case we have assumed. The general rule of emptying the bladder and rectum applies even more strongly to turning than to forceps or craniotomy operations. What shall be the position of the patient? I have, gen- erally, performed the operation of turning under whatever circumstances, the patient lying on her left side. It is of importance, I think, not to raise alarm in the patient or her attendants by adopting any great departure from the usual rules of the lying-in chamber. To place the patient on her back involves very considerable, even formidable prepara- tions. The patient must be brought with her nates to rest on the very edge of the bed; she must be supported at her head; and two assistants must hold the legs. Still, there are cases in which this position may be preferable or un- POSITION AND REQUISITES FOR BI-POL^ PODALIC VERSION. 189 avoidable. There is another position, also in some cases useful—the knee-elbow position. But this precludes the use of chloroform. We may obtain all the necessary facili- ties by keeping the patient on her left side. The nates must be brought near the edge of the bed; the pillows are removed so as to allow the head and shoulders to fall to the same level as the nates. The head is directed toward the middle of the bed, so that the operator's arm may not be twisted during manipulation; the knees are drawn up; and the right leg is held up by an assistant, so as not to ob- struct or fatigue the operator's right hand, which has to pass between the thighs to work on the surface of the ab- domen. The presence or absence of liquor amnii in the uterus is a matter of accident. If it be still present, so much the better; but you must be prepared to act all the same if it be not there. It is needless to state that the child will re- volve more easily if it be floating in water; but it must not only be made to revolve; you have to seize a limb. At some time or other, therefore, the membranes must be rup- tured. What is the best time to do this ? If you are pro- ceeding to turn in the old way—that is, by passing the whole hand into the uterus before seizing a foot—it is an advantage to follow the plan recommended by Pen, of slip- ping the hand up between the uterine wall and the mem- branes until you feel the feet, and then to break through and seize the limbs. During this operation the arm, plug- ging the os uteri, retains the liquor amnii, and, on drawing down the legs, the body revolves with perfect facility. But if you are proceeding to turn by the bi-polar method, with a cervix perhaps imperfectly opened, the membranes must be pierced at the os. In this case you may perhaps ac- complish the first act in version—that is, of removing the head or shoulder from the brim, and of bringing the knees over the os while the membranes are intact. This you can try first only rupturing the membranes when you are ready to 190 OBSTETRIC OPERATIONS. seize the knee. But sometimes an excess of liquor amnii imparts too great mobility to the child; you are unable to fix it sufficiently to keep the pelvic extremity steady upon the os; it will bound away as in ballottement, the moment you touch it through the os. In such a case it is better to tap the membranes first, and allow a part of the liquor am- nii to run off. While doing this you should keep your fin- gers on the presenting part to ascertain how its position and mobility are being influenced by the escape of the waters and the contraction of the uterus, so as to seize the right moment for proceeding. Now, if you assent to what I have stated, you will find that you are committed to the use of your left hand as the more actwe agent in the operation. You want the right hand to work outside on the abdomen; therefore, the left hand must be introduced into the vagina. It is a case where ambidexterity is eminently required. The left hand in most people is smaller than the right. The patient lying on her left side, the left hand follows the curve of the sa- crum far more naturally than the right. It meets the right hand outside, the two working consentaneously with com- fort, involving no awkward or fatiguing twisting of the body. Moreover, in the great majority of cases the anterior surface of the foetus, and consequently its legs, are directed toward the right sacro-iliac joint—that is, inclining back- ward and to the right, so that the left hand, passed up in the hollow of the sacrum, will reach the legs with the ut- most convenience. I strenuously advise every young man who is preparing for obstetric surgery to put his left hand into training, so as to cultivate its powers to the utmost. There are a thousand ways of doing this, and I hope it will not be considered idle to mention some. In all athletic ex- ercises or games requiring manual skill, use the left arm as well as the right. It is an excellent practice to dissect with the left hand. Shave the right side of the face with the ra- zor in the left hand; use your toothbrush with the left OPERATION OF BI-POLAR PODALIC VERSION. hand ; and, if you now and then come to grief through left- handedness, think how much less is this evil than injuring a woman or breaking down in an operation. We now proceed to the operation of bi-polar podalic ver- sion. In the case we have assumed, the head is over the os uteri; the os uteri is open enough to admit the play of two or three fingers; the liquor amnii is still present, or has been only recently and partially discharged. Turning is indicated by symptoms threatening danger to the mother. The preparations necessary have been made. One thing more I have to insist upon; it is to avoid all parade or fuss in your conduct. Make your preparations as quietly and unostentatiously as possible. Do all that is essential, and no more. Tell the patient and her attendants that you find it necessary to help the labor. But let your help be so given as to involve the least possible changes from the usual proceedings in ordinary labor. When the patient is in position, and under chloroform, if it be determined to give it, slip off your coat, turn up the shirt-sleeves above the elbows, anoint with oil, lard, or pomade, the back of the left hand and all round the wrist, and insinuate a piece of lard into the vulva. The Introduction of the Hand.—Bring the fingers to- gether in the form of a cone; pass in the apex of this cone, gently pressing backward upon the perinaeum, and pointing to the hollow of the sacrum. If you find any difficulty—as you probably will if the case be a first labor—you must watch for the most fitting opportunity. Wait till a pain comes on. There is good reason for deferring to the popular idea of " taking a pain." The pain caused hj expulsive action will partly mask that caused by the manoeuvre; and expulsive action tends to produce sphincteric relaxation, so that the passage of the hand will be actually facilitated. A source of difficulty is the tendency of the labia and hair to turn inward before the fingers. This is counteracted by drawing the labia open by the thumb of the right hand, by 192 OBSTETRIC OPERATIONS. an action similar to that you would use to lift up the closed upper eyelid. The passage of the vulva is often the most difficult part of the operation. It is commonly necessary to pass the entire hand into the vagina; and great gentleness and patience are required. I have, indeed, turned and ex- tracted a mature child without passing in more than two fingers, without even turning back or soiling the cuff of my coat; but circumstances must be favorable to admit of this. We have now got as far as the orifice of the uterus, and it is an immense improvement in obstetric art that we are able to complete the operation without pressing the whole hand through this part. The first act begins by passing the tips of the first two fingers through the os to the presenting part, which we assume to be the head. We ascertain to which side of the pelvis the occiput is directed, for it is to that side that we must send the head. At the same time, an assistant holding up the right leg at the knee, so as to give you freedom of action, you apply your right hand spread out over the fundus uteri where the breech is. And now begins the simultaneous action upon the two poles of the foetal ovoid; the fingers of the hand inside pressing the head- globe across the pelvic brim toward the left ilium, the hand outside pressing the breech across to the right side and down- ward toward the right ilium. The movements by which this is effected are a combination of continuous pressure and gen- tle impulses or taps with the finger-tips on the head; and a series of half-sliding, half-pushing impulses with the palm of the hand outside. Commonly, you may feel the firm breech through the abdominal walls under the palm, and this sup- plies a point to press against. A minute sometimes, sel- dom much more, will be enough to turn the child over to an oblique or nearly transverse position; the head quitting the os uteri, and the shoulder or chest taking its place. This act may be divided, for the sake of illustration, into two stages. FIRST AND SECOND ACTS OF BI-POLAR PODALIC VERSION. 193 At this stage it is important to keep the breech well pressed down, so as to have it steady while you attempt to Fig. 58. Fig. 58 represents the first stage of bi-polar podalic version. The right hand on the fun- dus uteri pushes the breech to the right and backward, bending the trunk on itself. The left-hand fingers on the vertex push the head to the left ilium, away from the brim. seize a knee. This is the time to puncture the membranes, if not already broken. The fingers in the os uteri are pressed through the membranes during the tension caused by a pain, and you enter upon the Second Act, the seizure of a knee. Which knee will you take ? In the particular case we have to deal with, it is not of much importance which you seize, but the* farther is, on the whole, to be preferred. You will observe in the diagrams Figs. 58, 59, 60, that the legs, doubled up on the abdomen, bring the knees near the chest, so that, as soon as 13 194 OBSTETRIC OPERATIONS. the head and shoulder are pushed on one side, the knees come near the os uteri. Fig. 59. Fig. 59 represents the second stage of the first act. The right hand, still at the fundus uteri, depresses the breech, so as to bring the knees over the brim, while the left hand pushes the shoulder across the brim toward the left iliac fossa. Fig. 60. Fig. 60 represents the second act. The trunk being well flexed upon itself, the knees are brought over the brim, the forefinger of the left hand hooks the ham of the farther knee, and draws it down, at the same time that the right hand, shifted from the fundus and breech, is applied, palm to the head-globe, in the ilium, and pushes it upward. THIRD ACT OF BI-POLAR PODALIC VERSION. The knee being seized, the further progress of the case is under your command. By simply drawing down upon the part seized, you may often complete version. But it will greatly facilitate the operation to continue to apply force to the two poles. You will observe, in Fig. 60, that the hands have changed places in relation to the two poles of the foetal ovoid. Although the left hand has never shifted from its post in the vagina, the ovoid has shifted; and the forefinger, drawing down the left knee, virtually acts upon the pelvic end of the ovoid. The right hand, therefore, is at liberty to Fig. 61. Fig. 61 represents the third act in progress The right band'continuess to.push up.the head out of the iliac fossa; the left hand has seized the farther leg, and draws it down head out of the iliac fossa- „..~---------------------- - in the axis of the brim. Version is now nearly complete. quit this end ; it is transposed to the head-end of the ovoid, which has been carried over to the left iliac fossa. The palm is applied under the head, and pushes it upward in response to and in aid of, the downward traction exerted on the child's 196 OBSTETRIC OPERATIONS. leg. This outside manoeuvre singularly facilitates the com- pletion of version. It may be usefully brought into play in almost every operation of podalic turning. If it is neglected, as I shall show on a special occasion, you will sometimes fail in effecting complete version ; for the head will not always quit the iliac fossa by simply pulling upon the legs. Continuing to draw upon the leg, as soon as the breech nears the brim a movement of rotation of the child on its long axis begins, the design of which is to bring the back to Fig. 62. \ >l Fig. 62 represents the completion of the third act. The right hand still supports the head, now brought round to the fundus uteri. The left hand draws down on the left leg in the direction of the pelvic axis. Version is complete. Rotation of the child on its long axis has taken place, the back coming forward as the breech enters the pelvis. the front of the mother's pelvis. This rotation depends upon a natural law of adaptation of the two parts. You are not COMPLETION OF BI-POLAR PODALIC VERSION. to trouble yourselves in " giving the turns," as some authors imagine they can. I cordially agree with Wigand when he says, " Nature knows better than we do how to impart the proper turns." What you have to do is simply this—to supply onward movement. If the uterus be doing its own work, propelling the child breech-first, we know we may rely upon Nature so to dispose the child in relation to the pelvis as to enable it to pass with the greatest facility. So it is when we sup- ply the moving force from below. If this force is wanted, supply it; but do not attempt to do more: avoid that fatal folly of encumbering Nature with superfluous help. Keep the body gently moving in the direction of the pelvic axis by drawing upon the leg, and Nature will do the rest. You will feel the leg rotate in your grasp, and the back will grad- ually come forward. I have said that, upon the whole, the farther knee is the better one to seize ; but, if you compare Figs. 60 and 62, you will see that, by drawing the nearer or anterior knee, you would directly secure the rotation of the child's back for- ward ; so that, as I have before said, it is not worth while to lose time in trying to seize the farther knee if you find the anterior one the more easy to seize. This completes version. The breech is substituted for the head. Nature may effect expulsion; but, if she fail, we have it in our power to effect delivery by extraction. We have assumed that extraction is necessary, and will proceed to this operation. [Statistics indisputably prove that great danger is in- curred by both mother and child, from the operation of ver- sion. The danger to the mother is greater in hospital than in private practice, and especially during the prevalence of puerperal inflammations and fevers. The increase of danger is in direct ratio to duration and extent of manipulation, pressure, and bruising, to which the uterus is subjected during the operation.] CHAPTER XYII. The Operation of Extraction after Podalic Version, or other Breech-first La- bors.—The three Acts in Extraction; the Birth of the Trunk, including the Care of the Umbilical Cord ; the Liberation of the Arms ; the Extraction of the Head. The operation of turning being completed by engaging the pelvic extremity of the child in the brim, we have next to consider the question of delivery. This, as I have already pointed out, is a distinct operation. Nature unaided may accomplish it. It is only in her default that we are called upon to undertake it. It is very desirable that as much of this operation be trusted to Nature as possible. Our duty is to watch the progress of the labor closely, interposing aid when that progress is too slow, or when the interest of the child demands it. As a general rule, the natural forces will carry the child through with more safety than the forces of art. But even in the most favorable breech-first labors, whether the breech or feet have originally presented or have been brought to present by art, care on the part of the prac- titioner is necessary to avert certain dangers incurred by the child in its transit; and in some cases serious difficulty to the transit arises to demand the exercise of active skill. The description I now propose to give of the operation of podalic extraction will embrace, and apply to, all the cases in which this operation is called for: We will begin with the most simple—that in which there is no serious compli- cation, in the shape of pelvic contraction, excessive size of EXTRACTION AFTER PODALIC VERSION. the child, or resistance by the soft parts. It is either a case of inertia or- one in which prompt delivery or the accelera- tion of labor is indicated in the interests of the mother or child. We possess, in our hold upon a leg, a security for the further progress of delivery, of which we can avail ourselves at pleasure. In this security consists one of the main argu- ments in favor of podalic version. We have divided the operation of extraction into three acts—drawing down the trunk through the vulva; liberation of the arms; extraction of the head. The first act is effected by simply drawing down upon the extended leg in the axis of the brim. Two rules have to be observed. The first is, to draw down simply, avoiding all attempts to rotate the child upon its long axis. You must not only not make such attempts; you must even be careful not to oppose the natural efforts at rotation. This is secured by holding the limb so loosely in the hand that the limb may either rotate within your grasp under the rotation imparted to it by the rotation of the trunk, or that the limb in its rota- tion will carry your hand round with it. The other rule is to draw well in the direction of the axis of the brim, and especially to avoid all premature attempts to direct the ex- tracting force forward in the axis of the outlet. When the breech has come to the outlet, the extracting force is directed a little forward, so as to enable the hip which is nearest the sacrum to clear the perinaeum. This stage should not be hurried. The gradual passage of the breech has been doing good service in securing free dilatation of the vagina and vulva, an essential preparation for the easy pas- sage of the shoulders and head. When the hips have cleared the outlet, you may pass the forefinger of your left hand into the groin, and gently aid extraction by this additional hold; and, at the same time, by pressing the knee forward across the child's abdomen, you may facilitate the liberation of the leg. \ 200 OBSTETRIC OPERATIONS. When both legs and breech are outside the vulva, you have acquired a considerable increase of extracting power. You must, however, use it with discretion. You may now draw upon both legs, holding them at the ankles between the fingers and thumb of one hand. And, if you still want more power, you can grasp the child's body just above the hips with the other hand. It is generally desirable to interpose a thin soft napkin between and round the ankles. It gives a better hold, and lessens the risk of confusion. Fig. 63. Fig. 63 represents the first act of extraction. Traction must now again be directed in the axis of the brim, in order to bring the shoulders through that aperture. EXTRACTION AFTER PODALIC VERSION. The shoulders will enter in the same oblique diameter, back forward, as that in which the breech traversed. As soon as the belly comes to the vulva, your attention will be turned to the umbilical cord. This is apt to be put upon the stretch, by slipping up under the influence of fric- tion as the body is drawn down; and, besides being stretched, it is liable to direct compression. The way to lessen these risks is to seize the cord near the umbilicus and draw down very gently a good loop ; this loop should be laid where it is least exposed to pressure, and you must further take care to keep off the pressure of the vulvar sphincter upon it by guard- ing it with your fingers. From time to time feel the cord, to ascertain if it continues to pulsate. If you find the pulsa- tions getting feeble or intermittent, you have an indication to accelerate extraction. The observations of May and Wigand upon this point are worthy of attention. Reasoning that the pressure suffered by the cord affects the vein more than the arteries, and hence that the access of blood to'the foetus is hindered, while the removal of the blood from the foetus is little obstructed, so that a fatal anaemia results, they advise to tie the cord, as soon as the body is born, as far as the navel, and then to complete extraction. The apparent asphyxia so produced is easily remedied by the usual means. Yon Ritgen says he has often done this, and affirms that when done there is little need to hurry extraction. I refer to Chapter VI. for some observations upon the length of time a child is likely to survive after arrest of the circulation in the cord. I have there stated my belief that the prospect of a live child is very small if three or five min- utes elapse before the head is born. This may be thought too narrow a limit, but certainly there is not a moment to be lost in starting aerial respiration. The second act comprises the liberation of the arms. In the normal position of the foetus the arms are folded upon the breast and, if the trunk and shoulders are expelled through 202 OBSTETRIC OPERATIONS. a normal pelvis by the natural efforts, they will commonly be born in this position. But, if ever so little traction-force be put upon the trunk, the arms, being freely movable, en- countering friction against the parturient canal as the body descends, are detained, and run up by the sides of the head. Hence often arises a serious delay in the descent of the head, for this, the most bulky and least compressible part of the foetus, increased by the thickness of the arms, forms a wedge which is very apt to stick in the brim. This is one great rea- son for not putting on extraction-force if it can be avoided. If, however, we find the arms in this unfortunate position, we must be prepared to liberate them promptly and, at the same time, without injury. It is very easy to dislocate or fracture the arms or clavicles if the proper rules are not ob- served. What are these rules ? The cases vary in difficulty, and therefore in the means to be adopted. In some cases the arms do not run up in full stretch along the sides of the head. The humeri are directed a little downward, so that the elbows are within reach. In such cases it is an easy matter to slip a forefinger on the inner side of. the humerus, to run it down to the bend of the elbow, and to draw the forearm downward across the chest and abdomen, and then to bring the arm down by the side of the trunk. But many cases require far more skill. The cardinal rule to follow is to observe the natural flex- ions of the limbs, always to bend them in the direction of their natural movements. The arms, therefore, must always be brought forward across the breast. The way to do it is as follows: Slip one or two fingers up along the back of the child's thorax, and bend the first joints over the shoulder between the acromion and the neck; then slide the fingers forward, catching the humerus in their course, and carrying this with them across the breast or face. This movement will restore the humerus to its natural flexion in front of the body. Of course, as the humerus comes forward the forearm follows. Your fingers, continuing to glide down, will reach EXTRACTION AFTER PODALIC VERSION. 203 the bend of the elbow, and, still continuing the same down- ward and forward movement across the child's breast and ab- domen, the arm is extended and laid by the side of the trunk. That is what has to be done. * But is it indifferent which arm you shall bring down first ? The most simple rule is to take that first which is the easiest, for when one is released the room gained renders the liberation of the second arm easy enough. Generally there is most room in the sacrum ; there- fore it is best to take the posterior arm first. Now I have to describe manoeuvres for overcoming the difficulties which not seldom oppose your efforts to release the arms. There are two principal ones. The first is this: You want to bring the posterior or sacral arm within reach Fig. 64. Fig. 64 represents the mode of liberating the posterior or sacral arm. of your finger. Carry the child's body well forward, bend- ing it over the symphysis pubis. The effect of this is a two- fold advantage. Space is gained between the child's body and the sacrum for manipulation, and, as the child's body re- 204 OBSTETRIC OPERATIONS. volves round the pubic centre, the farther or sacral arm is necessarily drawn lower down, commonly within reach. When the sacral arm is freed, you reverse the manoeuvre, and carry the child's trunk backward over the coccyx as a centre. This brings down the pubic arm. Fig. 65. Fig. 65 represents the mode of liberating the anterior or pubic arm. The second manoeuvre may be held in reserve, should the first fail. To execute it, you must bear in mind the natural flexions of the arms. You grasp the child's trunk in the two hands above the hips, and give the body a movement of rota- tion on its long axis, so as to bring its back a little to the left. The effect of this is to throw the pubic arm, which is prevented by friction against the canal from following the trunk in its rotation, across the breast. Then your object being accomplished so far, you call to your aid the first ma- noeuvre, and bring this arm completely down. This done, you reverse the action and rotate the trunk in the opposite direction. The sacral arm is thus brought to the front of EXTRACTION AFTER PODALIC VERSION. 205 the chest, and, by carrying the trunk back, your fingers will easily complete the process. It is desirable, for reasons we shall presently explain, to avoid this rotation if possible; but under certain circum- stances of diflficulty it is exceedingly valuable. The rotation Fig. 66. Fig 66 represents a mode of liberating the arms. The trunk is rotated an eighth of a circle from right to left, so as to throw the left arm across the face. need not be considerable ; an eighth of a circle is commonly enough, and, as it is neutralized by reversal, an objection that might otherwise be urged against the manoeuvre is removed. A paramount reason why you should be careful in im- parting rotation to the trunk or " giving the turns " is this: the union of the atlas with the occipital condyles is a very close articulation; it permits flexion and extension only. '206 OBSTETRIC OPERATIONS. The atlas forms with the axis a rotatory joint, so constructed that, if the movement of rotation of the head be carried be- yond a quarter of a circle, the articulating surfaces part im- mediately, and the spinal cord is compressed or torn. Thus, if the chin of the foetus pass the shoulder in turning back- ward, instant death results. I have no doubt that many Fig. 67. Fig. 6T represents the results of the manoeuvre begun in Fig. 65. By rotating the trunk from right to left, the left arm is thrown across the lace. children have been lost through oblivion of this fact. Sometimes the arm will hitch on the edge of the pelvic brim, or just above the imperfectly-expanded os uteri. Never attempt, by direct hooking on the middle of the humerus, to drag it through. You would almost certainly break it. Press it steadily against the child's face, and un- EXTRACTION AFTER PODALIC VERSION. 207 der its chin, running your finger down as near the elbow as possible, so as to lift this part, as it were, over the ob- struction. [Fracture of the arms is sometimes unavoidable, as in cases where the child's life will be lost unless instantly de- livered, and in such we may sometimes be compelled to do it designedly. In a large majority of cases, however, these in- juries are the result of carelessness or bad management.] The arms liberated, now begins the third act, the extrac- tion of the head, often a task of considerable difficulty, and always demanding the strictest observance of the laws which govern the mechanism of labor. This act differs from the first two in that, while these are sometimes effected by Nature, the liberation of the head must almost always be conducted by art. When the head is last, and has en- tered the brim, it is very much removed from the influence of expulsive action. The uterus can with difficulty follow it into the pelvis, and the trunk, unless supported by the hands, would, by its mere vis inertioe and friction against the bed, retard the advance of the head. Moreover, this is the stage of chief danger from compression of the cord. The round head fills the brim and the cervix uteri, so that the cord can hardly escape. It would be folly, therefore, to sit by and trust to Nature in this predicament, at the risk of losing that for which the whole operation of version and extraction has been performed—namely, the child's life. Let us sup- pose for a moment that the head is in the pelvis, and that you cannot extract it at once. If you can get air into the chest, which, being outside the vulva, is free to expand, there is no need to hurry the extrication of the head. You may sometimes get the tip of a finger in the mouth, and, drawing this down, while you lift up and hold back the pe- rinaeum, you may enable air to enter the chest. In this way I have kept a child breathing for ten minutes before the head was born. Another plan is to pass a catheter or other tube up into the mouth, so as to give, by means of a kind 208 OBSTETRIC OPERATIONS. of artificial trachea, communication with the external air. But I must warn you not to trust to these or similar plans, lest the golden opportunity be irretrievably lost. The real problem is, to get the head out of the pelvis. There are two principal modes of doing this. One is to apply the forceps. This operation I have described in full in Chapter VI. It has been advocated by Busch, Meigs, Rig- by, and others. I have practised it successfully, but think it is inferior in celerity and convenience to the second mode, by manual extraction. Remember that the head has to perform a double rotation in its progress. It must revolve round the symphysis pubis as a centre; it must rotate in the cavity on its vertico-spinal axis, so as to bring the face into the hollow of the sacrum*. You must then, in extracting, respect these natural movements. You will better follow or guide these movements if you fork the fingers of one hand over the neck behind, and at the same time, holding the legs with the other hand, draw down with careful attention to the curve of Carus. If you carry the body forward too soon, you simply convert the child's head and neck into a hook or crossbar, which, holding on the anterior pelvic wall, will effectually resist all efforts at extraction. When there is little or no resistance to the escape of the head, it is enough to support the trunk with one hand by holding it at the chest, while the other hand, on the nucha, regulates the exit of the head. Sometimes it requires considerable force to bring the head through the brim; but, while force will never compen- sate for want of skill, it is astonishing how far skill will carry a very moderate force. The modes of extricating the head under circumstances of unusual difficulty will be dis- cussed hereafter. But before passing on I must refer to one practice commonly taught, which is, I believe, based on er- roneous observation. You are told to pass a finger into the mouth, or to apply two fingers on the upper jaw, to depress the chin, in order to keep the long axis of the child's head EXTRACTION AFTER PODALIC VERSION. 209 in correspondence with the axis of the pelvis. Now, this is a piece of truly " meddlesome midwifery," because it is per- fectly unnecessary. The chin is not likely to be caught on FlG> 68- the edge of the pelvis or else- where, unless, by a previous piece of " meddlesome midwife- ry," you have been busy in " giving the turns." The truth is, Nature has taken care to ar- range the convenient adapta- tion of means to end in head- last labor as in head-first. It is true that the occipito-spi- nal joint is seated behind the centre. It might, prima facie, appear that the occiput, form- ing the shorter arm of the head- lever, would tend to roll back upon the nucha. But this is not so in practice. The broad, firm expanse of the occiput, forming a natural inclined plane directed upward, is sure- ly caught by the walls of the parturient canal as the head descends. The greater friction thus experienced by a larger superficies favorably disposed virtually converts the shorter arm of the lever into the more powerful one; it is more re- tarded in its course; and there- fore the chin is kept down near the breast, and therefore, again, FlG 68 repregents the extraction of the there is no need for the obstet- head- Tne dotted line i8 the curve of rist to meddle in the matter. 14 Carus, which indicates the direction to be observed in extraction. CHAPTER XVIII. Turning when Liquor Amnii has run off, the Uterus being contracted upon the Child—The Principle of seizing the Knee opposite to the Presenting- Shoulder illustrated. So long as there is any liquor amnii present in the uterus, and often for some considerable time afterward, the bi-polar method of turning is applicable. But a period arrives when it becomes necessary to pass the hand fairly into the uterus, in order to seize a limb. We will now discuss the mode of turning, under the more difficult circumstances of loss of liquor amnii, more or less tonic contraction of the uterus upon the child, and descent of the shoulder into the pelvis. The contraction of the uterus, necessarily concentric or centripetal, tends to shorten the long axis of the child's body (see Figs. 39 and 40, Chapter XII.). The effect is to flex the head upon the trunk, and to bend the trunk upon itself, reducing the ovoid to a more globular form. This brings the knees nearer to the chest, but does not diminish the difficulty of turning. I need not pause again to discuss minutely the prepara- tory measures. It is only necessary here to call to mind that chloroform or opium is especially serviceable, and that it is important to empty the bladder and rectum. The first question to determine is, Which hand will you pass into the uterus ? I have given some of the reasons why the left hand should be preferred, in Chapter XVI. In the majority of cases the child's back is directed forward; to reach the legs, which lie on the abdomen, your hand must VERSION WHEN THE LIQUOR AMNII HAS RUN OFF. 211 pass along the hollow of the sacrum, and this can hardly be done, the patient lying on her left side, with the right hand, without a most awkward and embarrassing twist of the arm. I need scarcely point out how violent and unnatural a pro- ceeding it would be to pass up the right hand between the child's back and the mother's abdomen, to carry the hand quite round and over the child's body, in order to seize the feet which lie toward the mother's spine, and then to drag them down over the child's back. If you attempted this, you would probably get into a difficulty. The child, per- haps, would not turn at all. To avoid this failure, the rule has been laid down to pass your hand along the inside, or palmar aspect of the child's arm. This will guide you to the abdomen and the legs. Or the rule has been stated in this way: Apply your hand to the child's hand, as if you were about to shake hands. If the hand presented to you be the right one, take it with your right, and vice versa. [If we place the palm of the presenting hand against the palm of our own right hand, we can readily ascertain which arm the child presents, and therefore its position. If it is the right hand of the child, then its thumb will be in appo- sition to ours, but the left hand will not so correspond. If the arm be not twisted, the direction of the palm will cor- respond with that of the child's abdomen.] Rules even more complicated are proposed, especially by Continental authors. Some go to the extent of determining the choice of hand in every case by the position of the child. The fallacy and uselessness of these rules are sufficiently evident from the disagreement among different teachers as to which hand to choose under the same positions. Rules, moreover, which postulate an exact knowledge of the child's position, are inapplicable in practice, because this diagnosis is often impossible until a hand has been passed into the uterus ; and it is, certainly, not desirable to pass one hand in first to find out which you ought to use, at the risk of having to begin again and to pass in the other. 212 OBSTETRIC OPERATIONS. The better and simpler rule is this: In all dorso-anterior positions, lay the patient on her left side • pass your left hand into the uterus—it will pass most easily along the curve of the sacrum and the child's abdomen; your right hand is passed between the mothers thighs to support the uterus externally. In the case of abdomino-anterior positions, lay the patient on her back, and you may introduce your right hand, using the left hand to support the uterus externally. If the patient is supported in lithotomy position, you can thus manipulate without straining or twisting your arms or body. But it is equally easy to use the left hand internally if the patient is on her back, so that the exception is only indicated to suit those who have more skill and confidence with the right hand. We will first take a dorso-anterior position. Introduce your left hand into the vagina, along the inside of the child's arm. The passage of the brim, filled witli the child's shoul- der, is often difficult. Proceed gently, stopping when the pains come on. At the same time support ^tie uterus exter- nally with your right hand. Sometimes you may facilitate the passage ot the brim by applying the palm of the right hand in the groin, so as to get below the head and to push ft up. This will lift the shoulder a little out of the brim. Or you may practise a manoeuvre attributed to Von Deutsch, but which had been practised by Levret. This consists in seizing the presenting shoulder or side of the chest by the inside hand, lifting it up and forward, so as to make the body roll over a little on its long axis. This may be aided by pressure in the opposite direction by the outside hand on the fundus uteri, getting help from the bi-polar principle. Sometimes advantage is to be gained by placing the patient on her elbows and knees. In this position yon are favored by gravity, for the weight of the foetus and uterus tends to draw the impacted shoulder out of the brim. [Several cases are on record in which version was facili- VERSION WHEN THE LIQUOR AMNII HAS RUN OFF. 213 tated by the " Postural Treatment" of Thomas. The most recent was a case of shoulder presentation, in which, the membranes having ruptured, cephalic version was performed as above, and both mother and child recovered. {New Or- leans Journal of Medicine, Vol. XXII., No. IV., October, 1869. By Dr. T. M. Stone.) ] The brim being cleared, your hand passes onward into the cavity of the uterus. This often excites spasmodic con- traction, which cramps the hand, and impedes its working. Spread the hand out flat, and let it rest until* the contrac- tion is subdued. In your progress you must pass the um- bilicus, or a loop of umbilical cord will fall in your way. Take the opportunity of feeling it to ascertain if it pulsates. You thus acquire knowledge as to the child's life. But you must not despair of delivering a live child because the cord does not pulsate. I have several times had the satisfaction of seeing a live child born where I could feel no pulsation in utero. You are now near the arm and hand. They are very apt to perplex. Keep, therefore, well in your mind's eye the differences between knee and elbow, hand and foot, so that you may interpret correctly the sensations trans- mitted by your fingers from the parts you are touching. At the umbilicus you are close to the knees. The feet are some way off at the fundus of the uterus applied to the child's breech. What part of the child will you seize f It is still not uncommon to teach that the feet should be grasped. You will see pictures copied from one text-book to another, rep- resenting this very unscientific proceeding. There ought to be some good reason for going past the knees to the feet, which are farther off and more difficult to get at. Now, I know of no reasons but bad ones for taking this additional trouble. You can turn the child much more easily and completely by seizing one knee. Dr. Radford insists upon seizing one foot only, for the following reason: The child's life is more frequently preserved where the breech presents 214 OBSTETRIC OPERATIONS. than where the feet come down first. A half-breech is also safer than cases where both feet come down. The dilatation of the cervix is better done by the half-breech. The circum- ference of the breech, as in breech-presentations, is from twelve to thirteen and a half inches, nearly the same as that of the head; the circumference of the half-breech, one leo- being down, is eleven to twelve and a half inches, while the circumference of the hips, both legs being down, is only ten to eleven and a half inches. But a knee is even better than a foot. You determine, then, to seize one knee; which will you choose ? The proper one is that which is farthest. The reasons are admirably expressed by Prof. Simpson. We have a dorso-anterior position—the right arm and shoulder are downmost; these parts have to be lifted up out of the brim. How can this be best done? Clearly by pulling down the opposite knee, Fig. 69, Fig. 69.—After Scanzoni. To show the error of attempting to turn by seizing the leg of the same side as the prolapsed shoulder. which, representing the opposite pole, cannot be moved without directly acting upon the presenting shoulder. If VERSION WHEN THE LIQUOR AMNII HAS RUN OFF. 215 the opposite knee be drawn down, and supposing the child to be alive or so recently dead that the resiliency of its spine is intact the shoulder must rise, and version will be com- plete or nearly so. But if both feet are seized, or only the foot of the same side as the presenting arm, version can hardly be complete, and will, perhaps, fail altogether. This point is worth illustrating. I have taken Fig. 69 from Scanzoni {Lehrbuch der Geburtshulfe, fourth edition, 1867), in order to show the error in practice which I wish you to avoid. It represents a dorso-anterior position, the right shoulder presenting. The operator's left hand is seiz- ing and drawing down the right leg. I have introduced the arrows to indicate the directions of the movements sought to Fig. 70. Fig. 70.—Showing the principle of turning by bringing down the knee of the opposite Fide to the presenting shoulder. The arrows indicate the reverse movements effected. The object is to carry up the right shoulder. By bringing down the left knee, this is most surely effected. be imparted, You want the shoulder to run up while you draw down the leg. Now, drawing on the right leg neces- sarily tends to bring it toward the shoulder, the line of mo- 216 OBSTETRIC OPERATIONS. tion of the leg being more or less perpendicular to that of the shoulder. The body bends upon its side, the leg and shoulder get jammed together, and you have failed to turn. Contrast this figure with Figs. 70 and 71, which I have designed to show the true method and principle of turning. The arrows, as before, indicate the direction of the move- ments. By drawing upon the opposite knee to the present- Fig. 72. Fig. 71 shows the turning in progress. As the Fig. 72.—Braun's sling-carri- left knee descends, the trunk revolves on its er to applv a loop round the transverse as well as on its long axis, and the foot, or to replace the urn- right shoulder rises out of the pelvis. bilical cord. ing shoulder, the movements run parallel in directly opposite directions, like the two ends of a rope round a pulley. You cannot draw down the left leg without causing the whole VERSION WHEN THE LIQUOR AMNII HAS RUN OFF. 211 trunk to revolve; and the right shoulder will necessarily rise. To turn effectively, the child must revolve upon its long or spinal axis, as well as upon its transverse axis. Turn- ing, in short, is a compound or oblique movement between rolling over on the side and the somersault. If you seize both legs, you mar this process. The only cases in which I have found it advantageous to seize both legs are those in which the child has been long dead. Here the spine has lost its elasticity. The body will hardly turn, and there is nothing to be gained for the child in maintain- ing the half-breech and preserving the cord from pressure. The seizure of a foot is not seldom a matter of so much difficulty that various instruments have been contrived to attain this object. To draw the foot or feet down, you must grip them firmly—that is, your fingers must be flexed in op- position to the thumb, or two fingers must coil around the ankle. This doubling of your hand takes room. Whereas, to seize a knee, only requires the first joint of the forefinger to be hooked in the ham. Fig. 72 shows Braun's con- trivance for snaring a foot. A loop of tape in the form of a running noose is carried by means of a gutta-percha rod, about a foot long, into the uterus, guided by the hand to the foot. When you have succeeded in getting the noose over the ankle, you pull on the free end, and withdraw the rod. Hyernaux, of Brussels, has invented a very ingenious instrument, a porte-lacs or noose-carrier for the purpose. There are many others, but, since they are created in order to meet an arbitrary—I might say a wantonly-imposed— difficulty, arising out of an erroneous practice, they need not be described. It is true that it is often convenient to attach a loop to the foot when brought into the vagina, to prevent it from receding before version is complete. But this can be done by the fingers with a little dexterity. The occasions on which it is necessary to seize a foot which can only be barely touched by the fingers are extremely rare. For 218 OBSTETRIC OPERATIONS. these I think the simple apparatus of Braun, which also serves for the reposition of the umbilical cord, is as efficient as any. [A common silk handkerchief, twisted and made into a running noose, is an admirable means of snaring and retain- ing a foot, and is one which is readily obtained.] CHAPTER XIX. Turning in the Abdomino-anterior Position—Incomplete Version, the Head remaining in Iliac Fossa ; Causes of; Compression by Uterus; Treatment of—Bimanual or Bipolar Turning when Shoulder is impacted in Brim or Pelvis. Turning in abdomino-anterior positions does not differ essentially from turning in dorso-anterior positions. I have already said that the best position for the patient is on her back, and that the right hand may be used. The uterus, as in all cases, is supported externally, while you pass your Fig. 73. Fig. 73 shows turning in abdomino-anterior position. The operator's right hand seizes the upper or left knee. As this comes down, the child's body, rotating upon its transverse and long axes, draws the right or presenting shoulder up out of the pelvis. right hand along the inner aspect of the child's arm and be- hind the symphysis pubis; it proceeds across the child's 220 OBSTETRIC OPERATIONS. belly to seize the opposite knee. Drawing this down in the direction of the arrow in Fig. 73, the presenting shoulder rises out of the pelvis. There is a feature in the history of turning which has not received the attention it deserves. I have found that, notwithstanding diligent adherence to the rules prescribed, turning is not always complete. The head and part of the Fig. 74 Fig. 74 represents an abdomino-anterior position, left shoulder presenting. Traction was first made upon the left leg, as shown by the arrow. The effect was to bend the trunk and jam the shoulder against the symphysis. chest are apt to stick in the iliac fossa, the trunk being strongly flexed. Indeed, I believe that complete version is rather the exception than the rule in cases where the liquor amnii is drained off and the uterus has moulded itself upon the foetus so as to impede the gliding round of the foetus. VERSION IN ABDOMINO-ANTERIOR POSITIONS. 221 The complete version which exists as the ideal in the minds of most of those who perform the operation is not often realized. Indeed, it can hardly take place unless the bi-polar method by combined external and internal manipu- lation is carefully pursued. The head may commonly be felt throughout the entire process nearly fixed in the iliac fos- sa, and sometimes the forearm remains in the upper part of the pelvic cavity. The nates and trunk are delivered as much by bending as by version. The process is something be- Fig. 75. Fig. 75 represents the correction of the error committed in Fig. 74. By drawing on the opposite or right leg, the trunk was made to revolve on its spinal axis, drawing up the presenting arm from the pelvis, and allowing the breech to descend. Although delivery was now effected, version was not complete, as the head remained in the iliac fossa, and the hand never quitted the pelvic cavity. tween spontaneous version and spontaneous evolution. The two accompanying diagrams (Figs. 7-1 and 75), taken from 222 OBSTETRIC OPERATIONS. memoranda made of a case which occurred to me, will serve to illustrate both this feature of incomplete turning and the importance of the principle of drawing upon the leg oppo- site to the presenting shoulder. If the head and shoulders rise enough to permit the breech to enter the brim, delivery will not be seriously ob- structed. But it not uncommonly happens in extreme cases of impaction of the shoulder in the upper part of the pelvis that, even when you have succeeded in bringing down a leg into the vagina, version will not proceed; the shoulder sticks obstinately in the brim. In such a case the bipolar principle must be called into action. It is obvious that, if you draw down upon the leg, while you push up the shoulder, you would act at a great advan- tage. But you cannot get both your hands into the pelvis. Sometimes you may release the shoulder by external manip- ulation, passing up the head by the palm of your hand in- sinuated between it and the brim of the pelvis. In cases of real difficulty, however, this will not answer. You must push up the shoulder by the hand inside. To ad- mit of this, you pass a noose of tape round the ankle in the vagina, and draw upon this. The noosing of the foot is not always easy. To effect it you carry a running noose on the tips of two or three fingers of one hand up to the foot, held down as low as possible in the vagina by the other hand. Then the loop is slipped up beyond the ankles and heel, and drawn tight. Often you will have to act with one hand only in the vagina, the hand outside holding on to the free end of the tape ready to tighten the noose as soon as it has got hold. Or, while holding the foot with one hand, you may carry the noose by help of Braun's instrument (see Fig. 72 preceding chapter). The foot being securely caught, the right hand is passed into the vagina, and the fingers or palm, if necessary,- are applied to the shoulder and chest. Now, you will find it difficult to draw upon the tape and to push upon the shoulder exactly simultaneously. There is so little BI-POLAR VERSION IN IMPACTION OF SHOULDER IN BRIM. 223 room that, whenever you push, there is a tendency to carry the leg up as well. The most effective movement is as fol- lows—pull and push alternately. Presently you will find the leg will come lower, and the prolapsed arm will rise. Fig. 76. Fig. 76 represents the bipolar method of lifting an impacted shoulder from the brim of the pelvis, so as to effect version. In pushing the chest and shoulder, it is not unimportant in what direction you push. You cannot push backward, or even directly upward. Your object is to get the trunk to roll over on its spinal axis. Here, then, is an indication to carry out the manoeuvre of Levret and Yon Deutsch. Push the shoulder and adjacent part of the chest well for- ward, so as to make them describe a circle round the prom- ontory as a centre. 224 OBSTETRIC OPERATIONS. Yarious other contrivances have been designed in order to accomplish this end. Crutches or repellers have been made by which to push up the shoulder instead of by the hand. The objection to these is, that you cannot always know what you are doing. But your hand is a sentient in- strument, which not only works at your bidding, but con- stantly sends telegrams to the mind, informing it of what is going on and of what there is to do. CHAPTER XX. Turning continued—Imitation or Facilitation of Delivery by the Process of Spontaneous Evolution—Evisceration—Decapitation—Extraction of a De- truncated Head from the Uterus. We have discussed the mode of dealing with those cases of difficult shoulder-presentation in which, the uterus having contracted closely upon the child, the shoulder is more or less firmly, but not immovably, fixed in the pelvic brim. In the majority of cases of this kind we are justified in attempting to turn, because there is still a prospect of the child being preserved. But there are cases in which matters have proceeded a stage further, in which the shoulder and corresponding side of the chest are driven deeply into the pelvis—in which, con- sequently, the body is considerably bent upon itself. Now, this can only occur after protracted uterine action, such as is scarcely compatible with the life of the child. Either the child was already dead at an early stage of labor—a condi- tion, especially if the child were also of small size, most favorable to the carrying out of this process of spontaneous evolution—or the child has b'een destroyed under the long- continued concentric compression of the uterus. In the presence of such a case, the first question we have to consider is, Will Nature complete the task she has begun ? Will the child be expelled spontaneously ? A little observa- tion will soon enable us to determine how far this desirable solution of the difficulty is probable, and when we ought to 15 226 OBSTETRIC OPERATIONS. interpose. If the pelvis is roomy in proportion to the child; if the child is dead, small, and very flaccid ; if we find the side of the chest making progress in descent under the influ- ence of strong uterine action possessing an expulsive charac- ter, and if the patient's strength be good, we shall be justified in watching passively. But if we find no advance, or but very slow advance, of the side of the chest, the child being large and not very plastic; if the uterus has ceased to act ex- pulsively, and the patient's strength is failing, we must aid delivery. Then comes the second question : In what man- ner ? This must depend upon the circumstances of the case. If a little help a fronte to make up for deficient vis a tergo promise to be enough, we may imitate the proceeding of Peu, who, in a case in which spontaneous evolution was in progress, passed a cord round the body to pull upon and aid the doubling. Or we may much facilitate the doubling and expulsion by evisceration. This operation consists in perforating the most bulging part of the chest, and picking out the thoracic and abdominal viscera. When this is done, traction upon the body by the crotchet or the craniotomy forceps, and dragging in the direction of Carus's curve, will commonly effect delivery without difficulty. This operation is repre- sented in Fig. 77. Sometimes perforation and evisceration are insufficient in themselves, and another step will be necessary in order to complete delivery. This ultimate step is decapitation, an operation of extreme importance, capable of bringing almost instant relief and safety to the mother. It is pointed out by Celsus, and was clearly described by Heister after Yon Hoorn. The recognition, or at least the application, of this pro- ceeding is so inadequate, that I think it useful to state the arguments in favor of it with some fulness. The late Prof. Davis, in his great work (" Obstetric Medicine"), a work too much neglected by his successors, VALUE OF DELIVERY BY DECAPITATION. 227 says: " It may be considered a good general rule never to turn when the death of the child is known to have taken place." In cases of long impaction he recommends an operation to be performed upon the child—namely, bisection Fig. 77. Fig. 77 represents extraction after perforation of the chest, and delivery in imitation of spontaneous evolution. of the child at the neck. Again, he says: " It ought to be an established rule in practice to decapitate in arm-presenta- tions not admitting of the safer performance of turning." ?28 OBSTETRIC OPERATIONS. Dr. Ramsbotham also {Medical Times and Gazette, De- cember, 1862) says: "It appears to me better practice either to eviscerate or decapitate the foetus than to endeavor to de- liver by turning, in all cases where the uterus is so strongly contracted round the child's body as to cause apprehension of its being lacerated by the introduction of the hand; be- cause, if such a degree of pressure is exerted on it as to ren- der the operation of turning very difficult, the child must have died, either from the compression on its own chest, or on the funis, or on the placenta itself." Such men speak with an authority that commands re- spect. Their opinions are not the crude utterances of dog- matism presuming on a little reading and small experience, but conclusions drawn from repeated encounters with great emergencies. The justness of the rule thus distinctly ex- pressed by Davis and Ramsbotham is attested by the prac- tice of the most eminent Continental practitioners. Decol- lation was practised in six cases by I'Asdrubali (1812), by Paletta ("Del Parto per il Braccio," Bologna, 1808), by Braun of Yienna, by Lazzati of Milan (" Del Parto per la Spalla," 1867), and by many others. Yarious instruments have been designed to effect decapi- tation. Ramsbotham's hook is perhaps best known in this country, and it has served as a model for several modifica- tions made abroad. It is named after the first Ramsbotham. It was described and recommended by Prof. Davis. It con- sists of a curved hook, having a cutting edge on the concave part, supported on a strong straight stem, mounted on a wooden handle. Prof. Davis also used another instrument of his own contrivance—the guarded embryotomy-knife. It consists of two blades working on a joint like the forceps. One blade is armed with a strong knife on the inner aspect. The other blade is simply a guard; it is opposed to the knife, and receives it when the neck is severed. A plan sometimes resorted to is to carry a strong string round the neek^ and then by a to-and-fro or sawing move- INSTRUMENTS DESIGNED TO EFFECT DECAPITATION. 229 ment, effected by cross-bars of wood on the ends to serve as handles, to cut through the parts. In a discussion on the subject at a recent meeting of the Edinburgh Obstetrical Society, Dr. C. Bell suggested the use of an instrument, like that for plugging the nares in epistaxis, to carry a cord. Dr. Keiller mentioned an instru- ment designed by Dr. Ritchie, like an ecraseur, with a per- petual screw and chain. Strong scissors have been made for the purpose, which cut through the vertebrae. A good instrument of this kind has been designed by Dr. Mattei, of Paris. I believe it is a very useful form, as it is sometimes easy to cut through the spine when it is difficult to pass a hook over the child's neck. It resembles the surgical bone-forceps. It is important to remember that the spine may be di- vided by piercing the vertebrae with the common perforator, then separating the blades so as to rend or crush asunder the bones. What remains may then be divided by scissors. Failing special instruments, the spine may be divided by strong scissors, or even by a penknife or a Wharncliffe blade. The favorite instrument in Germany and Italy is Braun's blunt-hook, or " decollator." I have not tried it, having hitherto used Ramsbotham's cutting-hook; but I am inclined to think it is a better instrument than Ramsbotham's. Dr. G-arthshore performed the operation with an ordinary blunt- hook. It is certainly desirable to do away with the cutting edge, which is not without danger to the mother and the operator. Braun's instrument is twelve inches long, includ- ing the thickness of the handle; the greatest width of the hooked part is one inch; the greatest thickness of the stem is from four to five lines. Lazzati introduces a gentle curve into the stem near the hook. The Operation of Decapitation.—It will be best de- scribed as consisting of three stages. The first stage is the application of the decapitator and the bisection of the neck; 230 OBSTETRIC OPERATIONS. the second is the extraction of the trunk ; the third the ex- traction of the head. The First Stage.—The patient may lie on her left side. Take Ramsbotham's hook or Braun's decollator. As the instrument should be passed up over the back of the child's neck, it is, in the first place, necessary to ascertain whether the position be dorso-anterior or abdomino-anterior. It is also necessary to determine accurately whether the foetus is still in great part above the brim lying transversely or obliquely, in which case the head and neck will be in one or other side ; or whether, a great part of the chest having descended into the pelvis, the movement of rotation has taken place, in which case the head and neck will be found in front near the symphysis. The observation of the rela- tions of the prolapsed arm and exploration with the hand internally will inform us as to these particulars. The next step is to get an assistant to pull upon the prolapsed arm, so as to bring down the shoulder and fix it well. This brings the neck nearer within reach. The operator then passes his left hand, or two or three fingers, if this be enough, into the vagina, over the anterior surface of the child's chest, until his fingers reach the fore part of the neck. With his right hand he then insinuates the hook, lying flat, as in the dot- ted outline in Fig. 78, between the wall of the vagina and pelvis and the child's back, until the beak has advanced far enough to be turned over the neck. The beak will be re- ceived, guided, and adjusted by the fingers of the left hand. The instrument being in situ, while cutting or breaking through the neck, it is still desirable to keep up traction on the prolapsed arm. In using Ramsbotham's hook, a sawing movement must be executed, carefully regulating your action by aid of the fingers applied to the beak. If Braun's decol- lator be used, the movement employed is rotatory, from right to left, and at the same time, of course, tractile. • The in- strument crushes or breaks through the vertebrae. When the vertebrae are cut through, some shreds of soft parts may THE OPERATION OF DECAPITATION. 231 remain. These may be divided by scissors, or be left to be torn in the second stage of the operation—the extraction of the trunk. The wedge widening above the brim, that hitherto ob- structed delivery, is now bisected, divided into two lesser masses, each of which separately can readily be brought through the pelvis. By continuing to pull upon the pro- Fig. 78. Fig. 78 represents the first stage of delivery by decapitation. The dotted outline shows how the hook (Ramsbotham's) is introduced, lving flat upon the back of tbe child's neck, the beak being then turned over tbe neck, and meeting the fingers of the left hand on the anterior aspect. lapsed arm the trunk will easily come through, the head being pushed on one side out of the way by the advancing body. (See Fig. 79.) The Third Stage: The Extraction of the Head.—The problem how to get away a detruncated head left behind in 232 OBSTETRIC OPERATIONS. the uterus is not always easy of solution. In the case before us, the child having probably been dead many hours, the bones and other structures have lost all resiliency, the con- nections of the bones are broken down by decomposition, and the whole becomes a plastic mass, easily compressible. Such a head will sometimes be expelled spontaneously. I Fig. 79. Fig. 79 represents the second stage of delivery after decapitation, or extraction of the trunk by pulling on the prolapsed arm. The head, no longer linked to the body, is pushed out of the way as the trunk descends. have taken away a head, under the circumstances under dis- cussion, by seizing it with my fingers. On the other hand, I have on several occasions been called in to extract a head which resisted ordinary means. There are three modes of action. The crotchet, the forceps, or the craniotomy-forceps, may be used. If tke crotchet can be passed into an orbit, or into the cranial cavity, getting a good hold, this plan may answer. The objection to it is the difficulty of getting such EXTRACTION OF THE DETRUNCATED HEAD. 233 a hold, and the risk of the point slipping and rending the soft parts of the mother. The head, being loose, rolls over in the uterus when an attempt is made to seize it. I therefore discard the crochet. The forceps is better adapted. If the head can be seized, which is not always easy, for it is apt to escape high above the brim, and roll about when touched by the blades, extrac- tion is not difficult. Care must, moreover, be taken to seize the head in such a manner that the spicula resulting from the severance of the vertebrae shall not drag along or injure the mother's soft parts. Fig. 80. Fib. 80 represents the third or last stage of delivery after decapitation. The head is seized by the craniotomy-forceps, and extraction is made in the direction of Carus's curve. I prefer the craniotomy-forceps, as being much the most certain and safe. In order to obtain a hold, it is generally necessary first to perforate. The free rolling of the head, when pressed by the point of the perforator, tends to throw this off at a tangent, missing the cranium, and endangering 234 OBSTETRIC OPERATIONS. the soft parts of the mother. To obviate this difficulty, the head must be firmly fixed down upon the pelvic brim by an assistant, who grasps and presses the uterus and head down by both hands spread out upon them. The operator then, feeling for the occiput with two fingers of his left hand, and guided by them, carries up the perforator with his right hand, taking care that the point shall strike the head as nearly perpendicularly as possible. He then, partly by a drilling, screwing, boring motion, partly by pushing, perfo- rates the cranium. The drilling movement avoids the neces- sity of using much pushing force, and thus lessens the risk of the instrument slipping.1 When a sufficient opening is made into the cranium, the craniotomy-forceps is applied, one blade inside, the other outside; the blades are adjusted and locked; and traction made in the orbit of Carus's curve commonly brings the head away without further difficulty. During extraction, the fingers of the left hand should be kept upon the skull at the point of grasp by the instrument, guarding the soft parts from injury by spicula, and regulat- ing the force and direction of traction. In cases where there was difficulty in extracting the trunk, Dr. D. Davis used a double-guarded crotchet, the two blades of which, fixing themselves in the trunk, extracted like a forceps. If there be any likelihood of difficulty in extraction, there is a last and an effectual resource in the cephalotribe. When the head is left behind after turning in contracted pelvis, the cephalotribe to crush down the head is invaluable. 1 It is in perforating under such circumstances that the vice of perforators curved in the blades is most apparent. Such instruments can hardly strike in a true perpendicular, and the point is almost certain to glide off. The superi- ority of a straight, powerful perforator, like Oldham's, will not be disputed by any one who has had to perforate under difficulties. The trephine-perforatora are not applicable to the case under discussion, owing to the difficulty of fixin« the head. CHAPTER XXI. Turning in Contracted Pelvis as a Substitute for Craniotomy—History and Appreciation—Arguments for the Operation: The Head comes through more easily, Base first; the Head is compressed laterally; Mechanism of this Process explained—Limits justifying Operation—Signs of Death of Child—Ultimate Resort to Craniotomy if Extraction fails—Indications for turning in Contracted Pelvis—The Operation—Delivery of the After-coming Head in Contracted Pelvis. We now come to a long-contested and still undecided question in obstetric practice—Is turning ever justifiable as a means of delivery in labor obstructed by pelvic deformity? The next alternative in the descending scale of operations is a transition from conservative to what may be distin- guished as sacrificial midwifery, involving the destruction of the child. It is obviously a matter of exceeding interest to cultivate any operation that shall hold out a reasonable hope of safety to the child, without adding unduly to the danger of the mother. So much may be conceded on both sides. The question, then, may be set forth as follows : Do cases of dystocia from pelvic contraction occur, in which the child can be delivered alive by turning, and without injury or danger to the mother, which must otherwise be condemned to the perforator? And, not to blink in any way the serious character of the inquiry, it is necessary to append this secondary question to the first—namely: Assuming that such cases do occur, can they be diagnosed with sufficient accuracy to enable us to restrict the applica- tion of turning to them ? And, if we err by turning in un- 236 OBSTETRIC OPERATIONS. fitting cases, what is the penalty incurred?—how can we retrieve our error? These questions I will endeavor to illustrate, if not to answer, by the light of the writings of others, and my own experience and reflections. The choice of an operation in obstetrics will, in many cases that fall within the debatable territory claimed by two or more rival operations, be determined by the relative per fection of these operations, and by the relative skill in them possessed by the individual operator. This law has governed the history of the progress of the art of delivering women in whom labor was obstructed by disproportion. " The Fluctuations in Opinion that have prevailed among Practitioners in Midwifery, with reference to the Perform- ance of Turning, and the Application of the Forceps in Cases requiring Artificial Delivery on account of Deformity of the Pelvis," is the title of a most interesting memoir by Dr. Charles West {Medical Gazette, 1850). I refer to it as the most important and most instructive epitome of this subject. The operation of extracting a child through a contracted brim has no doubt often been performed as a matter of as- sumed necessity, as when the shoulder has presented, and contraction of the pelvis is certainly a cause of shoulder- presentation. The observation of such cases, a certain pro- portion of which terminated successfully for the child, could not fail to suggest the deliberate resort to the operation in cases of similar contraction where the head presented. Before the forceps was known, and before the instruments for lessening and extracting the head had been brought to any degree of perfection, turning was commonly resorted to in almost all cases of difficult labor. Thus Deventer, who wrote in 1715, as well as La Motte, declaims against the use of instruments, and recommends turning by the feet in all cases of difficult cranial presentation. The consequence was, that the art of turning was cultivated very successfully by some of the followers of Ambroise Pare. It appears to HISTORY OF VERSION IN CONTRACTED PELVIS. 231 me evident that, in the early part of the last century, turn- ing was better understood and more skilfully performed than it was at the beginning of the present century ; and it is equally evident to me that, by turning, many children were saved under circumstances that are now held to justify their destruction. Of course, this gain was not achieved without a drawback. If children were sometimes saved, many mothers were injured or lost by attempts to turn under circumstances which are now encountered successfully by the forceps or by craniotomy. As instruments were improved, the choice of means was extended. The forceps first contested the ground. The contest, indeed, was for exclusive dominion. The reputed inventor of the forceps, Hugh Chamberlen, did not hesitate to accept the challenge of Mauriceau to attempt to deliver a woman with extreme pelvic contraction by means of his in- strument, feeble and imperfect as it was. As science ad- vanced, the contest was better defined. As the obstruction to delivery was due to contraction of the pelvic brim, and the problem was how to extract a live child arrested above the brim, it is obvious that a short single-curved forceps must fail. It was only when the long double-curved forceps was designed, that the knowledge and the power arose which enabled the obstetric surgeon to bring another means into Competition with turning for the credit of saving children from iriutilation. It is, then, from the time of Smellie and-Levret, who per- fected and used the long forceps, that the real interest of the inquiry dates. It is not a little remarkable, that among those who have most distinctly recognized the value of the long forceps have been found the advocates for turning in contracted pelvis. The following words, written by Smellie in 1752, challenge attention now: " Midwifery is now so much improved that the necessity of destroying the child does not occur so often as formerly ; indeed, it never should be done, except ichen it is impossible to turn or to deliver 238 OBSTETRIC OPERATIONS. with the forceps / and this is seldom the case but when the pelvis is too narrow, or the head too large to pass, and there- fore rests above the brim." Pugh, of Chelmsford (1751:), who advocated the long for- ceps, says: " When the pelvis is too small or distorted, the head hydrocephalic or very much ossified, or its presentation wrong.....provided the head lies at the upper part of the brim, or, though pressed into the pelvis, it can without violence be returned back into the uterus, the very best method is to turn the child and deliver by the feet." He then goes on to lay down the conditions which would induce him to prefer the curved forceps, and states that, as the re- sult of these two modes, " I have never opened one head for upward of fourteen years." Has not midwifery retrograded since his time ? Perfect (1783), who used the long forceps, delivered a rickety woman whose conjugate diameter measured three inches, the head presenting, and brought forth the first living child out of four, the three first having been extracted after perforation. La Chapelle (1825) advised and practised the method. She relates that, out of fifteen children extracted by forceps (long) on account of contracted pelvis, eight were stillborn, seven alive; and that, out of twenty-five delivered footling, sixteen were born alive, and nine dead. It is not less remarkable that it is among those who re- ject the long forceps that the strongest opponents of turning in contracted pelvis are to be found. This is the more aston- ishing when we reflect that this school, rejecting the two saving operations, has nothing to propose but craniotomy for a vast number of children that claim to be brought within the merciful scope of conservative midwifery. Denman, who used the short forceps exclusively, was, upon the whole, adverse to the operation, although he re- lates a striking case in illustration of its advantages. He de- livered a woman of her eighth child alive at the full period, all her other children having been stillborn. " The success VERSION OR FORCEPS IN CONTRACTED PELVIS. 239 of such attempts," he says, " to preserve the life of a child is very precarious, and the operation of turning a child un- der the circumstances before stated is rather to be considered among those things of which an experienced man may some- times avail himself in critical situations, than as submitting to the ordinary rules of practice." Those who have studied the history of obstetric doctrine cannot fail to see that this dread of encouraging enterprise in practice, lest disaster should result from unskilfulness, has cramped the teaching, obstructed the progress of knowledge, and enforced a slavishly-timid yet barbarous practice which still persists down to the present time. That the precepts and practice of Smellie and his immediate disciples were in- finitely more scientific and successful than those which pre- vailed in the time of Denman, and in the first half of the present century, cannot be doubted. Possibly the cautious teaching of Denman and many of his successors was justified greatly by the general imperfection of medical education. They had, as we now have, to teach according to the average capacity and trustworthiness of their pupils. They taught men with the same feeling of reserve with which we should still teach midwives. But surely the day is past for all this. We may safely venture to teach men of a higher standard upon more liberal principles. I am not aware that a similar reticence or restraint has at any time, to a like extent, gagged the teachers of medicine or surgery proper. May we not see in this fact a striking testimony that the practice of obstetrics demands, even more than medicine or surgery, steadiness yet promptitude in judgment, courage under diffi- culties, and physical skill ? On the other hand, the forceps has by some been held to be of superior efficacy to turning in contraction of the pelvis. That is, while certain lesser degrees of contraction may be dealt with by turning, the forceps claims the preference in more advanced degrees of contraction. It is needless to say that those who advocate this preference rely upon a very 240 OBSTETRIC OPERATIONS. powerful forceps. It is accordingly in Germany and France especially that the claim for the superiority of the forceps is contended for. Stein (1773), Osiander the elder (1799), preferred the for- ceps. Boer was opposed to turning. In France, Baudelocque maintained the same doctrine as Stein and the elder Osian- der. And the recent experiments of Joulin, Chassagny, and Delore with the "appareils a traction," by which a power- ful extracting force is added to the forceps, enabling it to bring a head through a greatly-contracted passage, seem to strengthen the comparative claim of this instrument. [Prof. G. T. Elliot, in his " Obstetric Clinic," in speaking of version as an elective operation in deformed pelvis, states that, having failed at delivery with the forceps in a case, he succeeded in accomplishing it by version, and that while he delivered satisfactorily and successfully by version in some cases, in others neither forceps nor version was successful. He expresses it as his opinion that, in a conjugate diameter of three inches and upward, with a living child and a head- presentation, first choice should be made of the forceps; but that when the diameter is between two and a half and three inches, with a living child, version is preferable. In the same excellent work are some valuable statistics of " German Experience in Yersion as an Elective Operation in Contracted Pelvis," which show that, as regards the safety of the child, the best results are obtained where moulding of the head is gradually accomplished by the uterine forces, but that, where there is insufficiency of the latter, the forceps is superior to version.] The value of turning in moderate degrees of pelvic con- traction rests greatly upon the truth of the following propo- sition : The head will come through the pelvis more easily if drawn through base first than if by the crown first. Baudelocque affirmed this proposition (" L'art des Accouche- ments "). He said : " The structure of the head is such that it collapses more easily in its width, and enters more easily ARGUMENTS FOR VERSION IN CONTRACTED PELVIS. 241 when the child comes by the feet, if it be well directed, than when it presents head first." Osiander had maintained the same opinion. Hohl (1845) also pointed out that the bones overlapped more readily at the sutures when the base entered first. Simpson (1847) insisted strongly upon the truth of this proposition, and illustrated the mechanism of head-last labors with much ingenuity. The proposition has, however, been disputed, and that by Dr. McClintock {Obstetr. Transact., vol. iv., 1863). He says: " I do not believe that the diame- ters of the head are more advantageously placed with regard to those of the pelvis, nor can I believe that the head is more compressible when entering the strait with its base than when it does so with its vertex, till this be demonstrated by direct experiment." It is also contested by Prof. E. Martin, of Berlin {Mo- natsschr. f. Geburtsh., 1867). He especially insists that, when the vertex presents, moulding may go on safely for hours; but that, if the base come first, the moulding must be effected within five minutes to save the child. I venture to submit that I have made such clinical obser- vations as are equivalent to direct experiments. In the first place, let me state a fact which I have often seen : A woman with a slightly-contracted pelvis, in labor with a normal child presenting by the head, is delivered, after a tedious time, spontaneously or by the help of forceps ; the head has undergone an extreme amount of moulding, so as to be even seriously distorted. The same woman in labor again is de- livered breech first; the head exhibits the model globular shape, having slipped through the brim without appreciable obstruction. For examples, see my outlines of heads {London Obstet. Trans., 1866). In the second place, I have on several occasions been called to an obstructed labor in which the head was resting on a brim contracted in the conjugate diameter. Of course, Nature had failed; the vis a tergo was insufficient. I have tried the long double-curved forceps, trying what a moderate 16 242 OBSTETRIC OPERATIONS. compressive power aided by considerable and sustained trac- tion would do to bring the head through, and have failed. I have then turned, and the head coming base first has been delivered easily. Upon this point I cannot be mistaken. And I think this greater facility can be explained. Dr. Simpson has illustrated by diagrams how the head, caught in the conjugate at a point below its biparietal diameter, is compressed transversely as traction-force is applied below, causing the mobile parietals to collapse and overlap at the sagittal suture. And surely no one can doubt that the traction-power, and therefore the compressing power, ac- quired by pulling on the legs and trunk, is infinitely greater than can be exerted by the strongest forceps. But there is another circumstance in the clinical history of head-last labors in narrow conjugate which affords a remarkable illustration of this proposition. The head is rarely, or never, seized in its widest transverse diameter y it is seized by the conjugate at a point anterior to its greatest width—that is, in the bi- temporal diameter • the bi-parietal and occiput commonly finding ample opportunity for moulding in the freer space left in the side of the pelvis behind the promontory. The head, in fact, fits or moulds into the kidney-shaped brim wherever there is most room. I have given illustrations of this point also in the memoir referred to {London Obstet. Trans., 1866). I think, therefore, it may be taken as demon- strated, that the head coming base first passes the contracted brim more easily than coming crown first. And, if the head comes through more easily, it may be inferred that the child will have a better prospect of being born alive. Can we define with any precision the conditions as to degree of pelvic contraction that are compatible with the birth of a living child ? The question is not easy to answer; nor is it important to be able to answer it very precisely. The great fact upon which the justification of the operation rests is this: many children have been delivered by it alive, with safety to the mother. We know accurately only one LIMITS OF CONTRACTION JUSTIFYING VERSION. element of the problem—namely, the degree of contraction of the pelvis. The other element, the relative size and hard- ness of the foetal skull, we can but estimate. We must assume, in many cases, a standard head. With this assumption the practical question is reduced to this : What is the extreme Fig. 81. Fig. 81 represents the head entering a contracted hrim, base first. It is nipped in the small transverse diameter, the greater or bi-parietal diameter and the occiput finding room in the side of the pelvis. The cord lies in the side of the pelvis to which the face is directed, and is protected by the promontory. limit of pelvic contraction justifying the attempt to deliver by turning ? In other words, this means : What is the nar- rowest pelvis that admits of the passage of a normal head ? This is answered chiefly by experience. It is not to be an- swered by a priori reasoning like that urged by Dr. Fleet- wood Churchill, who says, even in his last edition (" Theory and Practice of Midwifery," 1866): " The bi-mastoid diame- ter in the six cases measured (by Dr. Simpson) varied from 2f to 3-| inches, and a living child can pass through a pelvis of 3f inches antero-posterior diameter, with or without the 244 OBSTETRIC OPERATIONS. forceps. With a pelvis of this size, then, the operation is unnecessary; and, if the antero-posterior diameter be less than 2-f inches, the operation would be impracticable. These, then, are the limits of the operation; for us to attempt to drag a child through a smaller space wTould be un- justifiable." To this statement of the case serious objections may be taken. The proposition that a living child can pass through a pelvis with an antero-posterior diameter measuring 3.25", with or without the forceps, can only be accepted with con- siderable qualifications. I claim to speak with the confidence drawn from large experience, when I say that a head of standard proportions and firmness will hardly ever pass a conjugate reduced to 3.25// without the forceps, and very rarely indeed with the forceps—that is, alive. I might even extend the conjugate to 3.50", and affirm the same thing. The compressive power of the forceps, unless very long sus- tained, is not great, rarely great enough to reduce a bi-parie- ta! diameter of 4.00" to 3.50" without killing the child. My opinion, then, is, that a standard head, especially if it hap- pen to be a female head, which is more compressible than a male one, may be drawn through a conjugate of 3", but not with much prospect of life; and that the proper range of the operation of turning is from 3.25" to 3.75", at the latter point coming into competition with the forceps. I believe no one advocates resort to turning when the conjugate measures less than 3". A correlative proposition to the foregoing is the follow- ing : Compression of the head in its transverse diameter is much less injurious to the child than compression in its long diameter. The truth of this is attested or admitted by most authors who have considered the point. It is insisted upon by Radford, Ramsbotham, and Simpson. It is confirmed by the observation of the form which the head assumes under moulding in natural labor, which, as I have shown, is effected by the lengthening of the fronto-occipital diameter and the VERSION IN CONTRACTED PELVIS. 245 shortening of the transverse diameter {London Obstetrical Trans., vol. iii., 1866). Xow, it is an almost necessary consequence that, when the head, arrested on a contracted brim, is seized by the for- ceps, it is seized by its fronto-occipital diameter, and to the longitudinal compression is added the increased obstruction to the entry of the head into the narrowed conjugate caused by the lateral bulging. We will now discuss the question, What is the penalty incurred, or how can we retrieve our error, if we turn and fail to bring the head through the too contracted brim ? Un- doubtedly, the patient will have to go through a second op- eration. We are driven to perforate, after all. We have tried to save the child, and have failed. Is the mother im- perilled by this attempt and failure ? This also must be an- swered by experience. Of course, the mother may suffer if we persevere in dragging the child too long and too forcibly. But we have a right to assume that the attempt is controlled by skill and discretion. The amount of force that can be safely endured is very great—far greater than those who have never seen the operation would readily credit. The violence to which the soft structures are subjected seems to be small in proportion to the traction-force exerted. There appears to be some saving or protective condition. This, I think, is found in the mechanism of the process. I refer to Chapter VIII. for an illustration and description of the mech- anism of labor in contraction of the pelvis from projection of the promontory. This projecting promontory forms the centre of rotation around which the head must rotate in order to enter the pelvic cavity. The side of the head ap- plied to this point scarcely moves at all. The promontory catches the foetal skull in the fronto-temporal region. If the coarctation be decided, the skull where it is caught bends in. All the onward movement is effected by the opposite or pubic side of the skull sweeping in a circle, which I have called " the curve of the false promontory," until the equator 246 OBSTETRIC OPERATIONS. or greatest circumference has passed the plane of the brim, when the whole head slips into the cavity with a jerk. Kow, injurious pressure is avoided on the pubic side by the smooth- ness and flatness of the inner surface of the pelvic brim, and by a gliding movement of the soft parts intervening between the head and the bony canal. Injurious pressure is avoided over the promontory by the yielding or moulding of the head. The temporal and parietal bones will bend in, even break. Children have been born alive after this bending or breaking. Sometimes a large cephalhaematoma forms at the point of depression. In other cases the child perishes. The observation of these cases shows that the mother will bear with safety an amount of pressure which was sufficient to kill the child. What follows ? This obvious corollary—that the mother will safely bear that lesser degree of pressure which is re- quired to bring through a living child. The operation, then, is justified in cases of contraction that admit of the passage of a living child. It is further justified in cases of contraction to a certain, though small, degree of contraction beyond this, which admits of the pas- sage of a dead child. We have here, perhaps, carried the ex- periment to the verge of what is justifiable. Beyond this, there being no possibility of getting a child, live or dead, through the pelvis, it would of course be better not to go. And, if all the conditions of the problem could be precisely ascertained beforehand, we should not go beyond this. But, while calculating upon an average or standard head, we may encounter a head above the standard in size 6r hardness, and thus, in our endeavor to save the child, we may find our- selves in a difficulty. The extrication is by perforation. By lessening the head, it is brought within the capacity of the pelvis. This is, indeed, an acknowledgment of defeat; it is beating a retreat. The justification, however, is, that we accomplish in the end exactly that which those who re- ject the operation accomplish—namely, the safety of the VERSION IN CONTRACTED PELVIS. 24V mother. We have tried to do more—to save the child as well. Is there any great difficulty or danger in perforating after turning ? I believe not. The child's body is. drawn well over to one side by an assistant, so as to facilitate the access of the operator's guiding fingers and the perforator to the child. The best place to perforate is in the occiput; but, if that part be not easily struck, the perforator may be run up through the base of the skull. An opening into the cranium being made, the crotchet is passed into it, and the discharge of brain facilitated. Then, resuming traction on the trunk cautiously, the skull will probably collapse enough to pass easily. If not, the craniotomy-forceps can be applied; or, better still, the cephalotribe, to crush up the base of the skull. Now, under the postulates of the case, this late re- course to craniotomy must not be considered as a severe or hazardous addition to the risks of the woman. The turning has been performed early in labor—that is, before the liquor amnii has all drained away, while the child is still freely movable, and before there is any serious exhaustion of the mother. Under these circumstances the turning, especially if conducted, as it commonly may be, on the bi-polar prin- ciple, is not necessarily a long or a severe operation. If we fail in extraction, which is soon ascertained by observing that the head makes no advance, but that its globe expands broadly above the brim of the pelvis, perforation can be per- formed in good time. In short, the safety of the mother is secured by carrying through both operations while her strength is good. If exhaustion had set in, we should not have turned at all, but have proceeded to craniotomy in the first instance. To these considerations must be added the result of experience, which is to the effect that the retrieval by the secondary operation of craniotomy is successful. What is the chance of saving the child ? Dr. Churchill urges that " the life of the child is not secured, and its chance but little increased, even if our estimate of the pelvic diame- 248 OBSTETRIC OPERATIONS. ters be accurate; for, if, in turning with an ordinary-sized pelvis, rather more than one-third of the children are lost, the mortality will be surely much increased if its diameter be reduced more than one-fourth." I will not stop now to press the preliminary objection I entertain to submit the de- cision of this or any other question in obstetric practice to a priori arguments drawn from statistics. It would not be difficult to prove that the statistics employed by Dr. Churchill are a confused heap of incongruous facts, and that rules to guide practice drawn from them must be stultified by end- less fallacies. It is enough to state that the operation is not recommended by any one when the pelvis is contracted more than one-fourth—that is, below three inches—therefore the argument, statistical or other, is beside the question. I am not able to state or to estimate the proportion of children saved or lost under the operation. It is enough to justify the operation if we save a child now and then. I believe, however, that, exercising reasonable care in selection of cases, and skill in execution, more than one-half of the chil- dren may be saved. And to save even one child out of twenty is something to set against the deliberate sacrifice of all. Not assenting to the proposition that one child out of every three is lost by turning where there is no dispropor- tion, I do not doubt that a much larger proportion would be lost under turning where the conjugate diameter of the pel- vis is less than 3". But, as I have said, the comparison is gratuitous; for no one, I believe, recommends turning in this latter case, unless the child be premature. Experience here again corrects the foregone conclusion deduced from statis- tical reasoning. The risk to the child is considerably less than might be fairly anticipated. It is a matter of observa- tion that in cases of moderate contraction the funis is safer from compression than in cases of normal pelvis. I have found the cord commonly fall into the side of the pelvis toward which the face looks, and there it is protected in the VERSION IN CONTRACTED PELVIS. 249 recess formed by the side of the jutting promontory (see Fig. 81); so that, if the soft parts are sufficiently dilated not to compress the cord against the child's face, and if the labor can be completed under 5", or even a little more, the child has a very good chance indeed. This proposition is espe- cially true in the case of premature labor with contracted pelvis. In this case the child may, in the great majority of cases, be saved by turning. I have in this way saved many children who still survive to parents who would otherwise be childless. It deserves, I think, to be laid down as a rule in practice that, where the conjugate diameter measures from 2.75" to 3", delivery by turning should be the complement to the induction of labor at seven or eight months—at least, I have acted on this rule with the happiest results. Since the design of the proceeding is to save the child, it is obviously useless if the child is dead. How do we know when a child is dead ? It is by no means easy to acquire certain knowledge of this fact. Nothing is more common than to read in clinical records " that the pulsations of the foetal heart being no longer audible with the stethoscope," or, " the pulsation in the cord having ceased," or, " meco- nium having escaped," the death of the child was assumed, and the perforator was used without hesitation. I will not dispute that these are presumptive evidences of death, but I have too often experienced the satisfaction of seeing a child resuscitated after I had ceased to feel the pulsation in the cord, and after the free escape of meconium, to abandon the hope of saving the child without more certain evidence. This is found in great mobility and crackling of the cranial bones; the caput succedaneum falling into loose skin-folds; the coming away of epidermis and hairs. So long as there is tonicity, rigidity, or firmness of the limbs, life is present; but flaccidity is not a certain sign of death. A sign of threatening imminent death is a twitching or convulsive movement of the leg held in your hand. This indicates an attempt at inspiration made to supplant the sus- 250 OBSTETRIC OPERATIONS. pended placental circulation. When this is felt, it is a warn- ing to accelerate delivery, and to excite aerial respiration. THE INDICATIONS FOR THE OPERATION. Assuming a standard head whose base, unyielding, measures 3", this is obviously the limit beyond which the operation would be useless. For although the head is caught in the bi-temporal diameter, a little in front of the greatest transverse or bi-parietal diameter, the base must be exposed in its full width to the narrowed strait. Even if the side of the head be indented by the promontory, no im- portant degree of canting or obliquity of the base can be counted upon. If the head should fortunately be under- sized or unusually plastic, there is a fair prospect of the child being drawn alive through a conjugate diameter meas- uring 3.00". But, generally, from 3.25" to 3.50", or even a little more, is the working range for a child at term. The great major- ity of those who advocate the operation insist upon this amount of space. It is very important to have a fair oblique or sacro-cotyloid diameter on one side; for, if the ileo- pectineal margin of the brim incline rapidly backward, the occiput will not find room. The operation is also indicated if, the conjugate diam- eter being 3.50" or more, the forceps have failed. Yelpeau (1835), Chailly (1842), Edward Martin, and others, advise the operation in cases of unequally-contracted pelvis where there is more room in one side of the pelvis than in the other—when the thicker or occipital end of the head is not already engaged in this larger side. I have already shown that the head is always nipped in its small or bi-temporo-frontal diameter, which generally measures about 3", and is more compressible than the bi- parietal diameter. The mark of pressure or indentation against the jutting promontory is always seen at one end of this short diameter whenever there has been obstruction in VERSION IN CONTRACTED PELVIS. 251 delivery. It follows, then, that, for the operation to be suc- cessful there ought to be room enough on one side of the pelvis to receive the occiput or big end of the head. The operation may also be performed as the complement to the premature induction of labor where the conjugate measures from 2.75" to 3.50". Indeed, this I believe to be one of its most valuable applications. The next condition is, that there be reasonable presump- tion that the child is alive. The cervix should be dilated enough to admit the fingers pointed in a cone, and dilatable enough to yield with readi- ness under the extraction of the trunk. In this, as in most cases where the head cannot press fairly upon the cervix, we are not to expect complete spontaneous dilatation. The membranes should be intact, or there should be enough liquor amnii present to permit of the ready version of the child. The contraindications of the operation are: 1. A conjugate diameter narrowed to less than 3". 2. Firm and close contraction of the uterus round the child, compressing it into a globular shape. 3. Impaction or very firm setting of the head in the brim of the pelvis. 4. Marked exhaustion or prostration of the mother. 5. Death of the child. As Hohl has remarked, the sudden emptying of the uterus of a woman far gone in prostration, acting as a new shock, is apt to increase the collapsuspost partum. The Operation.—The preparatory steps are the same as for the ordinary operation of turning. As the conditions postulated admit of bi-polar action, it is important to avail ourselves of a means that so greatly lessens the force neces- sary to use, and which further enables the operator to bring a leg and the breech through a cervix that would not permit the passage of his hand. Chloroform will be useful chiefly during extraction. 252 OBSTETRIC OPERATIONS. If exploration by the whole hand in the pelvis satisfy us that the pelvis is symmetrical—that is, that there is equal and sufficient space for the big end of the head in either side—we turn according to the ordinary rules. Finding the head in the first position, or with the occiput to the left ilium, depress the breech toward the right with the right hand externally; push the head across to the left iliac fossa with the fingers of the left hand passed through the os uteri, and seize the farther knee. Extraction must be per- formed at first slowly, so as to allow the half-breech to dilate the cervix. This is especially a case where hurry is mis- placed. The extraction should go on slowly while the trunk is passing. As soon as the funis is felt, draw down a loop, and direct it toward the posterior wall of the pelvis. So long as it pulsates freely, do not hurry. But, if the pulsa- tions flag, lose no time in liberating the arms. The pelvic contraction makes this a little more difficult than under ordinary circumstances. I refer, for the description of this proceeding, to Chapter XVII. As soon as the arms are liber- ated, the real difficulty begins: the extraction of the head. Sometimes the head is delayed by being encircled by the imperfectly-dilated os uteri. This is an unfortunate com- plication, since compression at this point is likely to stop the circulation through the cord. To avoid this risk, it is necessary not to hurry the trunk through the cervix. It is above all things necessary to draw at first as much back- ward as possible, so as to make the head revolve round the jutting sacral promontory until it clears the strait, when the head can enter its natural orbit, the curve of Carus. Then traction is changed to the direction of the pelvic outlet. Traction is effected by holding the legs with one hand, and the nape of the neck with the other. Commonly, the force thus obtained is enough. But sometimes more is wanted. This is obtained by crossing a fine napkin or silk handker- chief over the neck, and bringing the ends in front of the chest, and drawing upon them, as in Fig. 82. VERSION IN CONTRACTED PELVIS. 25.1 Great assistance in extraction may be gained, and traction-force economized, by getting an assistant to press firmly upon the vault of the head througli the abdominal walls, thus helping to push the head through the strait. This proceeding was advised by Pugh and Wigand, and quite recently Dr. Strassmann* has insisted upon its util- ity. The possibility of deriving advantage from it should be borne in mind in all cases of head-last labor. Where the pelvis is unequally contracted, one half being smaller than the other, the object is to throw the big or occipital end of the head into the larger half. Prof. E. Mar- tin describes three modes of accomplishing this. 1. A suitable position of the woman. Let her lie on that side toward which the forehead is directed. The fundus uteri will gradually sink with the pelvic end of the child to this side; the spine draws the occiput to the opposite side of the pelvis, and the forehead sinks more deeply toward the brim. Martin refers to a case in which he successfully carried this plan into execution, the pelvis measuring three inches only. 2. The forceps is a means of releasing the posterior transverse diameter of the head when imprisoned in the pelvic conjugate. This explains the frequent easy extraction when a little traction has been made. Martin admits that we must not be sanguine as to the success of this plan. We must be prepared, he says, to perforate, if there be evidence of exhaustion. My own experience is decidedly adverse to it if the contraction is at all marked. 3. Turning by the Feet. How is this to be done ? In consequence of the well-known law that, in complete foot pre- sentation, the foot that is drawn down always comes under the pubic arch, if the foetus is not abnormally small, or the pelvis too large, if we draw down the right foot, the child's back, and also its occiput, will come into the right half of the uterus, and vice versa. If, therefore, the right half of 1 Monatsschr. f. Geburtsh., June, 1868. 254 OBSTETRIC OPERATIONS. the pelvis is the larger, seize the right knee; if the left side is larger, seize the left knee. Hohl and Strassmann doubt the possibility of securing this result. If it happens, it does so by accident. I believe, Fig. 82. Fig. 82 shows the mode of extraction after turning when the head is jammed in the con- jugate diameter. The right forehead fixed against the jutting promontory is the centre of rotation. The left side of the head, resting on the pubes, sweeps round in the orbit of the false promontory A B. To favor this first movement, traction is made well backward. As soon as the equator of the head-globe has slipped through the conjugate, the head enters the true orbit C D, revolving round the pubes. however, the rule and the practice are good and feasible. But the success of the operation is not necessarily imperilled, if even the occiput should fall into the narrower half of the pelvis. I have saved children when this has happened, and Strassmann relates some striking cases1 in proof of this proposition. 1 Monatsschr. f Geburtsh., June, 1868, VERSION IN CONTRACTED PELVIS. 255 To determine which side of the pelvis is more con- tracted, attention to the following points will help : 1. If the woman walks straight, and the legs are of equal length, the defect in symmetry will be but slight; but the presumption is, that the right side is larger. 2. If the woman has one hip affected, or one leg shorter than the other, the corresponding side of the pelvis will be the smaller. 3. You may measure and compare the two half-circum- ferences of the pelvis externally from the crest of the sacral spine to the symphysis pubis. 4. The hand in the pelvis may take a very close estimate of the relative space in the two sides. [Dr. William Goodell, of Philadelphia,1 has lately ad- vanced the foil owing method of delivering the after- coming head in contracted pelvis. In a brim contracted in its antero-posterior diameter, the sacral side of the after-coming head becomes fixed on the point of the project- ing promontory, and its extraction can take place only when the pubic side of the head can be made to revolve around the promontory as a centre of motion, by descending over the smooth surface of the symphises. And this can the more readily be done in such cases, because the sacrum is so scooped out and so shortened that traction can be often made in a line posterior to the axis of the superior strait. Bearing this fact in mind, after grasping the neck of the child Mrith one hand, and the ankles with the other, the phy- sician should make his first movement of traction in the axis of the outlet—indeed, in a line anterior to this axis—by, at the same time, forcing the child's neck well against the pubes; for then the pubic side of the head will recede from the inlet, while the sacral side will proportionately descend over the point of the promontory, and affront the inlet. This change of position can be materially aided by an intelligent as- 1 American Journal of Obstetrics and Diseases of Women and Children, voL iii., No. 3, November, 1870, p. 484. 256 OBSTETRIC OPERATIONS. sistant, who will make pressure with both hands, through the flaccid abdominal walls, upon the vault of the child's head from before, backward and downward. By this ma- noeuvre the promontory will nip the head at a point higher up and nearer to its vault; hence, the arm of the lever, meas- ured by a line drawn from the base of the skull to the point nipped by the promontory, will be correspondingly length- ened—an advantage not to be overlooked. If, now, without for a moment relaxing the original traction-force, its direc- tion be reversed, and the body of the child be swept back- ward upon the coccyx—the neck being also forced downward and backward into the hollow of the sacrum—and if the as- sistant at the same time reverses the direction of the external pressure upon the vault of the head, making it now from be- hind, forward and downward, the pubic side of the child's head is made to revolve around the promontory, and descend with the least expenditure of traction-force, and consequently with a much greater chance of safety to the child. Of course, as soon as the head has passed the brim, the line of traction must be changed to that of Carus's curve. Dr. Gr. states that, by this method, he has thus far de- livered three women with unusually bad pelves; in one of them the child's head had to be lessened in a previous labor. His last case presented the following points of interest: A secundipara, in her previous labor, had fortunately been prematurely delivered at the end of the seventh month of gestation. The child was still, weighed under five pounds, and yet her labor lasted over forty-eight hours, six of them being attended with extreme suffering and violent expulsive pains. At eight a. m., when labor had lasted ten hours, Dr. G. found the water dribbling away from an unexpanded os uteri. The head, presenting the occiput to the left ilium, could not bear upon the cervix, but rolled about upon the shelf formed by the promontory. By careful measurement with the finger the conjugate diameter of the brim was es- timated at a trifle over three inches. It was his intention DELIVERY OF THE HEAD IX CONTRACTED PELVIS. 25 V to dilate the os with the water-bags and apply the forceps. But, while he was preparing to do so, the woman suddenly began to twitch her muscles, start convulsively, and to com- plain of blindness and intense headache. Fearing an attack of eclampsia, he determined to deliver at once. Two fingers of the left hand were then squeezed into the os, and ulti- mately a third; by which, in conjunction with the right hand externally, version was made with great ease. One foot having been drawn down, a short time was allowed to elapse before the body and arms were delivered, in ordei that the breech might dilate the os. Then, by following the method he had just described, the child was soon deliv- ered in an asphyxiated condition, but promptly recovered. It presented a deep indentation on the right side of its head, weighed seven pounds and twelve ounces, and next day measured three and a half inches at the bi-parietal diameter.] 11 CHAPTEE XXII. Craniotomy: The indications for the Operation: the Operation ; two Orders of Cases; Perforation simple, and followed by breaking-up or crushing the Cranium, and Extraction—Exploration; Perforation; Extraction by Crotch- et ; by Turning; Delivery by the Craniotomy-Forceps—Use as an Ex- tractor—as a Means of breaking-up the Cranium—Use in Extreme Cases of Contraction—Delivery by the Cephalotribe—Powers of the Cephalotribe— Comparison with Craniotomy-Forceps—The Operation—Dr. D. Davis's Osteotomist—Van Huevel's Forceps-Saw—Injuries that may result from Craniotomy. We have lingered long on the border-land between con- servative and sacrificial midwifery, unwilling to abandon the hope of saving mother and child; striving to set back, as far as the dictates of science and the resources of art will en- able us, those limits where the death, certain or probable, of child or mother must be encountered. We must at length pass the boundary; we must lay aside the lever, the forceps, and turning, and take up the perforator, the crotchet, the craniotomy-forceps, the cephalotribe—instruments, the use of which is incompatible with the preservation of the child's life. A law of humanity hallowed by every creed, and obeyed by every school, tells us, where the hard alternative is set before us, that our first and paramount duty is to pre- serve the mother, even if it involve the sacrifice of the child. As, therefore, we have striven to give the highest possible perfection to the forceps and turning in order to save mother and child, so it now behooves us to exhaust every effort in perfecting the means of removing a dead child in order tc INDICATIONS FOR CRANIOTOMY. 259 rescue the mother from the Caesarean section, that operation which the late Prof. Davis justly called " the last extremity of our art, and the forlorn hope of the patient." THE INDICATIONS FOR CRANIOTOMY. These are generally—1. Such contraction of the pelvis or soft parts as will not give passage to a live child, and where the forceps and turning are of no avail. Contraction of this kind may be due to contraction or distortion of the pelvis, which is most frequent at the brim; to tumors, bony, malig- nant, or ovarian, encroaching upon the pelvic cavity; to growths, fibroid or malignant, in the walls of the uterus; to cicatricial atresia of the cervix uteri or vagina; to extreme spastic contraction of the uterus upon the child, forbidding forceps or turning. Craniotomy and cephalotripsy are the means of effecting delivery in cases where labor at term is obstructed from disproportion, the pelvic contraction ranging from 3.25" as a maximum to 1.5" as a minimum. If labor occur at seven months, these means may be applied to con- traction measuring even less than 1.50". We are not hastily to assume, because a woman has been delivered on previous occasions by natural powers or by forceps, that it is there- fore unnecessary to resort to craniotomy. It is, indeed, ample reason to pause and to examine anxiously. But it is a mat- ter of experience, that some women bear children with a constantly-increasing difficulty. This may be from two causes : 1. Advancing pelvic contraction; 2. Increasing size of the children. I can affirm the reality of the first cause from repeated observation. I have had to record the histo- ries of many women whose first labors may have been natu- ral, and whose subsequent ones exhibited difficulties increas- ing in a kind of accelerated ratio, rising from the forceps to turning and craniotomy. The second cause may be inde- pendent of, or aggravate, the first. D'Outrepont says he has constantly observed that, in fruitful women whose first 260 OBSTETRIC OPERATIONS. children were small, subsequent ones became bigger and bigger. On the other hand, Dr. Matthews Duncan contends that the maximum weight of children is found in women aged from twenty-five to twenty-nine, and that the weight afterward falls. But I have known many exceptions to this. [Prof. Gr. T. Elliot gives it as his opinion that the same degree of deformity admits of varying results in successive pregnancies, as for instance, that the child may have attained a different degree of development at the time of labor; or it may present differently; or the head may dip accurately in one labor and not in the others.] 2. Certain cases where obstruction to delivery is due to the child—as some cases of face-presentation ; some cases of locked twins in which the lessening one head is necessary to release the other ; excessive size of head, as from hydro- cephalus ; cases where there is obstructed labor, the head presenting, and the child is dead. 3. Conditions of danger to the woman, rendering it expe- dient to deliver her as speedily as possible, and where cra- niotomy is the quickest way, involving the least violence. Among these are some cases of convulsions; some cases of haemorrhage; great exhaustion ; some cases of rupture of the uterus ; and generally where, delivery being urgently indi- cated, the cervix uteri is not sufficiently dilated to admit of other operations. An important question is, At what stage of labor shall we begin ? As most of the dangers flow from exhaustion, it is obviously proper to begin as soon as the indication for the operation is clear. On the Continent especially, it is still urged by many that we should wait until the child is dead. Now, if it be admitted, and the conditions of the case involve these postulates—1. That the child cannot come through alive; 2. That the operation is undertaken in order to save the mother—waiting till the child is dead is opposed both to reason and to humanity. It seems a refinement of casuistry INDICATIONS FOR CRANIOTOMY. 261 to distinguish between directly destroying a child and leav- ing it exposed to circumstances which must inevitably de- stroy it; and it is risking the very object of our art to wait for this lingering death of the child until the mother's life is also imperilled. If, then, wTe have clearly determined by our knowledge of the patient, by exploration, by trial, that the child cannot come through the pelvis by spontaneous action, by forceps, or by turning, it is our duty at once to adopt the best means of securing the safety of the mother. There is no need to wait for the far advance of labor. We should not wait long after the rupture of the membranes. It would, in the majority of cases, be useless to wait for com- plete dilatation of the cervix uteri. It is one of the neces- sary results of contracted brim that the cervix uteri dilates slowly and imperfectly. The head-globe, resting by two points on the contracted brim, cannot bear upon the cervix. It is not, therefore, often desirable to wait for more opening than is enough to admit two or three fingers to guide the perforator. When the head collapses and comes down into the pelvis, it bears upon the cervix, which yields gradually. Although it is a good general rule to perform every op- eration as early as the indication for it is clearly recognized, it is not desirable, in minor degrees of contraction, to arrive at once at the conclusion that perforation is necessary. Some time and opportunity should be given to Nature. The head may be small or plastic, and occasionally even a full-sized head will, under continued action of the uterus, become so moulded as to admit of delivery either spontaneously or by aid of the forceps. Perforation should be the first step of all operations for lessening the bulk of the head. The necessary condition for full collapse of the bones of the head is that the support given by the brain and the integrity of the cranial vault should be broken down. Until this is done, you may obtain, with con- siderable expenditure of time and force, some amount of moulding or alteration of form, but no diminution of bulk. 202 OBSTETRIC OPERATIONS. It is astonishing what resistance to compression the unopened head possesses. The most powerful forceps, and even cephal- otribes, may be bent in the attempt to crush it in. Whereas, break the arch of. the cranial vault, allow the contents to escape, and very moderate compression will cause collapse, more or less complete. It is remarkable that not a few Conti- nental obstetrists practise cephalotripsy without perforating. Craniotomy, being used as a general term to include all the proceedings for reducing the bulk of the head, may be divided into two principal orders: The first includes those cases of minor disproportion in which perforation is enough to allow of such an amount of col- lapse of the head under the natural forces as will effect delivery. The second order includes those cases of major dispropor- tion in which perforation must be supplemented by breaking- up, removal of parts of the cranium, or by crushing down, and followed or not by extraction. The preparations are generally the same as for other operations. Position.—The patient lies on her left side, with her knees well drawn up, near the edge of the bed, and with the head supported on a low pillow, directed toward the middle of the bed. [In the United States the patient is placed in the same position as previously mentioned for forceps-delivery; on the back, near the edge of the bed, the thighs being held apart and flexed by two assistants.] Exploration.—The left hand of the operator is introduced, if necessary, into the pelvis, so as to explore thoroughly the shape and dimensions of the brim, and the relations of the head and cervix uteri. Three points especially should be clearly made out: first, the projection of the promontorv, which in extreme cases has been mistaken for the head • secondly, the head; thirdly, the os uteri. The finger passed inside the os should be made to sweep all round the circum- ference of the head. OPERATION OF CRANIOTOMY. 263 Perforation.—The point to be selected for perforation is the most centrally presenting. It is easier to strike; it offers a better resistance to the point of the instrument. The open- ing made allows a freer exit to the contents of the skull, and affords greater facility for the introduction of the crotchet or the blades of the craniotomy-forceps, which have to follow. Two most essential things to be attended to are—that an assistant shall support the uterus and child externally, press- ing them firmly down toward the pelvis, so as to fix the head upon the brim, and obviate the retreat or rolling of the head under the impact of the instrument. The other thing is, to take care that the instrument shall strike the head per- pendicularly. If it strike at an angle, the point will be apt to fly off at a tangent, at the risk of wounding the mother. [This may be avoided if we keep in mind the axis of the foetal head in the direction we have decided to perforate.] Sometimes, in cases of great deformity, the uterus is so twisted from its normal direction that reposition is necessary before the os can be brought near the centre of the brim to allow of safe perforation. Two fingers of the left hand then are passed up to the head, keeping the os uteri at their back ; the instrument is run up in the groove formed by the fingers ; the point hav- ing struck the part desired, the perforation is effected by a movement combining boring and pushing. When the skull is pierced, push the blades in up to the shoulders ; then open the blades to enlarge the aperture, turn the angles at right angles to the first position, and open the blades again so as to make a free crucial opening. This breaks the continuity of the arch ; allows free discharge of brain and ample entry for the crotchet or craniotomy-forceps. Now you may wait a little to afford opportunity for spon- taneous compression and collapse, or you may at once pass in the crotchet. This should be carried in as deeply as pos- sible, and moved freely round in all directions to break up 264 OBSTETRIC OPERATIONS. the tentoria and the brain. This proceeding greatly facili- tates the evacuation and collapse of the skull. If the disproportion is not great, and the powers of the patient are good, it commonly happens that uterine action sets in as soon as the bulk of the head is a little diminished, and the compression and propulsion resulting will often suffice to expel the child. Seasonable opportunity should be given for this spontaneous process. Should no advance be made, the case falls into the second order, and we must proceed to extraction, or artificial com- pression of the skull. Some operators advise to pass a cathe- ter or other tube into the skull, to inject a stream of water through it, in order to wash out the brain. Extraction may be accomplished in several ways: 1. By the Crotchet. This instrument is generally pre- ferred by the Dublin school. It was very naturally resorted to in preference to bad craniotomy-forceps. And some prac- titioners of great experience, who have acquired exceptional skill in the management of it, accomplish delivery by its aid in cases of extreme disproportion. Until I had contrived a good craniotomy-forceps I myself trusted to it entirely. I am now satisfied that, for safety and expeditiousness in ex- tracting a head, it is very inferior to the craniotomy-forceps. The way of using it is as follows : Two fingers of the left hand guide the end of the crotchet into the hole in the skull. The ends of the fingers are then passed up outside the skull, to serve as a guard and support to the sharp point of the crotchet, which is fixed into the bone inside. The part to which the crotchet is first applied is not perhaps very impor- tant, since, if there be any great resistance, the part will be broken away, and the instrument will have to find fresh hold. This may have to be repeated several times, pieces of the parietal occipital, or frontal bones being successively torn out. Whenever a piece of bone is detached it is wise to remove it altogether, which may be generally done with the fingers. By-and-by—for the process is apt to be tedious DELIVERY AFTER CRANIOTOMY. 265 —when the cranial vault is much broken up, if a good hold can be obtained in the occipital bone or in the foramen mag- num, collapse or falling in of the skull takes place, and ex- traction is successful. In very difficult cases, when the vault is well broken up, it is better to take hold in the orbital re- gion, fixing the point of the crotchet either inside the skull, under the sphenoid on one side of the sella turcica, or in the eyeball. In this way the base is brought into the brim edge- wise, or end on. In the last century it was a recognized plan to perforate and leave the evacuation of the brain and the compression of the skull to the action of the uterus. The process was usually slow and tedious; commonly, some degree of decom- position had to take place before the bones would collapse sufficiently, and exhaustion, or even inflammation of the uterus, and fatal prostration, would sometimes ensue. The late Prof. Davis records that, in his time, this mode of pro- ceeding was still followed by the disciples of one school in London, and that he was often called in to witness the most disastrous consequences. Indeed, when it is considered that craniotomy is not often performed except at an advanced period of labor', and after much suffering has been endured, it will hardly appear justifiable to throw upon an enfeebled system a task entailing further exhaustion, and under which it may sink. It is our duty to relieve Nature, and not to leave her to struggle through unaided. Dr. Hull says it was Dr. Kelly who first advised and practised the method of waiting twenty-four hours before using the crotchet, in order to allow the head to collapse and settle in the pelvis. Dr. Osborn advocated the same practice, and went so far as to assert that delivery by the crotchet might always be effected. 2. Delivery by Turning. When the cranial arch is broken, the bones will readily collapse if the skull be drawn through the contracted brim base first. In certain cases turning is a very efficient method of completing delivery. The torn scalp 266 OBSTETRIC OPERATIONS. during extraction is drawn over the aperture made by per- foration, and sheathes the jagged edges of the bones. The plan will be generally inferior to the use of the craniotomy- forceps. The child, being dead, does not always lend itself readily to turning. It may be necessary to pass the hand into the uterus, which is moulded upon the child, and through a brim so contracted as to oppose considerable difficulty. Turning, however, must be regarded as a valuable resource in certain cases of exceptional emergency. 3. Delivery by the Craniotomy-forceps.—The use of this instrument is twofold: it will seize and extract the head; it will seize and remove portions of the bones of the cranial vault. The first use is adapted to minor degrees of disproportion. [The best craniotomy-forceps is one that has separate blades, which can be locked after introduction. Simpson's cranioclast, Dr. Elliot says, is the best craniotomy-forceps, and as such is extensively used. It has the advantage of re- stricting the use of the cephalotribe, and consequently dimin- ishes the risk incurred in using the latter instrument, as also that of the crotchet.] What part is best to seize ? If the head is found to col- lapse well, and the disproportion is not great, it is enough to seize the forehead, which, being generally directed to the right ilium, is the easiest to do. But, if there is any great difficulty, it is better to quit the forehead, and seize by the occiput. The- head will not come down well, face present- ing, unless the vault and occiput are in a condition to be crushed in against the base. In this proceeding compression of the skull is effected by its being drawn through the nar- row passage formed by the soft parts supported by the pel- vis. The head must, therefore, be ductile enough to admit of the necessary compression and elongation. If the skull be too unyielding, or the passages too small for this process, a totally different principle must guide us. Portions of the vault must be removed, and then we get the most remark- able advantage. DELIVERY BY CRANIOTOMY-FORCEPS. 267 Dr. Osborn contended that, by canting the base of the skull, so as to bring it edgewise into the brim, it was quite possible to deliver a full-sized child through a conjugate diameter measuring an inch and a half only. His conten- tion was hotly disputed by Dr. Hull, who, nevertheless, ended by proving satisfactorily that it could be done. Dr. Burns came to the same conclusion, and showed that, by removing the calvarium, reducing the skull to its base, and bringing it through as in a face-presentation, nothing was opposed to the conjugate but the distance from orbital plates to chin, which is rarely much more than an inch. Thus an inch and a half to an inch and three-quarters conjugate diameter, with a transverse diameter of three inches, is enough; and degrees of contraction beyond this, requiring the Caesarean section, are rare indeed. This question has been investigated and illustrated anew by Dr. Braxton Hicks {Obstetrical Transac- tions, vol. vi., 1865). He describes very fully the mechanism of the proceeding. Having removed the calvarium, he grap- ples the orbit with a small blunt-hook, the hook of which is hard, and the stem soft, so as to admit of easier adaptation. The face is then gently drawn down, turning the chin for- ward, as occurs in ordinary face-labor. A fresh hold, in the mouth, or under the jaw, is then taken for traction. The evidence given by Dr. Hicks of the efficacy of this proceed- ing is conclusive. I, however, prefer the craniotomy-forceps. The proceeding I practise is as follows : I pass the inner or small blade into the cavity of the skull as usual, then the outer blade in between the portion of bone to be removed and the scalp. Then a considerable piece of parietal or oc- cipital bone being seized, by a sudden wrench is broken, and then cautiously torn away under the guidance and protection of the left hand in the vagina. If the distortion is not ex- treme, it may be enough to break away two or three pieces, say an angle of each parietal and of the occipital. This de- stroys the arch of the calvarium, so that the remains of the walls easily fall in upon the base, forming a flat cake, when 268 OBSTETRIC OPERATIONS. the head comes to be compressed in the chink of the brim. When enough has been taken away to admit of this flatten- ing in, the blades of the forceps are made to seize the fore- head and face, the screw working at the ends of the handles helping to crush in the frontal bones and to secure an un- yielding hold. Then traction is made, carefully backward at first, in the course of the circle round the false promon- tory. As the face descends it tends to turn chin forward, and this turn may be promoted by turning the handles of the instrument. It is not necessary that this turn should take place, for the case differs entirely from that of the normal head. There is no occiput to roll back upon the spine be- tween the shoulders. The head comes through flatwise like a disk by its edge. If the pelvic deformity be very decided—say to 2.50" or 2.00" or under—it will be wise to take away the greater part of the frontal, parietal, squamous, and occipital bones before beginning traction. By adopting this method I entirely agree with Osborn, Hull, Burns, and Hicks, that a full-sized head may be deliv- ered with safety to the mother through a pelvis "measuring even less than 2.00" in the conjugate, provided there be 3.00" in the transverse diameter. I go further, and declare that it is perfectly unjustifiable to neglect this proceeding, and to cast the woman's life upon the slender chance afforded by the Caesarean section. The late Prof. Davis, relying upon his method of embry- otomy, used these words: " There are few pelves with supe- rior apertures so small as not to furnish from 1" to 1^" in the conjugate diameter, or at least of antero-posterior diameter across the brim. In any such cases it would be the practi- tioner's duty to avail himself of the use of the osteotomist, and undertake delivery by the natural passages. It will have the effect of reducing almost to zero the necessity of having recourse to the Caesarean section." 4. Delivery by Cephalotripsy.—What are the relative DELIVERY BY CEPHALOTRIPSY. 269 powers of cephalotripsy and of craniotomy as just described ? I doubt much whether cephalotripsy can carry the possibility of safe delivery at all beyond the point attained by craniot- omy. It nevertheless possesses considerable independent advantages under many circumstances, and may lend much help to other proceedings. Fig. 83. Fig. 83 shows the bones of the calvarium removed, and the base of the skull, grasped by the craniotomy-forceps, drawn through the contracted hrim edgewise, face first. The Powers of the Cephalotribe.—The all-essential point is that it shall be able to compress and even crush down the base of the skull. A secondary property which it is de- sirable to possess is that of holding during extraction. The crushing power can be attained in sufficient perfection, and with a gain in the facility of handling, if the instrument be made much less formidable in bulk than are most of the 270 OBSTETRIC OPERATIONS. Continental cephalotribes. Three good modifications have been constructed here. Sir James Simpson's is the best known. He insists upon a pelvic curve in the blades as being less likely to slip than straight blades. Dr. Kidd's, of Dublin,1 is the best type of a straight-bladed cephalotribe. Dr. Kidd insists strongly upon the advantages of long Fig. 84. Fig. 84 shows the remains of the skull drawn through the chink of the brim, flattened like a cake. The calvarium being removed, the head resembles that of an anencepha- lous foetus. A. projecting promontory of the sacrum; C, coccyx. straight blades upon the following three grounds: first, straight blades admit better of the head being rotated while in the grasp; secondly, they are easier to introduce; and, lastly, they hold more securely. Dr. Braxton Hicks has modified Sir James Simpson's cephalotribe, producing a 1 See British Medical Journal, October, 186Y. DELIVERY BY CEPHALOTRIPSY. 271 very handy and efficient instrument. He preserves a mod- erate pelvic curve, and adapts a very convenient screw to the handles as a crushing power. I believe that, to seize a head above the brim, as is necessarily the case where crush- ing is required, the blades should be curved; but this curve should be moderate, otherwise the inconvenience in rotating or shifting the relation of the instrument to the pelvis referred to by Dr. Kidd will be felt. When the instrument is applied to the perforated head, it may be made to completely crush the base, flattening the head sideways, or doubling up the base; or, by the slipping of one of the blades inward a little, the base is tilted edge- wise, and the.skull is flattened by the pressing inward on to the base of the squamous and parietal bones. Under either of these proceedings the head can be so flattened as to allow the blades to meet, and, as the instrument then measures only 1.50", the obstacle is reduced to that degree. It is gen- erally desirable to repeat the crushing, which is done by taking a fresh hold in a different direction, and then com- pressing again. Two crushings will generally be enough. A distinctive advantage of the cephalotribe was pointed out by Curchod (Berlin, 1842). It is that the plasticity effected by crushing so modified the form of the head that it was easily moulded to the form of the pelvic brim. 1. What are the limits of application of the cephalotribe ? The maximum, of course, is not difficult to determine. It may be usefully employed in almost any case of minor dis- proportion. But what is the least amount of space admit- ting of its use? This must depend somewhat upon the form and size of the particular model adopted. In a discus- sion held at Berlin, the majority of the speakers thought a minimum of 51 mm., = 2.0" conjugate diameter, was neces- sary. Lauth1 says the application begins at 8 mm., or about 3 inches, at which point the forceps and turning are not available, and ends at 5.0 mm., or a little under 2.0". But 1 De la Cephalolripsie. Par J. F. Ed. Lauth. Strasbourg. 1863. 272 OBSTETRIC OPERATIONS. Pajot goes beyond this, and contends that it ought to be ap- plied where there is only 1.25" conjugate diameter. Crede thinks it should be used if only there is room enough to apply it. Dr. Hicks has applied it where there was If inches. I have recently used it with perfect success in a case of ex- treme rickety deformity, at St. Luke's Workhouse, aided by Messrs. Harris, Sogers, and Sisson, in which the conjugate certainly did not exceed 1.50". In this case, after the first crushing, I removed some pieces of the cranial vault which had cropped up, by means of my craniotomy-forceps. The delivery was completed, without hurry, in an hour. I have arrived at the settled conviction, that cephalotripsy is quite practicable with a pelvis measuring an inch and a half in the conjugate diameter; and that the risk to the mother is inconsiderable compared with that attending the Caesarean section. Other conditions are— 2. The os uteri must be sufficiently dilated, but this can be readily effected by the caoutchouc water-bags. 3. The head must be previously perforated. Abroad, sometimes the ordinary forceps is put on to hold the head during perforation; but this is sometimes not feasible for want of room, and is never necessary, since, by means of external pressure and a good perforator, this operation is not difficult. Position.—The patient may lie on her left side, as in other obstetric operations [or on her back, in manner de- scribed]. [The application of the cephalotribe in narrow pelves being often attended with considerable difficulty, it is well to first wash out the brain by injecting water within the cranium by means of a Davidson's syringe.] Operation.—The rules laid down for the long forceps will generally apply to the application of the blades, and it is equally unnecessary in either case to have an assistant or a " third hand." The lower or posterior blade is passed DELIVERY BY CEPHALOTRIPSY. 273 first, guided by the left hand passed well into the pelvis if possible. This blade is passed along the hollow of the sacrum until the point approaches the brim and touches the head-globe, when the handle is raised, and the point, turn- ing into the left ilium or to the left sacro-iliac synchondrosis, travels over the head. It is passed high up, for the point of the instrument must get beyond the base of the skull. This being in situ, the second or anterior blade is introduced, also at first in the hollow of the sacrum, crossing the handle of the first blade. When the point approaches the brim, the handle is lowered and carried backward, and the point rises over the head-globe into the right ilium, or opposite the right cotyloid cavity, when it falls into opposition with the first blade. Being locked, the screw is turned slowly and steadily, the hand in the vagina taking note of the work done. If spicula crop out of the scalp, they should be picked away by the fingers. When the base is crushed in the direction first seized, you may, if the instrument hold, use it as a tractor. If there be any marked resistance, it is better to take off the blades, to reapply them in the opposite oblique diameter and repeat the crushing; then, by rotating the head by turning the handles, you may find that the head is better adapted to the brim, and will come through. But you must be prepared to find the cephalotribe fail as a tractor. It is made to crush, and, if it has done this well, it has done good service. I have, however, found Dr. Hicks's instrument hold perfectly. Extraction may be completed by the crotchet or by the craniotomy-forceps, or by turning. The late Prof. Davis did not use the cephalotribe, but in extreme cases he cut away the head piecemeal by his oste- otomists, and seized and extracted the trunk by a double sharp body-crotchet. Pajot, of Paris,1 has practised a method analogous to that formerly employed in this country in craniotomy. He performs what he describes as " cephalotripsie repetee sans 1 Archives Gen. de Med., 1863. 18 274 OBSTETRIC OPERATIONS. tractions "—that is, he first crushes the base by one opera- tion ; he then gently tries to effect a slight rotation of the instrument so as to bring the crushed sides of the head into relation with the contracted diameter. If there is any resistance, he desists, and leaves the case for two or three hours for the uterus to mould the crushed head to the brim. He then repeats the crushing, and again gives twro or three hours to Nature. One or two crushings suffice for the trunk. (See also " Osservazioni di Cefalotrissia," by Dr. Chiara, Fig. 85. Fig. 85.—Dr. Hicks's cephalotribe seizing the perforated head. Turin, 1867, for a good case in illustration.) Pajot places this method in distinct competition with the Caesarean sec- tion. The cases related by Pajot lend weight to his recom- mendation ; but I cannot help thinking that the operation may and ought to be finished at one sitting. When the head is extracted, there may be some trouble with the shoulders and trunk. The shoulders will generally be disposed obliquely in the brim—that is, one will be an- terior to the other. By keeping up traction on the head backward, this anterior shoulder will be brought a little DELIVERY BY THE FORCEPS-SAW. 215 down, so that a finger or the blunt-hook or crotchet can be fixed in the axilla to pull it through. When this is done, the head is dragged down forward, so as to enable the same manoeuvre to be repeated with the posterior arm. If this cannot be readily done, it is a good plan to crush in writh the cephalotribe. Dr. Davis seized the trunk with his double body-crotchet. If turning had been practised after perforating or cephalotripsy, the arms fall in upon the crushed head, and offer no obstruction. To save the assistants the ghastly sight of the mangled head, wrap a napkin around it as soon as it is born. If traction is necessary in delivering the trunk, it is easier to hold when so treated. 5. Delivery by the Forceps-saw. This instrument, intro- duced by Yan Huevel in 1842, may be said to be the distinc- tive feature of the Belgian school. It is figured in the Obstet- rical Society's Catalogue of Instruments, 1867. Dr. Hyer- naux, who had been assistant to Dr. Yan Huevel at the Maternite of Brussels, in his " Manuel Practique de l'Art des Accouchements " (Bruxelles, 1857), rejects in its favor all crotchets and cephalotribes as comparatively dangerous and inefficient. It is therefore used in all cases where embry- otomy is indicated. It consists of a powerful long forceps with the pelvic curve, the blades of which are grooved along the inner aspect, in order to carry a chain-saw. When the head or other part of the child is seized by the forceps, this chain-saw is worked up from the point whence the blades spring, by means of cross-handles attached to the two ends. Thus travelling up the grooves, the saw crosses the head and cuts through it. For extraction, Yan Huevel contrived a pair of forceps, toothed on one blade, to seize the most con- venient part of the child. Notwithstanding the formidable and complex appearance of the forceps-saw, it seems to have steadily made its way into use. Prof. Faye, of Christiania, a man of singular judgment and ability, says it is the only instrument fitted to cut through any part of the 276 OBSTETRIC OPERATIONS. foetus. He has simplified the instrument considerably, and extols it as safe, easy, and effectual. It is also used in Germany, and in Italy Dr. Billi has modified it and intro- duced it into practice. We cannot refuse to lend favorable consideration to an instrument so recommended. It is cer- tainly a new power, and its claims to compete with or to displace other methods of facilitating delivery by embryot- omy should be tested inpractice. It appears to me, how- ever, who have not yet used it, that it is more especially adapted for those minor degrees of pelvic contraction which can be dealt with satisfactorily by perforation and the cra- niotomy-forceps ; and that in extreme cases, where the con- jugate diameter is 2" or less, where the craniotomy-forceps is still available, and in which the cephalotribe can do good service, the forceps-saw could hardly answer, owing to the size of the blades, and the necessity of getting them to lock accurately in order to work the chain. It is capable of being most useful in dividing the neck, or other part of the body, in cases of impaction of shoulder-presentation. 6. Delivery by the Author's New Method of Embry- otomy.—I have now to describe a new method of embry- otomy, designed by myself, to effect delivery in the most extreme cases of pelvic contraction. It had long appeared to me that, if the problem, how to break up and extract such a body as the mature foetus througli a chink measuring an inch wide and three or four inches long, were proposed to a skilful engineer, he would find a solution. It did not seem to me that we were necessarily restricted from the use of new instruments. I thought I saw in the wire-ecraseur the means of effecting the object in view. I had found no great difficulty in snaring an intra-uterine polypus of considerable size, with a wire loop passed through a cervix uteri, whose aperture was much smaller than the tumor, guided only by one or two fingers. Why should not the foetal head be seized in a similar manner and cut in pieces ? I performed several experiments with a very diminutive and DELIVERY BY NEW METHOD OF EMBRYOTOMY. 277 delicate rickety pelvis, measuring an inch in the antero- posterior diameter, and scarcely more in the sacro-cotyloid diameter, and I will now repeat the operation before you.1 The best instrument is Weiss's ecraseur, which has an Archimedean screw and windlass, admitting the use of a loop of any size. As in cephalotripsy, but not so urgently, it is desirable, first of all, to perforate the head. The wire cuts through the skull more easily if this be done. In doing this, the head is firmly supported against the brim by an assistant. The crotchet is next passed into the hole made by the perforator, and held by an assistant so as to steady the head. A loop of strong steel wire is then formed, large enough to encircle the head. The elasticity of the wire permits of the loop being compressed by the fingers so as to make it narrow enough to slip through the cervix uteri and the chink of the pelvic brim. The loop is thus guided over the crotchet to the left side of the uterus, where the occiput lies. The compression being removed, the loop springs open to form its original ring, which is guided over the occi- put, embracing all the posterior segment of the head. The screw is then tightened. Instantly, the wire is buried in the scalp; and here is manifested a singular advantage of this operation. The whole force of the necessary ma- noeuvres is expended on the foetus. In the ordinary modes of performing embryotomy, as by the crotchet especially, and in a lesser degree by the craniotomy-forceps and cephal- otribe, the mother's soft parts are subjected to pressure and contusion. The child's head, imperfectly reduced in bulk, is forcibly dragged down upon the narrow pelvis, the inter- vening soft parts being liable to be bruised, crushed, and even perforated. And this danger, obviously rising,in pro- portion to the extent of the pelvic contraction, together with the bulk of the instruments used, deprives the mother, in all cases of extreme contraction, of the benefit of em- 11 also demonstrated this operation at the meeting of the Obstetrical Society of the 2d June, 1869. 278 OBSTETRIC OPERATIONS. bryotomy, leaving her only the terrible prospect of the Caesarean section. When the posterior segment of the head is seized in the wire loop, a steady working of the screw cuts through the head in a few minutes. The loose segment is then removed by the craniotomy forceps. In minor degrees of contraction, the removal of the oc- cipital segment is enough to enable the rest of the head to be extracted by the craniotomy-forceps. But, in the class of extreme cases in which this operation is especially useful, it is desirable still further to reduce the head, by taking off another section. This is best done by reapplying the loop over the anterior side of the head. The wire seizes under the lower jaw beyond the ear. When the screw is worked, the wire has to cut through the base of the skull, dividing the sphenoid bone. The segment thus made is removed by the craniotomy-forceps. The small part of the head still remaining attached to the trunk offers no obstacle. It is useful as a hold for trac- tion. The craniotomy-forceps now seizes this firmly, and , you proceed to deliver the trunk. If the child be well de- veloped, this part of the operation will require considerable skill and patience. An assistant draws steadily on the crani- otomy-forceps, directing traction to one side, so as to bring a shoulder into the brim. The operator then hooks the crotchet into the axilla, draws it down, and with strong scissors amputates the arm at the shoulder. This proceed- ing is then repeated on the other arm. Boom is thus gained to deal with the thorax. You perforate the thorax. Intro- duce one blade of a strong pair of scissors into the aperture, and cut through the ribs in two directions. Then, by the crotchet, eviscerate the thorax and abdomen, until the trunk is in a condition to collapse completely. This done, moder- ate traction will complete the delivery. I have imagined a proceeding by which the arms can be amputated even more easily. A curved tube, shaped like Ramsbotham's hook, may be made to carry a strong wire DELIVERY BY NEW METHOD OF EMBRYOTOMY. 279 under the axilla, and the end beins,u&, post-partum, 251, 440. Cold, in haemorrhage, 444. Colpeurynter; Braun's, 323. Compressibility of head, proofs of, 33. ----experiments on, 34. Compression of head, where most inju- rious, 244. Compression of uterus in third stage of labor, 412. Compression of aorta in haemorrhage, 446. Compress-spring, for haemorrhage, 448. Conversazione of 1866,the obstetrical,11. Convulsions—indicate delivery, 333, 334. Cramps, uterine, the treatment of, 406. Craniotomy, dangers of, 279. Craniotomy-forceps, description and essentials of, 23. ----use of, 266. ----diagrams of, 269, 270. Craniotomy, in face presentations, 89. ----indications for, 259. ----limits of, 268. Crotchet, best form of, 22: ----author's use of, 23. ----preferred by Dublin School, 264. ----the double body, 275. Curve of Carus (see also Carus), 91, etc. Curve of false promontory, 92. Death of foetus, the condition of spon- taneous evolution, 143. Decapitation, instruments for, 24, 229. ■---- directions for and diagrams of, 230-233. Decapitation in impaction of foetus, 226. Decollation (see Decapitation). Dilatation (see Cervix, Hydrostatic, Va- ginal), etc. Disinfectants, 298, 364. Disproportion, varieties of, 15. Dorsal displacement of arm, 481. Douche, intra-uterine and vaginal, 316, 317. ----sometimes fatal, 317. ----abdominal, 444. Dynamometric forceps (Dr. Kristel- ler's), 13. Dystocia increases with long pregnancy (see Craniotomy-forceps, Induction of Premature Labor, Turning, etc.), 260. Ecraseur (wire), use of, in embryotomy, 276. . Embryotomy (see Cephalotripsy, Crani- otomy, etc.). Ergot, often uncertain, 316. ----in haemorrhage, 443. Ether-spray in Caesarean section, 294. Evisceration, in impaction of foetus, 226. Extraction, after version, 186,198. ----in "jammed" head, etc., 252. ----after craniotomy, 264. Face-presentations, how produced, 83, 84. ----diagrams to illustrate, 85, 86. ----management of, 83-89. ----long forceps in, 85. ----version preferable sometimes, 87. Factors in dynamical problem of labor, 13. Fear of unskilfulness cramps teaching, 239. Fibroid tumors and polypi, 474. First labors, when to interfere in, 71. Foetus, cause of normal position of, 117. ---- changes its position frequently, 124. Force required for natural labor, esti- mates of, 13, 14. Forcible dilatation of pelvis, 296. Forceps, advantages of long over short, 29. ----application, position of patient in, 47, 56. ---- applied to the " after - coming head," 74, 208. ----compressive power of, 32. ----diagrams, to illustrate use of, 34, etc. ----direction of traction, 63, 67. ----how blades are held in apposition, 31. ----how long should they be tried 1 68, 69. ----in impacted head, 253. ----is it necessary to feel the ears ? 52. ----limits of usefulness, 90, 94, 95. INDEX OF SUBJECTS. 501 Forceps, locking of, a presumption of their suitability-, 62. —— the long, should be applied in re- lation to pelvis, 56. ----mode of using, 47-61. ----not adapted to breech-cases. 176. ---objections to single-curved'52-54. ---powers of the (see Limits of Useful- ness), 29. ---really a lever, 43. ---removal of blades, 66. ---saw, delivery by, 275. ---modification of, 276. ----varieties of, 19, 20, 32. ---essential qualities, 19. ----should be strong, 19. ----handle not too short, 19. ----when they should be used, 38. —— which blade to apply first, 50. Friction, force of, in obstetrics, 84. Fronto-anterior, forehead and face pre- sentation, 78, 79. Funis, how to protect it in extraction, 201. ----may be tied before birth, 201. ----instruments for replacing pro- lapsed, 21. ----postural method in prolapse of, 21. 171. ----prolapse of, 171. Galvanism induces uterine action, 320. ----in haemorrhage, 320. Gastro-elytrotomy, 303. Genesial circle, the, 313. Hand, by side of head, descent of the, 170. ----the best instrument in abortion, 359. ---the master-instrument in obstetric practice, 25. ----as a uterine dilator, 106. ----removal of placenta by, 415. ----which to use in version, 190, 210. ----introduction of, in haemorrhage, 442. Haematocele, or thrombus, 473. Haemorrhage, after removal of placenta, 438. ----internal, caused by obliquity and retroflexion, of uterus, 441. ----ought never to be fatal, 467. ----post-partum, 409. —— causes of, 409. ----restorative treatment in, 456. ----secondary puerperal, 468. ----causes of, 468. ----stages of, 456. ----varieties and dangers of uterine, 350, 396, 409, etc. ----perchloride of iron in, 361, 451. Haemostatics, Nature's, 438. ----choice of, 441. Head, delivery of after-coming, in po- dalic presentations, 74. ----delivery of detruncated, 243. ----extraction of perforated, 272. ----extraction of, 217. Head, rarely seized by forceps in longi- tudinal diameter, 68. ----where generally seized, 252. Hook, Ramsbotham's cutting. (See Blunt.) "Hour-glass" contraction, 413. Hydatid cyst of liver necessitated Caesa- rean section, 296. Hydatidiform degeneration of ovum, 363. Hydrostatic dilators, the authors, 14, 107, 325, 390, 399. ----action of, 103. Hypodermic injection of morphia, 457. Hysterotomy, vaginal, 109,110. Ice, uses in haemorrhage, 444. Imitation of spontaneous evolution, Peu's proceeding, 236. Impaction of shoulder, 232. Incision of rigid cervix uteri, 109. Induction of premature labor, 311. Instruments required in obstetric opera- tions, 16-18. Intra-uterine injections, dangers of, 320. Inversion of uterus, 422. ----Thomas's operation for, 431. ----pathology of, 423. ----reduction of, 425. ----diagnosis and treatment of chronic, 431. ----incisions in, 428. ----Emmet's treatment of, 435. Irrigation in rigidity of cervix, 105. Iron (see Perchloride of). ----after haemorrhage, 458. Kneading uterus in haemorrhage, 445. Knee, which to seize in turning, 193. ----better to seize than foot in turning, 214, 215. Labor a problem in dynamics, 13. ----causes of suspended, or "missed," 97. ----management of third stage, 412. Lac, or cord, in breech-cases, 181. Laceration of cervix, 437. Laminaria-tents, and mode of using, 321. 360. Left hand, importance of dexterity in use of, 190, 211. Lever really such, not a tractor, 39. ----Mr. Symond's, the best kind, 18. ----use ot, in primiparae, 72. Liquor amnii, best dilator of cervb uteri, 102. ----ponding-up of the, 72. ----excess of, 121. 502 INDEX OF SUBJECTS. Liver, hydatid of, necessitated Caesa- rean section, 288. Locked head, etc. (see Twins). Malpositions, causes of, 122. Manoeuvres to liberate arms, 210. ----of Levret and Van Deutsch, 223. Mechanism of head-labors, 130. Medicines required in obstetric bag, 17. ----in haemorrhage, 442, 457. Membranes, rent in the, shows placen- tal site, 380. ----rupture of, in haemorrhage, 399. Membranes, detachment of, 321. ----puncture of, 322, 388. " Metastatic labor," 70. Monsters, varieties, and delivery of, 483. Movements of head in normal labor, 130. Nature competent to effect rotation, 80. Naevi, death from injection of, 453. Neck, danger of twisting the child's, 78, 82. Noose of tape, use of, in impacted shoul- der, 222. Obliquity of uterus, 122. Obstetric operations, relation to degree of pelvic deformity at seven and nine months, 91. CEdema, causes and treatment, 111. Opium, uses in obstetrics, 104, 306, 457. Osteo-malacia and rickets compared, 287, 296, 303. ----cases of recovery, 295. Osteo-malacic pelvis can be opened up, 303. Osteotomists (Prof. Davis), 281. Ovum-forceps and spoon, 358. Oxytocic remedies uncertain, 316. Oxytocics (ergot, etc.), when required, Paialysis of facial muscles from forceps, 54. ----of leg from ditto, 54. Pelvis, card-board model of normal, 131, 132. ----compared to rifle-gun, 56. ----contraction, degrees of, in relation to operations, 91. ----deformity causes malposition, 123. Pelvis, diagram of the normal, 91. ----which side deformed, 255. Pelvic version, spontaneous, 148. Pelvimeters, use of, on Continent, 330. Pendulous abdomen a cause of dystocia, 95. ----diagrams of, 97, 98. ----choice of operations in, 96, Perchloride of iron, 361, 451. Perforation after turning,!257. ----in craniotomy, 269, 271. Perforators, varieties of, 21, 22. ----Dr. Oldham's best. 22. Perinaeum, incision of the, 89, 111. ----rupture of, 54, 111. Pessaries, use of, 475. Phthisis and pregnancy, 286, 323, 298, 335. Phlegmasia dolens after haemorrhage, 455. Placenta, adhesion of, 417. ----cautions as to removal of, 418. ----cases of long retention of, 469. ----diseases of decidua, 417. ----double, supplementary, and dif- fused, 419, 420. ----how to remove retained or adhe- rent, 415. ----inferior attachment of, leads to malposition, 123. ----retained, 409. ----how soon to remove, 411. Placenta praevia, 365. ----dangers of, 383, 384. ----treatment of, 383. ----version in, 367. ----diagram of, 375, 379. ----diagnosis of, 382. ----prognosis of, 382. Placental-polypus and blood-polypus, 359. ----thrill, use of, 382. Plugging for haemorrhage, 348. ----os uteri, 321. ----proper method, 360. Plugs not to be trusted too much, 388. Porte-lacs, Braun's and Hyernaux's, 217, 218. Position, first, in " after-coming " head, 78. ----third and fourth? in ditto, 78. ----causes of delay in occipito-poste- rior, 79. Position of patient in forceps version, etc., 47, 56, 187. Post-partum haemorrhage, 409. Practice often determined by degrees of skill, or of perfection of instru- ments, 25, 26. Premature labor can be fixed to an hour, 314. ----author's method, 325. ----induction of, 311. ----morality of, 312. ----in deformed pelvis, 330. ----not to be done without a consulta- tion, 336. ----indications for, 3:^. ----various plans of producing, 315. ----when to be induced, 327. Pressure, economy of, 37. ----instead of extraction, on delivery by means of, 13,14. INDEX OF SUBJECTS. 503 Primiparae, why dystocia most common in, 70. ----treatment of dystocia in, 71, 112. Probang, use of, in Caesarean section, 305. ' Promontory of sacrum, projection of, 93. ----projection of, 255. Propositions, physiological and thera- peutical, iu placenta praevia, 393, etc. Quill of porcupine, the best instrument to rupture the membranes, 25. Reflex theory of foetal position, 118. Retroflexion of uterus a cause of haem- orrhage, 474. ----restoration of, 474, Rickets and osteo-malacia compared, 287, 296, 303. Rigidity of soft parts, treatment of, 15. ----causes and varieties of, 73,100,109. Rotation of the head, on artificial, 79. Rotation of head often spontaneous, 79-83. Salines; beneficial effects of, 452. Saline injections into veins, 460. Sea-tangle, tents of, 321, 360. " Shelling-out" the head, manoeuvre of, 67. Shoulder-presentations, mechanism of, 132. Spasmodic contractions cause malposi- tion, 124. Spondylolisthesis calls for Caesarean section, 288. ----author's paper on, 288. Sponge-tents, 321, 360. Sponge and tangle tents in rigidity of cervix, 104. Spontaneous version, 135, 150, 154. ----cases of, 155, etc. ----evolution, 124, 150. ----evolution and spontaneous version, true sense of, 134. ----diagrams of, 136. Statistics, fallacy of, 248. Sutures in Caesarean section, 298. Thrombus, of uterus, or vagina, vulva, etc., 113, 473. Tolerance of severe injuries, 301. Transfusion, apparatus for, 461, 463, 465. ----of blood, on mediate and immedi- ate, 461. ----of blood, 458. ----instruments for, 460. ----indications for, 465. ----may be repeated, 466. Transfusion, method of performing, 458-465. ----saline fluid used in, 463. Treatment of dystocia more simple than causes, 13. Turning, advantages of, 116. ---- bi-manual and bi-polar methods of, 159, 484, etc. Turning after craniotomy, 265. ----after death of mother, 290. ----in placenta praevia, 366. ---- (see Bi-polar, Cephalic, Podalic, Spontaneous Version, etc.) ----in face-presentations, 87. ----in deformed pelvis, indications and contraindications for, 249. ----in deformed pelvis, 236. ----fluctuations in opinions on, 236. ----incomplete, 220. ----indications for, 183. ----conditions of, 184. ----acts of, 185. ----limits of application, 243, 247. ----in deformed pelvis, bases of, 240. ----position of patient in, 188. ---- methods of, and diagrams, 190, 215, 216. ----Scanzoni's method erroneous, 215. ----as an elective operation, 240. Turpentine, use of, 359. Twins, cause of dystocia, 476. ----diagnosis of, 479. ----locked, treatment of, 479. Umbilical vein, cold injections into, 415. ----cord, prolapse of, 171. Uterus (see Inversion, Retroversion, etc., etc.). ----chronic hypertrophy of, 473. ----obliquity of, 122. ----flattened form of its cavity, 120. ----laxity of, 124. Vagina, dilatation of, 323. Valves, the uterine and perineal, ob- structions to labor, 71. Version (see Bi-polar, Cephalic Turn- ing, Spontaneous, etc.). ---- external and internal combined (Dr. Hicks), 159, 163. Violence, result of struggling feeble- ness 19, 20. Vomiting, obstinate, may call for de- livery, 328. Vulva, oedema of, 114. ----thrombus of, 115. Warm-bath, depressing effects of the, 75. ----in rigidity, 104. Weight (maximum) of child, 260. THE END. DESCRIPTIVE CATALOGUE OF Medical Woeks. D. APPLETON & CO., PUBLISHERS AND IMPORTERS, 549 & 551 BEOADWAT, NEW YORK. 1874. INDEX OF SUBJECTS. PAGE Anatomy................................15 Annesthesia.............................. 25 Acne....................................31 Body and Mind.......................... 17 Cerebral Convolutions.................... 6 Chemical Examination of the Urine in Dis- ease .................................. 9 Chemical Analysis........................12 " Technology.................... 29 Chemistry of Common Life............... 16 Clinical Electro-Therapeutics..............10 " Lectures........................ 31 Comparative Anatomy...................31 Club-foot................................ 24 Diseases of the Nervous System.......... 11 ' " " Nerves and Spinal Cord... 31 " " " Bones.................... 18 " " "Women.................. 25, 26 " " the Chest.................... 25 " " Children.................. 27, 31 " " the Eectum................... 26 " " the Ovaries................... 29 Emergencies............................. 14 Electricity and Practical Medicine......... 19 Foods................................... 24 Galvano-Therapeutics......'.............. 22 Hospitalism............................. 25 Histology and Histo-Chemistry of Man___ 31 Infancy................................. 5 Insanity in its Eelation to Crime.......... 10 Materia Medica and Therapeutics......... 22 Medical Journal.......................... 30 PAGE Midwifery........................... 25, 26 Mineral Springs.......................... 28 Neuralgia............................... 3 Nervous System......................... 11 Nursing................................. 22 Ovarian Tumors......................... 23 " Diagnosis and Treatment.........29 Obstetrics.......................... 3, 7, 25 Physiology......................... 8, 9, 15 Physiology of Common Life.............. 16 Physiology and Pathology of the Mind___17 Physiological Effects of Severe Muscular Exercise.............................. 10 Pulmonary Consumption................. 4 Practical Medicine....................... 20 Physical Cause of the Death of Christ..... 24 Popular Science..........................80 Puerperal Diseases....................... 31 Reports................................. 4 Recollections of Past Life................. 14 " of the Army of the Potomac. 16 Sea-sickness.............................. 3 Surgical Pathology...................... 5 " Diseases of the Male Genito-Uri- nary Organs...........................81 Surgery............................... g Syphilis................................. 31 Science.............................. 30, 32 Skin Diseases............................. 21 Uterine Therapeutics.................... 26 Winter and Spring....................... 4 CATALOGUE OP MEDICAL WORKS. ANSTIE. IN CUTcllglcl, and Diseases which resemble it. By FEANOIS E. ANSTIE, M. D., F. E. 0. P., Benior Assistant Physician to Westminster Hospital; Lecturer on Materia Medica in West- minster Hospital School; and Physician to the Belgrave Hospital for Children; Editor of " The Practitioner " (London), etc. 1 vol., 12mo. Cloth, $2.50. " It is a valuable contribution to scientific medicine."—The Lancet (London). "His work upon Neuralgia is one of the most interesting, instructive, and practical. we have seen for a long time. We have given it careful reading and thoughtful study, and, for a treatise of its size, we are free to say that we have never met one that gives more practical information and is fuller of useful suggestions."—Medical Record. BARKER On Sea-sickness. By FORDYCE BARKER, M. D., Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College, etc. 1 vol., 16mo. 36 pp. Flexible Cloth, 75 cents. Reprinted from the New Yoke Medical Journal. By reason of the great demand for the number of that journal containing the paper, it is now presented in book form, with such prescriptions added as the author has found useful in relieving the suffering from sea-sickness. BARNES. ObstetriC Operations, including the Treatment of Haemorrhage. By ROBERT BARNES, M. D., F. R. C. P., London, Obstetric Physician to and Lecturer on Midwifery and the Diseases of Women and Chil- dren at St Thomas's Hospital; Examiner on Midwifery to the Royal College of Phy- sicians and to the Royal College of Surgeons; formerly Obstetric Physician to the London Hospital, and late Physician to the Eastern Division of the Royal Maternity Charity. WITH ADDITIONS, by BENJAMIN F. DAWSON, M. D., T,atp Lecturer on Uterine Pathology in the Medical Department of the University of New York; Abs°stanf to the Clinical Professor of Diseases of Children in the College of Physicians and Surgeons, New York; Physician for the Diseases of Children to the New York Dispensary; Member of the New York Obstetrical Society, of the Medical Society of the County of New York, etc., etc. Second American Edition. 1 vol., 8vo. 503 pp. Cloth, $4.50. To the student and practitioner this work will prove of the greatest value, being, as it is, a most perfect text-book on " Obstetric Operations," by one who has fairly earned the right to assume the position of a teacher. "Such a work as Dr. Barnes's was greatly needed. It is calculated to elevate the practice of the obstetric art in this country, and to be of great service to the practitioner. —Lancet. 4 D. Appleton & Co.'s Medical Publications. Bellevue and Charity Hospital Reports. The volume of Bellovue and Charity Hospital Reports for 1870, containing valuable contributions from ISAAC E. TAYLOR, M. D., WILLIAM A. HAMMOND, M. D., AUSTIN FLINT, M. D., T. GAILLAED THOMAS, M. D., LEWIS A. SAYRE, M. D., FRANK H. HAMILTON, M. D., and others. 1 rol., 8vo. Cloth, $4.00. " These institutions are the most important, as regards accommodations for patients and variety of cases treated, of any on this continent, and are surpassed by but few in the world. The gentlemen connected with them are acknowledged to be among the first in their profession, and the volume is an important addition *,o the professional literature of this country."—Psychological Journal. BENNET Winter and Spring on the Shores of the Mediterranean; or, the JRiviera, Mentone, Italy, Corsica, Sicily, Algeria, Spain, and Biarritz, as Win- ter Climates. By J. HENRY BENNET, M. D., Member of the Royal College of Physicians, London; late Physician-Accoucher to the Royal Free Hospital; Doctor of Medicine of the University of Paris; formerly Resi- dent Physician to the Paris Hospitals (ex-Interne des HOpitaux de Paris), etc. This work embodies the experience of ten winters and springs passed by Dr. Bennet on the shores of the Mediterranean, and contains much valuable information for physi- cians in relation to the health-restoring climate of the regions described. 1 vol., 12mo. 621 pp. Cloth, $3.50. " Exceedingly readable, apart from its special purposes, and well illustrated."—Even- ing Commercial. "It has a more substantial value for the physician, perhaps, than for any other class or profession. . . . We commend this book to our readers as a volume presenting two capital qualifications—it is at once entertaining and instructive.''—N. Y. Medical Journal. On the Treatment of Pulmonary Con- sumptlon, by Hygiene, Climate, and Medicine, in its Connection with Modern Doctrines. By JAMES HENRY BENNET, M. D., Member of the Royal College of Physicians, London; Doctor of Medicine of the University of Paris, etc., etc. 1 vol., thin 8vo. Cloth, $1.50. An interesting and instructive work, written in the strong, clear, and lucid manner Which appears in all the contributions of Dr. Bennet to medical or general literature. "We cordially commend this book to the attention of all, for its practical common- iense views of the nature and treatment of the scourge of all temperate climates, pulmo- nary consumption."—Detroit E"view of Medicine. D. Appleton & Co.'s Medical Publications. 5 BILLROTH. General Surgical Pathology and The- rapeutics, in Fifty Lectures. A Text-booh for Stu- dents and Physicians. By Dr. THEODOR BILLROTH, Professor of Surgery in Vienna. Translated from the Fifth German Edition, with the special permission of the Author, fcy CHARLES E. HACKLEY, A.M., M.D., Burgeon to the New York Eye and Ear Infirmary; Physician to the New York Hospital; Fellow of the New York Academy of Medicine, etc. 1 vol., 8vo. 714 pp., and 152 Woodcuts. Cloth, $5.00; Sheep, $6.00. Professor Theodor Billroth, one of the most noted authorities on Surgical Pathology, gives in this volume a complete resume of the ex- isting state of knowledge in this branch of medical science. The fact of this publication going through four editions in Germany, and hav- ing been translated into French, Italian, Russian, and Hungarian, should be some guarantee for its standing. " The want of a book in the English language, presenting in a concise form the views of the German pathologists, has long been felt; and we venture to say no book could more perfectly supply that want than the present volume. . . . 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" This excellent little book should be in the hand of every mother of a family; and, if some of our ladv friends would master its contents, and either bring up their children by the light of its teachings, or communicate the truths it contains to the poor by whom they are surround- ed we are convinced that they would effect infinitely more good than by the distribution of any number of tracts whatever. . . . We consider this work to be one of the few popular medical treatises that any practitioner may recommend to his patients; and, though if its precepts are followed, he will probably lose a few guineas, he will not begrudge them if he sees his friend s children grow up healthy, active, strong, and both mentally and physically capable."— The Lancet. . 6 D. Appleton & CoSs Medical Publications. DAVIS. Conservative olirgery, as exhibited in remedying some of the Mechanical Causes that operate injuri- ously both in Health and Disease. With Illustrations. By HENRY G. DAVIS, M. D., Member of the American Medical Association, etc., etc. 1 vol., 8vo. 315 pp. Cloth, $3.00. The author has enjoyed rare facilities for the study and treatment of certain classes of disease, and the records here presented to the pro- fession are the gradual accumulation of over thirty years' investigation. " Dr. Davis, bringing, as he does to his specialty, a great aptitude for the solution of mechanical problems, takes a high rank as an oi*thopedic surgeon, and his very practical contribution to the literature of the subject is both valu- able and opportune. We deem it worthy of a place in every physician's library. The style is unpretending, but trenchant, graphic, and, best of all, quite intelli- gible."—Medical Record. ECKER The Cerebral Convolutions of Man, represented according to Personal Investigations, es- pecially on their Development in the Foetus, and with reference to the Use of Physicians. By ALEXANDER ECKER, Professor of Anatomy and Comparative Anatomy in the University of Freiburg. Translated from the German by Robert T. Edes, M. D. 1 vol., 8vo. 87 pp. $1.25. " The work of Prof. Ecker is noticeable principally for its succinctness and clearness, avoiding long discussions on undecided points, and yet sufficiently furnished with references to make easy its comparison with the labors of oth- ers in the same direction. " Entire originality in descriptive anatomy is out of the question, but the facts verified by our author are here presented in a more intelligible manner than in any other easily-accessible work. " The knowledge to be derived from this work is not furnished by any other text-book in the English language."—Boston Medical and Surgical Journal January 20, 1873. D. Appleton c& Co.'s Medical Publications. 7 ELLIOT. UuStetriC Clinic. A Practical Contribution to the study of Obstetrics, and the Diseases of Women and Children. By the late GEORGE T. ELLIOT, M. D., Late Professor of Obstetrics and the Diseases of Women and Children in the Bellevue Hospital Medical College; Physician to Bellevue Hospital, and to the New York Lying-in Asylum; Consulting Physician to the Nursery and Child's Hospital; Consulting Surgeon to the State "Woman's Hospital; Corresponding Member of the Edinburgh Obstetrical Society and of the Eoyal Academy of Havana; Fellow of the N. Y. Academy of Medicine; Member of the County Medical Society, of the Pathological Society, etc., etc. 1 vol., 8vo. 458 pp. Cloth, $4.50. This work is, in a measure, a resume of separate papers previously pre- pared by the late Dr. Elliot; and contains, besides, a record of nearly two hundred important and difficult cases in midwifery, selected from his own practice. It has met with a hearty reception, and has received the highest encomiums both in this country and in Europe. It is justly believed that the work is one of the most valuable contributions to obstetric literature that has appeared for many years, and, being emi- nently practical in its character, cannot fail to be of great service to obstetricians. " The volume by Dr. Elliot has scarcely less value, though in a different di- rection, than that of the Edinburgh physician (Dr. Duncan, ' Researches in Ob- stetrics ')."—Lancet. " This may be said to belong to a class of books ' after the practitioner's own heart,' and many circumstances concur to influence us to extend to this work a cheerful welcome, and to commend it as fully as possible. And we do thus welcome it as the production of a gentleman of great experience, acknowledged ability, and high position—as an emanation from one of the leading schools of our country—and as an honorable addition to our national medical literature."— American Journal of Medical Sciences. "There is no book in American obstetrical literature that surpasses this one."—Edinburgh Medical Journal. " It ought to be in the hands of every practitioner of midwifery in the coun- try."—Boston Medical and Surgical Journal. " It has no equal in the English language, as regards clinical instruction in obstetrics."—American Journal of Obstetrics. " The book has the freshness of hospital practice throughout in reference to diagnosis, pathology, therapeutical and operative proceedings. It will be found to possess a great amount of valuable information in the department of obstet- rics in an attractive and easy style, according to the most modern and improved views of the profession."—Cincinnati Lancet and Observer. " It is invaluable for the practitioner of obstetrics."—iV. Y. Medical Journal. 8 D. Appleton the identity, quality, and purity of every article dispensed or sold for med- ication. A work embracing the most approved methods of examinations, and forming a critical and useful guide for such tests, has as yet been a desideratum. This want has now been successfully met by the present work. The book is divided into two parts, the first of which treats of operations and reagents, and gives a general account of the principles and methods of chemical analysis. The second, or main part, gives, in an alphabetical order, a complete account of the medicinal chemicals, their physical and chemical characteristics, and directions for the establishment of their quality and purity, selected and arranged with care and judgment; each compound is fully de- scribed according to its aspect and properties, its solubility in the usual sol- vents, simple and chemical, and its deportment with reagents (tests of Identity); this is followed by the Examination, under which heading the defects, or the accidental impurities, resulting from the processes employed in the manufacture of the chemicals, or from insufficient purification, and also the adulterations and substitutions, are considered, and their detection clearly and precisely described so that they are readily understood by those having an average knowledge of chemistry, and ordinary chemical manipulations, many of which, as well Is the more important apparatus, are illustrated by excellent engravings. A number of very useful tables is scattered through the text; and the volume concludes with comparative tables of the thcrmometric scales, the troy and metric weights, and a complete index, embracing the common English terms and the Latin names and synonymes in use. _ The work has been brought up to the latest results of scientific research within the briefest possible compass ; and forms a thoroughly practical and trustworthy guide, combining easy operations, simple apparatus, and economy ot time, with the greatest attainable accuracy. D. Appleton <£• Co.'s Medical Publications. 13 In America it has already met with general and unqualified approval; and in Europe is now being welcomed as one of the best and most important addi- tions to modern pharmaceutical literature. To give a better idea of the real merits and popularity of the book, we would call attention to the following: hpnrtn7w?,^Silkind-^^05gvbeen,nee(ied' and for tWs reason alone this volume would be rnn?pnLW?t^^f7wnitltiha-d been ess comPlete than it is_____This brief outline of the Jw. «~«nSS —^bfe.W0Jk 1S- S?-areely suffioient to convey a correct idea of all the informa- tw &™i l J 6 descnPtlons and directions are clear and precise, and we feel sure w« ™ v Jllss? T00ajfn requires the examination of medicinal chemicals will find this valua- ble work what the author designed it to be-a trustworthy guide for the determination of their identity and quality."—American Journal of Pharmacy. " A work of this'character has long been a desideratum, and we may now truly say that the void has been well filled by this c*-cllent treatise, which will be cordially welcomed by every pharmacist and by all others to whom it is especially directed. In all the departments of the work Dr. Hoffmann displays extended research, and a critical familiarity with the subject, while at the same tune he has placed the matter before the student with system, and in a language at once clear and concise. Not only is the author to be congratulated upon the excellent result ot his labor, but every pharmaceutist also upon this most opportune addition to the literature ol his art, and most valuable assistant in his daily work."— The Pharmacist {Chicago). " In this excellent work, the author, a thorough practical pharmaceutist, eminently fitted to the task, has successfully endeavored to crystallize into a single volume all that is essential to form a reliable and practical guide."—New York Medical Review. " The object for which this book has been written has been successfully accomplished; it is an eminently practical work throughout; its style and descriptions are clear and accurate, and it will prove very valuable to those who have occasion to examine drugs and chemicals.11— Boston Medical and Surgical Journal. " This book has long been a desideratum, and will be well received. It treats of subjects of vital importance to the physician and druggist in a clear and concise manner. "We do most heartily recommend this work as the best aid in the examination of medicinal chemicals."— Nashville Journal of Medicine and Surgery. "This volume is a carefully-prepared %vork, aDd well up to the existing state of both the science and art of modern pharmacy. It is a book which will find its place in every medical and pharmaceutical laboratory and library, and is a safe and instructive guide to medical stu- dents and practitioners of medicine.11—American Journal of Science and Arts. " The appearance of this work must be regarded as very timely. That the physician and the pharmaceutist may have it in their power to examine by the most approved methods the arti- cles they prescribe and dispense, the author has, carefully and with a mature judgment and sound discretion, collected and arranged in accessible form the most trusty tests of purity in medicinal chemicals."—Medical and Surgical Reporter. " In this volume Dr. Hoffmann has supplied a want in the literature of his profession, by having gathered together the widely-scattered fragments of information relating to the exami- nation of chemicals, and has arranged them into a systematic and ready hand-book of especial interest and value, which certainly is entitled to a wide circulation. . . . "With regard to indices, the work is a model; it contains a number of valuable tables, and is largely illustrated with ex- cellent engravings, which serve to elucidate very much the descriptions of apparatus and ma- S nipulations. The work is issued in Messrs. Appletons1 best style, and presents not only an at- ^ tractive appearance, but an unusual freedom from typographical defects and errors.11—Ameri- can Chemist. " The reputation of the author of this book is the best guarantee of its accuracy and value. Dr. Hoffmann is well known as a highly-valued contributor to scientific journals, as a popular lecturer, and as an original investigator. He has himself practically applied the leading meth- ods set forth in the book, and has proved most of the tests recommended by him. . . . The book is a valuable addition to our pharmaceutical literature, and ought to have the effect of securing a still more extended knowledge of the medicinal chemicals most in use."—Journal of Applied Chemistry. "This excellent volume carries out fully the prefatory promises, and fills a void which has heretofore existed in American pharmaceutical literature. It is not only a valuable acquisition to the library of the average pharmaceutist, but also an invaluable aid to those better qualified and practically familiar with the subject, and there is no doubt that this work will be regarded as a standard among works on pharmacy.11—Prof. C. Lewis Diehl, Louisville, Kentucky. ^ " It is with great satisfaction that we note the appearance of this manual, especially adapted to the pharmaceutical chemist and manufacturer of medicinal chemicals. The processes recom- mended have been judiciously and carefully selected, and the instructions are full and trust- worthy; and we hope that the circulation of this elaborate work, on both sides of the> Atlantic, may tend to accomplish its objects."—Chemical News (London). 14 D. Appleton & CoSs Medical Publications. HOLLAND. Recollections of Past Life, By SIR HENRY HOLLAND, Bart., M. D., F. It. S., K. C. B., etc., President of the Royal Institution of Great Britain, Physician-in-Ordinary to the Queen, etc., etc. 1 vol., 12mo, 351 pp. Price, Cloth, $2.00. A very entertaining and instructive narrative, partaking somewhat of the nature of autobiography and yet distinct from it, in this, that its chief ohject, as alleged by the writer, is not so much to recount the events of his own life, as to perform the office of chronicler for others with whom he came in contact aud was long associated. The " Life of Sir Henry Holland11 is one to be recollected, and he has not erred in giv- ing an outline of it to the public.11— The Lancet. " His memory was—is, we may say, for he is still alive and in possession of all his faculties—stored with recollections of the most eminent men and women of this cen- tury. ... A life extending over a period of eighty-four years, and passed in the most active manner, in the midst of the best society, which the world has to offer, must neces- sarily be full of singular interest; and Sir Henry Holland has fortunately not waited until his memory lost its freshness before recalling some of the incidents in it."—The New York Times. HOWE. Emergencies, and How to Treat Them. The Etiology, Pathology, and Treatment of Accidents, Diseases, and Cases of Poisoning, which demand Prompt Attention. Designed for Students and Prac- titioners of Medicine. By JOSEPH TV. HOWE, M. D., Clinical Professor of Surgery in the Medical Department of the University of New York; Visiting Surgeon to Charity Hospital; Fellow of the New York Academy of Medicine, etc., etc. 1 vol., 8vo. Cloth, 83.00. " This work has a taking title, and was written by a gentlemen of acknowledged ability, to fill a void in the profession. ... To the general practitioner in towns, villages, and in the country, where the aid and moral support of a consultation cannot be availed of, this volume will be recognized as a valuable help. "We commend it to the profession.—Cincinnati Lancet and Observer. " This work is certainly novel in character, and its usefulness and acceptability are as marked as its novelty. . . . The book is confidently recommended."—Richmond and Louisville Med- ical Journal. " This volume is a practical illustration of the positive side of the physician's life, a constant reminder of what he is to do in the sudden emergencies which frequently occur in practice. . . . The author wastes no words, but devotes himself to the description of each disease as if the patient were under his hands. Because it is a good book we recommend it most heartily to the profession."—Boston Medical and Surgical Journal. " This work bears evidence of a thorough practical acquaintance with the different branches of the profession. The author seems to possess a peculiar aptitude for imparting instructiou as well as for simplifying tedious details. ... A careful perusal will amply repay the student and practitioner.1 —New York Medical Journal." D. Appleton & Co.'s Medical Publications. 15 HUXLEY AND YOTJMANS. The Elements of Physiology and Hygiene. With Numerous Illustrations. Bx THOMAS H. HUXLEY, LL. L\, F. E. S., and "WILLIAM JAY YOUMANS, M. D. New and Revised Edition. 1 vol., 12mo. 420 pp. $1.75. A text-book for educational institutions, and a valuable elementary work for students of medicine. The greater portion is from the pen of Professor Huxley, adapted by Dr. Youmans to the circumstances and requirements of American education. The eminent claim of Professor Huxley's "Elementary Physiology" is, that, while up to the times, it is trustworthy in its presentation of the subject; while rejecting dis- credited doctrines and doubtful speculations, it embodies the latest results that are established, and represents the present actual state of physiological knowledge. " A valuable contribution to anatomical and physiological science."—Religious Telescope. "A clear and well-arranged work, embracing the latest discoveries and accepted theories.11 —Buffalo Commercial. " Teeming with information concerning the human physical enconomy."—Evening Jour- nal. HUXLEY. The Anatomy of Vertebrated Animals. By THOMAS HENRY HUXLEY, LL. D.. F. Pv. S., Author of "Man's Place in Nature," "On the Origin of Species," "Lay Sermons and Addresses," eto. 1 vol., 12mo. Cloth, $2.50. The former works of Prof. Huxley leave no room for doubt as to the impor- tance and value of his new volume. It is one which will be very acceptable to all who are interested in the subject of which it treats. " This lon^-expected work will be cordially welcomed by all students and teachers of Com- parative Anatomy as a compendious, reliable, and, notwithstanding its small dimensions, most comprehensive guide on the subject of which it treats. To praise or to criticise the work of so accomplished a master of his favorite science would be equally out of place. It is enough to say that it realizes, in a remarkable degree, the anticipations which have been formed of It; and that it presents an extraordinary combination of wide, general views, with the clear, accu- rate, and succinct statement of a prodigious number of individual facts.11—Nature. 16 D. Appleton & Co.'s Medical Publications. JOHNSON. The Chemistry of Common Life. Illustrated with numerous Wood Engravings. By JAMES F. JOHNSON, M. A., F. K. S., F. G-. S., etc., etc., Author of "Lectures on Agricultural Chemistry and Geology," "A Catechism of Agricultural Chemistry and Geology," etc. 2 vols., 12mo. Cloth, $3.00. It has been the object of the author in this work to exhibit the present condition of chemical knowledge, and of matured scientific opinion, upon the subjects to which it is devoted. The reader will not be surprised, therefore, should he find in it some things which differ from what is to be found in other popular works already in his hands or on the shelves of his library. LETTERMAN. Medical Recollections of the Army of the Potomac. By JONATHAN LETTERMAN, M. L\, Late Surgeon U. S. A., and Medical Director of the Army of the Potomac 1 vol., 8vo. 194 pp. Cloth, $1.00. " This account of the medical department of the Army of the Poto- mac has been prepared, amid pressing engagements, in the hope that the labors of the medical officers of that army may be known to an in- telligent people, with whom to know is to appreciate ; and as an affec tionate tribute to many, long my zealous and efficient colleagues, who, in days of trial and danger, which have passed, let us hope never to re- turn, evinced their devotion to their country and to the cause of hu- manity, without hope of promotion or expectation of reward."—Preface. " We venture to assert that but few who open this volume of medical annals, pregnant as they are with instruction, will care to do otherwise than finish them at a sitting."—Medical Record. " A graceful and affectionate tribute."—N~. Y, Medical Journal. LEWES. The Physiology of Common Life. By GEORGE HENRY LEWES, Author of "Seaside Studies," "Life of Goethe," etc. 2 vols., 12mo. Cloth, $3.00. The object of this work differs from that of all others on popular Bcience in its attempt to meet the wants of the student, while meeting those of the general reader, who is supposed to be wholly unacquainted with anatomy and physiology. D. Appleton & Co.'s Medical Publications. 17 MAUDSLEY. The Physiology and Pathology of the Mind. By HENRY MAUDSLEY, M. L\, Loitdon, Physician to the "West London Hospital; Honorary Member of the Medico-Psychological Society of Paris; formerly Resident Physician of the Manchester Eoyal Lunatic Hospital, etc 1 vol., 8vo. 442 pp. Cloth, $3.00. This work aims, in the first place, to treat of mental phenomena from a physiological rather than from a metaphysical point of view; and, secondly, to bring the manifold instructive instances presented by the unsound mind to bear upon the interpretation of the obscure problems of mental science. " Dr. Maudsley has had the courage to undertake, and the skill to execute, what is, at least in English, an original enterprise."—London Saturday Review. " It is so full of sensible reflections and sound truths that their wide dissemi- nation could not but be of benefit to all thinking persons."—Psychological Journal. " Unquestionably one of the ablest and most important works on the subject of which it treats "that has ever appeared, and does credit to his philosophical acumen and accurate observation."—Medical Record. " We lay down the book with admiration, and we commend it most earnestly to our readers as a work of extraordinary merit and originality—one of those productions that are evolved only occasionally in the lapse of years, and that serve to mark actual and very decided advances in knowledge and science."— N. Y. Medical Journal. Body and Mind '. An Inquiry into their Con- nection and Mutual Influence, specially in reference to Mental Disorders; being the Gulstonian lectures for 1870, delivered before the Eoyal College of Physicians. With Appendix. By HENRY MAUDSLEY, M. D., London, FWlow of the Eoval College of Physicians; Professor of Medical Jurisprudence 5° ^mvers^ ^ F k4 London^Presldf nt-elect of the Medico-Psychokgical Associa^ the Medico-Psychological Society of Paris, of the Imperial Society of Phys cians of V.€snna, and of tteSoSy for the Promotion of Psychiatry and Forens c Psychology of Vienna; formerly Resident Physician of the Manchester Eoyal Lunatic Asylum, etc, etc. 1 vol., 12mo. 155 pp. Cloth, $1.00. The general plan of this work may be described as being to bring man, both in his physical and mental relations, as much as possible with- in the scope of scientific inquiry. «A representative work, which every one must study who desires to know what is doing in the way of real progress, and not mere chatter, about mental physiology and pathology."— The Lancet.. «It distinctly marks a step in the progress of scientific psychology. — Jn* Practitioner. 18 D. Appleton t& Co?s Medical Publications. MAKKOE. A Treatise on Diseases of the Bones. By THOMAS M. MARKOE, M. D., Professor of Surgery in the College of Physicians and Surgeons, New York, etc. WITH NUMEROUS ILLUSTRATIONS. 1 vol. 8vo. Cloth, $4.50. This valuable work is a treatise on Diseases of the Bones, embracing their structural changes as affected by disease, their clinical history and treatment, in- cluding also an account of the various tumors which grow in or upon them. None of the injuries of bone ate included in its scope, and no joint diseases, ex- cepting where the condition of the bone is a prime factor in the problem of disease. As the work of an eminent surgeon of large and varied experience, it may be regarded as the best on the subject, and a valuable contribution to medi- cal literature. "The book which I now offer to my professional brethren contains the substance of the lectures which I have delivered during the past twelve years at the college. ... I have followed the leadings of my own studies and observations, dwelling more on those branches where I had seen and studied most, and perhaps too much neglecting others where my own experience was more harren, and therefore to me less interesting. I have endeavored, however, to make up the deficiencies of my own knowledge by the free use of the materials scattered so richly through our periodical literature, which scattered leaves it is the right and the duty of the systematic writer to collect and to embody in any account he may offer of the state of a science at any given period."—Extract from Author's Preface. D. Appleton 'sicians in Ireland; Surgeon in Ordinary to the £^Sori?WSn™^£ .° ^Samaritan Hospital for Women; Member of the Im- ShrfffS? $ar\ 0f *° Medical Society of Paris, and of the Medical Soci- nf^Rni^If™« rf?S"ff ^em^r-0f.the Eo>'al S^iety of Medical and Natural Science ^0B™^f's'.andof. the Medical Societies of Pesth and Helsingfors; Honorary Fellow of the Obstetrical Societies of Berlin and Leipzig. ™««j 1 vol., 8vo. 478 pp. Illustrated. Cloth, Price, $4.50. In 1865 the author issued a volume containing reports of one hundred and fourteen cases of Ovariotomy, which was little more than a simple record of facts. The book was soon out of print, and, though repeatedly asked for a new edition, the author was unable to do more than prepare papers for the Royal Medical and Chirurgical Society, as series after series of a hundred cases accumulated. On the completion of five hundred cases he embodied the results in the present volume, an entirely new work, for the student and practitioner, and trusts it may prove acceptable to them and useful to suffering women. "Arrangements have been made for the publication of this volume in Lon- don on the day of its publication in New York." French and German transla- tions are already in press. WAG-INTER A Hand - book of Chemical Tech- nology. By RUDOLPH WAGNER, Ph. D., Professor of Chemical Technology at the University of Wurtzburg. Translated and edited, from the eigrhth German edition, with extensive additions, By WILLIAM OROOKES, F. R. S. With 336 Illustrations. 1 vol., 8vo. 761 pages. Cloth, $5.00. Under the head of Metallurgic Chemistry, the latest methods of preparing Iron Cobalt, NickeL Conner Copper Salts, Lead and Tin, and their Salts, Bismuth, Zinc, Zinc Salts, Cad- m urn AnUmon^Ireenic, Mercury, Platinum, Silver, Gold, Manganates Aluminum^ and TSsmmTe described. The vaSus applications of the.VoltaicCurrent tcjE^Me,al- lnrs-v follow under this division. The preparation of Potash and Soda Halts, tne manutacture SlDhuric Acid andtherecoverv of Sulphur from Soda Waste, of course occupyprominent sections of the book have been devoted to the Technology of Heating and Illumination. THE NEW YORK MEDICAL JOURNAL WM. T. JLT7SK, M. T>., \ Editors tTAS. S. HUNTER, M.D., f ^a^ors. Published Monthly. Volumes begin in January and July, " Among the numerous records of Medicine and the collateral sciences pub- lished in America, the above Journal occupies a high position, and deservedly bo."—The Lancet (London). Terms, $4,00 per annum. Specimen Copies, 25 Cents. The attention of the profession is called to the fact that subscribers to the New York Medical Journal will be supplied with any foreign or American Medical Jour- nals at a liberal discount from the regular subscription price. Commutation rates will be given on application. THE POPULAR SCIENCE MONTHLY. Conducted by Prof. E. L. YOUMANS. Each number contains 128 pages, with numerous Descrip- tive and Attractive Illustrations. PUBLISHED MONTHLY. Terms, $5.00 per annum, or Fifty Cents per Number. The great feature of this magazine is, that its contents are not what sci- ence was ten or more years since, but what it is to-day, fresh from the study, the laboratory, and the experiment; clothed in the language of the authors, inventors, and scientists themselves, which comprise the leading minds of this most scientific age. In this magazine we have the latest thoughts and words of Herbert Spencer, Prof. Huxley, and Mr. Darwin, and the fresh experiments of Tyndall, Hammond, andBrown-Sequard. It also contains accounts of all the recent important discoveries by the eminent scientists of France and Germany. The Monthly enables us to utilize at least several years more of life than it would be possible were we obliged to wait its publication in book-form at the hands of some compiler. The new volume commenced in May, 1873, and all new subscriptions should begin with that date. OPINIONS OF THE PRESS. "Ajournal which promises to be of eminent value to the ciii„i„- a this country."—New York Tribune. e of P°Pular education in "It is, beyond comparison, the best attempt at iournalism of th- i-^a ^„„ , . „ . country."—Home Journal. journalism ot tlie kind ever made in this "The initial numher is admirably constituted."—Evening Mail In our opinion, the right idea has been hanDilv hit in th* t.1-,',, „«• it.- Buffalo Courier. UUPP"7 nit in tne plan of this new monthly."— •'Just the publication needed at the present fay."—Montreal Gazette. New York Medical Journal and Popular Science Monthlv New ^ork M«Lcal Journal and Appleton* Weekly JournaiofLiieratu^e.-Scien^-and $S °° Appleton* Weekly journal and Popular Science Monthlv............................ 7 00 New lork Medical Journal, Popular Science Monthly, and Weekly Journal .'"J \\\;\;\ jf Jgj Payment, in all cases, must be made in advance. Remittances should be made by postal money-order or check to the Publishers D. APPLETON & CO, 549 & 551 Broadway, N Y ' 30 NEW MEDICAL WORKS IN PRESS. *>F Pei"al DiSeaseS. Clinical Lectures delivered at Bellevue Hospital. By Fordyce Barker, M. D, Clinical Professor of Mid- wifery and Diseases of Women in the Bellevue Hospital Medical College ; Obstetric Physician to Bellevue Hospital; Consulting Physician to the New York State Woman's Hospital, and to the New York State Hospital for Diseases of the Nervous System; Honorary Member of the Edinburgh Obstetrical Society, etc., etc. A course of lectures valuable alike to the student and the practitioner. Hand-Book of the Histology and Histo- chemistry of Man. By Dr. Heinrich Fret, of Zurich. Illustrated with 500 Woodcuts. Clinical Lectures on Diseases of the Nervous System. Delivered at the Bellevue Hospital Medical College, by Wtm. A. Hammond, M. D. Edited, with Notes, by T. M. B. Cross, M. D. ACI16 ; its Pathology, Etiology, Prognosis, and Treatment. By L. Duncan Bcxkley, A. M., M. D., New York Hospital. A monograph of about seventy pages, illustrated, founded on an analysis of two hundred cases of various forms of acne. Compendium of Children's Diseases, for Students and Physicians. By Dr. John Steiner. Diseases of the Nerves and Spinal Cord. By Dr. H. Charlton Bastian. Chauveau's Comparative Anatomy of the Domesticated Animals. Edited by George Fleming, F. R. G. S., M. A. I. 1 vol. 8vo, with 450 Illustrations. On Surgical Diseases of the Male Geni- to-Hrinary Organs, including Syphilis. By W. H. Van Buren, M. D., and Edward L. Keyes, M. D. D. APPLETON & CO., 549 & 551 BROADWAY, NEW YORK. 31 International Scientific Series. irsro^v :r, e -a. id -st - NO. 1. FORMS OF WATER, in Clouds, Kain, Rivers, Ice, and Glaciers. By Prof. John Tyndall, LL. B., F. K. S. 1 vol. Cloth. Price, $1.50. No. 2. PHYSICS AND POLITICS; or, Thoughts on the Application of the Principles of " Natural Selection " and " Inheritance " to Political Society. By Walter Bagehot, Esq., author of " The English Con- stitution." 1 vol. Cloth. Price, $1.50. No. 3. FOODS. ByDr.EDwAEDSMiTH,F.R. S. 1vol. Cloth. Price, $1.75. NO. 4. MIND AND BODY. By Alexandeb Bain, F. E. S. 12mo. Cloth. Price, $1.50. JiO. 5. STUDY OF SOCIOLOGY. By Hebbeet Spencee. 1 vol., 12mo. Cloth. Eeady November 1st. PROSPECTUS. D. Appleton & Co. have the pleasure of announcing that they have made arrangements for publishing, and have recently commenced tbe issue of, a Series op Popular Monographs, or small works, UDder the above title, which will embody the results of recent inquiry in the most meresting departments of advancing science. The character and scope of this series will be best indicated by a reference to the names and subjects included in the subjoined list, from which it will be seen that the cooperation of the most distinguished professors in England, Germany, France, and the United States, has been secured, and negotiations are pending for contributions from other eminent scientific writers. The works will be issued simultaneously in New York, London, Paris, and Leipsic. The International Scientific Series is entirely an American project, and was originated and organized by Dr E. L. Youmans, who spent the greater part of a year in Europe, arranging with authors and publishers. The forthcoming volumes are as follows : Prof. T. H. Huxley, LL. D., F. E. S., Bodily Mo- tion and Consciousness. Dr. W. B. Carpenter, LL. D., F. E. S., The Principles of Mental Physiology. Sir John Lubbock, Bart., F. B. S., Tlie Antiq- uity of Man. Prof. Eudolph Virchow (of the University of Berlin), Morbid Physiological Action. Prof. Balfour Stewart, LL. D., F. E. S., The Conservation of Energy. Dr. H. Charlton Bastian, M. D., F. E. S., The Brain as an Organ of Mind. Prof. William Odling, F. E. S., The New Chemistry. Prof. W. Thistleton Dyer, B. A., B. So., Form and Habit of Flowering Plants. Dr. Edward Smith, F. E. S., On Diets. Prof. W. Kingdon Clifford, M. A., The First Principles of the Exact Sciences explained to the Non-Mathematical. Mr. J. N. Lookyer, F. E. S., Spectrum Analysis. W. Lauder Lindsay, M. I)., F. E. S. E., Mind in the Lower Animals. B. G. Bell Pettigrew, M. D., The Locomotion of Animals, as exemplified in Walking, Swimming, and Flying. Prof. James D. Dana,M. A., LL.D., On Cepha- lization; or, Head Domination in its Re- lation to Structure, Grade, and Develop- ment. Prof. 8. W. Johnson, M. A., On the Nutrition of Plants. Prof. Austin Flint, Jr., M. D., The Nervous System-, and its Relation to the Bodily Prof. W. D. Whitney, Modern Linguistic Sci- ence. Prof. A. C. Eamsay, LL. D., F. E. S., Earth Sculpture. Dr. Henry Maudsley, Responsibility in Dis- ease. Prof. Michael Foster, M. D., Protoplasm and the Cell Theory. Eev. M. J. Berkeley. M. A., F. L. S., Fungi; their Nature, Influences, and Uses. Prof. Claude Bernard (of the College of France), Physical and Metaphysical Phe- nomena of Life. Prof. A. Quetelet (of the Brussels Academy of Sciences), Social Physics. Prof. A. De Quatrefages, The Negro Races. Prof. Lacaze-Dutiiiers, Zoologi/ since Cu-tier. Prof. C. A. Young, Ph. D. (of Dartmouth Col- lege), The Sun. Prof. Bernstein (University of Halle), The Physiology of the Senses. Prof. Herman (University of Zurich), On Res- piration. Prof. Leuckard (University of Leipsic),- Out- lines of Chemical Organization. Prof. Eees (University of Erlangen), On Para- sitic Plants. Prof. Vogel (Polytechnic Academy, Berlin), Tlie Chemical Effects of Light. Prof. Wundt (University of Strasbourg), On Sound. Prof. Schmidt (University of Strasbourg), The Theory of Descent—Darwinism. Prof. Eosenthal (University of Erlangen) Physiology of Mtiscles and Nerves. Functions. Professors H. Saint-Claire Deville. Berthelot, and Wurtz, have engaged to" write but have not yet announced their subjects. Other eminent authors, as Wallace, Helmholtz Parks Milne-Edwards, and Hdeckel, have given strong encouragement that they will also tako part in the enterprise. D. 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